481 CASE SCENARIO. RIGHT TMA.(S/P Right Transmetatarsal Amputation)

KINGDOM OF GOD HOSPITAL, LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

AGE/SEX: 39years old male.

Account #Q005667576.

MR# Q000334567892.

Admission Status: Inpatient.

Date of Admission: 01/09/21@0200.

Location : General Surgery.

Room: 62312.Attending doctor: Tumtum,Worry .

Name of Patient: Buhaman Wickin.

Resuscitation Status: Full Code.

Allergy: NKDA.

Primary Diagnosis: S/P Right Transmetatarsal Amputation (Due to poor wound healing. Wound culture +Staphylococcus)Dressing intact.Kerlex rolls with Cuban dressing intact. Elevated on two pillows.

Secondary Diagnosis: diabetes mellitus type 11,Hypertension, HLD.Groin redness.

Isolation Status: Contact Isolation (MRSA PRECAUTIONS).

Is patient at risk for falls: Yes.

Fall prevention protocols in place.

Do you have an advanceDirective: No.

Copy Advance Directive on the chart.

Risk for suicide: No.

Laboratory tests:

WBC: 12.9.

H/H9.3/30.8%.

K:3.7.(Replaced with 20mEqkcl po x1)

NA:140.

Medications:

Rocephin 1gm IV Q24hours. (MRSA gram negative)

Difflucan 200mg po daily. (Yeast urine and rash in groin)

Norco 10/325mg po Q6hours prn pain. Morphine Sulfate 2mg IV Q3hours prn pain. Tylenol 650mg po Q6hours prn temperature. Colace 100mg po Bid.

Accucheck Qac/Qhs.