516 CASE SCENARIO. ABDOMINAL PAIN/ELEVATED ENZYMES.

KINGDOM OF GOD HOSPITAL LOS ANGELES, CALIFORNIA 900000.

INTERDISCIPLINARY KARDEX.

Age/Sex : 69years Female.

Account number : Q005624311.

MR # :Q0005883750.

Admission date : 09/17/2021.

Status : Inpatient admit.

Location : MedTelemetry.

Room # : 42114.

Attending doctor: Tommy Holbib.

Patient name: Cute Isaac.

Resuscitation Status :Full code.

Primary diagnosis : Abdominal pain/Elevated Enzymes .

Secondary diagnosis:Left breast mastectomy 2014.Bilary Sphincteotmy.( Cutting of anal sphincter .Which is group of muscles connected to the rectum at the end of the digestive tract)Ballon removal of CBDS.

Allergy : NKDA.

Weight :135LBS.

Height : 5Feet 6inches.

Diet: NPO.

Laparoscopic Cholecystectomy at 4pm by dotor Bitche Omo MD.

Alert and oriented x4.

Constipation. Bowel movement 2 days ago.

Skin intact .

Isolation Status : Standard Precautions.

Risk for fall: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.Suicidal risk: No.

Transportation: Wheelchair.

Activity as tolerated.

Ambulates to the bathroom with steady gait.

Consent signed on the chart.

Laboratory results:

WBC 11.5H.

H/H : 14.0,42.5.

K: 3.7.

Na : 140.

Elevated Enzymes AST resolved.

Medications:

Dilaudid0.5mg IVQ3hours prn pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Colace 200mg po Bid.

Rocephin 1gm IV Q24hours.

D545NS @75ml/hour.

Saline lock right forearm 20guage clean/Patent/Dry.

Norco 10/325mg 1tablet po Q6hours prn pain with sips of water while npo.

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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