537 Case Scenario.Left Thigh Abcess.


Account number : Q005634372.

MR #: Q00058867544.

Admission date : 09/13/2020@0230am.

Status : Inpatient admission.

Location : General Surgery.

Room : # 62115.

Attending doctor : Tommy Holbib.

Patient name : Mangotree Wooden.

Resuscitation Status : Full code.

Weight: 200lbs.

Height: 5feet 8inches.

Primary diagnosis : Left Thigh Abcess. Secondary diagnosis:

Hypertension, BPH, Pain,UTI.

Mode of Transportation: Bed.

Isolation: Standard Precautions.

Risk for fall: No.

Suicidal risk: No.

Do patient have advance Directive: No.

Good Family Support. Daughter at bedside.

Copy of advance Directive on the chart.

Diet Carb Controlled cardiac diet.

Glucerna shake 1 can with wach meal.

NPO after midnight except medications. Incision, Drainage and Closure of left thigh wound by doctor Millernut and his associates. Consent signed and in the chart.

Procedure explained to patient and family by the doctor.

Zosyn 3.375gm IV Q8hours.

Metoprolol 10mg po 09am scheduled. Vancomycin 1gm IV Q24hours ×1.

Meropenem 1gm IV Q8hours.

Norco 10/325mg 2tablets po Q6hours prn severe pain.

Zofran 4mg IV Q4hours prn Nausea/ Vomiting.

Dilaudid 0.5mg IV Q3hours prn severe pain. Morphine sulfate 4mg IV Q4hours prn severe pain.

Norco 1tablet po Q4hours prn moderate.

Tylenol 650mg po Q4hours prn temperature. Vital sign:

T: 97.4.

Bp 119/77.

Respiration 18.

02 Saturation: 97% RA.

0.9NS @ 75ml/hour right forearm 18guage clean/ Patent/ Intact.


Discharge to Hollywater Skilled Nursing Facility for two weeks then discharge home with home health nurse.

Dressing change QOD with Aquacel ag and abdominal pad with transparent tape.

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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