PHYSICIAN’S ORDER

Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
08/24/10 >plss admit to ROC under the service of doctor Aquino (P)
6:40pm >TPR, I & O q Shift
BP: 140/70 >Full Diet
CR: 85 >CBR w/ BRP’s
RR: 20 #1 – Abdominal pain, Fever, Body weakness
T: 36.5 Dx: CBCpc, Urinalysis -------------------------- with SC Na, K -------------------------- -------- HOLD
SPO2: 88% UTZ of the whole abdomen -------------- HOLD Crea ------------------------- -------- 8p
Tx: Venoclysis PNSS 1L x 8 ----------------------------------------------------------------------- -------- 8p
IVF to FF 2) PNSS 1L x 12 ------------------------------------------------------------------------- -------- (A)
>Paracetamol 500 mg 1 tab q 4 PRN for T> or equal to 37.8 C ------------------------- -------- (A)
>Ketorolac 30mg 1 amp IV q 8 PRN for pain ------------------------------------------------ -------- HOLD
#2- HPN, CAD, DM type 2 ------------------------------------------------------------------------ -------- 325
Dx: CBG now then prebreakfast and predinner
12L EKG ---------------------------------------------------------------------------------------------- -------- 6:00
Tx: Humulin R 6 unit SQ now ------------------------------------------------------------------- -------- 8p
>Cont. Amplodipine 10mg 1 tab OD ---------------------------------------------------------- -------- 8 am
Aspirine 80mg 1 tab OD ---------------------------------------------------------------- -------- By pt
Simvastatin 40mg 1 tab at HS --------------------------------------------------------- -------- Pt stock
Metformin 500mg 1 tab BID ---------------------------------------------------------- -------- 8 by pt
Omeprazole 20mg 1 cap OD pre Breakfast ---------------------------------------- -------- 6 by pt
>Monitor V/S q 4 + Abd’l Status
>Dr. Aquino to be informed

>Hold Serum Na, K till further

>Hold UTZ of the whole abdomen
>Hold Ketorolac

>Pls give HNBB 1 amp IV q 8 PRN for pain ----------------------------------------------- -------- HOLD
>For CXR – PA -------------------------------------------------------------------------------------- -------- Done
>For O2 at 1 – 2 lpm/nc ------------------------------------------------------------------------- -------- Ads

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________

PHYSICIAN’S ORDER
Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
08/24/10 >Hold HNBB
7:25pm >Give 1 dose of ketorolac 30mg 1 amp IV now
>For FPA supin and Upright --------------------------------------------------------------------- -------- Done
>Maintain IVF rate at 8hr/L
>I/O quantitatively and record
>NPO temporarily

8:36 TO >BUN, FBS, HgOA1C in AM

>ABG Now

10pm >Include Urine Betmos

08/25/10 >Start Gentamycin 2mg IV q 8 hours ANST ( - )

12:40A >Maintain Pt on NPO
>CBG q 6 hrs

08/25/10 >Maintain IVF to 8hrs/Li

08/25/10
6:50A >Maintain on NPO temporarily
(RUQ) Tenderness >For KUB Ultrasound ________________ to include biliary tree
In palyotic

08/25/10 10:50A

>Pls give HN1NFS 1 amp IV q 8 PRN for pain ----------------------------------------------- -------- HOLD
>For CXR – PA -------------------------------------------------------------------------------------- -------- Done
>For O2 at 1 – 2 lpm/nc ------------------------------------------------------------------------- -------- Ads

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________

PHYSICIAN’S ORDER
Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
08/24/10 >plss admit to ROC under the service of doctor Aquino (P)
6:40pm >TPR, I & O q Shift
BP: 140/70 >Full Diet
CR: 85 >CBR w/ BRP’s
RR: 20 #1 – Abdominal pain, Fever, Body weakness
T: 36.5 Dx: CBCpc, Urinalysis -------------------------- with SC Na, K -------------------------- -------- HOLD
SPO2: 88% UTZ of the whole abdomen -------------- HOLD Crea ------------------------- -------- 8p
Tx: Venoclysis PNSS 1L x 8 ----------------------------------------------------------------------- -------- 8p
IVF to FF 2) PNSS 1L x 12 ------------------------------------------------------------------------- -------- (A)
>Paracetamol 500 mg 1 tab q 4 PRN for T> or equal to 37.8 C ------------------------- -------- (A)
>Ketorolac 30mg 1 amp IV q 8 PRN for pain ------------------------------------------------ -------- HOLD
#2- HPN, CAD, DM type 2 ------------------------------------------------------------------------ -------- 325
Dx: CBG now then prebreakfast and predinner
12L EKG ---------------------------------------------------------------------------------------------- -------- 6:00
Tx: Humulin R 6 unit SQ now ------------------------------------------------------------------- -------- 8p
>Cont. Amplodipine 10mg 1 tab OD ---------------------------------------------------------- -------- 8 am
Aspirine 80mg 1 tab OD ---------------------------------------------------------------- -------- By pt
Simvastatin 40mg 1 tab at HS --------------------------------------------------------- -------- Pt stock
Metformin 500mg 1 tab BID ---------------------------------------------------------- -------- 8 by pt
Omeprazole 20mg 1 cap OD pre Breakfast ---------------------------------------- -------- 6 by pt
>Monitor V/S q 4 + Abd’l Status
>Dr. Aquino to be informed

