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 Mary Crane  Physician's Orders
12/28/95
Allergies; 
Admit to Geropsychiatric Unit per Dr. Weitzel
Condition guarded 
Preliminary diagnosis: depression with psychotic features provisional psychosis
Activity: wheelchair, assist with transfers
Diet: American Diabetes Association 1800 calorie per day mechanical soft
Vital signs twice a day 
Special precautions every 15 minutes check for 24 hours
AIMS test
Occupational therapy evaluation and treatment - adaptive equipment and wheelchair cushion, nonslip fabric. 
EKG
Chest x-ray
Labs:CBC, Chem 20 RPR, T7, TSH, Urinalysis with culture and sensitivity if indicated.
Medications: 
Tylenol 1-2 tablets every four hours as needed for pain. 
Mylanta 30 cc by mouth every four hours as needed for dyspepsia. Milk of Magnesia 30 cc by mouth every evning as needed for constipation. 
Zantac 150 mg by mouth twice a day 
Lopressor 100 mg by mouth twice a day 
Glucotrol 5 mg by mouth every morning
Accuchex before meals and at bedtime for 3 days.
Dyazide 1 tablet by mouth every other day (even days) 
Artificial tears, one drop both eyes every 3-4 hours as needed while awake as needed for dry eyes.
Carafate 1 gm twice a day by mouth 0700 and 1600.
Lasix 80 mg by mouth every other day (odd days) 
Ferrous sulfate 325 mg by mouth every day with food
Metamucil 1 Tablespoon 3 times a day with meals
Please crush medications
Allergies: Penicillin, Dilantin, Catapress, Aspirin leads to ulcers, phenobarbital. 
Risperdol 1 mg every morning 1700 and bedtime.
Serzone 50 mg by mouth twice a day for 2 days, on 12/31 increased to Serzone 100 mg by mouth twice a day. 
Trazodone 100 mg by mouth every bedtime, may repeat once as needed for sleep. 
Mineral ice topical ointment twice a day as needed for headache (patient=s own).
Telephone order Dr. Weitzel L. Wilson, RN, MSW
Thanks, Robert Weitzel, MD 
Noted L. Wilson, RN 12/28/95 1900
 

12/28/95 1915
Duragesic patch 25 micrograms transdermal. Change every 3 days in the evening. 
Do Not Resuscitate
Verbal order Dr. Weitzel, L. Wilson, RN
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95
(unknown time)

12/28/95
Relafen 1000 mg with food now. 
Thanks, Robert Weitzel, M.D.

12/28/95
Change Duragesic to 50 microgram transdermal patch every 3 days. Apply in evening at 1900 
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95 2100

24 hour check 12/29/95 0130 T. Scholl, RN

12/29/95
1. K-Dur 20 meq twice a day
2. Restrict patient from heavy fluid intake.
Thanks, Robert Weitzel, M.D.
Noted 12/29/95 1100 S. Hansen, RN12/29/95

  
 
 
 

I CERTIFY THAT THIS PATIENT
NEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED Robert Weitzel, M.D.
DATE 12/28/96
12/29/95
Chem 7 in morning on 1/1/96.
Thanks, Robert Weitzel, M.D.
12/29/95 1100 Noted S. Hansen, RN

12/29/95 1 p.m. 
1. Check with family regarding past right shoulder injury and evaluation.
If none - perform x-rays right shoulder per Dr. Detricksen (?)
2. Hemoccult stools
Thanks, D. Dienhart, M.D.
Noted L. Wilson, RN 12/30/95 0030
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

24 hour check 0245 12/30/95 T. Scholl, RN 
 

  
 
 
 

12/29/95 1 p.m. 
Medicine Consult note: (asked to evaluate by Dr. Weitzel). 
Impression: 
1. History right thalamic stroke 1990 with residual partial left paralysis.
2. History of hypertension with increased coronary size on chest x-ray.
3. History chronic hyponatremia - possible polydipsia 
4. Peptic ulcer disease, status post partial gastrectomy and vagotomy.
5. History lumbar disc surgery and chronic low back pain. 
6.Right shoulder unknown abnormal density on chest x-ray.
Recommendation: 
1. Agree with non-steroidal anti-inflammatory drugs and duragesic patch.
2. Consider decreasing Lasix to daily dose of 20-40 mg. 
3. Consider discontinuing Diazide.
4. If more anti-hypertensive required, consider low dose acetylcholinesterase inhibitor, i.e. Zestrol 10 mg., especially with increased coronary size on x-ray. 
5. Fluid restrict 1400 cc. per day if needed for decreased sodium 
6. Potassium chloride probably can be decreased if Lasix and Diazide stopped
Full note dictated 
Thanks, D. Dienhart, M.D.
12/30/95
1. Discontinue Diazide
2. Lasix 40 mg by mouth every morning. 
3. Cipro 500 mg by mouth twice a day for six doses.
4. Do Not Resuscitate
Thanks, Robert Weitzel, M.D.
Noted 12/30/95 1350 B. Hardy, RN

