Course in the Ward On July 12, 2011 Mrs. Z was admitted at St.

Patricks Hospital Medical Center, ambulatory, accompanied by her maid, seen and examined by Dr. J. Mendoza. He recommended to be confined on the hospital for further examination and because of her underlying condition.

Date/ Time July 12, 2011

Doctors Order  Diabetic diet Total cal: 33cal/kg/day Protein: 0.6g/kg/day

7:05pm

Purpose  This diet is designed for patient with diabetes mellitus, a healthy-eating plan that can help to keep blood sugar under control.  Because PNSS has no glucose and electrolyte solution.  To prevent further complications.  To help control the blood sugar levels.

 IVF of PNSS 1L @ 80cc/hr by Dra. Malleta.  v/s every 4hrs.  regular insulin 6 sc for CBG 200mg/dl 8sc for CBG 250mg/dl 7sc for CBG 300mg0dl

 Actosmet 15mg/850 mg tab (1 tab after lunch)  Diamicron 60mg

 An anti-diabetic medication to control their glucose.  Used when diet and exercise are not enough to control blood glucose. 

 Accurate input and output  IVF of PNSS 1L PNSS has no glucose and @80cc/hr electrolyte solution.

July 13, 2011 8:00am

 RBS monitoring SI- mnol-----CU-mg/dl 11.9------216 8.4-------152 10.4------190  IVF of PNSS 1L @ 27-28gtts/min Dulcolax 1 tab

 To measure the level of glucose in the body at any point of time.  Because PNSS has no glucose and electrolyte solution.  To stimulates bowel movements.  To treat constipation by  For headache.  Used when diet and exercise are not enough to control blood glucose.

January 14, 2011

 biogesic 500mg Dra. Ribas.

3:45pm

 Diamicron to 60mg BID ac.

 follow up PLR @ 60 cc/hr.  RBS monitoring TID.

July 13, 2011 y Patient received awake lying on bed; conscious and coherent y With on-going IVF of PNSS at 900 cc level inserted on the right metacarpal to run for 8 hours. y (+) coughing y (-) DOB July 14, 2011 y Received patient awake sitting on bed; conscious and coherent y With on-going IVF of PLR 1L at 950 cc regulated at 60cc/hr inserted on the right metacarpal vein infusing well. y (-) DOB y (+) Crackles y On and off non productive cough noted.