nursing

Chief complain ---- hyperglycemia, headache, denies any vomiting nor abdominal pain.

Patient background information

Patient is a 56-year old African-American female, with a past medical history significant for diabetes mellitus, hyperlipidemia, Hypertension, transient ischemic attack (TIA), pneumonia, OSA, morbid obesity, GERD, carotid disease bilaterally and osteoarthritis. Patient came into ER complaining of hyperglycemia and headache. Her blood sugar was 416mg/dl. She reports compliance with medication. She also had some headaches, denies any nausea, vomiting and abdominal pain. In ER, she was in mild respiratory distress and ABG was performed that showed that the PCO2 was 55. As a result, she was placed on BiPAP. She was given regular insulin 10 units IV x1, followed by 8 units IV x1 with improvement of her blood sugar. Patient was also having episode of hypotension which she received IV fluids with good response. Patient was seen at bedside, morbid obese, not in distress, afebrile.

Surgical history – Lumpectomy and rotator cuff

patient weights – 106.25kg

Review of systems

1. Skin: No jaundice, no rash, no pruritus, no swelling, no edema, no cyanosis, no clubbing, no petechial, no stigmata of liver disease.

2. HEENT: Normocephalic, atraumatic, perrla, extraocular eye movement within normal limit . No eye pain, no ear pain, no sore throat, no nasal congestion, BiPAP in place

3. Respiration: No shortness of breath, no cough, clear auscultation, no wheeze, rales or adventitious sounds

4. Cardiovascular: No chest pain, no palpitations

5. Gastrointestinal: No abdominal pain, no nausea, no vomiting, no diarrhea, flat, soft, positive bowel sounds, no guarding, no rebound, no masses, no CVA tenderness

6. Genitourinary: No dysuria, no hematuria, no vaginal bleeding, no vaginal discharge, no suprapubic tenderness

7. Neurologic: headaches, no dizziness, no altered level of consciousness, alert and oriented x 4, no focal neurologic sign.

8. Endocrine: No polyuria, no polydipsia

9. Hematologic/lymphatic: No bleeding, no bruising

10. Musculoskeletal: No joint swelling, no redness, no effusion, normal range of motion (ROM)

11. Psychological: normal affect, no sign of depression

Vital Signs

Medications

· Bisoprolol 5mg, 1 tab, PO daily

· Chlothalidone 25mg, 1 tab, PO daily

· Clopidogrel 75mg 1 tab, PO, daily

· Duloxetine 20mg 1 capsule PO BID

· Ezetimibe 10mg, 1 tab, PO daily

· Famotidine 20mg 1-tab PO daily

· Folic acid 1mg 1-tab PO daily

· Gabapentin 400mg PO TID

· Heparin 5000 units, 1ml sub-Q every 12 hours

· Insulin detemir 70 units, 0.7 ml daily

· Losartan 100mg 2 tabs PO daily

· Miralax 17g/packet oral powder for constipation, PO, daily

· Morphine 15mg, 1tab PO, q12hours

· Senokot 1 tab, PO, nightly

· Sodium chloride 0.9% (NS) IV, 1000ml

LABS

· WBC: 10.4 x 10(3)/mcl

· HBG: 11.4

· HCT: 37

· Platelets: 273x10(3)/mcl

· Troponin: 4pg/m

· Na: 139

· K: 4

· Cl-: 108

· BUN: 42mg/dl

· Creatine: 2.01

· PH: 7.27

· PCO2: 55.2

· PO2: 67

· Glucose: 389

· Calcium: 8.4

· Magnesium: 2.1

· Albumin: 3

· Total protein: 7

· Alkaline phosphate: 196 unit/l

· Bilirubin total: 0.2

· Aspartate aminotransferase (AST): 14 unit/l