History Assessment Year Assignment Help: How to Answer This Question
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Original Question
History and Assessment 2/12/XX 06:15am A 50-year-old male patient was admitted for a scheduled open cholecystectomy secondary to gallstones and peritonitis. The patient’s past medical history includes hypertension and cigarette use, 1 pack per day x 25 years. This morning the patient is alert and oriented x 4, VS: T 98.0; P 62; R 14; BP 136/90 mm Hg; SpO2 98% on room air. Skin is intact. Lungs clear bilaterally. Heart sounds S1S2 auscultated; regular rhythm. Pulses 2+ in all extremities. Bowel sounds present in all quadrants. Patient has been NPO since midnight. Patient denies pain or nausea/vomiting. Nurses’ Notes 2/13/XX 12:25 Postoperative day 1. Patient reports pain 6/10 at the abdominal incision site. Incision is well approximated; scant amount of serosanguineous drainage on the gauze dressing is noted. Lung sounds diminished throughout bilaterally. Bowel sounds present in all quadrants. Last bowel movement this morning. Urinating clear yellow urine in the urinal. Orders to ambulate twice a day. Offered to assist patient up to chair for breakfast; patient refused, stating “It just hurts too much to move right now.” Vital Signs 2/13/XX 12:25 Temp. 99.2°F (37.8°C) HR 90 beats/min RR 20 breaths/min; shallow SpO2 92% on room air BP 130/88 mm Hg (MAP 70) Laboratory Results 12/12/XX 08:45am WBC – 8.8 cells/L (3.4 to 9.6 cells/L) RBC – 5.3 cells/L (4.3 to 5.6 cells/L) Platelets – 400 cells/L (150 to 450 cells/L) BUN – 10 mg/dL (6 to 20 mg/dL) Creatinine – 0.9 mg/dL (0.8 to 1.2 mg/dL) Sodium – 136 mEq/L (136 to 145 mEq/L) Potassium – 4.0 mEq/L (3.5 to 5.1 mEq/L)
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