ATTENDING:
RESIDENT: Dr. Kenneth Acha, PGY2
CONSULTANTS:
PROCEDURES PERFORMED:
REASON FOR SERVICE:
SUBJECTIVE:
Patient seen at bedside. NAEO. Patient improving clinically.
-No N/V/D.
-No CP, Palpitations.
-NO SOB, Tachypnea.
-No Fever / Chills.
OBJECTIVE:
Vital signs.
PHYSICAL EXAM:
GENERAL: NAD
HEENT: NC/AT. MMM. Conjunctivae are pink and anicteric.
LUNGS:CTAB, No W/R/R, no use of accessory muslces of respiration.
HEART: RRR, no M/R/G, no heaves or thrills.
ABDOMEN: Normal BS, soft, NT/ND, No HSMG, no guarding or rebound tenderness.
MUSCULOSKELETAL: Moving all four extremities spotaneously.
EXTREMITIES: No cyanosis, clubbing, or edema. 2+ dorsalis pedis, posterior tibial pulses.
DERMATOLOGIC: No rashes
NEUROLOGIC: AOX3
PSYCH: Normal mood with good judgement
Blood Gases Basic – Last 36 hours (0) Result Date/Time
Cardiac Studies Basic – Last 36 hours (0) Result Date/Time
Chemistry Comprehensive – Last 36 hours (0) Result Date/Time
Coagulation Basic – Last 36 hours (0) Result Date/Time
Hematology Basic – Last 36 hours (0) Result Date/Time
Microbioloby:
Microbiology (5) Result Date/Time
Anaerobic Cult (Tissue) 06/29 16:24
Positive for Anaerobic Gram Negative Rod
Tissue Culture (Tissue) 06/29 11:45
Positive for Enterococcus faecalis
Blood Culture (Peripheral Draw) 06/28 19:18
Negative
Wound Culture (Wound) 06/25 09:55
Positive for Candida albicans, Enterococcus faecalis, Klebsiella oxytoca, Streptococcus Alpha Hem
MRSA Screen Culture (Nasal) 06/23 16:16
Negative
Radiology – Last 36 hours (0)
No results in past 36 hours
No qualifying data available
ASSESSMENT:
PLAN:
FEN:
Prophylaxis: Enoxaparin
Code Status: Full code
Disposition:
Resident Statement: The attending physician personally examined and thoroughly discussed and directed the plan of care for this patient.
Kenneth Acha, MD
Family Medicine PGY2 Resident
University of California in Riverside