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.
Medications
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.
Plan:
Discharge home in am after doctors rounding.
Nurses You Move Me 