KINGDOM OF GOD HOSPITAL, LOS ANGELES,CA 900000.
Age/Sex 59years Female.
Account number Q00069696.
Status: Inpatient admission.
Attending doctor: Tumtum,Worry.
Resuscitation status: Full code.
Primary diagnosis: SBO.
Secondary diagnosis: Anxiety/ Lupus/ DM,HTN,HYPOTHYROIDISM/ Irritable bowel syndrome.
Isolation Status :Standard Precautions.
Is patient at risk for fall.No.
Do patient have advance Directive:No.
Copy of advance Directive on the chart.
High risk for suicide: No.
Room Air ,02 saturation of 94%.
NPO× Ice chips.
Surgical intervention today @ 1800 .
Consent signed.Exploratory laparotomy possible bowel resection by doctor: Forgetmenot,Jenije MD.
No bowel movements.
Abdominal Xray done today.
NGT to left nare.
Ngt to low continuous suction with dark green drainage. Emptied 400ml.
Flush ngt with 20ml of water Qshift.
Laboratory in am:
Cbc with differential,BMP,MG.
LR at 125ML/Hour left forearm 20guage,patent/clean/dry.
Morphine sulfate 2mg IV Q3hours prn pain. Dilaudid 0.5mg IV Q4hours prn pain.
Zofran 4mg IV Q4hours prn nausea/Vomiting.