445 CASE SCENARIO. SEPSIS / PNEUMONIA RHABDOMYOLYSIS.

Patient name: Lovegrove, Trees.

Age/Sex : 69years.Male.

Attending doctor: Lookme,Neigh.

Locationn:5southwest.

Room:46002.

MR# Bo55500056.

Account number #Booooo565.

Interdisciplinary Kadex.

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.

Weight:100lbs.

Height : 5ft 6inches.

Allergy: NKDA.

DIAGNOSTIC Studies:

MRI:Acute infarction.

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.

No Defibrillation.

Strict NPO.

D5Wwith 20meq at 50ml/hour ×1 bag.

Accucheck Q6hours.

Zosyn 3.375gm IV Q8hours.

0.9NS at TKO.

Laboratory results after blood transfusions:

WBC:11.9.

H/H9.3/30.8%.

K=3.6,

NA=142.