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    Kardex: Mental Status: Activities: Diet: Tubes: Special Info

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    Ryrey Abraham Pacamana
    Mr. Lourde Cortex, a 73-year-old male, was admitted to the hospital for a lump on his left hip causing pain. His doctors noted the lump was enlarged and the skin was red and swollen. He underwent needle aspiration and was diagnosed with a left hip abscess or possible blood clot. His treatment included antibiotics, pain medication, and monitoring of his vital signs.

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    Kardex: Mental Status: Activities: Diet: Tubes: Special Info

    Uploaded by

    Ryrey Abraham Pacamana
    2K views3 pages
    Mr. Lourde Cortex, a 73-year-old male, was admitted to the hospital for a lump on his left hip causing pain. His doctors noted the lump was enlarged and the skin was red and swollen. He underwent needle aspiration and was diagnosed with a left hip abscess or possible blood clot. His treatment included antibiotics, pain medication, and monitoring of his vital signs.

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    FORM-03-KARDEX

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    Mr. Lourde Cortex, a 73-year-old male, was admitted to the hospital for a lump on his left hip causing pain. His doctors noted the lump was enlarged and the skin was red and swollen. He underwent needle aspiration and was diagnosed with a left hip abscess or possible blood clot. His treatment included antibiotics, pain medication, and monitoring of his vital signs.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views3 pages

    Kardex: Mental Status: Activities: Diet: Tubes: Special Info

    Uploaded by

    Ryrey Abraham Pacamana
    Mr. Lourde Cortex, a 73-year-old male, was admitted to the hospital for a lump on his left hip causing pain. His doctors noted the lump was enlarged and the skin was red and swollen. He underwent needle aspiration and was diagnosed with a left hip abscess or possible blood clot. His treatment included antibiotics, pain medication, and monitoring of his vital signs.

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    © All Rights Reserved
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    KARDEX

    NAME: Mr. Lourde V. Cortex AGE: 73 SEX: M HOSPITAL NO.: 2021-10002


    ADDRESS: Cabasaan, Vigan City, Ilocos Sur. CLASSIFICATION: Private WEIGHT: 81kg
    ADMITTING PHYSICIAN: Dr. Ivan D. Magtira DATE/TIME ADMITTED: 4/5/2021 BLOOD TYPE: O
    +
    ATTENDING PHYSICIAN: Dr. Ivan D. Magtira/ Dr. Markus A. Planes (CP clearance) / Dr. Leo Nunez (anesthesiologist)
    COMPLAINT: Increasing size of a lump over left hip and has been causing pain and discomfort for over the past two weeks; Skin
    around the lump is red and swollen; 38.3ºC temperature.
    IMPRESSION DIAGNOSIS: Left hip Abscess, to rule out DVT vs Reoccurring left Hip Osteomyelitis
    SURGERY DONE: Needle aspiration(4/5); surgical incision and drainage DATE/TIME OF
    SURGERY:

    MENTAL STATUS: ACTIVITIES: DIET: TUBES: Special Info:


     Conscious  Ambulant  NPO  Foley Catheter  Weigh Daily
     Drowsy  Dangle and sit up  DAT  Thoracic tube  BP q shif
     Stupor  Bedrest with BRP  Soft  NGT  Neuro V/S q1
     Unconscious  CBR w/o BRP  Clear liquids  CVP  Abdominal girth
     Comatose Others:  Gen. liquids Others: Others:
    Others: LSLF Diet; PICC line at left TPR q shift and record
    NPO post-midnight brachial vein.
    Keep PICC area/line clean

    Date Date Date and Time


    Medication IV Fluids/Blood Transfusion
    Ordered Ordered Discontinued
    4/5/2021 Start Fondaparinux 2.5 mg SQ OD 4/5/2021 PNSS 1L x 12h 27-28gtts/min
    4/5/2021 Give Acetaminophen 325-650 mg tab
    q4hr PRN for Mild to Moderate Pain
    4/5/2021 Start Docusate sodium 300mg cap PO
    OD
    4/5/2021 Start Linezolid 600mg/300mL IV OD,
    ANST ( )

    Date Medical Treatment/


    Date Done
    Ordered Laboratories/Diagnostics
    4/5/2021 For Needle Aspiration of Abscess 4/5/2021
    4/5/2021 CBC 4/5/2021
    4/5/2021 FBS, Lipid Profile
    4/5/2021 BUN, Crea
    4/5/2021 SGPT, SGOT
    4/5/2021 CXR-PA
    4/5/2021 12 Lead ECG 4/5/2021
    4/5/2021
    KARDEX
    NAME: AGE: SEX: HOSPITAL NO.:
    ADDRESS: CLASSIFICATION: WEIGHT:
    ADMITTING PHYSICIAN: DATE/TIME ADMITTED: BLOOD TYPE:
    ATTENDING PHYSICIAN:
    COMPLAINT:
    IMPRESSION DIAGNOSIS:
    SURGERY DONE: DATE/TIME OF
    SURGERY:

    MENTAL STATUS: ACTIVITIES: DIET: TUBES: Special Info:


     Conscious  Ambulant  NPO  Foley Catheter  Weigh Daily
     Drowsy  Dangle and sit up  DAT  Thoracic tube  BP q shif
     Stupor  Bedrest with BRP  Soft  NGT  Neuro V/S
     Unconscious  CBR w/o BRP  Clear liquids  CVP  Abdominal girth
     Comatose Others:  Gen. liquids Others: Others:
    Others:

    Date Date Date and Time


    Medication IV Fluids/Blood Transfusion
    Ordered Ordered Discontinued

    Date Medical Treatment/


    Date Done
    Ordered Laboratories/Diagnostics

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