Patient Information Sheet

Patient Name: Elenaor Simulo Age 85 DOB 8/14/23 Gender female Pre admission medications

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