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.

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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