520 CASE SCENARIO. FALL DUE TO DIZZINESS/ SYCOPE.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 77years old man.

Account number: V006543293.

MR # :V0006543268.

Admitted date: 06/24/2021@04am.

Status: Inpatient admission.

Attending doctor: Greenwood,Pancake. Location: General Surgery.

Room 62114.Resuscitation status: Full Code.Weight 158.Height 5feet 8inches.

Alert and oriented x4.

Primary diagnosis: Fall/Dizziness/ Sycope.Secondary diagnosis: Hypertension, CKD,Thyroidectomy. Thrombocytopenia resolved.

Isolation status: Standard Precautions.

Is patient at risk for fall: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet Cardiac heart health diet.

Assisted with feeding.

Room Air.

Transportation method: Bed.

0.9NS @ 75ml/hour right forearm 20guage clean/dry/Patent.

PT/ OT due to generalized weakness.

Uses urinal to void.

(+) Constipation,no Bm ×2 days.

Laboratory results:

WBC 6.5.

H/H :12.0,34.1.

Na: 134.

K: 4.0.

Cr : 1.35.

AST: 295.

ALT : 288.

TAP:468.

Discharge plans :

Discharge to SNF with 24/7 care or Discharge home per patient family request if family can give patient 24/7 care at home.