447 CASE SCENARIO. MR LUCKY FRED LEFT FOOT INFECTION; SEPSIS.

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.

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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