Room 554 bed 1, Mr Jones, Smith. 80 years old. Admitted on October 4th. 2009, under the care of Dr Cooper. Consults: Dr Reyes – Infectious, Dr Moore – GI.
He came with Abdominal pain.
Pt is alert and oriented to times 3. Complaints sharp pain to right lower abdomen, pain score 8/10(อ่านว่า Eight out of Ten) and nausea.
He's generalized weakness, needs moderate assist.
He has history of Gout, GERD, Diabetes
No known allergy
He has Normal Saline running at 150 ml/hr to right forearm, gauge 22.
He has no vomiting today but still complaints of nausea and abdominal pain.
Ultrasound abdomen was done today but no result yet. Please call Dr Moore when you get the result. His vital signs stable, afebrile.
Pt has AccuCheck ac & hs with Novolog sliding scale coverage.
The recent Accucheck at 4 pm. was 114.
He has Zofran 4 mg IV PRN for nausea and I gave him once at 2 pm, Morphine 4 mg IV for pain given at 4 pm. He had no bowel movement today.
Urinal prepared by bedside. He’s on strict I/O.
Any questions?