474 CASE SCENARIO.RIGHT FALL/HUMERUS FRACTURE .

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.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: