Eleanor Sim DOB 8/14/23
MR # 333666777
Date and Time
10/5/09 4 PM
Physician Order Sheet
Admit to Medical Service on Telemetry ( Dx: altered mental status, R/O UTI, R/O diverticulitis )
IV 1000 ml D 5/0.45 NS @ 60 ml per hour
G Tube feeding Jevity 60 ml per hour
Bedrest
Low Air loss mattress
Change Foley catheter
VS q 4 hrs
Social Service Consult
Diagnostic Tests
Chest Xray and EKG (done in ER)
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
O2 @ 2 L via nasal cannula PRN
Digoxin 0.125 mg PO every am ( hold until Dig level available)
Enalapril 2.5 mg PO QD
Colace 100 mg PO daily
Atenolol 25 mg PO daily
Lasix 20 mg PO daily
ASA 81 mg PO daiy
Levaquin 500 mg IVPB once day
Sim Feelbetter MD
10/ 5
4:15pm
Sliding Scale Insulin
BG 150-200: 2 unit Regular Insulin sc
BG 201-250: 4 units Regular Insulin sc
BG 251-300: 6 units Regular Insulin sc
BG 301-350: 8 units Regular Insulin sc
BG 351-400: 10 units Regular Insulin sc
BG over 400 call MD
Recheck finger stick glucose in one hour after Insulin
Sim Feelbetter MD
10/ 5/09 5:00 PM
Increase IV fluid to 125 ml per hour
O2 via 80 % via Non rebreather mask
Sim Feelbetter MD
Eleanor Sim DOB 8/14/23
MR # 333666777
10/5/09 5:15 PM
Physician Order Sheet
Change IV fluid to 0.9 % Normal 500 ml over one hour
STAT Labs : Basic Chemistry Panel, CBC with Differential and Platelets, Lactate level, Coagulation
panel , Blood cultures
Sim Feelbetter MD
10/5/09 5:40 PM
Dopamine 400 mg in 250 ml 0.9 NS. Run @ 5 mcg per kg per minute
10 Units Regular Insulin in 500 ml D/ 10%/ W infuse IV over one hour
Portable chest X Ray stat
BIPAP IPAP @ 10 cm H2O. EPAP 5 cm H2O.
Decrease 0.9 NS IV to 100 ml per hour
Transfer to ICU ( Dx Sepsis and acute renal failure)
Sim Feelbetter MD