KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.
Interdisciplinary Kadex.
Primary diagnosis: Left foot infection;Sepsis,swollen.S/P incision and drainage of of left foot,woundvac placed. Secondary diagnosis: Polysubstance abuse- Meth ,homeless Incarcerated.
Age/ Sex 56years old man.
Admission Date: 06/22/21.
Status: Inpatient admission.
MR#Q3300009912.
A count #Q000000546.
Patient Name:Mr Lucky,Fred.
Attending Doctor :Richman,Palaba
Location 6th floor: MedicalMedical-Surgical. Isolation Status: Contact Isolation.(MRSA of Wound)
Is patient at high risk for fall :Yes.
Patient has advanced Directive : No.Copy of advanced Directive on the chart.
Room air with saturation of 94%.
Uses urinal at bedside, bowel movement ×1 today. Lactic acid 4.6.
Bolus 2liters of normal saline.
Recheck lactic acid:2.3.
Allergy: NKDA.
Diet: Regular diet.
Abnormal vital sign BP 80/49,Hr 120,temperature 100.2°F.
Plans:
D/C woundvac in one week.
Transfer to Skilled Nursing facility.
Zyvox 600mg IV Q24hours,
Unasyn 1gm IV Q8hrs ×4weeks.
Right upper arm midline intact.
Kerlex roll and cuban dressing.
Able to wriggle toes.
Norco 10/325mg po Q4hours prn pain.
Morphine sulfate 2mg IV Q3hours prn pain.
Laboratory tests :
Wound culture done.
WBC 12.0.
H/H 9.7,30.0%.
K=3.9.
NA= 140.
Bun 20,Cr=1.8.
Nurses You Move Me 