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.
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.
Cr : 1.35.
ALT : 288.
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.