453 CASE SCENARIO. UTI,RETRACTABLE NAUSEA/VOMITING.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 90000.

INTERDISCIPLINARY KARDEX.

Age/ Sex : 38years old female.

Admission date: 02/21/21 0340am.

Account number : Q009665437.

MR# Q56660004443.

Name of patient: Mymistake Monistat.

Attending doctor: Tumtum,Worry.

Location: Medical Surgical floor.

Room :356003.

Primary diagnosis: UTI,Retractable nausea/Vomiting.

Secondary diagnosis: Diabetes, UTI,Migraine.

Code Status: full code.

Patient belongings Checklist done.

Isolation Status:Standard precautions.

Do patient have advanced Directive: No.

Copy of advanced Directive on the chart. Transportation: Bed.

Allergy: Ciprofloxacin, Levothyroxine, Levaquin, Sulfamethoxazole.

Diet:Renal diet. (No Dialysis)

On Hemodialysis =90g protein,3g Na,3g k,1g Phosphorus.

No Dialysis =60g protein,2g Na, 2g K,1g phosphorus.

Medications:

Morphine sulfate 2mg IV Q3hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Phenergan 12.5mg IV Q4hours prn nausea/Vomiting.

Benadryl 25mg po Q6hours prn itching.

Zosyn 3.375gm IV Q8hrs.

0.9NS @ 50ml/hour.

Laboratory tests:

WBC 10.2.

H/H 8.9/28.0%.

K =4.4.

NA:138.

Plans:

Patient to be discharged home in two days. Discharge plans started upon admission. Patient lives with husband and four children. Patient will follow up with her primary care physician in two weeks.

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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