514 CASE SCENARIO. LEFT LOWER EXTREMITY CELLULITIS.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex : 34years Female.

Account number : Q005634374.

MR # : Q00058867522.

Admission date : 09/22/2021.

Status: Inpatient admit.

Location : General Surgery.

Room : 62113.

Attending doctor : Tommy Holbib.

Patient name : Isaac,Jenniferi.

Resuscitation: Full code.

Primary diagnosis: Left leg Cellulitis. Secondary diagnosis: Sunburn left calf.(Cellulitis is a common skin infection caused by bacteria)

Back of leg pain/ redness/ warmth/ swelling.

Whipping left leg.

Weight : 170lbs.

Height: 5feet 6inches.

Isolation Status: Standard Precautions.

Is patient at risk for fall: No.

Suicidal risk: No .

Impaired skin intergrity: Yes.

Language barrier: English.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

Allergy: NKDA.

Doctor orders: Vancomycin loading dose 1.5gram x1 now.

Blood culture ×3 before antibiotics stat.

Vancomycin 1gm IV Q8hours × 7days.

0.9NS @ 50ml/hour IV, Right forearm 20guage clean/Patent/Intact.

Norco 1 tablets 5/325mg po prn Q4hours moderate .

Norco 5/325mg 2tablets po Q6hours prn pain.

Colace 200mg po Bid.

Dry dressing change Q8hours and prn.

Morphine 2mg IV Q6hour prn severe pain. Laboratory tests @ 05am.

Laboratory Results:

WBC 8.5.

H/H 11.1/36.0.

NA= 140.

K=4.1.

Discharge plan:

Discharge to SNF with Zosyn 3.375gm IV Q8hours.