KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.
Age/sex 35years male.
Account number: Q001665897.
MR : Q00049593429.
Admitted date: 03/15/21@09am.
Status: Inpatient admit.
Location : MedTelemetry.
Resuscitation Status: Full code.
Primary diagnosis: polysubstance and Etoh abuse/AKI/Rhabdomylosis.
Secondary diagnosis:Altered mental status/ Hypertension. (Patient is found down due to altered mental status 911 called ,picked up by Premiere 🚑 ambulance, very restless and confused Narcan given,Ativan given)
Isolation Status : Standard Precautions.
Is patient at risk for fall: Yes.Fall prevention protocol implemented.
Do you have advance Directive: No.
Copy of advance Directive on the chart.
Diet Cardiac heart health diet.
Pulling out IVs,and wandering around while in Emergency room.
Bilateral soft wrist restraint applied to both arms.
Patient on CIWA Protocol Assessment Q4hours. Alert and oriented × 3.
Transfered to Medical/ Surgical floor.
0.9NS @ 150ml/hour right Ac.0.9NS 2liter bolus in ED.
Vancomycin 1gm IV Q12hours.
Rocephin 1gm IV Q24Hours.
Bruise bilateral upper and lower extremities.
K level low = 3.6 will not replace. (Due to AKI)
Magnesium 1.8 replaced.
Patient will be discharged home with parameters when medically stable.
Head CT scan(-),CXRAY (-) Trop(+) WBC 16.5,Lactic acid 4.8,2D ECHO : Ejection fraction:45%.