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)
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