CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Similar pain before-
Nausea-
Vomiting-
Diarrhea-
Constipation-
Loss of appetite-
Black/bloody stools-
Sick contacts- , Suspicious food consumed-
Fever/chills- , SOB- , CP- , Headache-
Dysuria-
ER Tx given-
PAST MEDICAL HISTORY:
PUD Gallstones Kidney stones UTIs MI CAD HTN DM
Stroke CA PVD DVT COPD Asthma
EGD-
Colonoscopy-
PAST SURGICAL HISTORY:
Cholecystectomy Hernia Appendectomy Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH:
CAD<> 55 yo DM Stroke HTN CA
SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker- no
Illicit drugs- no cocaine heroin marijuana
REVIEW OF SYSTEMS: unremarkable apart from above symptoms
PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS: Orthostatics-
SpO2- Initial vitals-
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
Rectal exam:
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal
LABS:
N= B= L= AG= LFT
Amylase , Lipase
CPP x 1 - negative , UA:
Blood cx:
ABG:
CXR:
KUB:
EKG:
ASSESSMENT:
-DKA due to
*Noncomplinace w insulin/diet
*Infection
-BUN/Cr elevation due to dehydration
-WBC/ due to DKA, dehydration, r/o infection
-Abdominal pain due to DKA
*Gastroenteritis
*Gastritis
*PUD
*Pancreatitis
*Cholecystitis
*Diverticulitis
*UTI
PLAN:
-NPO apart from meds
-IVF - NS 2 L over 2 hr until hemodynamically stable, then 1/2 NS@150 cc/hr,
keep urine output >50 cc/hr
-Insulin regular 7 U IV bolus & then 7 U/hr IV drip
-Adjust insulin drip to decrease Glu by 75-100 mg/dL per hr
-When HCO3>16 or AG<16> add D5W + KCl 20 mEq/L to IVF
-Accucheck Q 1 hr
-BMP q 4-6 hr
-EKG in AM
-Correct electrolytes
-MS 2 mg IV q 2-4 hr PRN pain
-O2 to keep SpO2 >92%
-I/O
-If Glu<100, use D 10% at 50 cc/hr while on insulin drip \
-CBCD, BMP in AM
-Change to ISS SQ when AG has cleared, D/C Insulin IV drip 2 hr after the SQ dose
Signature:
Created: 2/2005
Updated: 03/08/2007
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