ADC VANDIL MAX
January 1, 2050
Joe Sample
Admit: Admit Joe Sample to general medicine, floor _______
Resident- Mike R1 (pager #4671)
Attending- Dr. Mallet DPM
Diagnosis:
Condition: Stable, guarded, Serious, or critical.
Vitals: Check q6h. Call HO if : Temp >38.5C, RR <10, O2Sat <95%, HR <40 or >100, BP >190/100
Allergies: Honey
Nursing: Orders for daily dressing changes including kerlix, Coban, 4×4 gauze.
Diet: Advance liquids to solids
IV Fluids: Lactated ringers @ 50cc/h
Labs:
Medication:
- Nausea– Promethazine 25mg, or Zofran IV 4mg POR
- Constipation– Colace 100mg, or Sennoides 8.6mg 2 tabs PO q4h.
- Fever– Acetaminophen 325mg q6h. max 4g/day
- Itch– Benadryl 50mg PO q6h. max 300mg/day.
- Anxiety– Ativan 0.5mg PO q4h. max 10mg
- GERD– Omeprazole 40mg PO qd, TUMS, or Pepsid 40mg PO qhs.
- DVT Prophylaxis – ASA 325mg, Heparin 5,000 units, or Lovenox 30mg BID. Stop prophylaxis as soon as ambulant.
Activity: Bed rest with bathroom privileges. NWB on surgical site
Xray: Immediate post-op including 3 views, Ap/Lateral/MO of the Left foot at radiology floor.
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