Copy Of Or

Name: Catubay, Nestor 45 years old Admitted: June 21 2008; 9:15 AM Chief complaint: mild pain at right upper abdomen History of present illness: Patient complained of pain at right upper abdomen on April 2008. Consulted doctor regarding pain. Admitted for 6 days at NOPH and was diagnosed with cholelithiasis. Admitted again on June 21, 2008 for cholecystectomy on June 23, 2008. Vital signs: T = 36˚C PR = 100bpm RR = 20cpm BP = 120/80 CBC: 6/21/08 • Hemoglobin = 13.3 • Hematocrit = 39.9 • WBC = 7,200  Neutrophil Seg = 50%  Lymphocytes = 39%  Monocytes = 6%  Eosinophils = 4%  Basophils = 1% • Platelet = 191,000 Alkaline Phosphate = 73 U/L Prothrombin Time = 13.4 For open cholecystectomy 6/22/08     

NPO post midnight Start IV D5LR 1L at 33gtts/min PNSS 1L at KVO Insert FBC & NGT in AM For CP evaluation

Pre-orders  NPO post midnight  Meds: Nalbuphine 10mg  Promethazine 25 mg 6/23/08  DAT

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Resched patient for OR tomorrow AM NPO post midnight Continue meds Decrease IVF to KVO

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Cefuroxime 750mg IVTT q8H ANST Ranitidine 50mg IVTT q8H Nubaine 10 mg Promethazine 25 mg

Meds:

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OR: •

Smokes 10 sticks a day Drinks liquor occasionally Sleep decreased by 2 hours upon admission Verbalized anxiety regarding surgery

Vital signs: T = 36.1˚C PR = 69bpm RR = 16 cpm BP = 120/80 mmHg

Pre-med: Nalbuphine 10 mg Promethazine 25 mg Anesthesia: Thiopental Succylcholine Meds: Atropine Sulfate 0.5mg IM Atracunum 10mg IVTT Midazolam 2mg Post Op Dx: Chronic Cholecystitis secondary to Cholelithiasis Blood Loss: 300 ml Post Op Orders: • V/S q 15 x 2 hrs then 30 min x 1 hr then qhourly until stable • NPO • O2 • IVF: D5LR 1L at 30-33 gtts/min

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PNSS 1L at KVO Meds:  Ketorolac 0mg IVTT q8H  Tramadol 50mg IVTT q8H  Ranitidine 50mg IVTT q8H  Cefuroxime 750mg IVTT q8H  For repeat H&H in MA  MIO hourly

11:20 Received in OR per stretcher, awake & verbally responsive with 2 lines of IVF flowing well T=36.1, P=69, R=16, BP=120/80 With FBC in place attached to urobag O2 inhalation administered at 2L/min 12:00 General anesthesia induced Initial and final skin prep done aseptically 12:02 Open cholecystectomy done Instrument, sponge count done – complete 2:30

Operation done Dressing applied

3:35

Wheeled back to ward, semiconscious and in fair condition BP = 140/80 mmHg