Mary Crane

Brief History and Hospital Course

This 72 year old white female who had history of severe dementia, depression, agitation and combativeness suffered thalamic CVA in 1989, six years PTA, and had history of severe chronic low back pain after disc surgery, treated generally with opiates daily for years. She had chronic hyponatremia secondary to psychogenic polydipsia; she was reported to drink even from toilets, when on therapeutic fluid restriction, unless restrained. She also had history of HTN, PUD, meningitis, TIA’s, and psychotic depression. On admission her medications included Dyazide, Lasix, Glucotrol, Hyphen, Lopressor, Zantac, prn Lortab, as well as Thorazine, Zoloft, Tranxene, and prn Xanax.

Previous medications were continued but Duragesic patch 25 mcg./hour then 50 mcg./hour was substituted for Hyphen and Lortab. K-Dur was added, and Risperdal and Serzone were substituted for her previous psychotropics; she also was given trazodone for sleep. A UTI was treated with Cipro, Dyazide was discontinued, and hyponatremia treated with fluid restriction. Despite these measures, her psychiatric symptoms continued.

A rectovaginal fistula was discovered, GYN consulted, and she was started on Keflex. Because of history of possible seizure disorder, and valproate’s effect with aggressive agitation, Depakene was added. The patient continually complained of pain; moaning, groaning, and screaming, and had morphine prn’s given by the nurses, then Duragesic patch increased to 75 mcg./hour.

On about the eighth hospital day, on the 4^th, the patient apparently aspirated; CXR was clear but clinically she had breathing and airway problems and was choking on her food. This continued and then on 1/7, her eleventh hospital day, she became acutely and seriously ill, with hypernatremia (sodium of 159) white count up at 15K, hypotensive, and oxygen saturation of only 70 to 80. CXR showed a possible infiltrate. She appeared septic, secondary either to aspiration or the rectovaginal fistula, despite Keflex started previously.

The patient’s family refused aggressive intervention, and an IV was not started, following her Medical Treatment Plan. All medications, including her Duragesic patch, were ordered to be discontinued. She did have ordered and received two doses of morphine 5 mg. IM at that point, apparently in conjunction with the Duragesic, which the nurses failed to remove and which was found at autopsy. She died the evening of the 7^th, with her family at her side.

Mary Crane Phone Intake Data

DAVIS HOSPITAL AND MEDICAL CENTER GEROPSYCHIATRIC UNIT

1600 WEST ANTELOPE DRIVE

LAYTON, UTAH 84041

MEDICAL TREATMENT PLAN

Patient’s name: Mary Crane Date: 12/28/95

I, certify that I am the attending physician for the patient listed above. The declarant, the above named patient, is currently suffering from the following disease or illness:

I certify that I have explained to the declarant to the extent he/she is able to understand and to all available persons acting as proxy, the reasonable available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:

Directed by the declarant; or

That the declarant has a physical or mental condition which renders him or her unable to give personal direction for care and treatment and that the care and treatment alternatives directed below are in my opinion, and in the opinion of the declarant’s proxy, what the declarant would probably decide if able to give current direction concerning his/her care and treatment.

Date: 12/30/95Attending Physician: (Signed) Robert A. Weitzel, M.D.

The following care and treatment is directed with respect to the declarant:

YES NO YES NO

X ____ Do Not Resuscitate (DNR) ____ X Chemotherapy

X ____ Oxygen therapy _____ X Radiation

X ____ Respiratory therapy ____ X Surgery (advise family)

X ____ Suctioning ____ X I.V. fluids

____ X Mechanical ventilation ____ X NG (Nasal gastric tube - fluids feeding)

____ X CPR (CardioPulmResusc) ____ X Gastric tube

____ X Chest compression X ___ Oral Antibiotics

____ X Cardiac medication X ____ I.M. Antibiotics

____ X Defibrillation X ____ I.V. Antibiotics

(signed )Karen Bringhurst

Relationship to declarant of Signature of declarant or authorized agent/date

any signing for declarant

E. Cozzens, R.N.2499 Builders Drive, S.L.C. UT 84118

Facility Representative Complete Address

The following care and treatment or withholding of treatment is directed with respect to the declarant:

YES NO YES NO

X ____ oxygen therapy ____ X IV fluids

X ____ respirator treatments ___ X NG (nasal-gastric tube

X ____ suctioning for fluids feedings)

____ X mechanical ventilation ____ X gastric tube (for feedings/fluids)

____ X ventilator support X ___ oral antibiotics

____ X CPR X ____ IM antibiotics

____ X chest compressions X ____ IV antibiotics

____ X cardiac medications ____ X defibrillation

during CPR ____ X surgery

____ X chemotherapy ____ X radiation

Date: 3/22/91Attending Physician: Sara Anderson M.D.(?)

Self (Signed) Mary R. Crane

Relationship to declarant of any Signature of declarant or authorized agent

agent signing for declarant

Address of signer, including city, country and state of residence

Mary Crane Nursing Admission Assessment Page 1

Mary Crane Nursing Admission Assessment Page 2

Mary Crane Nursing Admission Assessment Page 3

Mary Crane Nursing Admission Assessment Page 4

Mary Crane Nursing Admission Assessment Page 5

Mary Crane Nursing Admission Assessment Page 6

Mary Crane Nursing Admission Assessment Page 7

Mary Crane Nursing Admission Assessment Page 8

Mary Crane Nursing Admission Assessment Page 9

Mary Crane Nursing Admission Assessment Page 10

Mary Crane Nursing Admission Assessment Page 11

Mary Crane Nursing Admission Assessment Page 12


12/28/95 1800		PRN medication given: Tylenol 650 mg by mouth given as ordered as patient complains of headache. D. Kley, RN
2000		Tylenol helpful. Patient complains of "still have headache, but it's better." D. Kley, RN

1600

Admission note. Behavior. Patient admitted to Geropsychiatry with diagnosis of depression with psychotic features. Long history of depression and psychiatric interventions. Has worked as LPN until death of her husband, then unable to cope with the stress. Comes to us from care center, where she has been biting, kicking, and verbally abusing staff. History of hyponatremia - craves fluids enough to drink from toilets when fluids are restricted. Has had seizure secondary to hyponatremia "in the past". Intervention - oriented patient and family to unit layout and policies. Completed admission assessment. Belongings inventoried.. 1800 calorie ADA diet provided. Duragesic patch instituted for chronic back pain due to old disc injury. Response - patient calmer, more quiet in late evening. (earlier yelling quite a bit). Does eventually respond to comfort measures. Plan- see treatment plan. L. Wilson, RN

12/28/95

Psychiatric evaluation done and dictated. Diagnosis: major depressive disorder with psychotic features. Plan - Risperdol / Serzone,/ Trazodone. Medical workup. Duragesic for pain. Robert Weitzel, M.D.

DAVIS HOSPITAL & MEDICAL CENTER

PSYCHIATRIC EVALUATION

PATIENT: Crane, Mary

Robert A. Weitzel, M.D.

12/28/95

CHIEF COMPLAINT

"Put me to bed, I just want to go to bed."

