so here is the note why i wanted to know where to quantify "iv lasix". the dr is telling me that iv lasix should be marked under high risk for drug therapy inquiring monitoring for toxicity. What do you think?
PLAN:
IV LASIX NOW
REPEAT CXR
STOP ATIVAN - WILL RESUME AT HOME DOSE WHEN PT FULLY AWAKE
CARDIOLOGY CONSULT
MOVE TO TELE
PROBLEM LIST:
1) Urosepsis
2) Sacral decubiti and possible cellulitis
3) CHF
4) DM2
5) Anxiety
6) Decrease in global functioning / failure to thrive
7) Pain control/neuropathy
8) A Fib
SUBJECTIVE:
PT NON-VERBAL. PER HUSBAND A LITTLE MORE AWAKE LAST NIGHT. NO EVIDENCE OF AGITATION OR PULLING AT IV AND FOLEY PER HUSBAND AND NURSING. MORE DYSPNEIC PER DTR.
OBJECTIVE:
Item Value Date Time
Patient Temperature 98.3 degrees F 9/18/09 0800
Temperature Source Axillary 9/18/09 0800
Pulse Rate 72 bpm 9/18/09 0800
Respiratory Rate 28 bpm H 9/18/09 0800
Blood Pressure Assessment 158/68 9/18/09 0800
Location Right Upper Arm
Bedside Pulse Oximetry 93 % L 9/18/09 0015
Sodium Level 143 mmol/L 9/17/09 0545
Potassium Level 4.1 mmol/L 9/17/09 0545
Chloride Level 109 mmol/L 9/17/09 0545
Carbon Dioxide Level 26.7 mmol/L 9/17/09 0545
Blood Urea Nitrogen 33 mg/dL H 9/17/09 0545
Creatinine 0.95 mg/dL 9/17/09 0545
Prothromb Time International Ratio 2.79 INR 9/18/09 0540
Percent Meal Consumed Bites 9/18/09 0926
Percent Meal Consumed 0% 9/17/09 1815
Bedside Blood Glucose 98 mg/dl 9/17/09 2029
Bedside Blood Glucose 114 mg/dl 9/18/09 0000
Bedside Blood Glucose 146 mg/dl H 9/18/09 0600
PHYSICAL EXAM:
General: Mod resp distress using abdominal accessory muscles.
Heart: Regular rate and rythym, no murmur, rub or gallop
Lungs: clear to auscultation bilaterally without wheezes, rales or rhonci
Abdomen: Soft, non-tender, nondistended, + bowel sounds
Extremities: warm and dry without cyanosis, clubbing, 2+peripheral pulses, edema