DOB: 12/14/1963
Sex: Male
Gender Identity: Male
Allergies: NKDA
MRN: 843220
| MEDICATION | DOSE | TIME | TIME GIVEN / INITIALS |
|---|---|---|---|
| Trade: CARDIZEM Generic: diltiazem Demo Dose: CARDIZIAM/DILTIAM |
120 mg PO Q 12 Hours | 0900 2100 |
|
| MULTIVITAMIN Demo Dose MVit |
PO Daily | 0900 | |
| Brand: Prilosec Generic: omeprazole |
20 mg Daily | 38 | |
| Trade: DILANTIN Generic:phenytoin Demo Dose: DILAT |
100 mg PO TID | 0900 1300 1700 |
|
| Trade: GLUCOPHAGE Generic:metformin Demo Dose: metformin/Gluchophag XR) |
500 mg PO AC BID | 0900 1300 1700 |
|
| Brand: AUGMENTIN Generic: Amoxicillin/Clavulanate |
400 mg PO Daily | 0900 | |
| 70/30 insulin | 10 Units SQ at meals | 0900 1200 1700 |
|
| Brand: HALDOL Generic: haloperidol |
5 mg IM Q 8 hours | 0000 800 1600 |
|
| MORPHINE | 2 mg IM Q 8 hours | PRN for pain scale 6-10 |
|
| HEPARIN SODIUM | 7500 Units SQ Q 12 hours | 0900 2100 |
| Time | Provider | Notes |
|---|---|---|
| 0800 | Mary Goodwell, MD | A 25 kg 8 yo comes to the ED with an acute asthma exacerbation. She is wheezing. The mother states she has had SOB for the past 2 days. Her peak Expiratory Flow value was between 50-80%. The mother has been giving her nebulizer treatments more frequently. |
| Status | Time | Ordering Physician | Order |
|---|---|---|---|
| Active | 1600 | Mary Goodwell, MD | ∙ Put on C/R monitor & pulse ox ∙ Get CBC, BMP, Respiratory viral panel Cx. ∙ Albuterol 2.5 mg IH q 1 hour ∙ IV Methylprednisolone 50 mg IV x1, then 12. 5 mg IV q 6 hours ∙ Oxygen to keep sats ≥93%; start 4 liter NC ∙ Stat CXR |
| Active | 1700 | Mary Goodwell, MD | ∙ Albuterol 5 mg continuous infusion via face mask ∙ Switch to 6 liter FM (I/E wheezing continues) |
| Active | 1800 | Mary Goodwell, MD | ∙ Orders: Switch to optiflow, 60% O2 & 15 liters |
| Time (in military time) | 1600 (ED) | 1700 (ED) | 1800 (ED) |
|---|---|---|---|
| Heart Rate | 110 | 120 | 140 |
| Blood Pressure | 115/70 | 116/72 | 128/90 |
| Respiratory Rate | 29 | 38 | 35 |
| Temperature | 37C | 37C | 37C |
| Pulse Ox | 92% | 89% | 88% |
| Oxgen in Liters | Room air | 4 Liter N/C | 6 Liter FM |
| Pain | 0 | 0 | 0 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 120 mg/dL | 65-100 mg/dL |
| BUN | 10 mg/dL | 7-20 mg/dL |
| Creatinine | 0.6 mg/dL | 0.2-0.6 mg/dL |
| Sodium | 138 mEq/L | 135-145 mEq/L |
| Potassium | 3.8 mEq/L | 3.5-5 mEq/L |
| Chloride | 98 mEq/L | 96-106 mEq/L |
| Calcium | 9.1 mg/dL | 8.5-10.3 mg/dL |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 6 μL | 5.5-15.5 μL |
| RBC | 3.9 | 3.8 - 4.8m/mm2 |
| HGB | 12 g/dL | 12 g/dL |
| HCT | 30 | 31-41% |
| Platelets | 301 μ/dL | 250-450 μ/dL |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 10.2 | 7.6-10.6 |
| PTT | None | |
| Respiratory viral panel | Pending |