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.

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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