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

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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Ryrey Abraham Pacamana
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2K views

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

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.

Uploaded by

Ryrey Abraham Pacamana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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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