493 CASE SCENARIO, FALL STENOSIS/ CERVICAL CORD CONTUSION/ COMPRESSION.

KINGDOM OF GOD HOSPITAL LOS ANGELES,CA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 65years old man.

Alert and oriented x3,slow speech.

Account number :Q00769932.

MR # Q00066043775.

Admission date: 04/15/21@04am.

Status Inpatient.

Location MedTelemetry.

Room 42117.

Attending doctor: Tumtum,Worry.

Patient name:Ogiligbo Alex.

Resuscitation status: Full Code.

Isolation Status: Standard precautions.

Primary diagnosis: S/P Cervical laminectomy posterior. ( Fall: C6- 7,Stenosis,Cervical cord contusion/ Compression.

Secondary diagnosis dm,htn,hypothyroidism,drug abuse.Chronic weakness, bilateral lower extremities weakness, strength 4/5.

History of frequent falls. On falls prevention protocols.

Transportation: bed.

02@4liter NC.

Allergy : NKDA .

Doctor orders:

Physical therapist/ Occupational therapist for evacuation and treatment.

Aspen collar at all times .(C6-7 ) C spine precautions.

Discharge to SNF when medically stable.

Foley catheter in place for urinary retention.

Dressing to back of the neck.

Change dressing Qday and prn.

Diet Cab control Cardiac health diet. Do patient have advance Directive:No.Copy of advance Directive on the chart. Suicidal risk: No.

Medications:

Lovenox 40mg SubQ Q24hours.

Keppra 1000mg po Bid x7days.

Decadron 4mg po Q6hours.

Lyrica 75mg po Bid.

Norco 5mg 1 to 2 tablets po Q6hours prn pain.

Accucheck Qac/Qhs. Laboratory tests:

WBC:10.0.

H/H10.3/31.8%.

K=3.9,NA=140.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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