KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.
Age/Sex 59years male .
Account number: Q009996645.
MR# : Q88009765233.
Location: General Surgery department. Room/bed 32116.
Attending doctor: Tumtum,Worry. Resuscitation status: Full code.
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.
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.
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.
Plans Discharge tomorrow to follow up with appointment in 4days.
Discharge teaching ongoing process.