Age/Sex 78years old man .
MR#Q5555533321.
Acount # Q0000991111.
Staus: Inpatient.
Attending doctor:Bigman, Jimmy. Location:Trauma unit.
Room # 43002.
Code Status: Full code.
06/21/2021
Weight: 132lbs.
Height: 5ft 2inches.
Primary diagnosis: Right femur fractures due to fall at home.
Secondary diagnosis:Hypertension, hypothyroidism, hyperlipidemia.
Isolation precautions: Standard precautions. Allergy: NKDA.
02 93% on Room Air.
Transportation by bed.
Skin intact.
Diet : NPO after midnight.
Uses urinal at bedside.
Surgical Consent to be sign ( In the chart).
Advanced Directive on the chart.NO.
SCD in place(left leg ).
Laboratory Studies:
WBC:8.3.
H/H:14/ 40.0%.
NA:136.
K=3.9.
Bun:18,Cr:1.0.
0.9NS,at 75ml/hr left forearm infusing well via pump.
Complain of pain.5/10.Morphine 2mg Q2hours given prn as ordered with relief. Reassessment of pain in 30minutes 0/10.Patientis resting comfortably in bed.
Nurses You Move Me 