528 CASE SCENARIO. INTRACTABLE VOMITING/ABDOMINAL PAIN.

Intractable Vomiting is the force in which you empty your stomach and the content of the intestine without stopping.You feel nauseous and then you start vomiting uncontrolleable and difficult to manage.You cannot keep food down.Unrelieved by ordinary medications.Several factors will trigger the Vomiting reflex these include poison, acute gastroenteritis due to irritation of the stomach by infectious organism such as Staphylococcus aureus,torsion or trauma to the bladder or kidney, ovaries, testes,uterus,tumor.If it is caused by bacteria or parasites the doctor will recommend and prescribe treatment for it.So it is very important to call your doctor or go to the emergency room.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 53years old Female.

Account number : Q005234392.

MR #: Q00058867845.

Admission date : 03/21/2021@04am.

Status : Inpatient admission.

Location: MedTelemetry.

Room: 42114.

Attending doctor : Tommy Holbib.

Patient name : Beautyqueen Shakeme.

Alert and oriented x4.

Allergy: NKDA.

Resuscitation Status :Full code.

Weight : 160lbs.

Height : 5ft 7inches.

Status: Standard Precautions.

Risk for fall: No

Suicidal risk: No.

Do you have advance Directive: No.

Copy of advance Directive on the chart.

Diet : NPO x icechips .

Start Clear liquid diet at dinner.

Transportation method: Bed.

02 saturation 95% RA.

Primary diagnosis :Intractable Vomiting. Abdominal pain.

Secondary diagnosis Hypertension Gerd,chronic Constipation.

Lactic acid 4.0.(initially received bolus)

Dropped down to Lactic acid: 1.2mmol/L.

0.9NS Bolus 1liter × 2.

D545NS @75ml/hour IV right forearm 20guage clean/ Patent/ Intact.

Phenergan 12.5mg IV Q8hours prn Vomiting.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Morphine sulfate 2mg IV Q6hour prn severe pain.

Dilaudid 0.5mg IV Q3hours prn severe pain. Rocephin 1gm IV Q8hours.

Flagyl 500mg IV Q8hours.

Doxyciline 100mg IV Q8hours.

Pnemonovax 13 vaccine 0.5ml subQ.

Laboratory results :

WBC 6.5.

H/H 13.0,39.2.

K: 3.5.( replaced 30mEq/kcl IVPB)

Na: 140.

Laboratory tests :

CBC with differential and Chem 7 in am

Cloudy amber urine.

Discharge plans:

Discharge home when medically stable.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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