510 CASE SCENARIO. ARTERIAL OCCLUSION RIGHT LOWER EXTREMITY/CHF.

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

Age/Sex: 53years.

Account number :Q005634333.

MR # : Q00098867543.

Admission date: 04/17/2021.

Status : Inpatient.

Attending doctor : Tommy Holbib.

Patient name :Isaac Apple.

Location : MedTelemetry.

Room # : 42114.

Resuscitation status: Full Code.

Weight :152lb.

Height: 5feet 6inches.

Primary diagnosis:Arterial Occlusion right lower Extremity.

Secondary diagnosis: Tabacco abuse, cocaine abuse, alcohol abuse,Hypertension,DM, high cholesterol,left foot ischemic due to embolic Occlusion.

Isolation Status: Standard Precautions.

Is patient at risk for falls: No.

Suicidal risk: Yes.Impaired skin intergrity:Yes.

Do patient have Copy of advance Directive?. No.

Copy of Advance Directive on the chart.

Diet: Carb Controlled cardiac health diet. Accucheck Qac/Qhs.

Transportation method: Bed.

02 at 4liters NC .

Suicidal risk: No.

Doctor orders: IR for Arteriogram infusion of TPA and Heparin per doctor orders during procedure. Possible amputation of toes .TPCO2?. Patient is alert and oriented x4,moves all extremities. Right lower Extremity elevated on pillows,SCD left lower Extremity. Hx of partial amputation of 2nd and 3rd right toes.

Plan:

discharge to SNF after normal WBC result.

Laboratory tests:

WBC : 14.8.

H/H: 13.6/43.0.

K: 4.3.

NA :140.

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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