Emergency Department Records
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School
Tennessee Technological University *
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Course
MISC
Subject
Medicine
Date
Apr 3, 2024
Type
xlsx
Pages
4
Uploaded by MegaFishMaster336
Emergency Department Records
Lambuth University Hospital
Arrival Date:
3/5/2024
Arrival Time:
1125
Mode of Arrival:
Chief Complaint:
Lethargy, confusion, lower abdominal pain
Temperature:
37.3 C
Pulse:
90
BP:
140/70
Initial Assessment:
Medication History
Medication History
Dosage
Route Frequency
Last Dose
Oxbutynin
5 mg
PO
Three times/day3/4/2024
Loratadine
10 mg PO
Daily
3/4/2024
Medication Administration in ED
Time
Medication
Dosage
Route
Systems Review
Neurological
Orientation: Lethargic; Disoriented to place and time
Emotional Status: Cooperative and quiet
Moving all extremities: Yes
Upper extremity strength: Weak
Lower extremity strength: Weak
Cardiovascular
Heart rate: Reguar and strong
Monitored cardiac rhythm: Normal sinus rhythm
Capillary refill: Less than 3 seconds
Patient Name: Barnes, Janie
Medical Record Primary Diagnosis: Urinary retention
Secondary Diagnosis: Possible urinary tract infection
Physician: M. Reed, MD
Code Status: Do signs stable. Lethargic, but arousable wtih verbal stimuli. Complaining of mild abdomi
Edema: None
Peripheral pulses-Radial: Present and strong
Periheral pulses-Pedal: Present and strong
Respiratory
Respiratory effort: Nonlabored
Breath sounds: Clear bilaterally
Integument
Skin: Warm, dry, and intact
Turgor: Decreased
Gastrointestinal
Abdomen: Soft and nontender
Bowel sounds: Present
Last BM: Yesterday
Genitourinary
Urine output: None; Bladder palpable above symphysis pubis
Vaginal bleeding: None
Vaginal discharge: None
Drug Use:
Denies
ED Nurse's Notes
Date
Time
Note
3/5/2024
1140
3/5/2024
1130
ED Physician's Notes
Date
Time
Note
3/5/2024
1245
3/5/2024
1151
ED Orders:
1. Do not resuscitate
2. Labs: Complete blood count, chemistry panel 3. Insert indwelling catheter
4. Urinalysis with culture and sensitivity
5. Rocephin 1 gm IM x 1 dose now
6. Acetaminophen 650 mg PO every 4 hours prn pain
7. Discontinue oxybutynin and loratadine.
8. Increase PO fluid intake 3/5/2024
1150
Reproductive: N/A
symphysis pubis. Offered patient bedpan. States she is unable to void
lethargic and oriented x 1 to person. Diaphoretic and uncomfortable.
Will ask urology to see. wish to be resuscitated if the need arises.
Female
Ambulance/EMS
TDaP:
Unknown
RR:
24
SpO2:
93%
Allergies Allergy
Reaction NKDA
Patient Response
#: 7753214
Age: 85
Weight: 121 lbs
Height: 5'3"
BMI: 21.4
DOB: May 10
Not Resuscitate
Allergies: NKA
DOB: May 10
inal pain. Mild diaphoresis noted.
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Nurse
J. Fletcher, RN
J. Fletcher, RN
Physician
M. Reed, MD
M. Reed, MD
M. Reed, MD
d. Dr. Reed notified of findings. . Dr. Reed to see patient.