KINGDOM OF GOD HOSPITAL, LOS ANGELES, CALIFORNIA 900000.
INTERDISCIPLINARY KARDEX. Age/Sex: 74years old female.
Account number :Q00499924.
MR # Q000659936.
Admission date: 03/22/21.
Status: Inpatient.
Location: Med/Oncology.
Room:42113.
Allergy: NKDA.
Attending doctor: Tumtum,Worry.
Patient name: Mrs Popcornse Genesis.
Resuscitation Status: Full code.
Primary diagnosis: Fall/Right Humerus fracture.
Secondary diagnosis: chronic afib,dm,htn,hypothyroidism ,gerd,gastritis.
Weight:260lbs.
Height: 5feet 4inches.
Isolation Status:Standard precautions. Transportation: Bed.
Is patient at risk for falls: No.
Do you have advance Directive:No. Copy placed on the chart .
Fell while drinking.
Alert and oriented x4.
Humidify 02 @2liter nc.
Diet: Carb controlled Cardiac diet .
Consultation:Orthopedic consult. Black eyes/ nose due to bruises from fall.Drank.
BAC level =0.16 % ( normal BAC level is 0.08%)
Laboratory tests:
WBC:12.9.
H/H11.3/35.8%.
K=3.9.
NA=139.
Medications :
Catapress 0.1mg po daily ( On hold)Low blood pressure 89/56,Pulse 64,Respiration 20.
02 saturation 95% with 2liter with humifier NC.
Dilaudid 0.5mg IV Q3hours prn pain.
Norco 10/325mg po Q4hours prn pain.
Zofran 4mg IV prn nausea/Vomiting.
Zosyn 3.375gm IV Q8hrs.
Merrem 1gm IV Q8hours.
Plans:
Doctor Saveme,Jonathan want to discharge patient home with home health services. Splint applied to right Humerus fracture.
Nurses You Move Me 