H and P with Update
Jason Bourne is a 35 year old Caucasian male, post op day 5. Full code. Allergies as noted. Fall risk secondary to surgery. He was in excellent health except for hypothyroidism. He was admitted for a surgical repair of a knife wound to the abdomen. His incision is healing. However, he has developed pneumonia and is now septic. Preliminary blood cultures reports show unspecified gram positive bacteria. Mr. Bourne is known to have traveled in obscure parts of the world for his work and it is suspected that he may be a carrier of an unfamiliar bacteria. Therefore he is in isolation and was started on Vancomycin until the microbiology reports are confirmed. He complains of nausea with the Vancomycin. He also is extremely anxious, he says it is work related, and occasionally takes medication for his anxiety. Neuro intact. Cardiopulmonary GI/GU and musculoskeletal systems wnl and through the course of his hospitalization. He was advanced to a regular diet yesterday and is tolerating poorly. OOB ad lib with assist of one.
You do not appreciate any significant issues on your head to toe exam. You are going in to pass your morning meds. You have taken your VS and checked your labs. (Review these results and consider their implications.)