1/10/96

COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

Ennis Alldredge Physician's Orders

1/10/96
Admit to Geropsychiatric Unit.
Allergies: No known allergies.
Condition: Poor
Preliminary Diagnosis: Psychosis not otherwise specified.
Activity: Bed rest, wheelchair.
Diet: 2000 calorie American Diabetic Association, no added salt, finger foods.
Labs: CBC, Chem 20, RPR, T7, TSH, Urinalysis with culture and sensitivity if indicated.
EKG
AIMES test
Chest x-ray
Occupational therapy evaluation and treatment
Vital signs: twice a day
Special precautions: check each 15 minutes for first 24 hours
Medications:
Tylenol 1-2 by mouth every 4 hours as needed for pain.
Mylanta 30 cc by mouth every 4 hours as needed for dyspepsia.
Milk of Magnesia 30 cc by mouth every bedtime as needed for constipation.
Lente insulin 20 units subcutaneously every morning Lente insulin 5 units subcutaneously every evening
Accuchex before meals and at bedtime
Risperdol 1 mg by mouth every morning, 5 p.m. and bedtime.
Pepcid 20 mg by mouth every day
L-thyroxine 0.1 mg by mouth every morning Trazodone 100 mg by mouth every bedtime, may repeat once by mouth as needed for insomnia.
Bumetadine 1 mg by mouth every morning.
Enteric coated aspirin 325 mg 1 by mouth twice every day
Oxybutinin 5 mg by mouth twice a day
Micro K (potassium) 10 meq one by mouth every day
Hytrin 5 mg by mouth every bedtime
Docusate sodium 100 mg by mouth twice a day
Buspar 10 mg by mouth 3 times a day
Do Not Resuscitate
Telephone Order - Dr. Weitzel/L. Long, RN
Signed: Robert Weitzel, M.D.
Noted, L. Long, RN 1/10/96 1300

I CERTIFY THAT THIS PATIENTNEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED: Robert Weitzel, M.D.
DATE: 1/10/96

1/10/96
1. Ativan 1 mg, and Haldol 10mg intramuscularly now.
2. Ativan 1 mg to 2 mg intramuscularly every 4 hours as needed for severe agitation.
3. Haldol 5 mg intramuscularly every morning, 5 pm and bedtime to be given Aas needed@ - if patient refuses Risperdol.
Thanks, Robert Weitzel, M.D.

1/10/96
Physical Therapy consult regarding ambulation.
Robert Weitzel, M.D.
Noted: L. Long, RN 1/10/96 1430

1/10/96 9 p.m.
Glycerin swish and swallow mouth four times a day Nystatin swab mouth 5 times a day for 7 days
Straight catheter urinalysis and culture and sensitivity if indicated.
Hemocult stool
Oxygen saturation (indecipherable) during periodic breathing
Head of bed elevated 20 degrees all times as feasible.
Signed D. Dienhart, M.D.
1/10/96 Noted B. Hardy, RN 2210

1/10/96 9 p.m. Medical consult note:
(asked to see by Dr. Weitzel)
Impression: Severe dementia
Agitation
History of hypertension
Coronary artery disease, status post coronary artery bypass graft 1982
Diabetes
Renal insufficiency
History of gastroesophageal reflux disease
History of mycoses fungoides -unknown stage
History total body irradiation ? Sezary
History hypothyroidism
Urinary incontinence and
decreased rectal -anal sphincter tone
Oral thrush probable
Recommend:
1. Agree screening labs
2. Rule out urinary tract infection
3. Aspiration precautions (unknown word)
Discussion:
Demented 82 year old male admitted for combativeness and agitation.
Currently lethargic-aroused only to painful stimuli following Ativan and Haldol injection for combativeness.
Exam:
Pupils equal reactive to light, tympanic membrane within normal limits. Gag poor, mucosa red - probable oral thrush. Lungs: decreased breath sounds with wheezes. Heart: regular rhythm (indecipherable) Rectal and sphincter tone (cut off of page). Other than pending labs, chest x-ray, EKG, see no major changes in other medications. Unknown prior evaluation of dementia (cut off of page) .
Note dictated

D. Dienhart, M.D.

24 hour check 1/11/96 0130 T. Scholes, RN

24 hour check 1/12/96 0100 T. Scholes, RN

1/12/96 Increase Haldol to 10 mg intramuscularly as needed - if patient refusing oral medication (give at morning, 5 p.m. and bedtime, as needed)
Thanks, Robert Weitzel, M.D.
1/12/96 1045 noted B. Hardy, RN

1/12/96
Magnetic Resonance Imaging
Thanks, Robert Weitzel, M.D.
1/12/96 noted 1045 B. Hardy, RN

1/12/96 1325
Ativan 1 mg intramuscularly now
Haldol 5 mg intramuscularly now
Telephone order Dr. Weitzel
Signed Robert Weitzel, M.D.
1/12/96 B. Hardy, RN 1325

RESPIRATORY CARE
PULSE OXIMETRY
OXYGEN SATURATION
Date 1/12/96 0835
ON O2 at ___L/MIN of %
SpO2(SaO2)______%
OFF O2; SpO2(Sao2) 96%
TECH S. Jensen CRT

1/12/96
Start intravenous line of D5 2 NS at 100 cc /hr
Chem 7 in morning
Telephone order Dr. Weitzel
Robert Weitzel, M.D.
L. Wilson, RN

May restrain wrists to prevent pulling out IV
Telephone order Dr. Weitzel, MD
Signed Robert Weitzel, M.D.
Noted L. Wilson, RN 1/12/96 2000

1/13/96 24 hour check L. Wilson, RN

1/13/96
1. Discontinue IV
2. Morphine sulfate 10 mg intramuscularly every 3 hr
3. Ativan 0.5 mg intramuscularly every 3 hr
4. Discontinue all oral medications
5. Discontinue Haldol prn as written
6. Haldol 10 mg intramuscularly every 4 hrs as needed for severe agitation
Thanks, Robert Weitzel, M.D.

1/13/96
1. Lente insulin decreased to 10 units subcutaneously every morning and 2 units subcutaneously every afternoon
2. Discontinue Accuchex
Signed Robert Weitzel, M.D.
1/13/96 E. Cuzzins, RN 0800

1/14/96 24 hour check L. Wilson, RN 2400

1/14/96 0600
Morphine sulfate 10 mg intramuscularly now
Telephone order Dr. Weitzel L. Wilson, RN
Signed Robert Weitzel, M.D.
Noted L. Wilson 0600 1/14/96

1/14/96
Morphine sulfate 10 mg intramuscularly now
Telephone order Dr. Weitzel B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted B. Hardy, RN 0920 1/14/96

1/14/96 0940
Release body to mortuary per Dr. Weitzel.
B. Hardy, RN
Signed Robert Weitzel, M.D.
1/14/96 noted B. Hardy, RN 0940

1/15/96
Formally discharge patient
Release body to mortuary
Robert Weitzel, M.D.
Noted 1/15/96 1400 S. Hansen, RN

1/14/96 10 a.m.
Patient without spontaneous respirations, pulse or blood pressure. Expired 0936 a.m. Spoke with family.
S. Hall,? M.D.

Psych Eval History & Physical Discharge Summary

Living Will / Medical Treatment Plan

Physician's Orders Progress Notes Nursing Staff Notes

<< Back To Home Page