Juan Manuel Medication Record

Pt. name: Juan Manuel                         Admitting Physician:   Dr. Cane
Age:64                                            DOB:1/27/1949                               Bed: 243
Admitting diagnosis: CHF, COPD
Pt. ID # 542768                                                Med Rec #: 78543
Wt. lbs: 200    kg: 90.9                  Ht.: 5 ft  2 in                                 Race:American- Hispanic
Major Support: wife                                                                     Religion:Catholic

Immunizations: not current
Allergies: NKDA

Physician Orders
History and Physical
Graphics/I&O
Laboratory
Diagnostics
Procedures/Surgeries
Nursing Assessment
Nursing Notes
Log Form
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Current MAR

Medication History:

Order #	Med/dose	Route/schedule	Reason	Date started
#1	Lasix	20mg po daily	diuretic	05/20/2013
#2	Lasix	10 mg po PRN	weigh gain greater than 4 lbs	05/20/2313
#3	Vasotec	3mg po daily	angiotensin converting enzyme inhibitor.	7/01/2008
#4	Aspirin	81mg po daily	nonsteroidal anti-inflammatory drug	7/01/2008
#5	Singulair	10mg po daily	Exercise-Induced Bronchoconstriction	02/01/2006
#6	Protonix	20 mg PO daily	proton pump inhibitor	10/01/2010
#7	Advair	1 disk bid	corticosteroid & Long-acting beta2-adrenergic agonists	10/01/2010
#8	Lovenox	40mg SQ daily	DVT Prophylaxis Protocal	10/01/2010
#9	Tylenol	650mg po q 4hr PRN	for pain or fever
#10	Influenza vaccine	upon discharge	per Influenza Vaccination Screening & Administration Protocol	refused
#11	Pneumonia vaccine	upon discharge	per Pneumococcal Vaccination Screening & Administration Protocol	refused
#12	Atrovent	0.5 q4 PRN	Nebulizer treatment anticholinergic agentindicated for the maintenance treatment of bronchospasm	03/15/2012