469 CASE SCENARIO. MULTIPLE LOWER EXTREMITIES FRACTURES.

KINGDOM OF GOD HOSPITAL, LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex Age/Sex 28years old Male.

Account number Q00093299.

MR# Q64450006654.

Admitted 04/12/2105pm.

Status: Inpatient admission.

Location: Trauma Department.

Room 60021.

RESUSCITATION STATUS :Full code. Primary diagnosis:Motor vehicle accident.Fell asleep and hit the tree/ Bilateral acetabular fractures, facial laceration.

Isolation Precautions: Standard Precautions.

Is patient at risk for falls: Yes. Star falling, yellow signs in place.Yellow gown and yellow ID.

02 @2liter NC. Saturation of 94%.

Do patient have advance Directive:No. Copy of advance Directive on the chart.

Allergy: NKDA.

Operating Room:Facial fracture surgery today. ORIF Right ankle 04/01/21..Splint with IMMOBILER in place.

High income.Not quality for support.

NPO × MEDICATION.

Facial stitches removed. Right zygomatic complex fracture repaired .

Voiding well using the urinal.

Bowel movement ×2 today.

External fixation right leg.

Laboratory tests:

WBC:12.2.

H/H9.4/28%.

K:4.2.

NA 137.

Medications:

Merrem 1mg IV Q8hrs.

Vancomycin 1gm IV Q12hours.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 10/325mg po Q4hours prn pain.

Flexeril 5mg po Q8hours prn muscle spasms. 0.9NS @ 125ML/Hour.

Urinal at the bedside.

Plans:

Discharge to Acute Rehabilitation when stable.