Kingdom of God’s hospital Los Angeles,CA90000.

Interdisciplinary Kadex.

Mr Babyme,Luum.

Attending doctor: Tumtum,Worry.

MR# Q555500000.

Account#: Q000000022.

Status: Inpatient admission.

Code Status: Full code.

Isolation Precautions: Standard precautions.

Primary diagnosis: Left leg Osteomyelitis/ Cellulitis.

Secondary diagnosis: Etoh abuse,polysubstance abuse,Hep C, right BkA.,Hypertension.

Age 64years old man.


Height: 5ft 7inches.

Transportation: Bed.Left leg red and swollen, elevated on two pillows. Right stump healed elevated.

02 at 2liter NC.02 sat 93%.

Allergy: NKDA.

Diet: Regular diet.


Vancomycin 1gm IV Q12hours.

0.9ND left AC @100ml/hour via pump.

Norco 5/5/325mg po Q4hours prn pain. Complain of pain 4/10,norco 5/325mg po given x1.

Re-evaluate pain after one hour, rated pain 0/10.

Laboratory Studies:

WBC “13.

H/H: 9.8,36%.

K:3.7 replaced with Kdur 20mEq ×1 as ordered.


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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