KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000. INTERDISCIPLINARY KARDEX.
Age/Sex: 90years old female.
Account number: Q00263469.
MR# Q00046539687.
Admission date:07/12/21 @0545am.
Status: Inpatient.
Location: MedTelemetry. Room 42111.
Attending doctor: Don’thate,Big.
Resuscitation status:Full Code.
Allergy: NKDA.
Primary diagnosis: UTI/ DEMENTIA. (Brought in by son)
Secondary diagnosis :dm,htn,hypothyroidism, altered mental status,frequent falls.
Alert and oriented ×1.
Weight 102lbs.
Height: 5ft 0inch.
Diet : Cardiac heart health diet.
Incontinent of bowel and bladder.
Bladder scan Q6hours.
Bladder scan after incontinent.
Isolation Status: Standard precautions.
patient at risk for falls: yes.
Suicidal risk: No.
Do patient have advance Directive:No.Copy of advance Directive on the chart.
MRI of head revealed Enlarged middle cranial tossa.
Medications:
Rocephin 1gm IV Q24HOURS. ( UTI)
Flomax po Qday.
Decadron 4mg po Q6hours. (Dexamethasone)
Laboratory tests:
WBC: 6.9mm3.
H/H13.3/40.4%.
K=4.0mEqkcl.
Na=141mEqkcl.
Plan:
Discharge patient to Skilled Nursing Facility. CBC with differential in am.
Nurses You Move Me 