Reason for Continued Hospitalization:
Subjective:
Objective:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Meds:
Studies:
Labs:
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending: Mark Richman
