KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.
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.
Medications:
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.
Nurses You Move Me 