Rm#

Admit Date:
Age:
Dx: Cellulitis
Contact Precaution: MRSA
Sex:
Code Status: Full
Allergies:
Reason for Admission: CC leg pain, worsening bilateral lower extremity cellulitis (>50% of leg).
LL wound open, weeping, failed outpatient PO abx (Bactrim)
Past Medical Hx: CKD (stage2), DM Type II, hyperlipidemia, hypothyroidism, cirrhosis, AAA,
gout, Afib
H2T:
System
Assessment
Treatment
Neuro AOx4, speech clear, audible, pupils 2mm brisk
Lyrica 25mg PO TID
Pain: 0/10 (intermittent, back) diabetic neuropathy
Oxycodone PRN
Sensation intact
Tylenol PRN
CV
Normal S1, S2, regular rhythm
Aspirin 81mg PO Daily
Edema: 1+ pitting (2mm, 15sec), ankles bilateral
clot prevention
Pulses: Radial normal 2+ bilat; PT, DP weak 1+ bilat
Lovenox 30mg SQ Daily
BP: 146/55 L, HR 66
clot prevention
Nail beds pink, cap refill <3 sec, brisk
Mucosa pink, moist
Resp
Respirations unlabored, normal, no retractions
RR 18, O2 Sat 98% RA
Lung sounds clear in all lobes
GI
Abdomen soft, non-tender, bowel sounds normoactive CBG checks ACHS
Last BM 10/19, brown, loose, soft
Insulin Regular 2-9 units
Serum blood glucose: 94 (10/19)
sliding scale
Diet: Heart healthy diet
Protonix 40mg PO Daily
GU
Foley patent, to gravity
Oxybutynin 15mg PO QHS
UOP 300mL yellow, cloudy
Incontinent of BM
Skin
Warm, dry
Kukui Nut Oil Topical BID to
Cellulitis Bilateral lower extremities, healing, open to BLE
air
NS 100ml/hr
Ecchymosis Bilateral upper extremities
Ceftazidime IV abx
Flaky/Peeling Bilateral lower extremities
Pressure Ulcers Coccyx, stage 1, periwound intact,
foam dressing; LLE (medial)
IV peripheral IV 22G R forearm, continuous infusion,
no drainage, no swelling, no phlebitis, dressing CDI
MS
Gait unsteady, uses walker
Moderate assist, 2-person assist
Limited ROM