IDENTIFYING INFORMATION

This is a 72 year-old widowed white female who had recently been at Sandy Regional.

HISTORY

This patient had been on the Alzheimer’s unit after having had a stroke in 1989. She has been extremely agitated, spitting, aggressive, drinking out of the toilet, hitting, verbally abusive, running into others with her wheelchair and screaming. She sticks her fingers down her throat to throw-up. She is very anxious, agitated, and complains of low back pain and headaches. She has been transferred to our unit for treatment of her depression and psychotic features.

PAST PSYCHIATRIC HISTORY

Apparently she has had a long history of previous depression. Currently she is on no antidepressants. She also has a history of apparent psychogenic polydypsia with hyponatremia, down to 108 and there were seizures associated with this. I have no clear history as to her previous psychiatric medications or antidepressants. I do have a report that she had been on Thorazine for some time and she does exhibit some signs of tardy dyskinesia.

PAST MEDICAL HISTORY

She had a stroke in 1989, has had a herniated disc in 1984, and poor control of her pain since then. She had a gastrectomy in the 1980’s, secondary to history of GI bleeds. She has been treated for this with Zantac and Carafate. As noted above, she has had chronic low sodium because of polydypsia.

Continued…..

PSYCHIATRIC EVALUATION

Mary Crane

Page 2 … PE

Robert A. Weitzel, M.D.

MEDICATIONS: Current medications include Zantac 150 mg b.i.d., Lopressor 100 g b.i.d., Glucotrol 5 mg q. a.m., Hyphen one tablet p.o. q. 4. hours p.r.n. pain, Dyazide one p.o. q.o.d., Lasix 30 mg p.o. q.o.d. (Dyazide and Lasix on alternate days), artificial tears, Carafate, Metamucil, ferrous sulfate.

SOCIAL HISTORY

As noted above, she is a widow, she has been treated in the alzheimer’s unit for some time. She had worked as an L.P.N. She has one year of college in the L.P.N. program. She worked at Salt Lake County Hospital and then in an extended care facility. She stopped working in 1976. She is L.D.S. She apparently does not smoke or drink.

FAMILY HISTORY

I have no history available for family history.

PATIENT STRENGTHS

She is verbal.

PATIENT LIMITATIONS

Dementia, chronic depression.

MENTAL STATUS EXAMINATION

In general the patient is an elderly appearing female in a wheelchair. Speech is normal in rate, rhythm, fluency, mood is quite dysphoric. Affect slightly labile. Thought process is slightly loose and there is some blocking thought content, revolves around getting into bed and relieving the pressure on her back. Hearing is fair, sight is fair. Cognition, IQ seems somewhat grossly depressed secondary to dementia. Calculations were not attempted. Memory is intact to some remote but very poor to immediate recall. She only remembered one of three objects with prompting. Fund of knowledge not tested, insight is poor, judgement is poor.

Continued…..

PSYCHIATRIC EVALUATION

Mary Crane

Page 3 … PE

Robert A. Weitzel, M.D.

DIAGNOSIS

Axis I: Major depression with psychotic features.

Axis II: Defer.

Axis III: DVA probable MID, history of BI bleeds, hypertension, and adult onset diabetes.

Axis IV: Three.

Axis V: Twenty-two.

DISCUSSION & RECOMMENDATIONS

THE PATIENT WAS STARTED ON Sersone and Risperdol to treat her depression and psychotic features. She will also be on Trazodone for sleep. I will give her Duragesic patch in a low-dose for her pain. Given her dementia and general medication condition I have very little fear of negative consequences of any addiction. We will set firm limits on her negative and aggressive behaviors and hope that in two or three weeks she will improve.

ESTIMATED LENGTH OF HOSPITALIZATION

Two to three weeks.

DISCHARGE CRITERIA

No agitation improved mood, no aggressiveness.

DISCHARGE PLAN

Back to her previous center.

(Signed)

Robert A. Weitzel, M.D.

RAW/

D: 12/28/95 19:40

T: 12/29/95 10:15

Job# 3577

I CERTIFY THAT THIS PATIENT
NEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED Robert Weitzel, M.D.
DATE 12/28/96

12/28/95
Allergies;
Admit to Geropsychiatric Unit per Dr. Weitzel
Condition guarded
Preliminary diagnosis: depression with psychotic features ~~provisional psychosis~~
Activity: wheelchair, assist with transfers
Diet: American Diabetes Association 1800 calorie per day mechanical soft
Vital signs twice a day
Special precautions every 15 minutes check for 24 hours
AIMS test
Occupational therapy evaluation and treatment - adaptive equipment and wheelchair cushion, nonslip fabric.
EKG
Chest x-ray
Labs:CBC, Chem 20 RPR, T7, TSH, Urinalysis with culture and sensitivity if indicated.
Medications:
Tylenol 1-2 tablets every four hours as needed for pain.
Mylanta 30 cc by mouth every four hours as needed for dyspepsia. Milk of Magnesia 30 cc by mouth every evning as needed for constipation.
Zantac 150 mg by mouth twice a day
Lopressor 100 mg by mouth twice a day
Glucotrol 5 mg by mouth every morning
Accuchex before meals and at bedtime for 3 days.
Dyazide 1 tablet by mouth every other day (even days)
Artificial tears, one drop both eyes every 3-4 hours as needed while awake as needed for dry eyes.
Carafate 1 gm twice a day by mouth 0700 and 1600.
Lasix 80 mg by mouth every other day (odd days)
Ferrous sulfate 325 mg by mouth every day with food
Metamucil 1 Tablespoon 3 times a day with meals
Please crush medications
Allergies: Penicillin, Dilantin, Catapress, Aspirin leads to ulcers, phenobarbital.
Risperdol 1 mg every morning 1700 and bedtime.
Serzone 50 mg by mouth twice a day for 2 days, on 12/31 increased to Serzone 100 mg by mouth twice a day.
Trazodone 100 mg by mouth every bedtime, may repeat once as needed for sleep.
Mineral ice topical ointment twice a day as needed for headache (patient=s own).
Telephone order Dr. Weitzel L. Wilson, RN, MSW
Thanks, Robert Weitzel, MD
Noted L. Wilson, RN 12/28/95 1900

12/28/95 1915
Duragesic patch 25 micrograms transdermal. Change every 3 days in the evening.
Do Not Resuscitate
Verbal order Dr. Weitzel, L. Wilson, RN
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95
(unknown time)

12/28/95
Relafen 1000 mg with food now.
Thanks, Robert Weitzel, M.D.

