483 CASE SCENARIO. NONPRODUCTIVE COUGH ×25DAYS.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 59years Male.

Account number Q00369694.

MR#Q0005458769.

Admission date 03/13/21 0730am.

Status: Inpatient. Location: Med/Oncology 5Northwest.

Room 43211.

Attending doctor: Tumtum,Worry.

Patient name: Pintos Garden.

Resusitation Status:Full Code.

Allergy: NKDA.

Height:5ft 8inches.

Weight :166lbs.

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.

Non-ambulatory patient.

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.