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DAVIS HOSPITAL & MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: Alldredge, Ennis
Robert A. Weitzel, M.D.
ADM: 1/ /96
DIS: 1/14/96
HISTORY
The patient was admitted secondary to psychotic behavior. On admission he was started on lente insulin 20 units q a.m. and 5 units q p.m. Accuchecks, Risperdal 1 mg t.i.d., Pepcid 20 mg q day, L-thyroxine 0.1 q a.m., Bumetanide 1 mg q a.m., aspirin 1 po b.i.d., Oxybutynin 5 mg po b.i.d., Micro-K 10 mEq 1 q day, Hytrin 5 mg 1 qhs, DSS 100 mg b.i.d. and Buspar 10 mg t.i.d. He was made DNR on admission.
On admission labs were notable for an elevated sodium and chloride, LDH and low iron. GFTs were normal. Repeat chemistries on the 13th revealed about the same, increased sodium. Also I should mention his glucoses were consistently elevated. Chest x-ray suggested either some infiltrate or left pleural effusion. CBC on admission was essentially normal except for high number of segmented cells. Urine on admission revealed what appeared to be pyuria, but grew out nothing on C&A.
HOSPITAL COURSE
On the 10th, Ativan 1 mg and Haldol 10 mg were given IM on a now basis because of agitation. Haldol was ordered if the patient refused or was unable to take his Risperdal. We got a physical therapy consultation regarding his ambulation. He did require restraints throughout hospitalization. On the 12th, Haldol was increased to 10 mg IM prn. MRI was ordered. It was found that he had a large left occipital stroke. On the 12th he was quite dehydrated so an IV was started of D5, ˝ normal saline at 100 cc an hour. On the 13th, when it was discovered that he had the stroke and he did appear to be in some pain and discomfort, discussion was held with the family and it was decided to discontinue all extraordinary measures and let him die, giving Morphine and Ativan for comfort. At that point Morphine sulfate was ordered 10mg q 3 hours IM, Ativan 1/2 mg IM q 3 hours. Oral medications were discontinued and lente insulin was decreased. On the 14th, at 6:00 a.m. he needed another 10 mg of IM Morphine and he got another 10 mg apparently at 9:20 that morning. He expired at 9:36 that morning and doctor from the Emergency Room was kind enough to come up here and pronounce him. He apparently experienced no discomfort toward the end and was able to die peacefully.
continued….
DISCHARGE SUMMARY
Alldredge, Ennis
continued …pg2
Robert A. Weitzel, M.D.
FINAL DIAGNOSIS
Axis I: Psychosis NOS
Axis II: Defer.
Axis III: Cerebrovascular accident, diabetes, mycosis fungoides,
hypothyroidism. History of GERD. Renal insufficiency. History of hypertension,
history of ASCD and status post CABG in 1982. Alzheimer’s dementia versus multi-infarct dementia.
(Signed) Robert A. Weitzel, M.D.
RAW/kl
D: 1/15/96 10:42
T: 01/16/96 11:45
JOB #6452
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan