451 CASE SCENARIO. OVERNIGHT OBSERVATION.LEFT LOWER EXTREMITY SWELLING/PAIN,2+ EDEMA.

KINGDOM OF GOD HOSPITAL, LOS ANGELES,CALIFORNIA 900000. INTERDISCIPLINARY KADEX.

Age/ Sex 49years old female.

MR# Q200000330.

Account # Q455500428.

Status: Observation.

Date: 03/28/21.

Weight :150lbs.

Height: 5ft 3inches.

Allergy: Aspirin, Motrin, amoxicillin rash,Quinine headache.

Name of Patient: Lovegod,Unknown.

Attending doctor: Tumtum,Worry.

Diet: Carb control diet.

No belongings Checklist list.Will place one on the chart.Daughter took patient belongings home and will bring her clothes upon discharge.

Advanced directive No.Copy of advanced Directive on the chart.

02 @ 2liter NC. Saturation of 94%.

Uses bedpan.

Medications.

Zosyn 3.375gm IV Q8hrs.

Morphine 4mg IV Q8hrs prn severe pain.

Norco 10/325mg po Q4hours prn mild to moderate pain.

Saline lock left forearm. Clean/Dry/ Intact.

MRI of left lower Extremity in am.

Left lower Extremity elevated on pillows.

Patient calls frequently for pain medications and she is medicated frequently with morphine sulfate alternating between norco as ordered by the doctor. Follow your facility policy and procedures.

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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