Age/Sex : 79years old man.
Status :Impatient Admission.
Attending Doctor: Don’thate,Big.
Medical record number: Q555500512.
No family members at his bedside.
Son: Lam Longboy. 999-999-0000
Limitation of treatment.
Aspiration Pneumonia, Encephalopathy, Leukocytosis,AKI,Hypernatremia.
No distress,quiet, denied pain 0/10.
Round the Clock Respiratory therapists treatment.
Lasix 20mg ivp Q8hours.
Zosyn 3.375gm IV Q8hrs.
Saline lock left forearm.
Morphine sulfate 2mg IV Q2hours .
Assessment of pain 0/10.
Reassessment of pain level 0/10.
H/H 9.3/31% .