12/28/95
Change Duragesic to 50 microgram transdermal patch every 3 days. Apply in evening at 1900
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95 2100

12/29/95

0615

Free text: Patient slept all shift, until she was awakened for her chest x-ray. No problems noted this shift. ?CNA

0800

Duragesic patch came off. New Duragesic applied. S. Hansen, RN

Mary Crane EKG

12/29/95
Chem 7 in morning on 1/1/96.
Thanks, Robert Weitzel, M.D.
12/29/95 1100 Noted S. Hansen, RN

12/29/95

Social Service

Patient was cognizant and alert when Social Worker I gave her the admission CQI's. Patient scored a 14 on the mini-mental status exam, and a 7 on the Geriatric Depression Scale. D. Padilla, SWI, K. Steglich, CSW

12/29/95 1 p.m.
1. Check with family regarding past right shoulder injury and evaluation.
If none - perform x-rays right shoulder per Dr. Detricksen (?)
2. Hemoccult stools
Thanks, D. Dienhart, M.D.
Noted L. Wilson, RN 12/30/95 0030

12/29/95 1 p.m.
Medicine Consult note: (asked to evaluate by Dr. Weitzel).
Impression:
1. History right thalamic stroke 1990 with residual partial left paralysis.
2. History of hypertension with increased coronary size on chest x-ray.
3. History chronic hyponatremia - possible polydipsia
4. Peptic ulcer disease, status post partial gastrectomy and vagotomy.
5. History lumbar disc surgery and chronic low back pain.
6.Right shoulder unknown abnormal density on chest x-ray.
Recommendation:
1. Agree with non-steroidal anti-inflammatory drugs and duragesic patch.
2. Consider decreasing Lasix to daily dose of 20-40 mg.
3. Consider discontinuing Diazide.
4. If more anti-hypertensive required, consider low dose acetylcholinesterase inhibitor, i.e. Zestrol 10 mg., especially with increased coronary size on x-ray.
5. Fluid restrict 1400 cc. per day if needed for decreased sodium
6. Potassium chloride probably can be decreased if Lasix and Diazide stopped
Full note dictated
Thanks, D. Dienhart, M.D.

Mary Crane Chest X-Ray 1 Dec. 29

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: CRANE, MARY

DATE OF CONSULTATION: 12/29/95

ATTENDING PHYSICIAN:

CONSULTING PHYSICIAN: DAVID DIENHART, M.D.

REASON FOR CONSULTATION

Medical evaluation on admission to the Geropsych Unit, provisional psychosis.

HPI

Mrs. Crane is a 72 year-old Caucasian female admitted now to the Geropsychiatric Unit with history of recent aggressiveness, verbally abusive behavior, increased anxiety, agitation.

PAST MEDICAL HISTORY

GENERAL:

1. Right cerebrovascular accident, 11/90, right thalamic region resulting in left hemiparesis. She is currently limited to the wheelchair and bed activities with significant left partial paralysis. She is also debilitated by chronic low back pain with history or prior low back surgery.

1. 1. Hypertension.

2. 2. Also remarkable for a history of chronic hyponatremia, in the 130 to 135 range, occasionally in the low 120 to 125 range, unclear etiology but by history has been evaluated in the past by her primary physician.

3. 3. History of peptic ulcer disease.

4. 4. Remote history of meningitis.

5. 5. History of transient ischemic attacks.

Today Ms. Crane has no complaints and she denies any shortness of breath and chest pain; she denies any significant pain. She has been placed on a Duragesic patch as well as Relafen for her low back pain with resultant marked improvement.

CONTINUED….

REPORT OF CONSULTATION

CRANE, MARY

PAGE 2…

DAVID DIENHART, M.D.

SURGERIES: 1. Partial gastrectomy vagotomy. 2. Lumbar disc surgery.

MEDICATIONS: Tylenol one to two p.o. Q 4hrs pain, Mylanta 30 cc p.o. Q 4 hours dyspepsia, Milk of Magnesia 30 cc. p.o. Q h.s. PRN constipation, Zantac 150 mg. P.o. BID, Lopressor 100 mg. P.o. BID, Glucotrol 5 mg. P.o. Q a.m., Accuchecks a.c. and h.s. x 3 days, Dyazide one tablet p.o. QOD, Artificial Tears Q 3 hrs PRN for dry eyes, Carafate one gram BID, Lasix 80 mg. QOD, ferrous sulfate 325 mg. P.o. daily, Metamucil one tablespoon TID, Risperdol 1 mg. Q a.m. at 5 p.m., Serzone 50 mg. P.o. BID for two days and then increased to 100 mg. P.o. BID, Trazodone 100 mg. P.o. Q h.s., Relafen 1000 mg. Given on 12/28/95 and Duragesic 50 ug patch Q 3 days, K-Dur 20 mEq BID.

ALLERGIES: PENICILLIN, CATAPRES, DILANTIN, TAGAMET, ASPIRIN, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, MEPROBAM.

SH: The patient has three children. The patient does not smoke or drink alcohol.

PHYSICAL EXAMINATION

GENERAL: The patient is a supine, elderly female, oriented to person, place, hospital site, Salt Lake City, year 1995, time of year (just after Christmas). The patient cannot recall the President of the United States.

VITAL SIGNS: Vital signs on admission show blood pressure 130/80, weight 148 pounds, temperature 98.1, respiratory rate 20 per minute, pulse 80.

HEENT: PERRLA. Conjunctiva are pink. Right TM is obscured by cerumen, the left is visualized and is dull. Nasal mucosa is pink, throat is clear. The patient has no teeth in her uppers and dentition is in poor repair in the lowers.

NECK: Supple. No adenopathy.

CHEST: Axilla show no adenopathy. Breasts are pendulous with no masses palpable. Lungs are clear without wheeze. There are minimal basilar rales are present.

HEART: Regular.

ABDOMEN: Soft, nontender with no hepatomegaly.

EXTREMITIES: No edema.

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 3

DAVID DIENHART, M.D.

DIAGNOSTIC STUDIES

EKG is normal sinus rhythm at 62 beats per minute, no acute ST T-wave changes.

Chest x-ray PA and lateral: enlarged cardiac silhouette, clear lung fields, density in the right shoulder region of uncertain significance, may represent old trauma but could not exclude a degenerative or metastatic process per Dr. Dedrickson.

Lab: sodium 131, potassium 3.3, chloride 99, CO2 30, anion gap is 2, glucose is 111, BUN 35, creatinine 1.4, calcium 9.1, uric acid 6.8, cholesterol 189, triglyceride 163, total protein 5.6, albumin 2.9, total bilirubin 0.4, alkaline phosphatase 112, GGT 16, ALT 12, AST 16, LDH 72, phosphorous 2.9, magnesium 2.2, iron 39, T3 31.6, T4 6.3, T7 1.99, pending TSA.

WBCs 9,400, hematocrit 35.7, MCV 82.3, platelet count 418,000, RPR is nonreactive.

IMPRESSION

Anemia, mild.
Hyponatremia.
Hypokalemia.
Mild metabolic alkalosis.
Hypoalbuminemia.
Low serum iron, may represent anemia of chronic disease.
History, right cerebrovascular accident, right thalamic region, 11/90, with residual left hemiparalysis.
Chronic low back pain, secondary to disc disease.
Hypertension.
History of peptic ulcer disease, status post partial gastrectomy vagotomy.
Right shoulder density, unclear etiology.
Cardiac silhouette enlargement by portable AP chest x-ray, possibly secondary to hypertensive cardiovascular disease, unknown, left ventricular function.

