KINGDOM OF GOD HOSPITAL
LOS ANGELES ,CALIFORNIA 900000.
Age/Sex 60years old female.
Account number: Q001336343.
Admision date 08/23/21 @ 0450am.
Location MedTelemetry.Room : 42113.
Attending doctor: Tomtom Worry. Resuscitation Status :Full code.
Primary diagnosis SBO.
Secondary diagnosis: Hypertension.
Isolation Status: Standard Precautions.
Is patient at risk for fall: No.
Do you have advance Directive: No.
Copy of advance Directive on the chart.
Patient belongings: Done.
Skin intergrity impaired: No.
Transportation method: Bed.
Room air with saturation of 97%.
NPO × Ice chips.
Ngt to low wall suction.
D5ns @ 150ml/hour left forearm 18guage clean/dry/ patent .
Morphine sulfate 2mg IV Q3hours prn pain. Zofran 4mg IV Q4hours prn nausea/Vomiting. Encourage ambulation.
Ngt to decompress the stomach.
Incentive Spirometry Q1hour while awake. Surgery consult. Surgery team to follow up. Zosyn 3.375gm IV Q8hours.
CBC with differential, Chem 7 in am.
Strict documentation of intact and output. Laboratory tests:
H/H 16.0 44.2%.