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.
Nurses You Move Me 