I Your Name: Leslie Lopez Your Title: Student Nurse Reason for Being There:
INTRODUCE
YOURSELF
Patient: Lieberman, Janet A.
Hi
Age: 36
Gender: Female
Height/Weight: 167.6cm (66 inches)/ 59kg (130 ibs)
S Allergies: Sulfa
SITUATION Code status:
Privacy Code: 534689
Time: 1500
Attending Physician: McGuire, Mark
Patient Chief Complaint: Abdominal pain , dizziness and blood in stool
Chief Informant: Family History:
Has a sister that is on her way to the hospital
Current Medications: Social History:
Past Medical History:
B Chrons diease, Intermitten
Remicade q 8weeks last dose
7weeks ago, otc anti inflammatory Drinks alcohol in the
BACKGROUND gastiritis, Iliostomy 6months
Morphine 4mg q2hr prn for pain
ago.
VITAL SIGNS:
B/P HR RR TEMP
A 94/56 110 26 98.6
ASSESSMENT
FALLS RISK IV Fluids:
Y N
IV Site: L arm Accu check: 1000ml 0.9% sodiu
ISOLATION Isolation Precautions: Y N Contact
HEENT Alert and orientated X3, normocephalic, EENT- WNL, Mouth and throat- p
rises on phonation.
RESPIRATORY Breathing sounds clear no adventitious sounds
CARDIOVASCULAR HR elevated, S1 and S2 normal
NEUROLOGICAL Exam intact
Abdomen- soft, flat, no apparent masses. Hypepractive bowl sounds prese
GI/GU in all 4 quandrants , Liver and spleen palpated no masses, Moderate overa
I&O rebound tenderness or gaurding. Ileostomy present on the lower right side
stool with red streaks
MUSCULOSKELETAL Exam intact
INTEGUMENTARY Skin smooth, fair, dry and pale. Nail beds pink, good capillary refill.
LYMPHATIC Reviewed within normal limit, continur to monitor
INTRODUCE
YOURSELF
Patient: Lieberman, Janet A.
Hi
Age: 36
Gender: Female
Height/Weight: 167.6cm (66 inches)/ 59kg (130 ibs)
S Allergies: Sulfa
SITUATION Code status:
Privacy Code: 534689
Time: 1500
Attending Physician: McGuire, Mark
Patient Chief Complaint: Abdominal pain , dizziness and blood in stool
Chief Informant: Family History:
Has a sister that is on her way to the hospital
Current Medications: Social History:
Past Medical History:
B Chrons diease, Intermitten
Remicade q 8weeks last dose
7weeks ago, otc anti inflammatory Drinks alcohol in the
BACKGROUND gastiritis, Iliostomy 6months
Morphine 4mg q2hr prn for pain
ago.
VITAL SIGNS:
B/P HR RR TEMP
A 94/56 110 26 98.6
ASSESSMENT
FALLS RISK IV Fluids:
Y N
IV Site: L arm Accu check: 1000ml 0.9% sodiu
ISOLATION Isolation Precautions: Y N Contact
HEENT Alert and orientated X3, normocephalic, EENT- WNL, Mouth and throat- p
rises on phonation.
RESPIRATORY Breathing sounds clear no adventitious sounds
CARDIOVASCULAR HR elevated, S1 and S2 normal
NEUROLOGICAL Exam intact
Abdomen- soft, flat, no apparent masses. Hypepractive bowl sounds prese
GI/GU in all 4 quandrants , Liver and spleen palpated no masses, Moderate overa
I&O rebound tenderness or gaurding. Ileostomy present on the lower right side
stool with red streaks
MUSCULOSKELETAL Exam intact
INTEGUMENTARY Skin smooth, fair, dry and pale. Nail beds pink, good capillary refill.
LYMPHATIC Reviewed within normal limit, continur to monitor