RECOMMENDATIONS

Agree with adequate pain control with nonsteroidal anti-inflammatory drugs and Duragesic, however, it has listed as allergy to nonsteroidal anti-inflammatory drugs on a past medication list. This may be from her past history of peptic ulcer

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 4

DAVID DIENHART, M.D.

disease. If she has had a vagotomy and partial gastrectomy, this may no longer be problematic.

Her laboratory suggests a mild volume depletion secondary to diuresis. Her low sodium may be a combination of this diuresis and a component of psychogenic water drinking although this evaluation is not clear.
If her sodium becomes problematic would suggest restriction of fluid to 1200 to 1400 cc per day.
For anti-hypertensive control with her current well controlled blood pressures, would consider discontinuance of Dyazide which will also aide in diminishing problems with hypokalemia, and decreased Lasix to a daily 20-40 mg. dose. Her potassium titration may need to be lessened with these changes. If she needs further anti-hypertensive control, would consider a low dose of an angiotensin converting enzyme inhibitor such as Zestril 10 mg. daily in addition to her current dose of Lopressor.
With consideration of possible mental status changes with H2 blockers, would consider stopping Zantac and the utilization of Carafate only. If needed, Carafate could be increased to a TID or QID dosage.
Would consider right shoulder films to evaluate right shoulder density see o chest x-ray.
Etiology for hypoalbuminemia is unclear, may represent poor nutritional intake. If any destructive lesions are seen on plain shoulder radiograph, would perform serum protein electrophoresis as well as other screening bone survey, i.e., of the pelvis and skull, to rule out any lytic disease consistent with myeloma.

Thank you for asking me to evaluate Ms. Crane.

(Signed)

David Dienhart, M.D.

DD/re

D: 12/29/95 14:01

T: 12/30/95 16:32

JOB #3712

24 hour check 0245 12/30/95 T. Scholl, RN

12/30/95
1. Discontinue Diazide
2. Lasix 40 mg by mouth every morning.
3. Cipro 500 mg by mouth twice a day for six doses.
4. Do Not Resuscitate
Thanks, Robert Weitzel, M.D.
Noted 12/30/95 1350 B. Hardy, RN

1230		Patient complains of pain "all over," medicated with Tylenol, 2 tablets by mouth. J. Jensen, LPN

1500		Behavior - patient has been in a flat mood today. Patient does not talk much; she just stares into space. When patient does talk she screams constantly. Intervention - offered patient meals, groups, and redirection. Response - patient ate 100% of breakfast and 80% of lunch. Patient attended groups but does not track. Patient needed redirection when she yelled out in the afternoon. Plan - to continue to redirect patient when she gets agitated and lethargic. Perry, CNA

12/30/95 1600		Respirations as though snoring, however; eyes wide open. Does not answer questions. No verbal responses. D. Kley, RN

2140		Behavior - patient quiet, nonverbal, first half of shift. Staring gaze. Would turn gaze slowly towards speaker without verbal response. Ate 80% of supper. Began to yell for help after supper. When asked what she needed, stated "I don't know." Had one medium green diarrhea stool this shift. Took medications as ordered. Has not displayed any verbal or physical abusiveness towards staff. Intervention - administered medications as ordered. Provided group. Monitored behaviors. Provided low stimuli environment. Response- patient did not participate in group. Was not responding verbally - was physically present. Took medications as ordered. Displayed no verbal or physical abusiveness towards staff. Plan - continue to administer medications as ordered. Provide a safe, low stimuli environment. Provide groups and one-on-one time as needed. D. Kley, RN

12/31/95
1. EEG on Tuesday 1/02/96
2. Trazodone 150 mg by mouth every bedtime.
3. Accuchex before meals and bedtime(4 times a day)for one more day.
Verbal order Dr. Weitzel/B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted 12/31/95 1250 B. Hardy, RN

1030

Patient very drowsy not able to stay awake. B. Hardy, RN

Behavior - patient has been very drowsy and hard to arouse today. Patient has been cooperative with staff when awake. Patient has been asleep in hall most of day. Intervention - offered patient activities of daily living cares, meals, one-to-one. Response- patient needed maximum assist with activities of daily living. Patient ate 100% of breakfast and 30% of lunch. Patient has not been interacting with peers. Plan - follow care plan. Encourage patient to stay awake. T. Sprague, CNA

12/31/95

1625

Behavior - patient has been up in chair this evening with some aggressive behavior towards staff. Patient would cry out "help me" but patient would not state what help was needed. Intervention - offered patient group, one-on-one, meal. Response - patient attended group, ate 50% of meal. Patient would reach for peers food but hardly ate any of her own. Plan - continue to follow care plan, and offer therapeutic environment. Unknown writer

12/31/95 1930 Telephone order Dr. Weitzel
1. If patient refuses Risperdol, give Haldol 5 mg intramuscularly.
2. Ativan, 1-2 mg by mouth or intramuscularly every 4 hours as needed for severe agitation.
Signed Robert Weitzel, M.D.
Noted L. Long, RN 12/31/95 1930

1625-2300

Med Note

Free text: Patient was increasing agitated from 7 p.m. on; screaming, trying to hit, biting CNA. Doctor notified, patient medicated with Ativan 2 mg intramuscularly with good results; patient settled down and agreed to take her evening medications. L. Long, RN

24 hour check L. Wilson 1/1/96 0030

1/1/96

11-7

Free text night shift - Patient rested quietly until 0500. Patient woke up and started moaning and wailing - when asked what was wrong, patient just stared at staff and wouldn't say anything. Patient was incontinent of urine twice. N. Hancock, CNA

1/1/96 AUTOMATIC DRUG STOP ORDER Patient: Mary Crane Room Drug(s) Exp. Date Last Dose 1. Duragesic patch 50 mcg transdermal, 2. change every 3 days in the evening, 1900 3. next dose due 1/1/96 4. According to hospital policy orders for these medications must be reordered or they will be discontinued. Signature: Robert Weitzel, M.D. Noted L. Long, RN 1/1/96 1700 (Mistaken entry B crossed out) 1/1/96 noon Decrease Duragesic patch to 25 mcg every 3 days CBC today, with differential. Signed D. Dienhart, M.D. 1/1/95 1210 Noted B. Hardy, RN			1/1/96 (noon) Medicine followup (asked to see by Dr. Weitzel) Report of vaginal stool today Patient more sedated. Received Ativan 2 mg last evening, Risperdol 3 times a day. Objective: Temperature 99.5, Respirations 24, Pulse 66, Blood Pressure 132/(80) Lungs clear, Abdomen soft Heart regular without murmur Vagina - brown fecal material on visual inspection Note 1/1/96 SMA-7, 12/28 WBC - 9400, Seg - 59 Impression: Probable rectovaginal fistula Recommend: 1. CBC today 2. Decrease Duragesic patch with increased sedation noted 3. Gynecology consultation Thanks D. Dienhart, M.D.

