I Your Name: Gabrielle Parker Your Title: Student Nurse Reason for Being There:
INTRODUCE
YOURSELF
Patient: Lieberman, Janet A.
Hi
Age: 36 years old
Tra
Gender: Female pre
Height/Weight: 167.6 cm (66 inches)/ 59 kg (130 lb)
S Allergies: Sulfa
SITUATION Code status:
Privacy Code:
Time:
Attending Physician: McGuire, Mark
Patient Chief Complaint: Weakness, Dizziness
Chief Informant: Family History: Patient came to ED alone and states her sister is on her way to the hospital
Current Medications: Social History:
Past Medical History:
B Crohn's disease, intermittent gastritis,
had an ileostomy six months ago
Infliximab IV every 8 weeks Current job is a stock
Patient states she dr
BACKGROUND
VITAL SIGNS:
B/P HR RR TEMP
A 94/56 110 26 37.0 Celcius
(98.6 Farenheit)
9
ASSESSMENT
100/60 114 22 37.1 Celcius 9
FALLS RISK IV Fluids:
IV Site: Left Forearm Accu check:
Y N 0.9% Sodium Chloride 1000mL
ISOLATION Isolation Precautions: Y NX Contact
HEENT
RESPIRATORY
CARDIOVASCULAR
Patient stated she felt light-headed and dizzy
NEUROLOGICAL
Patient states she feels like she is going to faint
Patient voided 500 mL at 1500 in ED
GI/GU
I&O Patient stated abdominal area feels sore and crampy
MUSCULOSKELETAL
INTEGUMENTARY Pale, warm, dry to touch
Blood type is A-. Patient was cross-matched for two units of packed
LYMPHATIC
INTRODUCE
YOURSELF
Patient: Lieberman, Janet A.
Hi
Age: 36 years old
Tra
Gender: Female pre
Height/Weight: 167.6 cm (66 inches)/ 59 kg (130 lb)
S Allergies: Sulfa
SITUATION Code status:
Privacy Code:
Time:
Attending Physician: McGuire, Mark
Patient Chief Complaint: Weakness, Dizziness
Chief Informant: Family History: Patient came to ED alone and states her sister is on her way to the hospital
Current Medications: Social History:
Past Medical History:
B Crohn's disease, intermittent gastritis,
had an ileostomy six months ago
Infliximab IV every 8 weeks Current job is a stock
Patient states she dr
BACKGROUND
VITAL SIGNS:
B/P HR RR TEMP
A 94/56 110 26 37.0 Celcius
(98.6 Farenheit)
9
ASSESSMENT
100/60 114 22 37.1 Celcius 9
FALLS RISK IV Fluids:
IV Site: Left Forearm Accu check:
Y N 0.9% Sodium Chloride 1000mL
ISOLATION Isolation Precautions: Y NX Contact
HEENT
RESPIRATORY
CARDIOVASCULAR
Patient stated she felt light-headed and dizzy
NEUROLOGICAL
Patient states she feels like she is going to faint
Patient voided 500 mL at 1500 in ED
GI/GU
I&O Patient stated abdominal area feels sore and crampy
MUSCULOSKELETAL
INTEGUMENTARY Pale, warm, dry to touch
Blood type is A-. Patient was cross-matched for two units of packed
LYMPHATIC
