S:

63 y/o M, with a PMHx of HTN, DM and sigmoid cancer, s/p open left hemicolectomy with colostomy creation and liver biopsy POD 2. Patient reports no overnight events but continued to be tachycardic throughout the night. He states he did not get up to walk yesterday, despite recommendations to do so. Colostomy bag has been draining. He reports abdominal pain at the incision site but denies fever, chills, chest pain, shortness of breath, abdominal pain, nausea or vomiting.

O:

VS: T: 98.2, Pulse 121 bpm, RR 17 breaths/minute, BP 129/97, O2 98%, Ht 6’1”, Wt 330 lb, BMI 43.74 kg/m²

Physical Exam: 

Gen: alert and oriented x3, no acute distress

HEENT: no gross abnormalities 

CV: tachycardia

Resp: normal breath sounds 

Abd: obese, soft, vertical wound in mid-abdomen with staples, clean, dry and intact with no discharge or bleeding. Colostomy bag intact with stool and with no surrounding erythema.

11.5 | 10.6 | 208

            33.1

139 | 106 | 10       137

3.4 | 26    | 1.43         

Calcium: 8.5 mg/dL

Albumin: 2.8 g/dL

Alk phos: 63 U/L

ALT: 49 U/L

AST: 47 U/L

Magnesium: 1.8 mg/dL

Phosphorus: 2.7 mg/dL

Past 24 hour I/O 

Input: 6493 ml

Output: 3155 ml

Net: 3788 ml

A:

63 y/o M, s/p left hemicolectomy, colostomy creation and liver biopsy, POD 2. Dressing changed at bedside. 

P:

Continue to monitor patient

Get patient out of bed to chair 

Remove NG tube and start clear liquid diet 

Perform ABG and repeat CBC 

Consult cardiology regarding EKG with occasional PVCs and widened QRS complexes, possible echo 

Continue Dilaudid PCA, fluids [D5W-LR], antihypertensives [Amlodipine, Losartan] and diabetic medications [insulin aspart injection 0-10 units q4h SC]

DVT prophylaxis with Lovenox 40 mg SC daily 

GI prophylaxis with Pantoprazole 40mg IV daily 

Replete potassium