<< Back To Home Page     <<Brief History     Phone Intake              PHOTO>> 

Psych Eval   History & Physical   Discharge Summary   Chemistries   CBC   UA   CXR   CT

Living Will / Medical Treatment Plan   EKG   Graphic Chart   Nursing Admission Assessment

Physician's Orders   Progress Notes   Nursing Staff Notes   Medication Administration Records

COLORS:  RED - PAIN   ORANGE - AGITATION   GREEN - TERMINAL

Judith Larsen  Progress Notes
12/6/95
MD		   Psychiatric evaluation done and dictated. 
Signed Robert Weitzel, M.D.
     
12/7/95
OT		   Attempt made to establish communication and have patient follow one-step command; patient unable to complete task. Patient demonstrates decreased cognition status. Will attempt to complete evaluation tomorrow. J.V.? COTA/L
     
12/7/95
MD		   Patient continues to moan and cry; quite dysphoric, will not respond to questions. Assessment - Major Depressive Disorder with psychotic features. Plan - Serzone and Risperdol with the Klonopin.
Signed Robert Weitzel, M.D
     
12/8/95
MD		   Much calmer today after starting Risperdol, lethargic at times. Very demented. Vital signs stable, afebrile. Assessment - Psychotic depression. Plan - taper Klonopin, continue other medications.
Signed Robert Weitzel, M.D.
Addendum B three old CT scan results January - September 1995 have been obtained - left frontal and occipital encephalomalacia consistent with old infarction. 
Signed Robert Weitzel, M.D.
     
12/8/95
Social Services		   Social work note - patient unable to complete CQI scales due to cognitive level of functioning . S. Bennion, LCSW
     
12/8/95
Social Services		   Social work note - met with patient=s two sons and daughter-in-law. They provided background information about patient and asked questions about the program and how patient will be treated. Both of these sons live outside of Salt Lake County and leave most of her care to their brother Merlin who admitted her here. They see her several times a month and were quite shocked at her decline. Explained the program to them and gave them unit schedules. S. Bennion, LCSW
     
12/9/95
MD		   Very dysphoric, continues to exhibit echolalic perseveration. Affect labile. No combativeness. Highly agitated. Assessment - very psychotic. Plan - Increase Risperdol and Trazodone. 
Signed Robert Weitzel, M.D.
     
12/10/95
MD		   Mild fever has disappeared. Much less agitation. Quite demented. Assessment - Stable. Plan - continue current medications.
     
12/11/95
MD		   Patient is taking fluids very poorly. Oxygen saturation was 77. Medical Treatment Plan proscribes IV. No intelligible responses noted. I spoke with her son Merlin and explained the situation. He reiterates a desire to follow her wishes and let her go. Assessment - Stable. Plan - Continue current medications. 
Signed Robert Weitzel, M.D.
     
12/11/95
OT		   An attempt was made to continue with evaluation. Patient was unable to comply secondary to medications preventing arousal. Occupational therapy will attempt to communicate with her tomorrow. J. V. ? COTA/L
     
12/12/95   Putting out some urine, despite poor fluid intake. Vital signs stable, afebrile. Very demented. Risperdol seems to be controlling most of her agitation. Assessment - stable. Plan - continue current care. 
Robert Weitzel, M.D.
     
12/13/95
MD		   Answered one question intelligibly today: "How are you?" - "I feel bad," then refused to answer. Eating and taking fluids now. Vital signs stable, afebrile. Appears to be in some pain. Remains fairly profoundly demented. Assessment - Major depressive disorder with psychotic features. Plan - continue Klonopin taper, and Serzone and Risperdol. Morphine sulfate for pain .
Signed Robert Weitzel, M.D.
     
12/13/95
OT		   Patient was unable to be assessed today secondary to medication. J.V.? COTA
     
12/14/95
MD		   Has made a miraculous recovery; ambulated yesterday, taking food well. Vital signs stable, afebrile. Assessment - Doing much better. Remains demented. Plan - continue current treatment. 
Signed Robert Weitzel, M.D.
     
