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

 

Current MAR

Medication History:

Order #
Med/dose
Route/schedule
Reason
Date started
#1
20mg po daily
diuretic
05/20/2013
#2
10 mg po PRN
weigh gain greater than 4 lbs
05/20/2313
#3
3mg po daily
angiotensin converting enzyme inhibitor.
7/01/2008
#4
81mg po daily
nonsteroidal anti-inflammatory drug
7/01/2008
#5
10mg po daily
Exercise-Induced Bronchoconstriction
02/01/2006
#6
20 mg PO daily
proton pump inhibitor
10/01/2010
#7
1 disk bid
corticosteroid & Long-acting beta2-adrenergic agonists
10/01/2010
#8 Lovenox 40mg SQ daily DVT Prophylaxis Protocal 10/01/2010
#9
650mg po q 4hr PRN
for pain or fever
#10
upon discharge
per Influenza Vaccination Screening & Administration Protocol
refused
#11
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

 

         
         
         
         
         
         
         

 

AC EMR