KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX.
Age/Sex 35years male.
Account number V006543294.MR #Q00058867522.
Admission date 01/12/2021.
Status: Inpatient admit.
Location MedTelemetry.
Room 42110.
Attending doctor: Tommy Holbib.
Patient name: Mangala,Greengrass.
Resuscitation: Full Code.
Transportation: Bed.
Weight 152.
Height: 5feet 6inches.
Allergy: NKDA .
Primary diagnosis MVA/ Intraparencymal hemorrhage, L3 fracture. Jewett brace in place.
Secondary diagnosis: Dizziness, Head laceration with sutures intact OTA(Open to Air)Bruises bilateral bruises to thigh and abdomen. Spinal Precautions.
Risk for fall : Yes.
Do you have an advance Directive NO.
Copy of advance Directive on the chart. Suicidal risk: No.
Isolation status: Standard Precautions.
NPO after midnight except medications Surgery for OMF in am.Consent signed in the chart.
D545NS with 20meqkcl at 100ml/hour left forearm 20guage clean/dry/intact/Patent. Cefazolin 1gm IV Q8hours.
Protonix 40mg po amac.Morphine Sulfate 2mg IV Q3hours prn pain.
Hydrocodone 10/325mg 1tablet po Q4hours prn mild pain.
Hydrocodone 10/325mg 2tablets po Q4hours prn severe pain.
Colace 200mg po Bid/scheduled.
Dilantin 100mg po TID/scheduled.
Normal saline 10ml flush Q8hours.
Plans: Discharged home with all belongings and medications. Follow up with your doctor in two weeks.
Nurses You Move Me 