Appendix B

Patient Report

Brief Description of Client
Name: Colin Batey Gender: M Age: 56
Race: Biracial
Weight: 220 lbs Height: 74 in
Religion: Not stated Major Support: Wife
Phone: 720-0000
Allergies: Sulfa
Immunizations: current, gets flu shot every year
Attending Physician/Team: Dr. Alex Reed
Past Medical History: COPD, CAD, Stent LAD 3 months ago, 60 pack year smoker.
History of Present illness: Presented to ER with complaints of nausea, vomiting, and severe abdominal pain.
Social History: Retired postal service worker, enjoys yard work.
Primary Medical Diagnosis: Ruptured Diverticulitis, Post op Colon resection with a resulting ileus.
Surgeries/Procedures & Dates: Stent LAD 3 months ago
Significant Lab Values
Na 136 Hgb 9.0
K 3.2 Hct 36.6
Glucose 161 WBC 10.1
Physician Orders:
Vital signs every 4 hours
Daily weight x 4 days
Full liquid diet
Progress to soft diet when tolerating fluids
Activity: Out of Bed ambulating with abdominal binder
Intake and Output every shift
Incentive spirometer 10 times every 2 hours while awake
Dry sterile dressing change BID (every 12 hours) / REPORT Time: 0700
Mr. Batey is a 56-year-old male who has a history of COPD. Prior to these new onset GI symptoms he has no medical concerns. Mr. Batey is a retired postal service worker. He has 60 pack year smoking history. Three days ago he was seen in the Emergency Department for complaints of nausea and vomiting and severe abdominal pain. He was found to have a ruptured diverticulum and was emergently sent to surgery for a bowel resection. He is 48 hours post op. He has a peripheral IV in the forearm with NS at 100ml/hour. Foley catheter is in place draining dark orange urine. He has a small ulcer on the coccyx which was present on admission. His abdomen has been very quiet since O.R. He is not passing gas and bowel sound were hypoactive yesterday. I did not hear any bowel sound during the night. He was complaining of nausea yesterday and had one episode of vomiting during the night.
Dr. Reed was in early this morning. He suspects a paralytic ileus and left the following orders:
NPO
Insert NG tube
Zofran, IVP
Follow placement of NG tube with Abdomen series x-ray to r/o ileus and free air
Acapella 8-10 breaths – start low setting
Duoneb Q4hrs w/ C/A or Alb/Atrovent UD
Albuterol q 2hrs prn
Advair I Bid
OT to evaluate and treat: wound care