Pt. name: Dale Mayman                        Admitting Physician:   Dr. S Phillips
Age: 51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis: Confusion bleeding gums
Pt. ID # 542768                                                Med Rec #: 78543
Wt. lbs: 172 kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support: Wife                                                                      Religion:Not stated

Immunizations: current
Allergies: Ace inhibitors (angioedema)

History and Physical
Physician Progress Notes
Graphics/I&O
Laboratory
Diagnostics
Procedures/Surgeries
Medication Record
Nursing Assessment
Nursing Notes
Nursing Map of Care
Complete Patient Assessment
Return to Patient Index
Return to Unit Index

Physician Orders

date/time	orders
	ER Orders

	Lab: CMP, Pt/INR, Ammonia, CBC with diff, Blood Cultures x 2 separate sites, UA and Urine Culture, Sputum Culture, Serum ETOH level, Urine Tox Screen
	Permit for paracentesis

	Gram stain, C & S on paracentesis fluid

date/time	orders
	Discharge Orders

	Discharge home in stable condition
	Home health for assist with Medications, diet, and IV antibiotics administration
	2 g sodium diet
	discharge medications: Aldactone 100 mg PO Daily Lasix 40 mg PO Daily Inderal 10 mg PO BID - hold if HR < 60, SBP < 100 MVI table PO Daily Lactulose 30 mL PO Daily Vancomycin 1 gram IVPB every 12 hours Zosyn 3.375 grams IVPB every 6 hours

date/time	Physician’s Orders