495 CASE SCENARIO. HOMELESS, FREQUENT FLYER TO THE EMERGENCY ROOM WITH ALCOHOL ABUSE 🍸AND SEIZURE DISORDER.

KINGDOM OF GOD HOSPITAL 🏥LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex 53years old man.

Account number: Q00696313.

MR# Q0006969452.

Admitted date 01/13/21@0540am.

Status : Inpatient.

Location :General Surgery.

Room 62114.

Attending doctor :Tommy Holbib.

Patient name:Badboy James.

Resuscitation Status: Full code.

Primary diagnosis Seizure disorder/ Fall ,grade 11 splenic laceration. Rib fracture, clavicle fracture.

Secondary diagnosis: Hypertension, Etoh abuse. Height: 6ft 4inches.

Weight: 160lbs.

Alert and oriented ×3.

Isolation Status: Contact +MRSA NARES.

Allergy: NKDA.

Is patient at risk for fall: yes.

Suicidal risk: No.

Patient belongings list: Done.

Do patient have advance Directive: No

Copy of advance Directive on the chart.

Diet Cardiac health diet.

Doctor orders: Orthopedic consult.

2liter of 0.9NS bolus,then 0.9NS @50ml/hour.

02 @ 2liter NC.

Pelvic xray negative,cxray negative.

Abdominal CT scan splenic laceration.

Enlarged fatty liver,possible liver cirrhosis. Shoulder Xray shows nondisplaced bilateral clavicle.

Transportation method: By wheelchair.

Medications: Tylenol 650mg po Prn Q4hours.

0.9NS at 50ml/hour.

Norco 10/325mg po prn Q4hours.

Morphine sulfate 2mg Q8hours prn pain .

Ativan 2mg IV Q8hours seizures.

Flagy 500mg IV Q8hours.

Laboratory tests:

WBC 6.8.

H/H: 12.0/ 34.0.

Na: 140.

K 3.9.

Trop 0.9

Lactic acid 1.8.

Bun 18.

Creatinine 1.0.

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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