Patient name: Lovegrove, Trees.
Age/Sex : 69years.Male.
Attending doctor: Lookme,Neigh.
Account number #Booooo565.
Kingdom Hospital of Los Angeles,CA 900000
Primary diagnosis: Sepsis, Pneumonia/Rhabdomyolysis. Altered mental status.
Secondary diagnosis dm,htn,hypothyroidism.
Do you have advanced Directive No.Copy of Advanced Directive on the chart.
Isolation precautions: Standard precautions.
Is patient at risk for fall: Yes.
02 @ 4liter NC.
Method of transportation: Bed.
Height : 5ft 6inches.
Atrophy and bilateral periventricular white matter. Hypercapnic respiratory failure co2 over 105.
Intubated and self extubated.
High flow oxygen 40%.
CT scan of Head,abdomen and chest done.
Urine sent,sputum sent to laboratory.
H/H 5.7/ 21%.
Two units of PRBC given.
Will recheck lab results in an hour.
Code status: Limited Treatment.
Comfort care only.
D5Wwith 20meq at 50ml/hour ×1 bag.
Zosyn 3.375gm IV Q8hours.
0.9NS at TKO.
Laboratory results after blood transfusions: