519 CASE SCENARIO. LEFT GLUTEAL ABCESS.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 35years years old female.

Account number Q005634372.MR # Q00069593424.

Admitted date 8/17/2021@ 05am.

Status: Inpatient admission.

Attending doctor Tommy Holbib.

General surgery consult.

Neurosurgeon consult done.

Plastic surgeon consult.

Patient name Jollof Richland.

Location MedTelemetry.

Room 42110.

Resuscitation Status: Full Code.

Weight 285Ibs.

Height 5feet 5inches.

Alert and oriented x4

Primary diagnosis: Left Gluteal Abcess/ Necrotizing Fasciitis. Debridement of left gluteal done 08/18/2021 with dressing in place.

Secondary diagnosis: Hypertension/ Diabetes.

Isolation Status: Standard Precautions.

Risk for fall: No.

Suicidal risk: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet Carb Controlled cardiac diet.

02 @ 3liter NC.

Transportation method: Bed.

Allergy: NKDA.

Woundvac in place.

LR at 50ml/hour IV right forearm 20guage clean/dry/ Patent.

Medications:

Zosyn 3.375gm IV Q8hours.

Zofran 4mg IV Q4hours prn nausea / Vomiting.

Dilaudid 0.5mg IV Q3hours prn pain.

Norco 10/325mg 1tablet po Q4hours prn pain. Morphine sulfate 4mg IV Q4hours prn severe pain.

Norvasc Q4hours, 10mg po daily.

Hctz 12.5mg po daily.

Feso4 325mg po Qday.

Accucheck Qac/Qhs.

Laboratory tests in am.

CBC with differential, Bmp.

Plans:

Discharge to SNF with Zosyn 3.375gm and all current doctor orders. SNF charge nurse to call the doctor upon patient arrival to SNF.