KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.
INTERDISCIPLINARY KARDEX.
Age/ Sex 79years old female.
Account number :Q005634375.
MR # :Q00058367544.
Admission date: 07/12/2021@03am.
Status Inpatient admit.
Attending doctor : Tommy Holbib.
Patient name: Kwadom French.
Location : MedTelemetry.
Room: 42114.
Resuscitation status: Full Code.
Weight : 158.
Height : 5feet 8inches.
Alert and oriented x3.
Allergy : NKDA.
Isolation Status :Standard Precautions.
Sitter room for assistant and constant monitoring.
Primary diagnosis MVA/Sternal Fracture/ Rib Fracture,L3,4. Displaced sternal fx and Fracture of two left ribs due to car accident. Conservative treatment no surgical intervention.
TLSO Brace at all times.
Secondary diagnosis: Hypertension, Spinal surgery,Appendectomy. Osteoarthritis. Irregular heart beat.
Does patient have advance Directive: No.
Copy of advance Directive on the chart.
Diet Cardiac heart health diet.
Laboratory results:
WBC 8.5.
H/ H 11.5/33.4.
K: 3.8.
Na : 142.
Mg : 2.1.
Medications:
Norco 1tablet 5/325mg po Q4hours prn moderate pain.
Morphine sulfate 2mg IV Q6hour prn severe pain.
Zofran 4mg IV Q4hours prn Nausea Vomiting. Tylenol 650mg po Q4hours temperature.
0.9NS @50ml/hour right forearm 20guage clean/Patent/Intact.
Zosyn 3.375gm IV Q8hours.
Colace 100mg po Bid.
Plavix 75mg po Qday.
Hctz 12.5mg po daily scheduled.
Norvasc 10mg po 09am scheduled.
Purwick for urination, bedpan for bowel movement.
PT/OT for evaluation and treatment.
Discharge plans:
Discharge to Skilled Nursing Facility or Home when medically cleared.
Vital signs Q4hours.
Bp 110/56.
Hr 60.
02 saturation on RA 96%.
Respiration: 18.
Laboratory test in am.
Ambulates with assistance.
Case manager consult for placement.
Social worker consult.
Nurses You Move Me 