24 hour check L. Wilson, 12/31/95 0030

12/31/95 
1. EEG on Tuesday 1/02/96
2. Trazodone 150 mg by mouth every bedtime.
3. Accuchex before meals and bedtime(4 times a day)for one more day.
Verbal order Dr. Weitzel/B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted 12/31/95 1250 B. Hardy, RN

12/31/95 1930 Telephone order Dr. Weitzel
1. If patient refuses Risperdol, give Haldol 5 mg intramuscularly.
2. Ativan, 1-2 mg by mouth or intramuscularly every 4 hours as needed for severe agitation. 
Signed Robert Weitzel, M.D.
Noted L. Long, RN 12/31/95 1930

24 hour check L. Wilson 1/1/96 0030

 

    
1/1/96
AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room 
Drug(s) Exp. Date Last Dose
1. Duragesic patch 50 mcg transdermal, 
2. change every 3 days in the evening, 1900 
3. next dose due 1/1/96 
4.
According to hospital policy orders for these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
Noted L. Long, RN 1/1/96 1700

(Mistaken entry B crossed out)

1/1/96 noon 
Decrease Duragesic patch to 25 mcg every 3 days 
CBC today, with differential. 
Signed D. Dienhart, M.D.
1/1/95 1210 Noted B. Hardy, RN

  
 
 
 
 
 
 
 
 
 
 
 

1/1/96 (noon)
Medicine followup (asked to see by Dr. Weitzel)
Report of vaginal stool today
Patient more sedated. Received Ativan 2 mg last evening, Risperdol 3 times a day. 
Objective: Temperature 99.5, Respirations 24, Pulse 66, Blood Pressure 132/(80)
Lungs clear, Abdomen soft
Heart regular without murmur
Vagina - brown fecal material on visual inspection
Note 1/1/96 SMA-7, 12/28 WBC - 9400, Seg - 59
Impression: Probable rectovaginal fistula 
Recommend:
1. CBC today
2. Decrease Duragesic patch with increased sedation noted 
3. Gynecology consultation
Thanks D. Dienhart, M.D.
 
1/1/96
1. Accuchex to continue after meals and bedtime.
2. Insulin sliding scale: 
150 - 200 B 2 units regular insulin
201 - 300 B 5 units 
301 - 400 B 10 units
>400 B 15 units and call M.D.
3. Duragesic - 50 mcg every 3 days 
4. Trazodone 200 mg by mouth every bedtime as routine 
5. Trazodone 100 mg by mouth every bedtime as needed for sleep (please try to give within one hour of routine Trazodone).
Thanks, Robert Weitzel, M.D. 
Noted L. Long, RN 1/1/96 1700

24 hour check L. Wilson, RN 1/02/96 0030
 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1/1/96 2000 
Telephone conversation with Dr. Hall, on call gynecologist at Tanner Clinic contacted: notified of large amount fecal matter excreted from patient=s vagina. Dr. advised getting consult in morning as planned since patient=s vital signs are stable at this time and no infection is indicated.
Lynn Long, RN

 
1/02/96
1. Glucotrol 5 mg by mouth twice a day.
2. Please chart all insulin given in diabetic chart.
Thanks, Robert Weitzel, M.D.
Noted 0730 1/02/96 S. Hansen, RN

24 hour check 1/03/96 T. Scholl, RN

   1/02/96 Gynecology Consult
72 year old with complaint of fecal matter out of vagina. On exam has a high rectal vaginal fistula. Can repair under spinal anesthetic if patient cleared for surgery by her internist. Also may try to heal spontaneously (probably 25-35%) by treating with broad spectrum antibiotics and low residue diet (constipating). 
Thanks, Steven Meeks MD

773-4840
 

 
 
 
1/03/96
1. B-12 and folate - serum 
2. Depakene syrup 250 mg by mouth every morning every 1700 and 500 mg by mouth every evening. 
Robert Weitzel, M.D. 

1/03/96 Oxygen by nasal cannula at 2 liters per minute
1/03/96 Urinalysis in morning 
Thanks, Robert Weitzel, M.D.

1/03/96
1. Low fiber, low residue diet
2. Please have Dr. Dienhart made aware of gynecologist=s recommendations. (Give him my beeper number phone number 597-7979, so he can call me if necessary) 
Thanks, Robert Weitzel, M.D. 
Noted, Lynn Long, RN 1/03/96 1100

1/03/96 1200 1130 Telephone order Dr. Weitzel: 
1. Morphine sulfate 3 mg intramuscularly now
Signed: Robert Weitzel, M.D.

Noted Lynn Long, RN 1/03/96 1200

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1/03/96 1100 - Dr. Dienhart's secretary notified of phone number change. L. Long, RN

 

1/03/96 1445 Telephone order Dr. Weitzel:
1. Morphine sulfate 5 mg intramuscularly now.
Robert Weitzel, M.D.
Noted L. Long, RN 1/03/96 1445
24 hour check 1/04/96 0230 T. Scholl, RN

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room
Drug(s) Exp. Date Last Dose
1. Duragesic patch 50 mcg transdermal,
2. change every 3 days in evening 1/.4
3.
4.
According to hospital policy orders for these medications
must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.

