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DATE _________________________________________________ Time _____________________________________
1. Admit to Service of ______________________________________________________________
2. Allergies: ____________________________________________________________________________________
3. Admit to:
4. Diagnosis:
Additional Diagnoses: ___________________________________________________________________________ 5. Condition:
6. Code Status:
7. Nursing Documentation:
Other______________________________________ Daily Weights (kg) / I&O and record on admission and daily. Saline lock or IV fluids: ____________________________________________________________________ 9. Activity:
10. Diet:
11. Fluids:
Fluid Restriction _________________ml/day 12. Medication Choices:
Pharmacy to dose all medication for creatinine clearance. Ceftriaxone (Rocephin) 1 gram IV every 24 hours and Doxycycline 100mg every 12 hours
Other ________________________________________________________________ Other ________________________________________________________________ Acetaminophen 650 mg orally every 4 hours prn temp greater than 100.5 F or mild pain / headache not to Other______________________________________________________________________ Milk of Magnesia 1-4 tablespoons orally every day – titrate to soft stools Other__________________________________________________________ Other_________________________________________ Other_________________________________________ Continued on page 2
8761-EH03 (12-16-08)

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Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : _______________________________________________________________________________________ Other : ________________________________________________________________________________-______
14. Diagnostic Studies:
15. Admit Lab:
Blood Cultures x2, 15 minutes apart from different sites, prior to antibiotics Sputum gram stain and culture. If patient not able to provide sample within 15 minutes, RT to induce with 2.5 mg Albuterol in 2.5cc normal saline. If patient cannot provide a sample within 30 minutes, consider nasal Other ____________________________________________________________________________ 16. Lab in AM: _______________________________________________________________________________________

17. Respiratory:
O2 __________________________________________________________ SVN with Albuterol + 2.5 mg QID / PRN or
SVN with/2.5 mg Albuterol + 0.5 mg Atrovent QID / PRN Advair 100/50 1 click every am or
Other: ________________________________________________________________________________________
18. Assessments/Consultations:
Other ___________________________________________ Smoking cessation counseling/education if patient smoked in last year 19. Discharge planning:
_______________________________________________________________________________________ Physician’s Signature PATIENT LABEL


D-gel1000 9-11-06.indd

Technical Information Desensitized Extra Gelatin Nitroglycerin Dynamite Density (g/cc) Avg Energya (cal/g) Relative Weight Strengtha Relative Bulk Strengtha,b Velocityc (m/s) Product Description D-GEL 1000 is a desensitized, nitroglycerin-based dynamite formulated to reduce Detonation Pressurec (Kbars) sensitivity to sympathetic detonation (hole-to-hole pr

Kerman university of medical sciences, kerman, iran. resistance pattern of Escherichia coli causing urinary tractinfections, and that of human fecal flora, in the southeast of Iran Author(s): Mansouri, S (Mansouri, S); Shareifi, S (Shareifi, S) Source: MICROBIAL DRUG RESISTANCE-MECHANISMS EPIDEMIOLOGY AND DISEASE Volume: ٨ Issu

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