12/14/95
RD		   Weekly nutrition summary: oral intake very poor, must have assist with feeding at all meals, generally 5-30% of meals eaten. Goal for patient - 30% of all meals to be eaten. Weight decreased to 121.8 lbs (decreased approximately 1lb.) 12/9/95 albumin 3.3 decreased total protein 6.5 Glycolated hemoglobin - 5.8 - within normal limits. Pureed diet order appropriate, will make changes on breakfast meal to increase intake. Adding (?) to all meals to encourage increased oral intake of kilocalories/ protein. Following. M. Fagg, RDCD
     
12/15/95

MD

   Responded to me this morning fairly appropriately. Blood pressure a little labile. Dysphoric. Often lethargic. Mildly febrile yesterday, now okay. Assessment - Major Depressive Disorder with psychotic features, improved. Better intake. Plan - continue treatment, probably won't need "hospice."
Signed Robert Weitzel, M.D.
     
12/16/95
MD		   Continues to do well, despite earlier moribund state. Vital signs stable, afebrile. Demented, but much more responsive. Eating/sleeping well. Assessment - improved. Plan - continue current care.
Signed Robert Weitzel, M.D.
     
12/17/95
MD		   Stable, doing well. Vital signs stable, afebrile. Assessment - Stable. Plan - continue current care.
Signed Robert Weitzel, M.D.
     
12/18/95
MD		   I spoke extensively with her son this morning to inform him of the changes in her status. We will have to wait and see how she does in future before making plans for placement. Although quite demented, she is self-feeding, walking, and responding in a semi- normal manner to questions. Vital signs stable, afebrile. Assessment - much improved. Plan - Decrease Risperdol. Signed Robert Weitzel, M.D.
     
12/18/95 ?
Recreation Therapy		   Recreation weekly -patient has made a lot of progress this week. Earlier she wasn=t able to attend group due to confusion and calling out. She has woke up able to follow simple commands. Will continue encouragement and (R.O.?) with her encouraging interaction. B. Foulger, IRT
     
12/19/95
MD		   Doing well, although quite demented. Vital signs stable, afebrile. Fed herself tonight. Assessment - stable. Plan - continue current care. Signed Robert Weitzel, M.D.
     
12/20/95
MD		   Continues with slow improvement. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. 
Signed Robert Weitzel, M.D.
     
12/21/95
MD		   Sleeping well. Vital signs stable, afebrile. Doing quite well: feeding herself, much more alert, better energy, answers responsively, occasionally labile mood with tears. Remains demented. Assessment - improved. Plan - continue current medical treatment. 
Signed Robert Weitzel, M.D.
     
12/22/95
FT		   Social Work Note: Met with patient=s son and daughter-in-law. Discussed patient's progress. Facilitated discharge planning. Family is considering various nursing home facilities which include Holladay Care Center, St. Joseph=s Villa and possibly Godfrey's in Brigham City. Encouraged son to discuss those options with siblings to determine which facility family deems most appropriate. Provided supportive counseling. K. Steglich, CSW
     
12/22/95
MD		   Remains demented. Stable overall. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.
     
12/23/95
MD		   I was called regarding patient being somewhat unresponsive with nystagmus yesterday, but now she is doing well, overall. Mild fever (versus borderline normal), vital signs stable. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.
     
12/24/95
Nursing		   Weekly nursing note: patient has at times fed self and responded to questions appropriately this week, but at other times has been unresponsive, unable to (continued) L. Long, RN
12/24/95
Nursing		   (continued) feed self, staring with flat affect or sitting with eyes closed, at times refusing medications or food by tightly clamping lips together. Continue current care. L. Long, RN
     
12/24/95
MD		   Quite lethargic. Vital signs stable, afebrile. No assaultive behavior. Sleeping well. Eating fairly well, overall. Has few bowel movements. Assessment - Stable. Plan - Prune juice. 
Signed Robert Weitzel, M.D.
     
12/25/95
MD		   Remains less responsive than one week ago, after the initial improvement. No agitation. Slept well. Vital signs stable, afebrile. Assessment - stable. Plan - continue current therapy.
Signed Robert Weitzel, M.D.
Addendum - patient seems to be in pain, once woken. Will try some low dose Morphine sulfate at frequent intervals, to see if this is the problem.
Signed Robert Weitzel, M.D.
     
12/26/95
OT		   Occupational Therapy Weekly Summary Note: Patient attended occupational therapy group sessions 50% this week. Patient cannot follow one-step commands and requires multiple cues to redirect. Patient continues to make inappropriate comments when in group. J.V.? COTA/L
     
12/26/95
MD		   Yesterday morphine sulfate was tried for comfort care. She had a seizure this morning, was started on Dilantin, looked pretty ill at first, blood pressure decreased; now feeding self again. Assessment - Unstable health status. Plan - continue current medications and ltreatment.
Signed Robert Weitzel, M.D.
     
