460 CASE SCENARIO. GI BLEED.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX

Age/Sex : 76years old man.

Account number :Q0096651665.

Status: Inpatient admission.

Admission date:05/21/21 0340am.

MR # Q8600660043044.

Attending doctor: Carmex,Dogins.

Location: MedicalMedical-Surgical floor.

Room 34009.

Primary diagnosis: GI bleed.

Secondary diagnosis:Diabetes mellitus, hypertension, Gout.

Weight: 170lbs.

Height : 5feet 8inches.

Is patient at risk for falls:Yes.

Fall precautions protocols in place.

Is patient at risk for suicide: No.

Do you have advance Directive No.

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

Impaired skin integrity:No.

Family support: Yes.Miss Miliki Ambubag.900-000-0000.

Isolation status: Standard precautions. Allergy:NKDA.

Diet : Carb control diet.

NPO after midnight.

EGD in am.

Patient is found unresponsive. H/H 5/15.4%

Consent signed for EGD in am.Patient prep for procedure in am.

Laboratory tests.

WBC 7.0.

H/H 8.6/26.6%.

NA: 138.

K ;4.0.

Right hand 0.9NS at 50ml/hour.

Ambulatory.

BM× 1 dark stool.

Accucheck Qac/Qhs.

Patient has been accepted at Kilimanjaro Skilled Nursing facility in Los Angeles, California 900000.Will be transferred when medically stable.