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Patient name:  Wiley Joe                        93M                        Height:  5’4”  Weight:  150 kg

PAL ADMIT

Full Code with 4 different HCPOA’s in 4 different states

Hx:  CAD, CHF, COPD, CVA x 6, HTN, DM (insulin dependent), anxiety, insomnia, ulcerative colitis, chronic back pain, morbid obesity, fecal incontinence, multiple impactions, right BKA, neuropathy, sleep apnea (refuses CPAP), smoking “in remission,” former cocaine user

Isolation:  contact for C. diff

Allergies: morphine, hydromorphone, toradol, phenergan, pt stated “I am allergic to all pain med stuff except for Versed, nubain, and dilaudid”

This admission:  pt came into ED one week ago with left foot pain, rating 3/10.  Once in the ED, pt stated he was having mild chest pain, rating 4/10.  EKG, cardiac enzymes, cardiac cath, TEE completed.  Pt consulted for an 18 vessel CABG.   Scheduled for tomorrow.  TEE revealed significant vegetation on mitral valve, will now need MVR.   Despite 6 past CVAs, pt is not on ASA or any other blood thinning regimen. 

IV:  #22 in left hand, due today.  Extremely hard stick, took 14 SICU nurses with Doppler to place.  MD refuses PICC line placement.

O2:  10L – dyspnea with exertion (exertion defined as position changes in bed)

Diet:  Regular (for dinner had 4 Pepsi’s, 2 orders of chicken strips, 3 cookies, and family brought in 2 double cheeseburgers.  Blood sugar 616, refused insulin because he “doesn’t like shots”)

Accuchecks:  AC/HS + 0300 (pt does not eat at meal times because he “doesn’t do that at home”)

Dressings:  multiple sores on lower leg and back/buttocks, all which need to be dressed with gauze q4hrs due to copious drainage from all sites

Orders:  surgical prep (clipper prep, hibaclens), turn q1hrs per pt request, under no circumstances do NOT insert foley d/t risk of infection (pt cannot hold urinal for self), 80 mg IV lasix, merrum q 4 hrs, start heparin drip, start another IV, keep wounds dry, ambulate TID (use lift and 3 nurses while walking in hall with walker), notify if SBP is greater than 140 (no PRN BP meds available).