12/27/95
MD		   No evidence pain now - no crying out - does appear quite lethargic. Vital signs stable, afebrile. Assessment - same. Plan - continue to observe. Robert Weitzel, M.D.
     
12/28/95
Dietary		   Weight 125 lbs, increased 4 lbs since admission. New labs: albumin 2.7, total protein 5.8. Intake continues to vary greatly. Nursing reports that patient does better with very liquid foods, especially (?) and Healthshakes. Will provide these with each meal and Sustacal (free of charge) three times a day. Will monitor intake, labs and weight. R. Warner Nutritionist
     
12/28
Rec		   Recreation note - for a few days patient was awake attempting to participate . Her medical condition deteriorated so she was unable to participate - will continue working with her. B. Foulger, IRT
     
12/28/95
MD		   I met with her son and daughter-in-law. She appears medically stable at this point. The Dilantin appears to be causing some sedation; the lethargy continues. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.
     
12/29/95
MD		   Has quit feeding self - stares off into space. No further seizure activity. I wish to keep medications to a minimum. Vital signs stable, afebrile. Assessment - Major Depressive Disorder with psychotic features, status post cerebrovascular accident, dementia. Assessment - discontinue Dilantin - we=ll see if we can get her to be responsive again. If she seizes will use intramuscular Ativan.
Signed Robert Weitzel, M.D.
     
12/29/95
Social Services		   Late entry for 12/26/95. Social Work Weekly Summary Report: Patient involved in individual and group at times therapy. Patient participation in group very limited. Patient alert, but disoriented and confused. Patient participates in one-on-one therapy but limited in ability to verbalize feelings, has difficulty tracking. Continue with master treatment plan. K. Steglich, CSW.
     
12/30/95
MD		   Met with son and daughter this evening regarding patient=s condition; she had coffee grounds - vomitus of greater than 200 cc this morning. Stomach is distended, has hyperactive bowel sounds, heart rate quite erratic. Assessment - gastrointestinal bleed. Plan - make sure she's comfortable with routine morphine sulfate .
Signed Robert Weitzel, M.D.
     
12/31/95
MD		   Unresponsive. Melena during the night. Blood pressure fluctuates and is low, generally. Taking no oral fluids or nourishment, is receiving oral care. I spoke to her son per telephone this morning, and am meeting with son and daughter soon. Afebrile. Assessment - gastrointestinal bleed, low blood pressure, unresponsive. Plan - continue comfort care. Robert Weitzel, M.D.
     
1/1/96
MD		   Generally unresponsive. Blood pressure remains pretty good. Seems in some discomfort. Afebrile. Assessment - Quite ill. Plan - Increase morphine sulfate dose schedule (decrease interval). PRN now. Continue all comfort care. Robert Weitzel MD
 
     
1/02/96
Nursing		   Weekly Nursing Advocate note: Patient's medical status has rapidly and profoundly deteriorated this week. She has experienced a seizure and multiple episodes of vomiting coffee grounds material. She is no longer verbally responsive. The care plan has been altered to reflect the need to support patient and family through a positive death and dying process.  Patient is currently receiving morphine sulfate intramuscularly every 3 hours for comfort. L. Wilson, RN
     
1/02/96
MD		   Stable vital signs, actually. Unresponsive, overall, does open eyes at times. Afebrile. Assessment - quite ill. Plan - continue comfort care. Robert Weitzel, M.D.
     
1/02/96
OT		   Patient continues to require maximum assist to arouse: patient is unable to participate in sessions secondary to decreased arousal. J.V. ? COTA
     
1/03/95
MD		   Despite 5 mg of intramuscular morphine sulfate at 0730 and 0930, patient has not responded at all - eyes open, groaning, appears in some pain. Unfortunately, nursing staff have been holding morphine sulfate for low respiratory rate. Remains unresponsive to any questions. Vital signs stable, actually, and she=s afebrile. Assessment - stable. Plan - morphine sulfate 25 mg now, continue with 5 mg every 3 hours, PRNs as needed. Robert Weitzel, M.D.
     
1/4/96
MD		   Patient given large amounts of morphine sulfate yesterday evening for comfort. Finally, she expired at about 8 p.m. Appeared to be in no pain. Assessment - respirations decreased, poor blood pressure secondary to dehydration leading to cardiac arrest. Plan - release to family. Robert Weitzel, 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