Age/Sex. : 58years Male. Unit : Q00000035
Admitted :10/12/2011Location :4EAST.
Room Number. 411003Attending doctor. DON’T, HATE.
CODE STATUS: Full code.
Diagnosis : Abdominal Wall abscess/Pneumonia/Coughing.
I &D with iodoform packing at the bedside by the doctor Miller,Spermide
Secondary Diagnosis:Chronic IV drug abuse COPD, Schizophrenia and bipolar, 2gm herone every day.
Weight 140lbs,height 5ft 8inches.
Allergy: PCN. Reaction Rashes.
Diet Regular diet.
A& O x 4
Uses urinal at his bedside.
02 Saturation > 93 RA.
Expirational Wheezing
Sputum culture sent.
(+) moderate gram positive cocci in clusters in the wound.
Ambulates.
Abdominal packing i/2 inch iodoform packing strip.
MEDICATIONS:
Morphine 2mg IV Q3hours prn pain.
Norco 10/325mg 1tablet po Q4hours prn pain.
0.9NS at 100ml/hour left hand 20guage,patent/clean/Dry.
MRSA Right buttocks.
Contact Isolation.
Lab Values:
Lactic acid 1.4
NA 134mEqkcl.
K 4.4mEqkcl
WBC 13.3mm3
H/ H 12.2 /33.8
Miss Carolyn Noten came to the hospital with right lower quad abdominal pain. Diagnosis Ruptured Appendicitis. The doctor placed the patient on seven days antibiotics due abdominal wall infection.
0.9NS at 100ml/hour left forearm. Lactic acid 1.7
K 3.6mEqkcl.
Ativan 0.5mg IVP Q6hours prn agitation.
Dilaudid 1mg IV Q8hrs prn pain.
Zosyn 3.375gm IV Q8hrs.
Bowel movement ×1 today.
Nurses You Move Me 