H&P A&P

[checkbox name="116" value="Diabetic Ketoacidosis - Initiate Adult DKA protocol. Trend pH, potassium, blood glucose, anion gap, HCO3, magnesium, phosphorous.  Blood sugar reduction goal no more than 75 mg/dl per hour. Strict intake and outflow monitoring. NPO."]
[checkbox name="30" value="Sepsis (not severe) - Will maintain MAP > 65 with vital signs every 4 hours. Will obtain serial lactic acid measurements and trend CRP. Will obtain procalcitonin and troponin."]
[checkbox name="31" value="Sepsis with Septic Shock - Will maintain MAP > 65 with titration of pressor and with vital signs every 4 hours. Will obtain serial lactic acid measurements and trend CRP. Will obtain procalcitonin and serial troponin."]
[checkbox name="62" value="Pneumonia - Aggressive pulmonary hygeine. Consult respiratory therapy.  Obtain sputum culture.  Blood cultures pending.  Oxygen therapy as needed to keep oxygen saturation greater than 92%.  Solu-Medrol 80mg IV every 8 hours.  DuoNeb treatments every 4 hours. Streptococcus pneumoniae antigen. Respiratory virus / pathogen panel. PSEUDOMONAS risk factors NEGATIVE - (Cystic fibrosis, Mechanical ventilation, Tracheostomy, Neutropenia, Immune compromise: Exam for AIDS, transplantation, cancer chemotherapy)"]
[checkbox name="63" value="Chronic Obstructive Pulmonary Disease with Exacerbation - Consult respiratory therapy. Oxygen therapy as needed to keep oxygen saturation greater than 92%.  Solu-Medrol 80mg IV every 8 hours.  DuoNeb treatments every 4 hours. ABG in the morning."]
[checkbox name="70" value="Small Bowel Obstruction - Bowel rest.  Nasogastric tube with intermittent suction. Surgery service consultation.  NPO."]
[checkbox name="73" value="GI Bleed - Obtain blood type and screen, serial CBC and BMP. Consult GI. Start PPI. NPO status. SCD as DVT prophylaxis. No NSAIDS. Morphine as needed for pain, ondansetron as needed for nausea."]
[checkbox name="74" value="Pancreatitis - Full liquid diet.  Trend lipase. Obtain lipid panel. Antiemetics and analgesia as needed."]
[checkbox name="" value="Chest Pain - Will obtain serial troponins and EKGs. 81mg Aspirin daily. Will obtain lipid panel."]
[checkbox name="96" value="Congestive Heart Failure WITH Exacerbation - IV lasix as tolerated.  1500mL daily fluid restriction. Will closely monitor electrolytes. Daily weights. Strict IN/OUT monitoring. Low sodium diet. NYHA CHF classification of X.  "]
[checkbox name="99" value="New Onset Atrial Fibrillation - ChadsVasc score of X; Anticoagulate with Eliquis. Cardizem drip titrated to heart rate less than 100. Consult cardiology."]
[checkbox name="101" value="Hypokalemia - Present on admission and mild (3.0-3.5) OR moderate (2.5-2.9) OR severe (<2.9). Repletion per protocol."]
[checkbox name="102" value="Hyperkalemia - IV fluids, monitor renal function and serum magnesium and potassium"]
[checkbox name="103" value="Hypothyroidism - Check TSH. Check lipid panel. Continue levothyroxine."]
[checkbox name="104" value="Hypomagnesemia - Will replete with 2GM magnesium IV and planned re-evaluation in the morning. Present on admission and mild OR severe (<1.4)."]
[checkbox name="105" value="Hyperglycemia (no DM history) - Will obtain A1c in the morning."]
[checkbox name="106" value="DM2 - Diabetic diet.  Continue long-acting insulin and Accu-Checks AC and HS with sliding scale insulin."]
[checkbox name="112" value="Hyponatremia - Will trend serum sodium with a goal of no more than 12 MEQ increase in the first 24 hours, then no more than 8 MEQ increase over subsequent 24 hour periods. Present on admission and mild (130-145) OR moderate (120-129) OR severe (<120)."]
[checkbox name="20" value="Lupus - not exacerbated at this time."]
[checkbox name="21" value="Paraplegic - Total care to be provided including turning every 2 hours."]
[checkbox name="22" value="Parkinson's Disease - Continue home medication regimen."]
[checkbox name="23" value="Dementia - Bed alarm, fall risk, close monitoring."]
[checkbox name="24" value="Dizziness - Will provide gentle IV fluids. Heart healthy diet. Will consult neurology as indicated. Meclizine as needed for dizziness."]
[checkbox name="25" value="Transient Ischemic Attack - Consult neruology. Will obtain CTA head/neck, MRA/MRI, echocardiogram with bubble study, carotid ultrasound. Neuro checks every 4 hours."]
[checkbox name="40" value="Cellulitis - Will treat with cefazolin and vancomycin."]
[checkbox name="41" value="Stage III sacral pressure ulcer with - Turn and reposition q2 hours, continue foley catheter, consult wound care, continue wound VAC, wound culture."]
