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Psych Eval Discharge Summary Living Will / Medical Treatment
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COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
| 12/29/95
Admit to Geropsychiatry Condition: Poor Preliminary Diagnosis: Panic Disorder Activity: Up in Wheelchair Diet: Mechanical Soft Labs: CBC, Chem 20 RPR, T7, TSH, UA with C&S, EKG, Chest X-ray. AIMS Test - done LW OT: Evaluate and treat Special Precautions: every 15 minutes for 24 hours Vital Signs: Twice a day Weight: Weekly Allergies: No known allergies Medications: Amitryptyline 25 mg by mouth every bedtime Lasix 40 mg a day KCl 20 milliequivalent by mouth every day Nitrostat 0.4 mg sublingual every 5 minutes 3 times as needed for chest pain. Ambien: 5 mg by mouth every bedtime as needed for sleep. Dulcolax: 5 mg by mouth every day as needed for constipation. Trazodone: 150 mg by mouth every bedtime Tylenol: 2 tablets by mouth every 4 hours as needed for pain. Mylanta: 30 cc by mouth every 4 hours as needed for dypepsia. Milk of Magnesia: 30 cc by mouth every bedtime as needed for constipation. Morphine sulfate: 10 mg IM now for pain. Telephone Order: Dr. Weitzel Signed Robert Weitzel, M.D. Noted L. Wilson, RN, MSN 12/29/95 2130 |
I CERTIFY THAT THIS PATIENT
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12/30/95 0325 Morphine SO4: 10 mg IM one time now Do Not Resuscitate Verbal Order: Dr. Weitzel / T. Scholl RN Noted: T. Scholl, RN 12/30/95 Signed: Robert Weitzel, M.D. 24 hour check 12/30/95 0445 TS RN
12/30/95 Patient expired at 0855 this a.m. Please see
progress notes
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Psych Eval Discharge Summary Living Will / Medical Treatment
Plan
Physician's
Orders Progress
Notes Nursing Staff Notes
Nursing Admission Assessment