448 CASE SCENARIO MR ABLEGOD NEEW;S/P COMMUNITY ACQUIRED PNEUMONIA.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 90000.

Interdisciplinary Kadex.

Age/Sex: 79years old male.

MR#Q990056787.

Account #Q00002234.

Attending doctor: Tumtum,Worry .

Primary diagnosis Pneumonia.

Secondary diagnosis dm,htn,hypothyroidism,bph,tremors.

Code Status: 02 at 2liter NC ,saturation:93%.

Weight:150Ibs.

Height:5ft ,7inches .

Code Status:Full code.

Is patient at risk for fall:Yes.

Do you have advanced Directive:NO.

Copy of advanced Directive on the chart.

Next of king: Son at the bedside.

Allergy: NKDA.

Diet: Cardiac Heart Health diet.Ate 75% of dinner .

Alert and oriented x3.

Ambulates slowly but steady gaits.

Saline Lock left forearm.

Uses urinal.

CT Scan of chest done, results pending.

Plans:

Antibiotics: Zosyn 3.375gm IV Q8hrs.

Blood sugar Q Ac/ Hs.

Norco 5/325mg po pain.

0.9NS at 50ml/hour.

Discharge home in 2 to 3days.