Care plan infos

Description

Care plan infos

65-year-old male

Admitted Jan 27

Admission diagnosis: Hyponatremia. Left eye swollen due to fall. Patient fell in the shower twice, did not sustain any fracture

Other admission notes

Patient complained of fatigue, recent weight loss, fever and night sweat

Medical history

Enlarge prostate, myocardial infarction, chronic back pain, schizophrenia. Also have history of cocaine use

Vitals

Height 67”

Weight 67kg

BMI 23.13

Awake and alert X3

BP 124/71

Pulse 83

Spo2 97%

Respiratory 18

Temperature 98.3

Urine output 250 ml recorded at 9.30am

Bowel movement at 11:15am (black tarry) about 200 ml

Pulse 2+

Clear bilateral

No allergies

Sodium 128

Wbc 10.07

Hemoglobin 6.9

Hematocrit 20.6

Potassium 3.8

Chloride 97

Calcium 7.3

Glucose 86

BUN 18

Creatinine 1.07

Co2 26

Medications

3 units of blood day 1 of admission

Potassium

Sodium chloride

Lovenox

Magnesium

Methocarbamol

Tramadol

Aspirin

Other notes

On regular diet

Instruction Files

ClinicalCarePlanEntryFormCD-13.docx

18.4 KB

careplaninfos.docx

12.8 KB

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