RUN THE RED LIGHT AND T-BONE BY ANOTHER DRIVER.

THE KINGDOM OF GOD HOSPITAL LOS ANGELES ,CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.

Age/Sex 53years old man πŸ§“

Account number : Q005543291.

MR # Q0004556789.

Admitted date : 01/17/2021.

Status: Inpatient.

Attending doctor: Tommy Johnjus MD.

Patient name : Mr. Fearless Georgiatown.

Location : General Surgery.

Room: 62113.

Resuscitation Status: Full code.

Primary diagnosis Left ribs 5,6,7,8,9,and 10 Rib fracture, motor vehicle accident.

Secondary diagnosis: Hypertension, Fentanyl, Meth and Etoh abuse.

Isolation Status: Standard Precautions.

Allergy: NKDA.

Weight :185lbs.

Height: 5ft 7inches.

Risk for fall: No.

Suicidal risk: No.

Do you have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

Skin intergrity impaired: No.

02 @ 5liter NC with sat of 93- 95%.

Patient denied drug use but tested (+)for Opiate and BAC >0.08

Chest xray shows left hemothorax.

Check tube to wall suction 20cm.

Doctor: Nohate performed a VAT with rib plating with some nerve block but patient remains in a lot of pain and calls frequently for pain medications.

Oclussive dressing to the left chest intact.

Meditated as ordered with dilaudid 2mg iv for pain without relief. Norco 10/325mg 2tablets po given Q6hours prn pain with relief.

Zosyn 3.375gm IV Q8hours.

Ativan 0.5mg IV Q4hours prn anxiety.

Phenergan 12.5mg Im Q6hours prn Nausea and Vomiting.

0.9NS @ 50ml/hour iv right forearm 18guage saline lock Clean/Patent/Intact.

Voiding well using urinal at the bedside.

Good support system. Friend Michael and his wife.Phone number 609-000-0003.

Plans:

Discharge to Rehabilitation center in three days. Follow up with primary doctor in three weeks and Orthopedic doctor in ten 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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