	1100	Behavior - patient had large soft greenish stool on toilet with staff assist. (B. Hardy,RN)

	1130	Patient had another stool in diaper while in Geriatric chair. When cleaning peri area, staff nurse observed bowel movement coming from vagina. Area cleansed and fissure was noted. Doctors notified. B. Hardy, RN

	1200	Doctor Dienhart in to see patient, received orders for CBC with differential and gynecology consult. Decreased Duragesic patch to 25 mcg. B. Hardy, RN

	1430	Behavior - patient very resistant to staff's efforts to perform activities of daily living. Patient kicking, biting staff's fingers when placing dentures in mouth. Patient would not stay placed in wheelchair, keep sliding down, grabbed other patient's meal trays (continued) B. Hardy, RN

1/1/96
1. Accuchex to continue after meals and bedtime.
2. Insulin sliding scale:
150 - 200 B 2 units regular insulin
201 - 300 B 5 units
301 - 400 B 10 units
>400 B 15 units and call M.D.
3. Duragesic - 50 mcg every 3 days
4. Trazodone 200 mg by mouth every bedtime as routine
5. Trazodone 100 mg by mouth every bedtime as needed for sleep (please try to give within one hour of routine Trazodone).
Thanks, Robert Weitzel, M.D.
Noted L. Long, RN 1/1/96 1700

24 hour check L. Wilson, RN 1/02/96 0030

1/1/96 2000
Telephone conversation with Dr. Hall, on call gynecologist at Tanner Clinic contacted: notified of large amount fecal matter excreted from patient=s vagina. Dr. advised getting consult in morning as planned since patient=s vital signs are stable at this time and no infection is indicated.
Lynn Long, RN

2210

Behavior - patient was physically and verbally abusive to staff this shift. Patient continued to hit, kick and try to bite staff members. Not easily redirectable. Intervention - tried to provide a safe environment for patient. Response - patient's response was very negative. Plan - continue with groups and medications per Doctor's order. Continue to follow care plans.

(Ables, CNA

24 hour check L. Wilson, RN 1/02/96 0030

1/02/96 11-7		Free text - night shift. Patient rested well all night, did not get up or make any complaints. N. Hancock, CNA
	1/02/96 MD		Slept last night. Gynecologist will probably see her today. Glucose fluctuating. Vital signs stable, afebrile. Assessment - improved with increased Trazodone. Plan - continue current care. Robert Weitzel, M.D.
	1/02/96 1. Glucotrol 5 mg by mouth twice a day. 2. Please chart all insulin given in diabetic chart. Thanks, Robert Weitzel, M.D. Noted 0730 1/02/96 S. Hansen, RN

1/02/96 Behavior - patient has been hitting, throwing food tray on floor and kicking staff. Patient has been uncooperative with staff. Patient has been alert and disoriented. Intervention - offered patient Activities of daily living group, meal. Response - patient needed maximum assistance with Activities of daily living. Patient attended group and participated. Patient ate 60% of breakfast and none of lunch. Plan - follow care plan, redirect patient when agitated. T. Sprague, CAN

1/02/96 Gynecology Consult
72 year old with complaint of fecal matter out of vagina. On exam has a high rectal vaginal fistula. Can repair under spinal anesthetic if patient cleared for surgery by her internist. Also may try to heal spontaneously (probably 25-35%) by treating with broad spectrum antibiotics and low residue diet (constipating).
Thanks, Steven Meeks MD

1/02/96 2100		(Mistaken entry, crossed out)

2110		Problem 1: - Behavior - patient has been very socially inappropriate. Patient has been hitting, biting, verbally aggressive at times. Patient is not cooperative with staff. Intervention - patient was offered medication, group, meals, snacks, fluids. Response - patient did not participate, however patient was not disruptive. Patient did eat well at dinner. Patient became very stubborn when she wanted to go to bed. Patient was told it wasn't time, patient forced herself in her room. Plan - patient needs to cooperate with staff. Patient needs to participate in group. Patient needs redirection when inappropriate. S. Thomas, CNA

24 hour check 1/03/96 T. Scholl, RN

1/03/96

11-7

Free text night: Snored all night with eyes open. Oxygen 1 2 liters nasal cannula color pale, skin warm and dry, no response. Temperature elevated, RN attempted to give Tylenol, unable to get her to take. Up and diaper changed once. Accuchex 178. D. Shelton, Can

1/03/96

EEG read as possible seizure: diffuse slowing, possibly metabolic versus cerebrovascular accident. Clinically, she shows evidence of absence and partial complex seizures. Continues to call out a lot, behavior is a problem. Quite febrile today, other vital signs stable. Continues to get insulin. Assessment - Diabetes Mellitus. Seizure disorder probable. Major depressive disorder with psychotic features. Plan - Add Depakene, change diet, oxygen by nasal cannula, check urinalysis tomorrow (now off Cipro). Robert Weitzel, M.D.

1/03/96
1. B-12 and folate - serum
2. Depakene syrup 250 mg by mouth every morning every 1700 and 500 mg by mouth every evening.
Robert Weitzel, M.D.

1/03/96 Oxygen by nasal cannula at 2 liters per minute
1/03/96 Urinalysis in morning
Thanks, Robert Weitzel, M.D.

1/03/96
1. Low fiber, low residue diet
2. Please have Dr. Dienhart made aware of gynecologist=s recommendations. (Give him my ~~beeper number~~ phone number 597-7979, so he can call me if necessary)
Thanks, Robert Weitzel, M.D.
Noted, Lynn Long, RN 1/03/96 1100

1/03/96 ~~1200~~ 1130 Telephone order Dr. Weitzel:
1. Morphine sulfate 3 mg intramuscularly now
Signed: Robert Weitzel, M.D.

Noted Lynn Long, RN 1/03/96 1200

1/03/96 1100 - Dr. Dienhart's secretary notified of phone number change. L. Long, RN

1/03/96 1445 Telephone order Dr. Weitzel:
1. Morphine sulfate 5 mg intramuscularly now.
Robert Weitzel, M.D.
Noted L. Long, RN 1/03/96 1445

0950 Med Note		Sleep well, calm in morning, agitated in afternoon, when going to bed. A.M. care complete. Hit out at the nurse. Intervention - offered group and fluid but was agitated with food. Response - became agitated in group, tried to calm patient. Plan - treat patient with medications and one-on-one care.

