Name: Charles Jones								Allergies: NKDA
D.O.B. 02/19/42  Age: 68		MR# 342397                   	Physician: Carl Mitchell, MD

	Emergency Room Orders
•	Admit to Medical-Surgical Unit with Telemetry on
•	Admitting Dx:  SOB, Hx of CHF, R/O DCHF		
	•			
	•	Secondary Diagnoses: HTN, Anxiety, Hyperlipidemia, Depression		
	•	Condition:  Stable Code status: Full Code		
	•	VS:  Q hours until stable then Q		
	•	Admission Labs:
1.	CMP; BNP, PT/INR; CPK-MB, Troponin-I, Pre-Albumin
2.	CBC w/diff & platelets
3.	U/A (admission)
•	Admission orders:
•	STAT Lasix 80 mg IV
•	Diet: cardiac 2 gm Na, low cholesterol, NCS
•	Strict I & O
•	Daily weights 
•	Saline lock X2 
•	Activity: CBR call for additional activity orders; BRP only.
•	Incentive Spirometer Q1-2H W/A encourage DB&C
•	Standing Oxygen Orders:
•	Keep O2 saturation >er 92% 
•	May administer O2 @ 2-4 L/min via nasal cannula
•	Resume medications as at home but discontinue any beta blockers		
	•	Diagnostic Tests:
1.	CXR PA & LAT; 
2.	12-lead EKG & REPEAT 2D-M mode Echocardiogram
3.	Schedule CT Scan of Chest w/out
4.	Pulse oximetry with VS and prn
5.	Call for orders for ABGs as above		
	Medication Orders:
1.	Lasix 80 mg IV BID
2.	Altace 5 mg PO daily
3.	Coreg 3.125 mg PO BID with food (hold for SBP < 90),
4.	Amiodarone 200 mg PO daily,
5.	K-dur 40 mEq PO BID with food, 
6.	Spironolactone 12.5 mg PO daily, 
7.	Coumadin 2.5 mg PO daily – call with PT/INR
8.	Lipitor 20 mg PO daily
9.	Zoloft 50 mg po hs.
10.	Ativan 0.5mg po every six hours as needed for anxiety.
PRN Medication Orders:
1.	Tylenol 500 mg tabs: 2 tabs/ 1,000 mg Q6H PO prn pain
2.	Morphine Sulfate 1-2 mg IVP prn chest or severe pain & call MD                                                                  Dr. Carl Mitchell, MD

Orders Clarified: _________________________ date/time: __________
		
	Physician Orders