Age 56years Sex Male.Unit Q000099977
Admitted Date 02/15/2013
Attending doctor: Dr. Robert Hate.
Medical record number :Q00009594963.
Medical/Surgical Floor. Room: 42066.
CODE STATUS: Full Code. GCS 15
Alert and Oriented × 4.
Lungs clear. RA.
Diagnosis: Acute Appendicitis.
PSH: Bowel Resection 09/20/2011.
PMH: Diverticulitis, RLQ Abdominal pain(unbearable pain),Nausea/Vomiting.
Consultation: Dr. Nor Smile.
Lap Appy and Lysis Adhesion 02/15/13.Abdominal incisions × 3 sites with demoband.
Activity: As tolerated. SCD while in bed.
Incentive Spirometry 10times Q1hour while awake.
Abdomen: Hypoactive Bowel sounds.
DIET : Clear liquid diet. Allergy: NKDA.
Home Medications reviewed and reconciled.
Medications:
Zosyn 3.375gm IV Q8hrs.
Flagyl 500mg IV Q8hrs.
Morphine 2mg IV Q3 prn breakthrough pain.
Zofran 4mg IV Q4hours prn nausea/Vomiting
Narco 5/325mg 2tablets po Q4hours prn pain.
PLAN:
Discharge home with daughter.
Discharge in two days if:
No temperature 24hours.
Labs in am CBC WITH DIFFERENTIAL. CHEMISTRY 7.
Nurses You Move Me 