DOCTORS ORDER

Patient: Ms. San Francisca Gaisano

Attending Physician: Dr. Alexis De Castro
Diagnosis: Cardiac Dysrhythmia
Date Admitted: July 26, 2015
Secondary to Coronary Artery Disease
Date/Time
July 26, 2015
12:10am
BP: 150/90
Sinus
Bradycardia

Doctors Order
Rationale
Please admit at IMCU
For prompt collaborative
(Intensive Medical Care
care and management.
Unit)
To make sure there is an
Secure consent with care
approval from the patient
and management
as to take care and
treatment that will be given
to her during the course of
admission.
It is a hypertonic solution
D5W 500cc at KVO
which helps to ensure that
a woman is fully hydrated.
Also serves as vehicle for
IVTT medications.

Low Salt; low fat

Low fat - reduce the

amount of cholesterol in
the body and also to
prevent fluid retention; Low
salt it helps maintain the
balance of water in and
around your cells and for
proper muscle and nerve
function and it keeps blood
pressure stable.

Diagnostic:
Complete
Blood
Count with Platelet
count
Urinalysis
Na+, K+, Creatinine,
BUN
Trop I
CBG
Treatments:
Salbutamol 1 nebule

It is used to demonstrate
the presence or absence of
infection and it is the
process in determining in
the nature of a disease or
disorder and distinguishing
it from other possible
conditions.
Is used in asthma and

every 6 hours
Aspirin 50 mg tab
O.D. at before meals

Lozartan 50 mg +
HCTZ 12.5mg tab
O.D.
Celecoxib 40mg cap
O.D.

Vital signs every 4 hours

Input and Output every shift

bronchospasm.
To reduce the stickiness of
platelets that prevents clot
building up within arteries
such as the coronary
arteries of the heart or the
carotid arteries that take
blood to the brain
Cause the blood vessels to
relax and so lowers your
blood pressure
Celecoxib is a Nonsteroidal anti-inflammatory
drug (NSAID) which is
thought
to
inhibit
prostaglandin
synthesis,
produces anti-inflammatory,
analgesic, and anti-pyretic
effects, used to relieve pain
and decreases edema.
To obtain baseline data and
monitor
patients
hemodynamic status
To check whether there is
problem with her kidney
function in excreting fluids

Refer

July 26, 2015

2:00PM
Complaints
of epigastric
pain

Sucralfate 1 gram Tab QID;

1 Tablet 20mins before
meal then 1 tablet after
dinner
Atropine 0.5 mg IVTT now

Terbutaline 2.5 mg Tab BID

For collaborative care to

help in the management of
patient medical condition.
Used to treat and prevent
the return of duodenal
ulcers. (Ulcers located in
first part of the small
intestine)
Atropine dilates the pupils,
increases heart rate, and
reduces salivation and
other secretions
Treating
or
preventing
symptoms cause by spasm
or contraction of the
muscles
around
the
bronchioles (air tubes,

 Omeprazole 40mg
every 12 hours

IVTT

It is a hypertonic solution
which helps to ensure that
a woman is fully hydrated.
Also serves as vehicle for
IVTT medications.

D5Water 500cc @KVO

July 27, 2015

Lactulose 30cc O.D. @H.S.

7:45AM
Awake
afebrile

and

For 2D Echo

Abdominal
Pain

Continue medications

D5W 500cc @KVO

Omeprazole
now

40mg

associated with asthma,

bronchitis
and
emphysema.)
Used to treat symptoms of
gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid.

Used to treat chronic

constipation.
To provide the doctor the
important ff:
Size of the chamber,
dimension, volume and the
thickness of the wall
-Pumping function, if the
pumping power of the heart
is normal or reduce to a
mild or severe degree.
Compliance to medication
ensure
proper
management of existing
medical problems
It is a hypertonic solution
which helps to ensure that
a woman is fully hydrated.
Also serves as vehicle for
IVTT medications.

IVTT

Ranitidine 50mg IVTT now

then every 8 hours

Used to treat symptoms of

gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid
Used to treat and prevent
ulcer in the stomach and
intestines.

-May increase your risk of

developing pneumonia.
July 28, 2015

Still for 2D Echo

For further observation.

8:46AM

Schedule ultrasound of the

whole abdomen tomorrow
Refer to General Surgery
for evaluation and comanagement re-hernia

To identify any occurring

problems.

Incisional
hernia noted
(2014)
and
scheduled for
correction
July 28, 2015

July 28, 2015

May trans out to medical

ward
Please
issue
medical
certificate
Shift
Ranitidine
to
Omeprazole 40mg IVTT
every 12 hours
Patient seen and examined
Labs and PA reviewed
Abdomen (+) midline scar,
soft; NABS (-) tenderness
Incisional Hernia reducible
Appraised for surgery when
medically stable
Patient and accompanying
still to decide
Continue meds

July 29, 2015

10:00am

For request CT-scan if with

continuation of surgery
Hold Aspirin
Cloripidogrel 75mg 1 tab
O.D. before lunch

Discontinue Salbutamol

Collaborative care to help

in the management of
patient medical condition.

For important purposes.

To identify arising problem

To detect any significant
changes in patients status

Compliance to medication
ensures
proper
management of existing
medical problems.

Stopping of the medication

Is used to prevent blood
clots after a recent or heart
attack or stroke and in
people
with
certain
disorders of the heart and
blood vessels.

 Domperidone 10mg T.I.D

Indicated for the relief of

the symptoms of nausea
and vomiting

IVFTF: Plain Lactacted

Ringers 1liter @KVO

Is a sterile solution that is

used to replace fluid lost of
the body. It is commonly
used for fluid resuscitation,
meaning that the patient
needs aggressive fluid
replacement for their injury
or illness.

July 30, 2015

May go home

7:35am

Home medications:
Terbutaline 2.5mg 1
tab BID

Lozartan 50mg 1 tab

O.D.

Omeprazole 20mg 1
cap BID 1 week

OPD follow-up after 1 week

Advised

Treating
or
preventing
symptoms cause by spasm
or contraction of the
muscles
around
the
bronchioles (air tubes,
associated with asthma,
bronchitis
and
emphysema.)
Cause the blood vessels to
relax and so lowers your
blood pressure
Used to treat symptoms of
gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid
To identify any occurring
problems and development
in of health status.
Patient
was
given
discharged instructions.