473 CASE SCENARIO. FELL AT HOME/ UROSEPSIS.

KINGDOM OF GOD HOSPITAL ,LOS ANGELES,CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.

Age/Sex 69years.Female.

Account number: Q004388939.

MR# :Q00087563498.

Date of admission:02/20/21 @0320am.

Status: Inpatient admission.

location: MedTelemetry.

Room 42113.

Allergy: PCN.

Weight : 160lbs.

Height :5ft 4inches.

Primary diagnosis: Fall, Urosepsis.

Secondary diagnosis : Osteoarthritis/DM,HTN,HYPOTHYROIDISM/Depression.

Isolation status: Standard precautions.

Is patient at risk for falls:Yes.

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

Is patient at risk for Suicide: No.

Skin integrity: No.

Transportation : Stretch.

MRI done (-)CT Scan done(-)

Lumbar puncture done.Diet: Cardiac Heart Health diet.Glucerna shake 1can TID.

Encough patient to try to eat more. Standby assisst.

D545NS c 20mEqkcl at 75ml/hour.

(+) Bowel movement. Voiding well.

Laboratory tests: WBC:11.9.

H/H:10.3/32.0%.

K=4.3.

NA=142 .

Medications:

Rocephin 1gm IV Q24hours.

Zosyn 3.375gm IV Q8hrs.

Vancomycin 1mg IV Q24hours.

Norco 10/325mg po Q4hours prn pain.

Zofran 4mg po Q4hours. Zofran 4mg IV Q4hours prn nausea/Vomiting.

Plans:

Discharge to: Calm and Beautiful Behavioral Health facility, Los Angeles California 900000.