1130		Late entry: Patient crying out in group, groaning, yelling, grimacing. Dr. Weitzel called: patient subsequently medicated with Morphine sulfate 3 mg intramuscularly per Doctor's orders. L. Long, RN

1/03/95 1200 Med Note		Day shift notes continued. Free text; late entry: patient was calm after lunch, took a nap; Morphine sulfate effective in decreasing pain as evidenced by patient saying when asked if she still has pain, "no." L .Long, RN

NSG 1400 Med Note		Free text; late entry: patient awoke from nap yelling. When asked if she had pain, she said, "yes." When asked if her tummy hurt, patient said "no." Asked if patient had a headache: patient said "yes." Then patient yelled "oh, oh, oh, hurry!" Doctor notified; patient medicated with Morphine sulfate 5 mg per Doctor's order. L. Long, RN

NSG 1530 Med Note		Free text, med note entry: patient asked if she was still in pain. Patient said "yes" patient asked if she had head or tummy pain and patient responded "yes," although her diminished mental condition makes her responses suspect as far as accuracy goes. L. Long, RN

		(Mistaken entry - crossed out)

(No time noted) NSG		Behavior - patient called out repeatedly, patient was alert and disoriented. Patient remained with decrease affect all shift. Intervention - patient offered medications, meals, redirection, decreased stimuli at bedtime, one-on-one care for activities of daily living. Response- patient had short term compliance with redirection, resistant to ADL cares, grabbing caregiver's hands. Compliant with crushed medications in juice. Limited vocabulary when responding verbally (continued)

		(continued) or calling out. Patient was restless in bed, needing repositioning twice. Plan - explain all procedures to client, set limits for behaviors, document medication effects on behavior. R. Clark, LPN

1/03/96

(Mistaken entry - entire page crossed out)

24 hour check 1/04/96 0230 T. Scholl, RN

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room
Drug(s) Exp. Date Last Dose
1. Duragesic patch 50 mcg transdermal,
2. change every 3 days in evening 1/.4
3.
4.
According to hospital policy orders for these medications
must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.

1/04/96
1. Straight catheterization for today=s urinalysis.
2. Morphine sulfate 5 mg intramuscularly now, and then
every 4 hours as needed for pain.
3. Duragesic patch 75 mcg every 3 days
4. Valproic acid level in 2 days (in morning on 1/6/96)
Thanks, Robert Weitzel, M.D.
Noted T. Scholl, RN 1/4/96 0630

1/4/96 OT		Occupational Therapy note - Seating cushing has been researched and OT will discuss funding source and order of cushion with team tomorrow at team meeting. S. Nelson, (OTA?)

1/4/96 Individual Therapy		Individual session - talked to patient one-on-one. She was moaning throughout the session and could not be engaged in conversation. Staff reports that patient does talk, and frequently becomes agitated. S. Bennion, LCSW

1/4/96 Social Service		Social Work weekly progress summary. Patient has been involved in group and adjunctive therapies this week. According to group facilitators, patient's participation has been minimal. Individual therapy has been attempted but patient was unable or unwilling to engage. Continue with master treatment plan. S. Bennion, LCSW

1/04/96

1430

Behavior - patient has had a flat affect today. Patient has been hitting out at staff and spitting food at staff. Intervention - offered patient meals, groups, redirect. Response - patient ate 5% of breakfast and 90% of lunch. Patient needs much encouragement to participate in groups and to cooperate with staff, when they do transfers and when they give her medications. Plan - to continue to encourage patient when agitated and continue to redirect when confused.

( ? CNA)

1/4/96 2010		Patient coughing profusely with audible wet lung sounds noted after transferred to bed. No cyanosis noted, face reddened. Doctor Weitzel notified - ordered to notify respiratory therapy for treatment. Respiratory therapy notified. Suction set up at bedside if needed.
		1/4/96 2010 1. Notify respiratory therapy for treatment secondary to aspiration. 2. Swallow and speech evaluation in morning Telephone order Dr. Weitzel/D. Kley, RN Noted D. Kley RN 1/04/96 2010 Signed Robert Weitzel, MD
2015		Respiratory therapist arrived to unit, assessed patient. Patient with good strong cough reflex. Patient coughing up thick, mucousy, brown (from food or applesauce?) secretions. Less distressed.

2025		Patient no longer coughing, resting quietly in bed with eyes open. Respirations even and unlabored. Oxygen at 2 liters per nasal cannula.

2200		Patient turned on to left side. Resting quietly with eyes open. Respirations even and unlabored. Decreased lung sounds in bases with inspiratory scattered rales and wheezes throughout. Daughter (Karen) notified of incident. Call light within reach. D. Kley, RN

2205		Behavior- patient has been quiet this shift with somewhat glassy expression - stare. Occasionally yells out "help me!" When (continued) D. Kley, RN

1/4/96		(continued) asked what she needs, does not answer. Rocking in wheelchair after dinner, had to be asked to stop, as was posing a fall risk. Some difficulty swallowing noted at supper. Attended group; listened, however, did not interact. Took medication as ordered. Intervention - administer medication as ordered. Offered verbal redirection as needed. Provided group. Monitored behaviors. Response - patient quiet, yelling out occasionally, "help me." Attended group, did not interact, took medications as ordered. Plan - continue to administer medications as ordered. Provide groups. Monitor behaviors. Verbally redirect as indicated. Monitor lung sounds. Speech and swallow evaluation as ordered. D. Kley, RN

24 hour check 1/5/96 0200 (T. Scholl, RN)

1/5/96 RN

11-7

Patient slept through the night. Patient sounded gurgly early in night, suctioned once. Oxygen at 2 liters per nasal cannula. Respirations very erratic with periods of apnea. Respirations 8 to 12. Temperature 100.5 this morning. T. Scholl,, RN

1/5/96 MD		Continues to cry out in pain. Swallowing poorly - I was informed she may be aspirating. Has had fever, intermittently; this morning 100.5 now 99.9. To have swallow evaluation this evening. Assessment - no improvement. Plan - probably will hold on surgery. Chest x-ray and CBC. Morphine sulfate against pain. Robert Weitzel, M.D.


	0920 Med Note		Free text: Patient increasingly uncomfortable: groaning, moaning. Patient medicated with Morphine sulfate 5 mg intramuscularly. L. Long, RN

	1030 Med Note		Free text: patient continued to moan and groan audibly. Patient medicated with Morphine sulfate 5 mg intramuscularly as per Doctor's order. L. Long, RN

	1100		Patient silent, with eyes open, watching group activities. No answer to questions regarding her pain. L. Long, RN

1/5/96
1. Chest x-ray for aspiration pneumonia.
2. CBC now
3. Morphine sulfate 5 mg intramuscularly now.
Thanks, Robert Weitzel, MD
Noted L. Long, RN 1/5/96 1120

1/5/96 OT			Occupational therapist met with team and social worker to make recommendation for seating adaptation. Social worker will contact patient's family to arrange purchase. Nelson OTR

1/5/96 OT			Occupational therapy weekly summary: Patient unable to attend to a task or follow a simple one-step command at this time. Patient is unable to communicate her wants or needs with verbal cues and minimal assistance. J.V ? COTA/L

1/5/96 Family Therapy			Phone conversation with patient's daughter Karen. We discussed patient's condition and possible discharge plans. Her family is checking out other long-term care facilities before making a placement decision. I will talk to the family again next week about patient's progress. S. Bennion, LCSW

1/?/96 Dietary			Patient receiving puree with thick liquids secondary to recommendation from speech therapist. Patient oral intake varies 5 to 100%, generally 60-80%. Good intake secondary to staff has to feed her because she spits or throws her food. Diet order: decreased fiber, decreased residue, 1800 ADA diet with thick liquids puree. Sending snacks twice a day. Weight 148 lbs. Accuchex: 127. 12/28/95 - Albumin 2.9 (moderate depletion ) Total protein 5.6 decreased BUN 35 - 31. Toni Anderson, RD

