513 CASE SCENARIO.MVA ,RIGHT FRONTAL INTRAPARENCYMAL HEMORRHAGE,L3 FRACTURE.

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.

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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