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 Ă—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.

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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