Med-surg.docx
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09/30/2018 7:16am SVI; SLE; AOM with effusion AD Combivent x 3 doses given at ER
Paracetamol 600mg T IV now.
>Admit to ICU under Dr. Andal. >Consent. >NPO temporarily. >Hook to cardiac monitor and pulse oximeter. >Hook to 02 via NC at 1-2L/min. >VS q1 include O2. >I & O q4. >TBR with BP >IVF: PNSS 1L x KVO >Dx: CBC, SGOT, SGPT, UA, CRP, BUN, CREA, 12 L ECG, CHEST X RAY, ABO TYPING, FBS, C3, ESR, >Meds: Paracetamol 500mg/tab 1 tab q4 for T < 37.8c. Paracetamol 1 amp IV q4 for T < 38.5c. Amoxicillin 500mg 1 tab TID. Pulmodual 1 neb x 3 doses, Q 15 minutes apart then Q6 do CPT after. >Continue patient’s meds: Imuran 50mg BID Prednisone 10mg 2 tabs BID Enalapril 10mg 1tab OD FeSO4 and FA 1 tab OD Calcium and vitamin D 1 tab OD Furosemide 40mg 1 tab OD with BP precaution. >Omeprazole 40mg IV OD >Refer to Dr. Villeno for nephrology. >Consent. >Dr. >Accurate I & O >Relay all labs once available ASAP. >Refer.
9/30/2018 SLE Pneumonia Anemia
>For BT 2 units PRBC to run for 4 hours each unit, 2 hours apart. >Pre-BT meds: Paracetamol 500mg/tab, 1 tab per unit of blood. >Post-BT meds: Furosemide 20mg IV after each unit of blood, with BP precaution. >Suggest to shift Amoxicillin to Cefuroxime 750mg IV q8.
>N Acetylcysteine 600mg/tab; 1 tab with ½ glass of water TID. >Suggest rheumatology referral. >For sputum GS CS, Blood CS >Suggest pulmo referral. >Update Dr. Villeno accordingly. >Relay labs once in. >NPO except meds. 9/30/2018 10:21am
>May shift antibiotic to cefuroxime. >May proceed to blood transfusion as ordered. >Will see patient later.
9/30/2018 11:25 am Patient diagnosed with SLE May 2018 Noted on shifting Aprovel to Captopril (+) colds (-) bleeding 1 day fever, SOB (+) Facial edema (+) ear discharge (-) (+) stridor L,R (+)
11:42am 9/30/2018 2:00pm
>Facilitate BT as ordered. >Accurate I & O. >Inform undersigned about cross matching. >Start Nafarin A 1 tab TID >Atrovent neb q8. >Refer back to Dr. Lanzon. >Retrieve chart from previous admission. >Refer.
>Hold Enalapril. >Resume Aprovel 1 tab OD. 150mg/tab. >Refer. >Discontinue pulmodual neb. >Discontinue prednisone. >Start Hydrocortisone 100mg IV q8. >For C3, ANA, Anti ds-DNA >Will see patient tomorrow
3:22pm Incompatible on cross matching
>Hold BT for now. >Facilitate steroids as ordered. >Trial on cross matching tomorrow after 4th dose of hydrocortisone.
8:35pm
>May have general liquid to minimal soft diet with aspiration precaution.
Paracetamol 600mg T IV now.
>Admit to ICU under Dr. Andal. >Consent. >NPO temporarily. >Hook to cardiac monitor and pulse oximeter. >Hook to 02 via NC at 1-2L/min. >VS q1 include O2. >I & O q4. >TBR with BP >IVF: PNSS 1L x KVO >Dx: CBC, SGOT, SGPT, UA, CRP, BUN, CREA, 12 L ECG, CHEST X RAY, ABO TYPING, FBS, C3, ESR, >Meds: Paracetamol 500mg/tab 1 tab q4 for T < 37.8c. Paracetamol 1 amp IV q4 for T < 38.5c. Amoxicillin 500mg 1 tab TID. Pulmodual 1 neb x 3 doses, Q 15 minutes apart then Q6 do CPT after. >Continue patient’s meds: Imuran 50mg BID Prednisone 10mg 2 tabs BID Enalapril 10mg 1tab OD FeSO4 and FA 1 tab OD Calcium and vitamin D 1 tab OD Furosemide 40mg 1 tab OD with BP precaution. >Omeprazole 40mg IV OD >Refer to Dr. Villeno for nephrology. >Consent. >Dr. >Accurate I & O >Relay all labs once available ASAP. >Refer.
9/30/2018 SLE Pneumonia Anemia
>For BT 2 units PRBC to run for 4 hours each unit, 2 hours apart. >Pre-BT meds: Paracetamol 500mg/tab, 1 tab per unit of blood. >Post-BT meds: Furosemide 20mg IV after each unit of blood, with BP precaution. >Suggest to shift Amoxicillin to Cefuroxime 750mg IV q8.
>N Acetylcysteine 600mg/tab; 1 tab with ½ glass of water TID. >Suggest rheumatology referral. >For sputum GS CS, Blood CS >Suggest pulmo referral. >Update Dr. Villeno accordingly. >Relay labs once in. >NPO except meds. 9/30/2018 10:21am
>May shift antibiotic to cefuroxime. >May proceed to blood transfusion as ordered. >Will see patient later.
9/30/2018 11:25 am Patient diagnosed with SLE May 2018 Noted on shifting Aprovel to Captopril (+) colds (-) bleeding 1 day fever, SOB (+) Facial edema (+) ear discharge (-) (+) stridor L,R (+)
11:42am 9/30/2018 2:00pm
>Facilitate BT as ordered. >Accurate I & O. >Inform undersigned about cross matching. >Start Nafarin A 1 tab TID >Atrovent neb q8. >Refer back to Dr. Lanzon. >Retrieve chart from previous admission. >Refer.
>Hold Enalapril. >Resume Aprovel 1 tab OD. 150mg/tab. >Refer. >Discontinue pulmodual neb. >Discontinue prednisone. >Start Hydrocortisone 100mg IV q8. >For C3, ANA, Anti ds-DNA >Will see patient tomorrow
3:22pm Incompatible on cross matching
>Hold BT for now. >Facilitate steroids as ordered. >Trial on cross matching tomorrow after 4th dose of hydrocortisone.
8:35pm
>May have general liquid to minimal soft diet with aspiration precaution.
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