Age/Sex :61years old Male.

Account number : Q005634372.

MR # : Q00058867544.

Admission date : 07/14/2021@08am.

Status :Inpatient admission.

Attending doctor :Tommy Holbib.

Patient name : Davido Plantaine.

Resuscitation Status: Full Code.

Weight :156lb.

Height: 5feet 4inches.

Alert and oriented x4 .

Primary diagnosis :MVC bilateral ankle Fracture.

Secondary diagnosis:Hypertension, polysubstance abuse Fentanyl, alcohol.

Isolation Status :Standard Precautions.

Is patient at risk for fall: Yes.

Suicidal risk: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet : Cardiac heart health diet.

02 @ 4liter NC.

Hx of Pneumothorax.

Transportation method: Wheelchair.

Right hip dislocation,acetabular fracture.

S/p ORIF left Calcaneous fracture by Doctor Money Goode.

Skin intergrity impaired.

Myperlex dressing in place.

ORIF right ankle to be done by doctor Money,Goode on 07/16/2021 @10am.

Consent to be signed on the chart.Isolation Status Standard Precautions.

Alert and oriented ×3.

Diet: Regular diet,NPO after midnight.

Uses urinal .

0.9NS @ 75ml/hour right forearm 20guage clean/Patent/Intact.

Lovenox 40mg SubQ Q24hours after surgery. On 07/24/2021 External Fixators removal and right Pilon Tibia ORIF.Dressing in place and intact.

Laboratory results :

WBC 8.5.

H/H 12.0,37.2.

K 3.9.

Na 145.

Magnesium 1.8.

Laboratory tests:

CBC with differential and Chem 7 in am.


Zosyn 3.375gm IV Q8hours.

Norvasc 10mg po 09am scheduled.

Colace 100mg po Bid.

Morphine sulfate 2mg IV Q3hours prn severe. Zofran 4mg IV Q4hours prn nausea/vomiting.

Tylenol 650mg po Q4hours prn temperature. Ativan 1mg IV Q8hours scheduled.

Ativan 2mg po Q4hours prn agitation. Benadryl 25mg po Q4hours prn itching.

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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