Age/Sex 21years/Male

Patient :Roudin,Mike.

Medical record number : Q000000433.

Admission : March 12th 2021.

Admission status: Inpatient.

Allergy: Amoxicillin.

Attending doctor: Doctor Big,Smiley.

Oxygen: 02 @ 2L NC. D/c if sat >93%RA.

Sister: Yankarin,Deserti. 909- 555-9999

Location:Trauma unit.

Room number: 51603.

Code status : full code.

Isolation precautions:Standard Precautions.

Complaint:Assault, Mandibular fracture, Orbital fracture.( gang related) S/P ORIF of the left mandible. Extracted tooth. Left face swelling. Sutures in place.

Secondary diagnosis:

Anemia,Sickle cells. (Not in crisis)

Risk for Fall: No.

Suicidal Risk: No.

Do patient have advanced Directive: No.Copy of advanced Directive on the chart.

Skin integrity: Intact skin.

Transportation : bed. OOB to Chair when feeding or drinking liquid.

Diet : Consistency Pureed diet. Do not use straw.Thin liquid. 24hour fluid restriction.


Lortab 5mg po Q6hours prn pain given ×1.

Dilaudid 0.5mg IV Q3hours prn severe pain × 1 01am.

Peridex 15cc oral rinse switch and spit after each meal.

Able to ambulate to the bathroom.


Discharge home in am after doctors rounding.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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