Age/ Sex: 86years female.
Account number Q5555500678.
Date of birth 00/00/1925.
Attending doctor: Shieldme,Jimmy.
Diagnosis Left foot Cellulitis. Swelling, redness, 2+edema, pulses noted.
Secondary diagnosis: Hypertension.
Past medical history:Dementia, cough,hypertension osteoporosis, Pyelonephritis.
Allergy: No known Drug Allergy.
Weight 120lbs.Alert and oriented x3.GCS =15.
Family members at his bedside.
Room air.Uses bedpan.No other skin issues. 0.9NS @ 50ml/hour. 20 gauge right ac.
VSS: 123/54,88,18,98%Room Air.Arm ID band in place.Fall risk assessment completed. Fall precautions initiated.Placed patient on fall precautions based on her age.Side-rails upx2,bed brakes on.Bed in low position, yellow fall risk sign on her door, fall risk armband in place.Abuse assessment done.Patient is asked if she feels safe at home.She said yes.Suicide risk assessment done.Patient has no plans for suicide. She answers “NO”. Non English speaking, communicated through family members. Patient did not travel out of USA in the last three months. She is not exposed to tuberculosis,Influenza, COVID19.
Lactic acid =2.6.Blood culture result pending ,CBC with difference,Comprehensive Metabolic Panel(CMP).
Medications:Vancomycin 1gm IV Q24hours.
losartan 100mg po daily.
Aspirin 81mg po daily.