C10030741 / invoice 10000

Eating: Yes Drinking: Yes Urinating: Yes Defecating: NoMedical Progress: no more vomitting, eating small amounts, no defecation today told O to give us a call back if she is concerned about him or for anything at all. 

vomited about 6 times not long agofroth and bilelast night okhistory of pancreatitisvomited bit of foam heredroolingabd palpation appears soretemp 38.3Cadmitbloods IV fluids hartmannsprevomax 1.6ml SQbloods - biochem okhigh hctabd US with Silvana:Comments:Bladder is regular size.Contents are normal, anechoic.Walls are smooth, normal thickness.Urethra and prostate are normal..Kidneys have normal shape and size.Cortical echogenicity and corticomedullar definition are normal.Pelvic diameter is normal .Adrenal glands : normal size, and echogenicity.Spleen and liver: sharp margins, normal size.Parenchyma are homogeneous, with normal echogenicity.Gallbladder has normal size.A small amount of flocculent material , partially adhering the walls is present.Walls are normal in thickness.Pancreas is heterogeneous, normal size.Peripancreatic serosa is normal.GIT: stomach contains a small amount of semi-fluid contents .Normal walls.Pyloroduodenal junction is patent.Duodenum, and the observed segments of the small intestine show normal wall architecture and luminaldiameter.No luminal foreign material seen.Ileocecocolic junction is patent.Caecum, and transverse colon show semi-fluid fecal material, normal walls.Normal jejunal and colic LN size and echogenicity.FINDINGS:No GIT foreign body or pattern of outflow obstruction.Some gastric material consistent with semi-digested food / froth.Large intestinal contents suggestive of impending diarrhoea.----------------------------gastritis/early ADHS??warned o may have impending diarrhoeamethadone 0.35ml IVondansetron 8mg IVesomeprazole 16mg IV 

H:had AHDS and pancreatitis last week. has been feeling better every day. still have regurgitation every day. appetite improving. diarrhoea still ongoing but no blood nowExam:MM:PPCRT:<2dental: grade 2Nose:wnlLN:wnlEars:wnlEyes:wnlThoraxsounds okAbdomen:wnlInteg:wnlMsk:wnlNeuro:wnlReprownlPer rectum temp 38.3. maybe blood still?Assessmentrecovering gastrointestinal issue =/- hiatal hernia?Plan:rec repeat bloodO declinedto continue pro-kolinto be put on omeprazole 10mg sid 12 tabsto be back on ondansetron 8mg 1 tab bid 10 tabsto be fed on height