	1430	Behavior: patient has had a flat affect today. Interventions - offered patient meals, group, redirect. Response - patient ate 30% of breakfast and 5% of lunch but was in groups but does not track groups. Patient has very flat affect and does not respond to staff. Plan - to continue to redirect patient when she is confused. ?CNA

1/5/96 2030		Free text. Patient=s breath sounds are audibly rattling and bubbling. Patient appears to have aspirated. Patient was suctioned and some mucous removed. Patient has decreased audible rattling and bubbling, but is still present. R. Clark, LPN

3p - 11p		Problem; altered thought process. Behavior - patient is more alert today. Able to sit up at dinner. Ate 90% of puree diet with staff feeding assistance. Verbally and visually responsive to the presence of others. Continues to have much difficulty clearing secretions. Intervention - patient was evaluated by speech therapy (please see consult notes) who requests that liquids be thickened. Observe and document behavior. Administer medications as ordered and monitor effects. Provide safe environment. Response - no evidence of hallucinations or other psychotic symptoms. Required suctioning twice to assist in management of secretions. Plan - continue interventions as specified above. L. Wilson, RN

2230		Patient suctioned twice, rattling breath sounds now absent. R. Clark, LPN

Chest X-Ray 2 Jan. 5

24 hour check 1/6/96 0030 T. Scholl, RN

1400		Behavior - patient has not hit or kicked anyone but has called out at times and been oppositional. Patient had to be fed, patient wouldn't feed herself. Intervention - support, one-ona-one time. Medications as per Doctor. Therapeutic environment. Response - demanding and withdrawn and doesn't acknowledge staff. Plan - medications as per Doctor. Therapeutic environment. E. Cozzins, RN

1/6/96

1710

Free text - patient medicated with Tylenol grains 10 by mouth for moaning. RN (Doe) made aware. Patient settled within 30 minutes. ? Signature

2200

Behavior - patient has moaned, "oh, help me" much of shift. When asked what she needs, does not verbalize needs. When spoken to, stares blankly at speaker. Took medications as ordered. Has not struck out at staff; however, grabs hold of whomever is near. Intervention - administered medications as ordered. Provided group, monitored behavior. Response - patient has not verbalized needs. Moaned most of shift (as needed pain medication given) Stares blankly. Did not participate in group. Took medications as ordered. Coughing a lot after Depakene syrup - suctioned back of throat with Yoncher, wet lung sounds. Oxygen 2 liters per nasal cannula. Plan - continue to administer medications as ordered. Provide groups. Redirect as needed. Monitor lung sounds closely. Monitor behavior. D. Kley, RN

1/7/96 11-7

1400

Night shift free text. Patient rested quietly throughout shift. Awake several times. Suctioned once for small amount, thick, dry, oral secretions. Respirations remain labored. Oxygen continuous by nasal cannula. Color pale. L. Wilson, RN

Behavior patient has had no episodes of being combative because she has been lethargic all shift. Intervention - Dr. Dienhart notified of patient's status. Family notified. Patient had oxygen per mask. Suctions times 3 by nurse and twice by respiratory therapy. Chest x-ray taken, lab drawn. Response - patient having labored respirations with periods of apnea. Saturation level 80 to 70 pulses irregular. Patient lethargic to almost unresponsive. Plan - medications as per doctor. Close observation. E. Cozzins, RN

VALPROATE: 40.9 (SUBTHERAPEUTIC)

1/7/96
SMA-7
Oxygen saturation level
Chest x-ray
Telephone order Dr. Dienhart/E. Cozzins, RN
Signed D. Dienhart, M.D.
Co-signed Robert Weitzel, M.D.
1/7/96 E. Cozzins, RN 1930

RESPIRATORY CARE
PULSE OXIMETRY
OXYGEN SATURATION
DATE 1-7-96 TIME 1445
On O2 AT 86 L/MIN. Or % MASK
Sp02(Sa02) ________%
OFF 0K2; Sp02 (Sa02) _____%
TECH: O2 remained on face via mask - notified nurses.
D. Baker CRTT

1/7/96 3:10 pm Medicine Consult (asked to see by Dr. Weitzel)
Possible seizure today for 10 seconds. Increased unresponsiveness for 3 days.
Oral intake decreased.
Oxygen saturations down to 70-80 B 86% on face mask
Chest x-ray (?) infiltrate
Lab - sodium 159, potassium 3.7, glucose 134
chloride 117, C02 33, BUN 47, Creatinine 1.9
Exam:
Reported blood pressure one hour ago 108/--
Now 60/palpable
Unresponsive, eyes point to right
Lungs: rales on right
Impression:
Hypotension/ possible sepsis
Probable seizure
Volume depletion and free water depletion
Probable aspiration
Case discussed with Dr. Weitzel patient felt to have declining status and wish not have CPR performed. If treatment chosen, would reduce volume repletion, free water repletion, antibiotics and possible ventilation. After discussion with primary medical Doctor will not offer(continued)
D, Dienhart, M.D.

1/7/96 3:10 p.m. Medicine followup
(continued) further aggressive supportive care
I suspect she may die soon.
Advise family notification.
D. Dienhart, M.D.

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room
Drug(s) Exp. Date Last Dose
1. ~~Serzone 100 mg po 2 x day 1/7~~
2. ~~Zantac 150 mg po 2 x day 1/7~~
3. ~~Risperdol 1 mg po am, 1700,hs 1/7~~
4. ~~Lopressor 100 mg po 2 x day 1/7~~
According to hospital policy orders for these medications
must be reordered or they will be discontinued.
DISCONTINUE - Robert Weitzel, M.D.

AUTOMATIC DRUG STOP ORDER
Patient: Mary Crane Room
Drug(s) Exp. Date Last Dose
1. ~~Carafate 1 gm po 2 x day 1/7~~
2. ~~Fesulfate 325 mg po/day w/food 1/7~~
3. ~~Metamucil 1 TBS 3x day w/meals 1/7~~
4. ~~Duragesic patch 75 mcg every 3 days 1/7~~
According to hospital policy orders for these
medications must be reordered or they will be discontinued.
DISCONTINUE - Robert Weitzel, M.D.

1/7/96

Has become quite ill today: febrile, low blood pressure, had extremely low oxygen saturation, sodium highly elevated, unresponsive; thrashing, with apparent pain and/or anxiety. Abdomen is distended. White blood cell count elevated, may have had a seizure earlier and aspirated. I have spoken with her two daughters and they do not want extraordinary measures taken, but would rather have comfort care given. Assessment - probable aspiration pneumonia, quite demented, hypotension, possible sepsis, volume depletion. Plan - will respect family's wishes; provide comfort care but no extraordinary care. Robert Weitzel, M.D.

