Saturday, April 23, 2016

Medical science treatment of the patient

1.  Neurologic:  For pain management, the patient received p.r.n. analgesia; for any nausea, p.r.n. antiemetics.  For mobility, the patient to be encouraged to be up and out of bed as tolerated with goals of ambulation.
2.  Cardiovascular:  Chest pain, rule out acute coronary syndrome.  The patient does not have any known coronary artery disease previous diagnosis.  She does have cardiac risk factors to include metformin as well as obesity.  The patient will be admitted for chest pain, rule out acute coronary syndrome.  She will be placed on cardiac tele monitoring with serial EKGs and serial cardiac enzymes.  During the Emergency Room, the patient did develop recurrent chest pain.  Her EKG did not show any concern for any ischemia.  There are some nonspecific T-waves.  The patient's chest pain improved with administration of nitro paste.  Therefore, the patient will be kept n.p.o.  She will have a stress test this a.m.  She will be placed on antiplatelet therapy with aspirin.  Her lipid panel is stated as above.  No indication for statin at this time, made diet modification and glycemic index.  The patient will need to be educated on risk factor modification to include weight control.  Her blood pressure upon arrival was within normal limits as well as glycemic control and exercise requirement of aerobic activity 3 times a week.
3.  Respiratory:  At this time, there is no evidence of respiratory distress.  The patient's O2 saturations are currently within normal limits.
4.  Gastrointestinal/Endocrine:  At this time, the patient denies any history of gastroesophageal reflux disease; therefore, GI prophylaxis is not warranted.  For patient's history of diabetes, she was elevated with a blood sugar of 300.  If she may be indicated, she may require some subcutaneous insulin.  Therefore, the patient has been placed on a sliding scale a.c. and at bedtime and I will have the attending in the a.m. to determine if the patient can go back on metformin upon discharge and may warrant her following up with her primary care physician for further diagnostic testing to see if the patient now has positive antibodies for insulin-dependent diabetes.  Upon admission, there is no evidence of transaminitis.
5.  Renal/FEN: The patient's renal function is within normal limits for age and stated height.  Her BUN is 15 with a creatinine of 0.6.  She is currently making yellow-colored urine at this time without difficulty and her GFR is greater than 60.  We will monitor her electrolytes and replete as necessary.
6.  HEME/ONC: At this time for VT chemical prophylaxis, the patient was currently placed on enoxaparin.  Her hematocrit was 27.4 as well as her platelet count was 195.
7.  Infectious disease:  At this time, the patient is currently afebrile and no concerns for infection.  WBCs are within normal limits and she has no subjective complaints.
8.  Psychiatric:  At this time, the patient denies any suicidal or homicidal ideations.  No issues with depression, former or current.  She requested to be made a full code.  The MOLST was placed in the computer per the patient's request.