517 CASE SCENARIO. PANCREATITIS/LIVER MASS.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex:50years old Female.

Account number Q005634372.MR #Q00058867544.

Admission date 08/13/2021.

Location MedTelemetry.

Room 42112.

Attending doctor Tommy Holbib.

Patient name :Milikan Pauline Chinne.

Primary Diagnosis: Pancreatitis, Liver Mass.

Secondary diagnosis: Seizure disorder, Nicotine addiction, Thyroid disorder,Diabetes type 11.

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 Method: Bed.

02 at 2liter NC with Saturation.

Allergy: Codeine, Dust.

Saline lock left hand.Clean/ Dry/ Intact.

Diet: Carb Controlled cardiac health diet.

SCD: bilateral lower Extremity.

MRI/ MRCP of the abdomen ■.

Doctor orders:

Nicotine 21mg Daily/ scheduled @09am

Levetiracetam po 500mg Bid/scheduled. @09am,2100.

Thiamine Hcl 100mg po Daily/ Scheduled @09am.

0.9NS @ 75ML/HOUR.

Multivitamin po Daily/Scheduled @09am. Folic acid 400mcg po Daily @ 09am.

Pantoprazole IVP 40mg AMAC/ Scheduled 0630am. (Protonix iv may dilute in 10ml sodium chloride and give atleast 2minutes IVP)

Morphine IVP 2mg IV Q6hour prn pain.

Acetaminophen po 650mg Q4hours Prn Pain/ Temperature.( Do not exceed 4000mg in 24hours)

Temazepam po 30mg HS/Scheduled @ 2100.

Accucheck Qac/Qhs.

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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