1/7/96
1. Hold all above medications
2. Morphine sulfate 5 mg intramuscularly now and every 3 hours around the clock.
Thanks, Robert Weitzel, M.D.
1/7/96 E. Cozzins, RN 2100

1/7/96 2200		Behavior - patient has been unresponsive his whole shift. Intervention - comfort measures, turned every two hours. Morphine sulfate given. Response- patient Cheyne-Stoking very cyanotic. Plan - family with patient. Patient "Do Not Resuscitate." Morphine sulfate for comfort. E. Cozzins, RN
	1/7/96 Nursing Free text note			Free text note. Several immediate family members present with patient at 11 p.m. Patient remains unresponsive. Cheyne-Stokes respirations. Nursing supervisor present on the unit. At 11:40 pm patient is without vital signs. Dr. Weitzel has been notified of patient=s death and will request emergency room physician Dr. B. Neilson MD to pronounce patient. Midnight: Dr .B. Neilson, MD in to pronounce patient=s death. Larkin Mortuary has been notified by Kathy Dean, RN, Nursing supervisor. Emotional support provided to all family members. All are tearful but accepting of Mary=s death. Family members have retrieved all patient belongs from her room. Larkin Mortuary arrived at 0130. Laurie E. Wilson, RN, MSW

	2335		Expired. Belongings with family.

1/8/96 at 0015
Patient without vital signs - family been here. Mortuary notified - released to them.
Nielson, M.D.

1/8/96

As noted, patient died shortly before midnight. Body released to mortuary. Discharge summary dictated. Robert Weitzel, M.D.

1/8/96

1/8/96
Release patient=s body to mortuary,
Signed Robert Weitzel, M.D.

DAVIS HOSPITAL AND MEDICAL CENTER

DISCHARGE SUMMARY

PATIENT: CRANE, MARY

ROBERT WEITZEL, M.D.

ADM: 12/28/95

Dis: 1/8/96

HISTORY

The patient was admitted to the Geropsychiatric Unit with preliminary diagnosis of depression with psychotic features. She had quite demented for some time and is status post CVA.

HOSPITAL COURSE

On admission she was started on Zantac 150mg b.i.d., Lopressor 100mg b.i.d., Glucotrol 5mg q.a.m, Accu-Cheks, Dyazide one tablet q.o.d., artificial tears, Carafate 1 gram b.i.d., Lasix 80 mg q.o.d., Ferrous sulfate, Metamucil t.i.d., Risperdal 1mg t.i.d., Serzone 50 mg b.i.d., times two days with an increase to 100mg b.i.d. and Trazodone 100mg q.h.s.- may repeat times one. Additional labs were notable for sodium which was low at 131 but acceptable. Rather low potassium at 3.3. Non-reactive RPR. A UTI on UA. Acceptable CBC. Iron was slightly low. Her C&S grew out Kluyvera sensitive to both Cipro and Bactrim. TFTs came back normal. Repeat chemistries on the 1^st revealed rising sodium and potassium. Slightly elevated glucose. Repeat CBC on that day was essentially normal. B12 and folate were within normal limits. Repeat CBC on the 5^th revealed white count of 15 and chemistry on that date revealed sodium of 159 and chloride up to 117.

aOn the 28^th she was started on low-dose Duragesic patch and made DNR. On the 28^th also, Relafen 1000mg was given as a one-time order. On the 28^th the Duragesic was increased to 50mcg q. 3 days. On the 26^th K-Dur 20mgEq b.i.d. was started. Moderate fluid restriction was instituted. On the 30^th we discontinued her Dyazide and started Lasix 40mg p.o./q.a.m., Cipro 500mg p.o./bi.d. was given for six doses and once again DNR was ordered. On the 31^st we ordered an EEG, Trazodone was ordered 150mg p.o./q.h.s.. On the 31^st the patient was started on Haldol 5mg IM on refusing any Risperdal and Ativan was ordered as a p.r.n.. On the 1^st we continued her Accu-Cheks and instituted an insulin sliding scale. Duragesic was continued. Trazodone was increased to 200mg q.h.s. and 100mg q.h.s./p.r.n.. On the second Glucotrol was increased to 5mg b.i.d.. On the 3^rd she was started on Depakene syrup 250mg q.a.m., q. 1700 and 500mg q.h.s.. By the way, a Depakote level on the 6^th came back at 40. On the 3^rd she was also started on oxygen. On the 3^rd a UA was ordered for the morning and on the 3^rd low-fiber, low-residue diet was started

CONTINUED… DISCHARGE SUMMARY

DAVIS HOSPITAL AND MEDICAL CENTER

DISCHARGE SUMMARY

PATIENT: CRANE, MARY

Page 2…

I had talked to her gynecologist, Dr. Meek, and he felt okay with not doing surgery until after psychiatric care had been completed and felt that a low-residue diet and broad spectrum antibiotics were the best course. On the 3^rd she was in some pain so she received some Morphine times two – 3mg and 5mg IM injections. On the 4^th she again received some Morphine and it was re-ordered 5mg q. 4 hours p.r.n.. Duragesic patch was increased to 75mcg q. three days. On the 4^th we asked respiratory therapy to see her for possible aspiration and a swallow and speech evaluation was ordered. On the 5^th a chest x-ray was ordered for aspiration pneumonia. We got a CBC and some more MS was given. On the 5^th pureed diet was ordered secondary to dietician’s recommendations. On the 5^th I talked with Dr. Meek who recommended Keflex be used as a broad spectrum antibiotic. We started that at 250mg q.i.d.. On the morning of the 7^th Mary appeared quite ill. She spiked a fever. She appeared to have a seizure and probably aspirated. Dr. Dienhart was in to see her. Her sodium was up to 159, chloride 117, glucose and other chemistries were elevated. CBC revealed a white count of 15. She was breathing very poorly so oxygen was started as well as chest x-ray ordered per Dr. Dienhart. I came in on the evening of the 7^th, spoke with the family. She was quite ill at that point and the family did not want excessive or extraordinary measures taken so we discontinued all medications and started Morphine 5mg IM q. 3 hours. She expired approximately two hours later of respiratory failure. Dr. Nilson was kind enough to come up from the emergency room and pronounce her dead.

DISCHARGE DIAGNOSIS

Axis I: Major depression with psychotic features.

Axis II: Defer.

Axis III: Multiple systems failure.

Axis IV: Three.

Axis V: Zero, zero.

(Signed)

ROBERT WEITZEL, M.D.

RW/rn

D: 01/08/96 10:06T: 01/10/96 0:35

JOB # 5260

< <Back to Home Page

(INSERT MEDICATION ADMINISTRATION RECORD)

Occupational therapy discharge note. Patient died around midnight. J.V...?COTA/L

12/29/95

MD

Labs are within normal limits except chemistries - potassium quite low, sodium is also low, consistent with polydipsia, but it's not at dangerous levels. Remains dysphoric and somewhat difficult. Vital signs are stable, afebrile, blood glucose so far is in normal range. Assessment - same. Plan - continue current care. Robert Weitzel, M.D.

12/29/95
1. K-Dur 20 meq twice a day
2. Restrict patient from heavy fluid intake.
Thanks, Robert Weitzel, M.D.
Noted 12/29/95 1100 S. Hansen, RN12/29/95