457 CASE SCENARIO. LEFT KNEE PATELLA FRACTURE. S/P ORIF OF LEFT PATELLA.

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

Age/Sex 76years female.

Account # Q866660043.

MR#Q000656597802.

Status: Inpatient admission.

Admission date:04/21/21.

Location : 4Center.

Room number :456505.

Attending doctor: Tumtum,Worry.

Code status: Full code. Primary diagnosis Left Patella fracture.

S/P ORIF of left patella by doctor Smiling Mann.Ace wrapped to left knee with Left knee IMMOBILER in place.

Secondary diagnosis: Hypertension, Hyperlipidemia,cataract removal 3years ago.

Allergy: NKDA.

Weight =108lbs.

Height=4ft 11inches.

Diet: Cardiac heart Health diet.

Medications:

Labotelol 5mg given IV x1.

Hydralizine 5mg ×1 IV .

Blood pressure 198/101.Hr 89,Respiration 14,02 saturation 91% on Room air. 02 at 2liters NC saturation of 93 to 94%.

Ancef 1gm IV given in OR.

Pneumonia and flu vaccine given.

Morphine sulfate 4mg IV Q4hours prn severe pain.

Dilaudid 0.5mg IV Q3hours prn severe pain.

Norco 10/325mg po Q4hours prn mild to moderate pain. Decadron cocktail given in OR.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Plans:

Physical therapy consult ordered for evaluation and treatment.

Case manager and Social worker consult for discharge planning.

Nutrition consult for nutritional guidelines. Doctor ordered patient to stop smoking.

Lives at home with daughter in a single story house.

BP =145/78 .

Hr =78.

Respiration = 18 .

02 .sat on Room air 94%.

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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