Age/Sex 45years male.

Acount number: Q002101364.

MR# : Q000558215476.

Admitted: 02/13/21 @ 0450am.

Location: MedTelemetry.

Room 42120.

Attending doctor: Tomtom Worry,MD. Resuscitation Status Full code.

Isolation Status: Standard Precautions.

Suicidal risk:No.

Risk for fall:No.

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

Diet Carb Controlled cardiac diet.

Alert and oriented ×4.

Patient belongings at his bedside.

Primary diagnosis :Left hand Cellulitis.+ Blisters.( Etiology of wound Bug bite developed Cellulitis.Sharp debridement done 02/13/21 @1pm.)Cellulitis will appear as red,swollen and painful.It is caused by different types of bacterial. It is warm and tender to touch.Cellulites can appear in any part of the body but this Cellulitis is in the left hand.Some people can develop fever and chill due to Cellulitis. Antibiotics is usually given intravenously to eradicate that bacteria. Some Cellulitis will lead to open wound which must be addressed. Dressing change done as ordered by the doctor or the wound care team.

Secondary diagnosis: Hypertension, DM, infection. Gram+ infection left hand wound. Doctor orders:

Amolodipine 10mg po daily.

Hctz 12.5mg po daily.

Dressing change. Irrigate with saline .

Apply Bactroban adaptive, guaze and band net.Goal is a complete wound healing. Infection control doctor on Board -doctor Vancuva,Micha, MD.

Vancomycin 1gm IV Q12hours.

Zosyn 3.375gm IV Q8hours.

Lovenox 30mg SubQ 09am.

Norco 10/325mg po prn Q4hours pain. Morphine sulfate 4mg IV Q4hours.


0.9NS @ 50ml/hour right forearm 18guage clean/dry/patent.

Laboratory tests:

WBC 10.5.

H/H 12.9,38.3.

Na 138.

K: 4.0mEqkcl.

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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