Inpatient Systems Based A/P

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. 
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-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: