Assessment & Plan Elements
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Impression:

Neuro/Pain/Psych: Patient with no known history of underlying neurological, chronic pain, or psychiatric disorders. Normal neurological examination on admission, with no acute emotional concerns.
-Acetaminophen PRN pain

Cardiac: No history of underlying cardiac disease. Currently hemodynamically stable, with vital signs as described above.
-Monitor VS

Pulm: No history of underlying pulmonary disease, and currently saturating well on room air. No accessory muscle use, or adventicious sounds on auscultation during admission examination.
-Monitor pulse oximetry with vitals
-Not active tobacco user

GI: No current Nausea, vomiting, or diarrhea/constipation concerns. No underlying GI disorders.
-[checkbox name="variable_1" value="Regular diet |NPO|Full-liquid diet|Diabetic d "]
-Zofran PRN Nausea

Renal: No active electrolyte disturbance on admission BMP, and patient currently making adequate urine.
-Monitor electrolytes with daily BMP, Will replete as needed

Heme: No evidence of active hemorrhage, and no anemia on admission labs.
-Will continue to monitor with daily CBC

ID: No evidence of active infectious progress. Currently Afebrile, and no leukocytosis on admission CBC.
-Full Fever work up if patient becomes febrile -Monitor for leukocytosis with daily CBC

MSK: No acute musculoskeletal concerns.

Endo: No history of underlying endocrine pathology.
-Monitor random glucose with daily BMP

Prophylaxis: PADUA

Disposition:
Impression:

Neuro/Pain/Psych: Patient with no known history of underlying neurological, chronic pain, or psychiatric disorders. Normal neurological examination on admission, with no acute emotional concerns.
-Acetaminophen PRN pain

Cardiac: No history of underlying cardiac disease. Currently hemodynamically stable, with vital signs as described above.
-Monitor VS

Pulm: No history of underlying pulmonary disease, and currently saturating well on room air. No accessory muscle use, or adventicious sounds on auscultation during admission examination.
-Monitor pulse oximetry with vitals
-Not active tobacco user

GI: No current Nausea, vomiting, or diarrhea/constipation concerns. No underlying GI disorders.
-
-Zofran PRN Nausea

Renal: No active electrolyte disturbance on admission BMP, and patient currently making adequate urine.
-Monitor electrolytes with daily BMP, Will replete as needed

Heme: No evidence of active hemorrhage, and no anemia on admission labs.
-Will continue to monitor with daily CBC

ID: No evidence of active infectious progress. Currently Afebrile, and no leukocytosis on admission CBC.
-Full Fever work up if patient becomes febrile -Monitor for leukocytosis with daily CBC

MSK: No acute musculoskeletal concerns.

Endo: No history of underlying endocrine pathology.
-Monitor random glucose with daily BMP

Prophylaxis: PADUA

Disposition:
Result - Copy and paste this output: