KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.
INTERDISCIPLINARY KARDEX.
Age/Sex 69years female.
Account number : Q00009944868.
MR# :Q00888866467.
Date of admission: 01/20/21.@ 1900.
Attending doctor: Don’thate,Big.
Location: General surgery.
Room :30017.
Patient name: Watermelon, Micheline.
Code Status: Full Code.
Chief complaint: Right foot Diabetic wound that needs amputation.
Height: 5ft 2inches.
Weight:180lbs.
Primary diagnosis:Right foot diabetic ulcer/ infected wound.
Secondary diagnosis: HLD/DM/CVA/HTN.
Is patient at risk for falls:Yes.
Do you have advance: No.Copy of advance Directive on the chart.
Risk for suicide: No.
02 @ 4liter NC.
Allergy: NKDA.
Diet: Carb controlled diet. Consistency: Regular. Orthopedic consult: Doctor Saveme,Jonathan.
PT/ OT Consultation for evaluation and treatment.
Dressing with splint to right leg.
Alert and oriented x4. Right lower Extremity swollen. Elevated on pillows .
SCD to left lower Extremity.
Wound culture (+)Staphylococcus.
Laboratory tests.
WBC :13.2.
H/H=11.1/32%
Bun =22.
Creatinine =1.4.
Vancomycin through 18.7.
Blood sugar:176.
Medications: Norco 10/325mg po Q4hours prn pain.
Zofran 4mg IV Q4hours prn nausea/Vomiting. Purwick placed at 8pm.
Saline lock right AC 20guage,patent/clean/dry.
Nurses You Move Me 