KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.
INTERDISCIPLINARY KARDEX.
Age/Sex 92years old male.
Account number Q002696229.
MR#Q00004335697.
Admitted 05/23/21 @02am.
Status: Inpatient admission.
Location: General Surgery department. Room:62014.
Attending doctor: Tumtum,Worry.
Patient name: Paulinus Firewood.
Resuscitation status: Full Code.
Weight: 150lbs.
Height:5feet 6inches.
Allergy: NKDA.
Primary diagnosis: Intractable nausea/Vomiting/ Fainting.
Secondary diagnosis:Prostate cancer 2009,HTN,CVA,HTN,HYPOTHYROIDISM, COPD,ASTHMA, CKD.
Alert and Oriented ×2.Dementia.
Isolation Status: Standard Precautions.
Is patient at risk for falls: Yes( Age/language/Dementia)
Do patient have advance Directive: No .
Copy of advance Directive on the chart.
Risk for Suicide: No.
02 at 2liters NC. Respiration:rales,rhonchi,coughing out blood, refused CPAP machine.
Doctor aware.
Left pacemaker.Abdomen distended.
Voiding frequently 100ml amber colored urine. Patient is very weak,reposition frequently. Redness to his buttocks. Nonblanchable. Laboratory tests:
WBC= 5.9.
H/H=11.3/33.8%.
K=3.9.
NA=136.
Bun=19.
Medications:
Levaquin 500mg IV Q24hours.
Norco 10/325mg po Q4hours prn.(crush medication and mix with apple sauce.)
Right sided weakness.
Right wrist saline lock.
Diet: Cardiac Heart Health diet.
Nectar thicken liquid. Ensure Bid.
Family member: Johnsone Firewood.
Phone number 555-555-5555.
Patient belongings taken home by his son.Plan: Discharge home with God Choice Home Health Services.
Nurses You Move Me 