Patient Information Sheet
Patient Name: Elenaor Simulo
Age 85
DOB 8/14/23
Gender female
Admitting Diagnosis: Altered mental status, abdominal pain R/O UTI, R/O diverticulitis
Reason for Hospitlization: Sudden change in mental status, weakness, chills ,nausea and abdominal pain
Medical History: CHF, MI , Hypertension , Type 2 DM, urinary retention , dementia, CVA , dysphagia
diverticulosis
Height
5 “ 2”
Weight 99 lb
Physician: Sim Feelbetter MD
Advanced Directive: at daughter’s home
The patient was recently hospitalized 10 days ago for management of CHF and urinary retention. She was
discharged to a subacute facility with a Foley catheter and G tube. The Foley catheter is now draining a
moderate amount of cloudy foul smelling urine with clumps of sediment
ER Assessment
Admission MD orders
MD orders : Diagnostic tests
Alert and oriented X 1 ( person
only)
B/P 118/ 72
Pulse 84
S1 S2 regular rhythm
Resp 16
Sa O2 96 %
Lungs clear
Foley drained 200 ml of cloudy
urine with sediment
Abd soft , non-distended
-Admit to Medical Service ( Dx:
altered mental status, R/O UTI,
R/O diverticulitis )
-Digoxin 0.125 mg PO daily
(hold until dig level available)
-Colace 100 mg PO daily
-Atenolol 25 mg PO daily
-Lasix 20 mg PO daily
-Enalapril 2.5 mg PO daily
-ASA 81 mg daily
-Tylenol 650 mg PO q 6 hrs PRN
for pain or fever over 101
-Levaquin 500 mg IVPB daily
-IV 0.45 % NS @ 80 ml/hr
-I & O
-Vital Signs and SaO2 q 4 hrs
-Telemetry
-Change Foley Catheter
-Jevity @ 50 ml /hr via G Tube
-Alternating pressure mattress
Chest XRay
EKG
CBC , Complete Metabolic panel, Hgb A1
C , BNP , Digoxin level (all done in ER)
CT of the Abdomen with Contrast
Urinalysis
Urine for Culture and Sensitivity
Pre admission medications
Digoxin 0.125 mg PO daily
Colace 100 mg PO daily
Atenolol 25 mg PO daily
Lasix 20 mg PO daily
Enalapril 2.5 mg PO daily
Glucophage 500 mg PO BID
ASA 81 mg PO daily
Social History
Occupation: retired seamstress
Lived with daughter and her family
prior to last hospital admission
Currently admitted from subacute
facility
Race:
Caucasian
Religion: Roman Catholic
Culture: Italian
Smoking none
ETOH hx. occasional glass of wine
Safety:
Fall Precautions Yes
Alternating Pressure Mattress
Braden score on admission (12) and
every three days
Aspiration Precautions Yes
ADL Full Assist
Discharge Planning /Learning needs
Daughter may not be able to care
for patient at home
Involve family in discharge planning
Explain all procedures to patient
Teach daughter rationale for all care