>Hold Serum Na, K till further

>Hold UTZ of the whole abdomen
>Hold Ketorolac

>Pls give HN1NFS 1 amp IV q 8 PRN for pain ----------------------------------------------- -------- HOLD
>For CXR – PA -------------------------------------------------------------------------------------- -------- Done
>For O2 at 1 – 2 lpm/nc ------------------------------------------------------------------------- -------- Ads

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________

PHYSICIAN’S ORDER
Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
08/24/10 >plss admit to ROC under the service of doctor Aquino (P)
 6:40pm >TPR, I & O q Shift
BP: 140/70 >Full Diet
CR: 85 >CBR w/ BRP’s
RR: 20 #1 – Abdominal pain, Fever, Body weakness
T: 36.5 Dx: CBCpc, Urinalysis -------------------------- with SC Na, K -------------------------- -------- HOLD
SPO2: 88% UTZ of the whole abdomen -------------- HOLD Crea ------------------------- -------- 8p
Tx: Venoclysis PNSS 1L x 8 ----------------------------------------------------------------------- -------- 8p
IVF to FF 2) PNSS 1L x 12 ------------------------------------------------------------------------- -------- (A)
>Paracetamol 500 mg 1 tab q 4 PRN for T> or equal to 37.8 C ------------------------- -------- (A)
>Ketorolac 30mg 1 amp IV q 8 PRN for pain ------------------------------------------------ -------- HOLD
#2- HPN, CAD, DM type 2 ------------------------------------------------------------------------ -------- 325
Dx: CBG now then prebreakfast and predinner
12L EKG ---------------------------------------------------------------------------------------------- -------- 6:00
Tx: Humulin R 6 unit SQ now ------------------------------------------------------------------- -------- 8p
>Cont. Amplodipine 10mg 1 tab OD ---------------------------------------------------------- -------- 8 am
Aspirine 80mg 1 tab OD ---------------------------------------------------------------- -------- By pt
Simvastatin 40mg 1 tab at HS --------------------------------------------------------- -------- Pt stock
Metformin 500mg 1 tab BID ---------------------------------------------------------- -------- 8 by pt
Omeprazole 20mg 1 cap OD pre Breakfast ---------------------------------------- -------- 6 by pt
>Monitor V/S q 4 + Abd’l Status
>Dr. Aquino to be informed

>Hold Serum Na, K till further

>Hold UTZ of the whole abdomen
>Hold Ketorolac

>Pls give HN1NFS 1 amp IV q 8 PRN for pain ----------------------------------------------- -------- HOLD
>For CXR – PA -------------------------------------------------------------------------------------- -------- Done
>For O2 at 1 – 2 lpm/nc ------------------------------------------------------------------------- -------- Ads

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________

PHYSICIAN’S ORDER
Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
08/29/10 >BUN, Crea, AST, ALT, ASP in AM
>Continue meds
 >May Discontinue CBG monitoring

5P >IVF to ff: 9 PNSS iL x 16

08/30/10
9:30A >Pls relay labs
>Cont. meds

9:35A >IVF to ff: 10 PNSS iL x 12 hrs

08/30/10
6:50A >IVF to ff: 11 PNSS 1L x 16 hrs

08/31/10 >request 1GBP UTZ on september 2 2010

10A >Cont. meds

08/31/10 >IVF to ff: 12 PNSS iL x 16

7p

09/1/10 >Decrease IVF to KVO

>For possible discharge in AM
>In AM ____________ Cefoxime (fixxx) 200mg 1 tab BID
>Give last dose of Ceftriaxone tonight

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________

PHYSICIAN’S ORDER
Date Time Prob No. --- WRITE ACCORDING TO PROBLEMS --- Time Nurse
09/2/10 >May go home today
10AM >Home meds
1. Co-Amoxiclav 625 mg 1 tab BID
 2. Ciprothxacin 500mg 1 tab BID
3. Metronidazole 500mg 1 tab TID
4. Amplodipine 10m 1 tab OD
5. Aspirine 100mg 1 tab OD p.c
6. Simvastatin 40mg 1 tab OD at HS
7. Omeprazole 20mg 1 cap OD pre-BF
8. Metformin 500mg 1 tab TID
9. Losarta 100mg 1 tab OD
10. Vessel Due 1 tab BID

ff-up w/ Dr. Aquino in Sept 9, 2010

ff-up w/ me anytime Rm 218 Notre dame 11 – 2pm M- F

PATIENT’S IDENTIFICATION

Name: Sangao, Berry

Age: 75
PHYSICIAN’S ORDER
Sex: M

Ward or Unit: 226

Registry No: ________________________