EMERGENCY ROOM REPORT
This 67-year-old female was evaluated by me in the emergency department at approximately 0630 hours for complaints of repeated episodes of vomiting, numbering at least 5 during the preceding 8 or so hours. She stated that she is a known diabetic and has taken fingerstick readings of 423 and 241 at home. She is on multiple medications including regular insulin 10 units in the a.m., along with Ultralente 16 units at h.s., along with Trental, Pamelor, and niacin. She is a known diabetic for 54 years. She also admits to some chest pain, somewhat burning in nature, without radiation into her face, neck, or arms. There is no history of diarrhea. She has a previous history of coronary artery bypass surgery some 4 years earlier.
PHYSICAL ASSESSMENT
Physical assessment reveals her temperature to be 98.2, pulse 60, respirations 20, and a blood pressure of 102/50. Initially her color was pale. Her mucous membranes did appear dry. Heart rate was regular without murmurs. There was a well-healed cicatrix to the anterior midsternal region. Lungs were clear to auscultation. The abdomen was soft with generalized tenderness. No unusual pulsating masses. Lower extremities were free of any pretibial edema.
IMPRESSION
1. Diabetes mellitus, out of control.
2. Dehydration.
3. Electrolyte imbalance.
PLAN
While in the emergency department, multiple diagnostic studies were performed, including CBC, glucose, BUN, potassium, sodium, UA, Panel A, ABG, PT, PTT, electrocardiogram, CPK-MB via electrophoresis. Her serum glucose was noted to be 511, serum sodium of 129, and a BUN of approximately 30.
During her ER stay she was given normal saline with some subjective improvement. She was also given Compazine 10 mg IM for repeated vomiting. Her condition at the time of admission was slightly improved.
FOOTNOTE
Line 9 (Page 1). In duration was deleted. (Duration indicates time span. Five episodes of vomiting is the amount, not the duration.)
Line 11 (Page 1). Alternative: Finger stick.
Line 36-40 (Page 1). The abbreviations used were expanded for clarity.
Line 42 (Page 1). Plan was deleted since it had already been dictated in
Line 43 (Page 1). Alternative: I.M.
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