1/04/96
1. Straight catheterization for today=s urinalysis.
2. Morphine sulfate 5 mg intramuscularly now, and then
every 4 hours as needed for pain.
3. Duragesic patch 75 mcg every 3 days
4. Valproic acid level in 2 days (in morning on 1/6/96)
Thanks, Robert Weitzel, M.D.
Noted T. Scholl, RN 1/4/96 0630
 
 

1/4/96 2010 
1. Notify respiratory therapy for treatment secondary to aspiration.
2. Swallow and speech evaluation in morning
Telephone order Dr. Weitzel/D. Kley, RN
Noted D. Kley RN 1/04/96 2010
Signed Robert Weitzel, MD

24 hour check 1/5/96 0200 (T. Scholl, RN)

1/5/96 
1. Chest x-ray for aspiration pneumonia.
2. CBC now 
3. Morphine sulfate 5 mg intramuscularly now. 
Thanks, Robert Weitzel, MD
Noted L. Long, RN 1/5/96 1120

1/5/96 1200
1. Pureed diet. (still 1800 American Diabetic Association low-fiber, low residue) 
Verbal order Dr. Weitzel/L.Long, RN
Signed Robert Weitzel, M.D.
Noted L. Long, RN 1/5/96 1200
 

  
 
 
 
 

 
1/5/96 1330 Telephone order Dr. Weitzel:
1. Keflex 250 mg 4 times a day by mouth
Signed Robert Weitzel, M.D.
Noted L. Long, RN 1/5/96 1330

24 hour check 1/6/96 0030 T. Scholl, RN

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room 
Drug(s) Exp. Date Last Dose
1. Serzone 100 mg po 2 x day 1/7
2. Zantac 150 mg po 2 x day 1/7 
3. Risperdol 1 mg po am, 1700,hs 1/7
4. Lopressor 100 mg po 2 x day 1/7
According to hospital policy orders for these medications 
must be reordered or they will be discontinued.
DISCONTINUE - Robert Weitzel, M.D.

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room 
Drug(s) Exp. Date Last Dose
1. Carafate 1 gm po 2 x day 1/7
2. Fesulfate 325 mg po/day w/food 1/7 
3. Metamucil 1 TBS 3x day w/meals 1/7
4. Duragesic patch 75 mcg every 3 days 1/7
According to hospital policy orders for these
medications must be reordered or they will be discontinued.
DISCONTINUE - Robert Weitzel, M.D.

 

    
1/7/96
SMA-7 
Oxygen saturation level
Chest x-ray
Telephone order Dr. Dienhart/E. Cozzins, RN
Signed D. Dienhart, M.D.
Co-signed Robert Weitzel, M.D.
1/7/96 E. Cozzins, RN 1930 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1/7/96
1. Hold all above medications
2. Morphine sulfate 5 mg intramuscularly now and every 3 hours around the clock.
Thanks, Robert Weitzel, M.D. 
1/7/96 E. Cozzins, RN 2100
 
 

   RESPIRATORY CARE
PULSE OXIMETRY
OXYGEN SATURATION
DATE 1-7-96 TIME 1445
On O2 AT 86 L/MIN. Or % MASK
Sp02(Sa02) ________%
OFF 0K2; Sp02 (Sa02) _____%
TECH: O2 remained on face via mask - notified nurses.
D. Baker CRTT

1/7/96 3:10 pm Medicine Consult (asked to see by Dr. Weitzel)
Possible seizure today for 10 seconds. Increased unresponsiveness for 3 days.
Oral intake decreased. 
Oxygen saturations down to 70-80 B 86% on face mask 
Chest x-ray (?) infiltrate
Lab - sodium 159, potassium 3.7, glucose 134
chloride 117, C02 33, BUN 47, Creatinine 1.9
Exam: 
Reported blood pressure one hour ago 108/--
Now 60/palpable
Unresponsive, eyes point to right 
Lungs: rales on right
Impression: 
Hypotension/ possible sepsis 
Probable seizure 
Volume depletion and free water depletion 
Probable aspiration 
Case discussed with Dr. Weitzel patient felt to have declining status and wish not have CPR performed. If treatment chosen, would reduce volume repletion, free water repletion, antibiotics and possible ventilation. After discussion with primary medical Doctor will not offer(continued)
D, Dienhart, M.D.
 

 
 
 
 
 
 
 
 
 

1/8/96
Release patient=s body to mortuary,
Signed Robert Weitzel, M.D.

   1/7/96 3:10 p.m. Medicine followup
(continued) further aggressive supportive care
I suspect she may die soon.
Advise family notification.
D. Dienhart, M.D. 

1/8/96 at 0015
Patient without vital signs - family been here. Mortuary notified - released to them.
Nielson, M.D.

 
     
 

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