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.

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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