490 CASE SCENARIO. CEREBRAL VASCULAR ACCIDENT. (CVA)

KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 75years old man.

Account number: Q00645743.

MR# Q0002299936.

Admitted date: 01/20/2010 @ 0520am.

Location: 5Northwest.

Room 52116.

Attending doctor: Miranda Lovingston.

Resuscitation status:Full Code.

Primary diagnosis CVA,left distal vetebral Stenosis. Secondary diagnosis dm,htn,hypothyroidism, IGT(Impaired Glucose Tolerance)

Weight 144lbs.

Height 5ft 5inches.

Procedures: CT scan of the head.

MRI of the head.CTA of head and neck.

Allergy : NKDA.

Diet: Cardiac heart health diet.Pureed diet, crush medications, feeder,no straws.Slurred Speech.

Right sided weakness. Right side is flaccid. Patient on room air.Reposition for comfort and pleasure redistribution.

GI/ GU: Incontinent of bowel and bladder.

IVF: D51/2ns at 80ml/hour.Accucheck Qac/Qhs.

Iv site patent intact clean. Rt Ac.

Hydralizine given for blood pressure of 170/90.

Plan: Discharge patient to SNF( SKILLED NURSING FACILITY) when medically stable. Need to follow up with Medical/Medicare.