525 CASE SCENARIO. CHOLECYSTITIS.

Cholecystitis is an inflammation of the gallbladder which can be acute or chronic. It is caused by the gallstone inability to pass through Cystic duct.You will feel pain in the right upper quadrant of the abdomen.Most patients complain of lots of pain.

Follow doctor orders.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX.

Age/ Sex : 53years old man.

Account number: Q005634372.

MR #: Q00058867564.

Admission date : 06/23/2021 @03am.

Status: Inpatient admission.

Attending doctor: Tommy Holbib.

Patient name: David Water.

Location:MedTelemetry.

Room: 42114.

Resuscitation status: Full Code.

Weight : 152.

Height : 5feet 6inches.

Allergy: NKDA.

Alert and Oriented x4.

Vital signs stable:

Bp 123/86.

Hr 67.

Respiration 18.

02 Saturation 97% RA.

Risk for falls: No

Skin intergrity impaired: No.

Suicidal risk: No.

Do you have advance Directive: No.

Copy of advance Directive on the chart.

Diet NPO.

Doctor orders:

Ultrasound of the gallbladder.

Rocephin 1gm IV Q24hours.

Zosyn 3.375gm IV Q8hours.

D545NS @ 75ml/hour right forearm 20guage clean/Patent/Intact.

Norco 1tablet po Q4hours prn pain.

Tylenol 650mg po Q4hours prn temperature. Laboratory results :

WBC 11.5.

H/H 12.0,37.2.

K:4.0mEqkcl.

NA: 140.

Mag:1.8.

Laboratory tests:

CBC with differential, Comprehensive Metabolic panel in am.

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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