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Psych Eval Discharge Summary Living Will / Medical Treatment
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COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
DAVIS HOSPITAL & MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: Anderson, ELLEN
R. Weitzel, M.D.
ADM: 12-29-95
DIS: 12-30-95
HISTORY
The patient was admitted for treatment of intractable anxiety and severe depression. She initially had been quite demented.
HOSPITAL COURSE
On admission she was continued on Amitriptyline 25 mg p.o. q. h.s.; Lasix 40 mg p.o. q. day; potassium chloride 20 mEq q. day; Nitrostat 0.4 mg sublingual p.r.n. Trazodone 150 mg p.o. q. h.s. was started and she was given Tylenol, Mylanta, and Milk of Magnesia p.r.n. She was given Morphine sulfate 10 mg IM as a now ordered at approximately 2130.
On admission her EKG revealed sinus tachycardia with marked sinus arrhythmia, low voltage QRS and T wave abnormalities. She did not get other laboratories drawn.
She was quite agitated on admission. She settled down with the MS and Trazodone. Approximately 3:00 in the morning she became agitated again and was given another 10 mg of IM morphine. Later in the night her breathing became very erratic and then converted to Cheyne-Stokes respirations. At 3:30 she was given another 10 mg of MS IM. She slept after this. Respirations did remain erratic.
At 7:30 the nurse was unable to get a blood pressure, pulse was at 50. The patient was unresponsive. At 8:55 the patient ceased breathing and she was noted to have no pulse.
Her family was notified, and I have met with them this morning. She will be released to the mortuary immediately for funeral services.
FINAL DIAGNOSES
AXIS I: Major depression with psychotic features, anxiety disorder, NOS.
DISCHARGE SUMMARY
Anderson, ELLEN
Continued…pg 2
R. Weitzel, M.D.
AXIS II: Deferred.
AXIS III: History of angina, hypertension, osteoporosis, hip fracture, dementia.
(Signed) R. Weitzel, M.D.
RW/TL414
D: 12-30-95
T: 1-03-96
JOB #3851
ZDSAMDE1/RW-
Psych Eval Discharge Summary Living Will / Medical Treatment
Plan
Physician's
Orders Progress
Notes Nursing Staff Notes
Nursing Admission Assessment