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.