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DAVIS HOSPITAL AND MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: SMITH, LYDIA
ROBERT WEITZEL, M.D.
ADM: 12/20/95
DIS: 1/9/96
HISTORY
The patient was admitted with a diagnosis of anxiety disorder.
HOSPITAL COURSE
She was started on Lasix 40 mg q. a.m., potassium chloride 8mEq q. a.m., Lanoxin 0.125 q. a.m., Normodyne 200 mg b.i.d., Vasotec 10mg q. a.m., Risperdol 0.5mg q. a.m., 1700, and h.s., Vasotec 10mg q.day p.r.n. blood pressure greater than 175/100, Serzone 100 mg p.o./b.i.d..
On admission her chemistries were fairly normal except for an elevated glucose and BUN. TFTs were within normal limits. A digitalis level on the 21st was 0.5. Valproic acid on the 4th of January was 37.4. Chest x-ray really unremarkable. Initial urine was pyuric, RPR non-reactive. Repeat urinalysis on the 25th revealed low amount of white cells and some epithelials consistent with a non-sterile collection.
On the 21st she was started on Cipro 500 mg b.i.d. and Risperdal was increased to 1mg .a.m., 1700 hours, and q.h.s. – may repeat times one. On the 25th we ordered Haldol given if patient refused Risperdal. She frequently did refuse oral medications. On the 29th Depakene was started at 125mg q. a.m., 1700 hours, and 500mg q.h.s. and Haldol was increased to 3mb IM if patient refusing oral Risperdal and Haldol 5mg p.o. or IM as ordered p.r.n. severe agitation as well as some Cogentin as a p.r.n. On the 1st Depakene was increased to 250 mg. Q.a.m., 1700 hours and 500 mg q.h.s. and of course a level was ordered for the 4th which was slightly low. On the 3rd Serzone was increased to 150mg q.h.s. and a Clonidine transdermal patch was ordered 0.2mg one per dermis q. week.
The patient became quite ill on the 7th and was not taking any nourishment or fluids and had no urine output. After a family discussion with her two sons and daughter, the family decided that they did not want her life artificially prolonged, but rather would like comfort care.
C O N T I N U E D ……
DISCHARGE SUMMARY
DAVIS HOSPITAL AND MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: SMITH, LYDIA
PAGE 2 . . .
At that time she was thrashing about in apparent pain and anxiety and her medications were changed so that all usual meds were held but rather she was given Morphine Sulfate 5 mg q. 3 hours IM. On the 8th she was once again unresponsive for the most part. She appeared to be in some discomfort at times and so Morphine sulfate was increased to 10mg q. 3 hours. On the morning of the 8th she died of respiratory arrest. Dr. Nilson was kind enough to come and sign off for usual paperwork.
The body has been released to the mortuary.
DISCHARGE DIAGNOSIS
Axis I: Anxiety disorder, NOS.
Axis II: Defer.
Axis III: Hypertension, congestive heart failure.
Axis IV: Four.
Axis V: Zero, zero on discharge.
(Signed) Robert Weitzel, M.D.
RW/rn
D: 01/09/96 6:19
T: 01/10/96 5:28
JOB # 5375
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan