THE KINGDOM OF GOD HOSPITAL LOS ANGELES ,CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.
Age/Sex 53years old man 🧓
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.
Nurses You Move Me 