467 CASE SCENARIO. LEFT FACIAL CELLULITIS DUE TO TOOTH EXTRACTION.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 59years male .

Account number: Q009996645.

MR# : Q88009765233.

Location: General Surgery department. Room/bed 32116.

Admitted: 01/12/21.@1640.

Status: Inpatient.

Attending doctor: Tumtum,Worry. Resuscitation status: Full code.

Weight:240lbs.

Height:6ft 2inches.

Chief Complain: left shoulder weakness, left neck redness and swelling.

Primary diagnosis: Left facial Cellulitis due to tooth extraction. (tooth removal)Incision and drainage with JP done today by doctor Smiley,Jacoboy ,DDS.

Secondary diagnosis:H Pyloric chronic renal failure, hip surgery, Hypertension, HLD/DM.

Isolation status: Standard Precautions.

Is patient at risk for fall: Yes. ( Language barriers)Interpreter at the bedside. Fall precautions protocol in place.

Medication reconciliation done.

Do patient have advance Directive:No.

Copy of advance Directive on the chart.

Suicidal risk: No.

Family Support: Daughter at his bedside:Mrs Elizabeth Successful.

Transportation: Bed.

02 @ 2liters NC.Saturation 93%.

Transferred from Coconut Hospital, Fresno California.

Tooth extraction was done 01/02/21 by doctor Draining, Peter.

Intraoral debridement by doctor: Badboy,James. DDS.Allergy: NKDA.

Diet: Carb controlled diet.Thin liquid. Consistency Regular. Glucerna 1can tid.( Chocolate or Vanilla.

Medications:

Zosyn 3.375gm IV Q8hrs.

LR @ 75ml/hour. Right Forearm clean/Dry/ Intact.

Clean mouth with hydrogen peroxide mouth swab after eating. No straws.

Discourage the use of straws.

Laboratory tests:

WBC:10.6.

H/H10.0/32.4%.

NA:140.

K:4.4.

Plans Discharge tomorrow to follow up with appointment in 4days.

Discharge teaching ongoing process.

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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