Patient name: Timbuktu, Neverme.
Attending Doctor: Y’knowme,Benson.
Inpatient admission. Date of admission 05/01/0000
33years old male coughing out blood for two days,night sweats. Brought in by ambulance.
Primary diagnosis: Coughing up blood ×2 days (Hemoptysis)R/O TB.
Secondary diagnosis:No Medical History. Isolation Precautions:Airborne. Sweating, showered twice today.
TB infection G.expert positive. AFB culture.1-2-3,first AFB(-)(AFB in am x 2 )Ambulatory ,saline lock left ac 20guage,patent/clean/dry.
Advanced Directive : No. Copy on the chart. K=3.8,Na=140,Wbc =5.0,H/H=11.6/34.6.Allergy NKDA.
Diet :Regular diet.
Room air ,full code.
Next of king:Timbuktu, Yeye.
Phone: 999-99-9999
plan:
Discharge home in 2 to 3days once cleared by San Bernadino County.
Please follow doctor orders and your facility policy and procedures.
Nurses You Move Me 