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.
Nurses You Move Me 