KINGDOM OF GOD HOSPITAL , LOS ANGELES,CALIFORNIA 900000.
Age/Sex 59years female .
Account number Q002696922.
Admission date: 03/11/21@0130am.
Admission Status: Inpatient admission.
Attending doctor: Tumtum,Worry.
Patient name: Engwoma Johbaby.Resuscitation Status: Full Code .
Height : 5ft 2inches.
Isolation Status: Standard precautions. Primary diagnosis:Acute Hypoxic Respiratory failure.
Secondary diagnosis: Hypertension, HLD/DM,Schizophrenia disorder, Depression, anxiety, Sinus infection.
Is patient at risk for falls:Yes.Fall risk prevention protocols maintained.
Do you have advance Directive:No.
Copy of advance Directive on the chart.
Risk for suicide:no.Intubated and extubated.
02 @2liter NC.Saturation of 94%.
Alert and oriented x4. One person assistance. Ambulates to the bathroom with front wheel walker.
Monitor intake and output.
Saline lock left forearm 20guage,patent/clean/dry .
Diet: Cardiac Heart Health diet ( Mechanical Soft ground) Thin liquids. Okay for patient to use straw.
PT/ OT evaluation and treatment done.
K= 4. 0.
Septra 800mg po bid.
Azithromax 250mg IV Q24hours .
Rocephin 1gm IV Q24hours.
Prednisone 20mg po daily at 09am.
Plans: Discharge with Parameters.
Discharge home if patient is able to ambulate without assistant. CBC, BMP,ANCA,VASCULITIS LAB before discharge home.