539 Case Scenario. Motor Vehicle Accident/ Sternal Fracture/ Rib Fracture L3 and 4.

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.

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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