Age/Sex 53years old man.

Account number Q005634372.

MR #Q00058867544.

Admission date 📅2021.

Status: Inpatient admit.

Location General Surgery.

Room 62112.

Attending doctor: Keehope Benjamin.

Patient name:Thompson Mystone.

Resuscitation Status: Full code.

Primary Cellulitis/ Dysphagia.

Secondary diagnosis: Hypertension. Recurrent ICP AVM.S/P Craniotomy No bone flap on the left.(intracranial pressure with A brain arteriovenus Malformation. )Hx of Stroke. Isolation Status: Standard Precautions.

Suicidal risk:No.

Is patient at risk for falls: yes.placed in a sitter room and fall Precautions protocols maintained.

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

Diet Cardiac heart health diet- Pureed.Feeder patient.

Liquid thickness:Nectar thick liquids.

Allergy: NKDA.

Weight :135lbs.

Height: 5feet 3inches.

Alert and oriented × 1.

Transportation: Bed.

Lung sounds diminished. 02 @2liter NC.

Impaired skin intergrity: Yes.

Language: Spanish speaking.

Debridement of left leg 🦵Cellulitis by the Podiatry : Doctor Buttermilk,Kent.

Infection disease doctor :Hussain, Babylon MD following patient.

Neurosurgeon on board,doctor Nguyen Godforbid.

Saline right Ac intact.

Incontinent of bowel ,condom catheter in place. Drained 400ml of clear yellow urine.

SCD to right lower Extremity.

Stage 1 pressure ulcer to the occyx areas,myperlex dressing change QOD. Restraint left hand ,right hand flaccid.

Mumble all the time and does not follow simple commands.


Seroquel 50mg Qam and Before bedtime.

Keppra 100mg IV Q8hours.

Lisinoprol 10mg po daily.

Hctz 12.5mg po daily.

Laboratory tests:

WBC 8.5.

H/H 12.0,37.2 %.

Na: 142.

K: 4.4mEqkcl.


Discharge to boarding Care in two days.

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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