478 RETENTION OF RING TO THE RIGHT MIDDLE FINGER FOR 28DAYS.

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

Age/Sex 52years old Female.

Account number: Q009665445.

MR # Q00666004305.

Location: General Surgery.

Room 62117.

Attending doctor: Don’thate,Big.

Patient name: Dennis Stubbon.

Primary diagnosis: Retention of RING to right middle finger ×28days.

Incisision and Drainage and excision of ring by the Plastic Surgeon doctor Dumpty,Mildred. Parenthesis to the finger.Evaluation of perfusion of fingers.Perfusion intact.

Alert and oriented x4.

Allergy: NKDA .

Full Code.Weight :128lbs.

Height: 5feet,8inches.

Isolation Status: Standard Precautions.

Room Air: 97%.

Diet: Regular diet.

Ambulates to the bathroom and hallway. Laboratory tests:

WBC: 6.9.

H/H: 10.3/33.0%.

K:4.2.

NA: 138.

Lactic acid: 1.0.

Plan:

Discharge patient to homeless Shelter by 10am.Case manager/ Social worker made arrangement.

Patient referred Senior Girls Homeless Shelter, East Los ANGELES,CA 900000(Bus pass given)

Laboratory tests:

WBC:10.9.

H/H:12.8/38.8.

K=3.8.

NA: 142.

Mag: 2.0.

Discharge Medications:

Norco 5/325mg 1to 2 tablets po Q6hours prn pain.

Keflex 250mg po Q6hours ×7days.

Dry dressing change as ordered daily.

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.

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