KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.
Age/Sex 59years Male.
Account number Q00369694.
Admission date 03/13/21 0730am.
Status: Inpatient. Location: Med/Oncology 5Northwest.
Attending doctor: Tumtum,Worry.
Patient name: Pintos Garden.
Resusitation Status:Full Code.
Primary Diagnosis: Nonproductive cough x25days.
R/O TB,generalized pain especially in the joints and extremities.
Secondary diagnosis dm,htn,hypothyroidism, Rheumatoid arthritis.
Isolation Status: Airborne Isolation precautions. Suicidal risk: No.
Is patient at risk for falls: Yes.
Do you have advance Directive:No.
Copy of advance Directive on the chart.
Patient belonging list done.
Bilateral lower extremities:
Redness and swollen.
Chronic bilateral upper Extremity pain.
Plans:AFB × 3□,□,□.
Morphine sulfate 2mg IV Q3hours prn pain. Norco 10/325mg po Q6hours prn pain.
Saline lock 22guage,patent/clean/dry.Initial 02 of 3liters NC saturation of 99%.
D/C oxygen,encourage deep breathing. Room air with saturation of 94%.
Condom catheter in place,change everyday,+ prn.