494 CASE SCENARIO. PERIRECTAL ABCESS.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/ Sex:48years old man 👴

Account : Q00969388.

MR# Q000999326673.

Adminssion 06📅2021.

Status: Observation.

Location :General Surgery.

Room: 62114.

Attending doctor: Keehope,Johnson MD.

Patient name: Guysin Harry.

Allergy: NKDA.

Resuscitation Status: Full code.

Primary diagnosis:Abcess poterior Buttocks. (Worsening pain in the rectal region)

Secondary diagnosis:Hypertension, hld,diabetes.

Isolation Status: Standard Precautions.

Risk for fall: No.

Suicida l risk: No .

Do patient have advance Directive:No.Copy of advance Directive on the chart.

Diet :Carb Controlled cardiac diet.

Doctor orders.

NPO after MN.

Zosyn 3.375gm IV Q8hours.

Flagy 100mg IVQ8hours.

Rocephin 1gm IV Q24hours.

Surgery in Am.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 10/325mg po prn Q4hours.

0.9NS @75ML/HR Left forearm.

Ambulates 3times per shift. Accucheck Qac/Qhs. Room air.