KINGDOM OF GOD HOSPITAL LOS ANGELES,CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex: 64years female.
Admission date:03/21/21 @0430am.
Status : Inpatient admission.
Account Number: Q00269542.
MR # Q0006999328.
Attending doctor: Tumtum,Worry.
Patient name: Monica Woodutter.
Primary diagnosis: S/P Spinal Fusion by neurosurgery doctor Exceptional Tional MD. ( Ground level fall. Fell at home on 03/21/21@ 0230am)Posterior dressing intact/ dry and clean.
Secondary doctor: Htn,dm,hypothyroidism. Isolation Status: Standard precautions.
Is patient at risk for falls: yes.
Do patient have advance Directive:No.
Copy of advance Directive on the chart. Suicidal risk: No.
Room air.Cough and deep breathe.
Incentive Spirometry every 1hour while awake
Physical therapy for evaluation and treatment. Transfer to Skilled Nursing Facility rehabilitation when medically stable.
Diet: Carb controlled cardiac health Mechanical Soft diet.
Follow up with Neurosurgery in 2- 3 weeks. Follow up with her Primary Care Physician in 12 weeks. CBC with differential, LFT ,Chem 7 in laboratory tests: WBC: 6.9.
Medications: Norco 5/325mg 2tablets po Q6hours prn pain.
Tylenol 650mg po prn temperature.
Dilaudid 0.5mg IV Q3hours prn pain. Morphine sulfate 4mg IV Q4hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Hydrochlothyzide 25mg po Qday.
Colace 100mg po Qday.
Zosyn 3.375gm IV Q8hrs.
0.9NS @ 75ml/hour right hand patent ,clean and dry.