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DAVIS HOSPITAL & MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: LARSEN, JUDITH
ROBERT WEITZEL, M.D.
ADM: 12/6/95
DIS: 1/3/96
ADMITTING DIAGNOSIS
Major depression with psychotic features, rule out organic brain syndrome.
HOSPITAL COURSE
On admission she was started on Betagan to her eyes, Surfak, Klonopin 0.5 t.i.d., Trazodone 100 mg q.h.s./p.r.n. insomnia, Synthroid 0.088 mg q. day, a baby aspirin a day, Isosorbide 10mg b.i.d., Ativan p.r.n. On the 6th she was ordered some oxygen, she was found to be 94% on the 7th. On the 7th she was started on Serzone 50mg b.i.d. for two days and then it was advanced to 100mg b.i.d.. On the 8th Nystatin swabs were ordered to her mouth q.i.d.. Serum protein electrophoresis was ordered. On the 8th Klonopin was decreased to 1/2mg b.i.d. through the 12th and then on the 13th it was to be decreased to 1/4mg b.i.d.. Lab on admission notable for no UTI. Non-reactive RPR. Normal CBC. Essentially normal chemistries except for an elevated glucose and low iron. Chest x-ray was notable for a hiatal hernia, cardiomegaly and some atelectasis. TFTs were normal. Serum protein electrophoresis was not abnormal. Repeat chemistries on the 25th were about the same except for a lowered iron and albumin. Repeat CBC on the 26th revealed an anemia consistent with GI bleed. A Dilantin level on the 26th revealed a slightly subtherapeutic level. CT of her head on the 26th revealed atrophy and fairly pronounced small vessel ischemic changes consistent with MID.
Continuing with her clinical course, on the 9th Risperdal was started 1mg p.o./q.a.m., 2mg q. 1700 and 2mg q.h.s.. At night she also needed Ativan 2mg. Risperdal was changed to 1mg q.a.m. 1700 and q.h.s. and Nystatin was discontinued on the 13th. MS 15mg IM was ordered q. 4 hours p.r.n. severe pain. She also got Dulcolax suppository on the 15th and Fleet’s ordered p.r.n. On the 17th, after her condition had improved, she was ordered a PG consult on the 18th. Risperdal was decreased to 0.5mg q.a.m., 1700 and q.h.s.. On the 19th we discontinued the MS p.r.n. On the 22nd her Risperdal was held secondary to sedation as well as on the 24th Risperdal was decreased to 1mg q. 1700 and q.h.s and Trazodone was changed to 50mg q.h.s./p.r.n. On the 25th she got 2mg of IM MS thrice in the morning secondary to apparent pain.
Continued…
DAVIS HOSPITAL & MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: LARSEN, JUDITH
PAGE 2…
On the 26th she had an approximately 40 minute seizure and Dr. Dienhart saw her and ordered 02 saturations, a brief IV for Dilantin loading, EKG, chem-20 CBC and CT scan of the head as well as a Dilantin level. On the 26th she was given another 2mg of IM MS and IV therapies were stopped later in the day. On the 29th we discontinued her Dilantin because of quite a bit of lethargy and unresponsiveness at times. On the 30th she was once again ordered Morphine this time at 5mg IM q. 4 round the clock. Then on the 31st the 5mg IM q. 4 was continued and 5mg IM q.2 was ordered p.r.n.-pain. On the 31st she did get one now order of IM MS and then on the first another and the MS was increased to 5mg IM q. 3 hours. On the 1st she required one IM order of MS as a now order. She rallied briefly on the 2nd and Morphine was held briefly. On the 3rd she once again appeared to be in pain. Morphine was given 25mg IM in the late morning. Another 30mg at noon. Natural tears q.i.d. were ordered. Vital signs changed to q. shift at that point. At 14:45 another 30mg of IM Morphine were given and then at 18:20 15mg IM were given and her Morphine dose was changed to 10mg q. 3 hours. At approximately 8:15 on the evening of the 3rd, she did expire of combination of low blood pressure secondary to extreme dehydration and GI bleed as well as low respiratory rate and finally cardiac arrest. At death she appeared to be in no pain. Her body will be released to the mortuary for funeral services per family request.
DISCHARGE DIAGNOSIS
Axis I: Major depression with psychotic features.
Axis II: Defer.
Axis III: Status post multiple CVAs, hypothyroidism, history of hypertension.
Axis IV: Three.
Axis V: Twenty.
(Signed) Robert Weitzel, M.D.
RW/rn
D: 01/04/96 6:52
T: 01/08/96 6:03
Job #4608
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan