INCISION AND DRAINAGE RIGHT HEEL.(DEBRIDEMENT)

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex: 35years male.

Account number: Q006543299.

MR # Q0006184002.

Admission date: 09/17/2021.

Status Inpatient.

Location :MedTelemetry.

Room : 42114.

Attending doctor: Tommy Goldman.

Allergy: PCN.

Weight : 190lbs.

Height : 5feet 7inches.

Primary diagnosis : S/P I& D debridement right heel.

Secondary diagnosis:Hypertension, hx car accident.

Diet : Cardiac heart health diet.

Saline lock left forearm. C/D/Intact

SCD : Bilateral lower extremities.

Woundvac to right heel.

Woundvac dressing change Monday, Wednesday and Friday.

Medications: zosyn 3.375gm IV Q8hours.

Morphine sulfate 2mg IV Q4hours mild pain prn.

Morphine sulfate 4mg IV Q4hours severe pain prn.

Give hydrocodone 10/325mg 1tablet Q6hours prn moderate pain.

Hydrocodone 10/325mg 2tablets po Q6hours prn severe pain.

Give hydrocodone in between the Morphine sulfate.

Colace 200mg po Bid.

Nicotine patch 14mg topical daily.

Hctz 12.5mg po daily.

Laboratory tests CBC with differential, Comprehensive Metabolic panel, PT/ PTT in am.

Call the doctor within 30minutes of any critical laboratory results.

Plans for discharge.

Discharge home with wife 2days if medically stable.

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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