463 CASE SCENARIO. S/P LAP GASTRECTOMY (HX STOMACH TUMOR)

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex: 68years.

Account Number Q0096654455.

MR# :Q45665434098.

Attending doctor: Niceman,Tom.

Patient name: Mywood,Jennyblue.

Location : General Surgery.

Room #: 43222.

Primary diagnosis: Stomach tumor. S/P : LAP GASTRECTOMY.

Isolation status: Standard Precautions.

Is patient at high risk for falls: Yes.

Allergy: Eggs, Shell fish.

Diet : Clear liquid diet.

D5.45NS @ 50ml/hour left ac,Banana bag at 125ml/hour.

Abdominal dressing intact.

Voiding well after foley catheter is discontinued.

Ambulates to the bathroom.

Ambulated to the hallway ×2.

Norco 10/325mg po Q4hours (crushed mix with apple sauce)

Phenergan 12.5mg IV Q4hours prn nausea/Vomiting.

Case manager consulted. Discharge in am after doctors round.