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. -[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:
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