[checkbox name="50" value="Suicide Attempt - 6404 in place.  One-to-one observation. Suicide precautions."]
[checkbox name="51" value="Anxiety - Ativan 1mg PO as needed every 6 hours."]
[checkbox name="52" value="Chronic depression / anxiety - Will continue home medication regimen."]
[checkbox name="53" value="Insomnia - Will continue home medication regimen."]
[checkbox name="54" value="Altered Mental Status - Will obtain non-contrasted CT of the head and TSH as these were not part of initial work-up. Urinary tract infection presumed cause with urine and blood cultures pending."]
[checkbox name="60" value="Hypoxia - Will obtain chest x-ray and ABG and will support with supplemental oxygen via nasal cannula with respiratory consultation. Duoneb treatments every four hours as needed."]
[checkbox name="61" value="Admit to inpatient due to acute on chronic hypoxic respiratory failure"]
[checkbox name="64" value="Chronic Obstructive Pulmonary Disease WITHOUT Exacerbation - Consult respiratory therapy. Oxygen therapy as needed to keep oxygen saturation greater than 92%.  DuoNeb treatments every 4 hours as needed."]
[checkbox name="65" value="Chronic Respiratory Failure - Continue baseline supplemental oxygen.  Consult respiratory therapy."]
[checkbox name="71" value="Stress Ulcer Prophylaxis - Criteria met (Risk factors include past history of gastric ulcer; GI bleeding in the past 12 months; trauma including TBI, spinal cord injury, major burns; 2 or more of: > 1 week in ICU, occult GI bleeding, steroid dose > 250mg hydrocortisone weekly; mechanical ventilation for more than 48 hours; coagulopathy. Will give pantoprazole daily."]
[checkbox name="72" value="Colitis - IV ciprofloxacin and metronidazole. Liquid diet."]
[checkbox name="75" value="Elevated Liver Enzymes - Will obtain GGT and hepatitis panel, PT, PTT, and amonia level.  Child Pugh score of XX. Will obtain contrasted CT scan of the abdomen if not completed in emergency department."]
[checkbox name="76" value="GERD - Continue home medication regimen."]
[checkbox name="80" value="Dysphagia - A mechanically separated and softened diet will be maintained."]
[checkbox name="81" value="Chronic kidney disease - Gentle IV fluid hydration."]
[checkbox name="82" value="Urinary tract infection - Urine culture pending.  Rocephin 1GM twice daily."]
[checkbox name="58" value="Benign prostatic hyperplasia - Will maintain home medication regimen."]
[checkbox name="83" value="Acute Kidney Injury - Will trend creatinine and BUN with gentle IV fluid repletion."]
[checkbox name="90" value="Chronic venous insufficiency - Will continue diuresis and involve Wound Therapy as indicated for venous stasis ulcers."]
[checkbox name="91" value="Chronic Atrial Fibrillation - Continue anti-arrhythmic medications and aspirin"]
[checkbox name="92" value="Essential Hypertension - Continue current antihypertensive medications"]
[checkbox name="93" value="Hyperlipidemia - Continue statin therapy"]
[checkbox name="94" value="Peripheral Vascular Disease - No evidence of venous stasis ulcers at this time."]
[checkbox name="95" value="Congestive Heart Failure without Exacerbation - Continue oral Lasix and Oral potassium if needed."]
[checkbox name="97" value="Anemia - New onset. Will work up as indicated."]
[checkbox name="98" value="Anemia - Established. Will monitor CBC."]
[checkbox name="100" value="Hypoalbuminemia - Will trend. High protein diet."]
[checkbox name="107" value="Lactic acidosis - Will trend lactate level."]
[checkbox name="108" value="Elevated CPK - Will trend CPK."]
[checkbox name="109" value="Methamphetamine abuse - Will obtain serial troponins and morning EKG."]
[checkbox name="110" value="Dehydration (mild lactic acidosis, proteinuria, ketonuria) - Will gently hydrate with normal saline."]
[checkbox name="111" value="Leukocytosis - trend WBCs."]
[checkbox name="113" value="Gout history - Will maintain home medication regimen."]
[checkbox name="114" value="Alcoholism - CAGE score of X. CIWA score of 1. Last drink was X. Blood alcohol level is X.  Will monitor closely for alcohol withdrawal syndrome.  Will obtian serum phosphorous and TSH.  Benzodiazapenese as needed for withdrawal symptoms. Banana bag per protocol every 24 hours."]
[checkbox name="115" value="Failure to Thrive WITH DNR - Consult Case Management for transition to hospice care."]
[checkbox name="130" value="Femur fracture - Orthopedic service to round in the morning.  NPO after midnight.  Pain and nausea medication as needed.  Foley catheter in place.  Bed in reclined position."]
[checkbox name="200" value="Morphine 2mg IV push as needed every 6 hours with as needed ondansetron 4mg"]
[checkbox name="201" value="Chronic pain - Continue home pain regimen."]
[checkbox name="202" value="Constipation - Bisacodyl 5 mg orally daily when necessary."]
[checkbox name="203" value="Neuropathy - Will continue home medication regimen."]
[checkbox name="204" value="Restless leg syndrome - Will continue home medication regimen."]