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.

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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