Progress Report Overview

Student: Daisy Muga

Activity: Student Portfolio

Start Time: 07/05/2020 13:13:08

End Time: 07/06/2020 06:52:51

Total Time: 00:53:11

Actions

Note at 07/06/2020 06:52:46

Student Portfolio Documentation
Student: Daisy Muga
Activity Start: 07/05/2020 13:13:08
Activity Completion: 07/06/2020 06:52:51
Activity Completion: 00:53:11

Patient Data

Patient: Student Portfolio DOB: 03/01/1990

Age/Sex: 30 yo F MR#: MR20045
Location: General Hospital Admit Date: 07/05/2020

Notes

Note at 07/05/2020 13:13:12

Admission Plan (Admit Order)

Basic Information

Date:

07/05/2020 13:13:12

Author:
Daisy Muga

Location:
General Hospital

Admission Details

Admit to (service, attending; or STO status):

Admit to inpatient medicine under care of Dr. Jane

Diagnosis:

Primary Dx: Acute Interstitial Edematous Pancreatitis (ICD- 10 K85.9) caused by gallstones.

Condition (e.g., stable, fair, poor, etc.; code status if applicable):

Condition: Fair
Vital signs (e.g., VS q4, VS qshift; orthostatics, pulse ox checks? telemetry?):

Q4H; alert PA or MD if pulse is <60 or >100, if BP is <90/60 or >150/90, if respirations are <12 or >25, or if temperature >100
degrees F

Activity (bed rest, up ad lib, etc.):

ambulate as tolerated; early ambulation for DVT prophylaxis

Allergies (and reactions or NKDA):

"cat allergies"
Reaction: coughing and wheezing

Nursing (e.g., I&O's, weights, O2, Foley, NG tubes, etc.):

Vital signs and I&O's hourly

AM weights

Diet (e.g., NPO, regular, cardiac, etc.):

NPO until pain and nausea has resolved; Parenteral nutrition for 2 days
Clear liquid diet for 24 hours on day 3

IV fluids (type, amount or rate):

Lactated Ringer's solution 1 L IV at 100mL/hour

Medications (name, dose, route, schedule, indication if prn med, etc.):

Ursodiol 300mg PO BID

Meperidine 100mg PO Q4H
Anzemet 12.5mg IV PRN for nausea or vomiting

Labs/diagnostics (specify what and when):

CBC with diff Q24H

CT on 7/4/20 at 2pm to assess progress