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.

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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