APPENDIX B:

MEDICAL MANAGEMENT
Doctor’s Order Rationale

8/25/2010

4pm
 please admit under the service of Dr. Judy Suarez Chua
 Secure client to care
 problem dizziness
 condition stable
 activity complete bed rest with toilet privileges. - to prevent further injuries due to the clients condition of
 allergies none dizziness
 full low fat, low salt diabetic diet 1800kcal/ day in 3 main - standardize diabetic diet therapy for the client, in order to
meals with snacks in between 60% CHO but no simple adjunct the client drug therapy
sugars,20%CHON of HBV, the rest as fats mainly MUFAs
and PUFAs
 venoclysis with PNSS 1L @120ml/day - provide hydration
 nursing care
1. TPR q 4 -Standardize hospital protocol for vital signs
2. BP monitoring q 2
3. strict I & o monitoring - to monitor client’s hydration status

4:10pm
 labs:HGT now, ECG 12leads now
 CBC, U/A, Na, K, creatinine, SGPT, FBS,HBAIC,lipids panel,
BUN
 Meds:
1. captopril 25mg 1 tab sublingual now
2. Humulin R 4 units subcutaneously now
3. insulin lispro 25% +insulin lispro protamine suspension
-monitor clients glucose levels and cardiovascular function
-to monitor clients blood, urine, serum potassium, kidney and liver
functioning and adherence to therapy
-decrease client’s blood pressure
-decrease client’s glucose levels
 25%(Humalog mix 25) 10 units 15 mins pre breakfast and 15
mins. Pre dinner subcutaneously.
 HGT monitoring 3 times daily pre meals -to monitor clients glucose levels
 refer for worsening, dizziness, onset of neurologic
deficits,chest pain,dyspnea and other unsualities.
 will inform attending physician

8/26/10

3:53am

 give captopril 25mg tab SL now -to decrease client’s blood pressure

9:50am
- to decrease client’s client’s blood pressure
 amlodipine 5mg tablet once a day orally @8pm

2pm

 give humulin R 3 units subcutaneously now -to decrease client’s glucose levels

7pm

 IVF to follow with PNSS @ 120cc/hour To ensure hydration

7:40pm
-to monitor for the client’s unstable bp
 secure BP monitoring to q 4 and chart please

9/1/10

6Am

 IVF to follow with PNSS @ 120cc/hour To ensure hydration

9:10am

 increase amlodopine to 10mg tablet OD/orally @8pm -to decrease Bp

 rosuvastatin 10 mg tablet OD @ bedtime/ orally - to decrease levels of cholesterol in the body
 terminate present IVF when consumed -to prepare client for discharge.

Laboratory Results
 HEMATOLOGY RESULT

Date Taken: 8/25/2010 Time Take: 6:18pm

COMPLETE BLOOD COUNT

BLOOD COUNT RESULTS NORMAL RANGE UNIT

WBC 9.10 4.8-10.8 10^3/uL

RBC ↓4.19 4.2-5.4 10^6/uL

HEMOGLOBIN 13.3 12.0-16.0 g/dL

HEMATOCRIT 39.6 37.0-47.0 %
PLATELET 246 130-400 10^3/uL

BLOOD INDICES
MCV 95.0 81-99 fl
MCH ↑31.7 27.0-31.0 pg

MCHC 33.5 33.0-37.0 g/dL

RDW 12.3 11-16 %

PDW 11.5 9-14.0 fl

MPV 8.4 7.2-11.1 fl

Relative differential count

Neutrophil (%) ↑78.2 40-74 %

Lymphocyte (%) ↓14.1 19-48 %

Monocyte (%) ↓2.6 3.4-9.0 %

Eosinophils (%) 5.0 0.0-7.0 %

Basophils (%) 0.1 0.0-1.0 %

CHEMISTRY REPORT

DATE PERFORMED: 8/25/10 @ 10:05 AM.

TEST RESULT REFERENCE UNIT

Glucose ( Fasting) ↑121 60-100 mg/dL

Cholesterol ↑284 130.0-200.0 mg/dL

Triglycerides ↑131 60.0-130.0 mg/dL

VLDL 26.2 0.0-50.0 mg/dL

LDL ↑216.8 0.0-150.0 mg/dL

HDL 41.0 35.0-105.0 mg/dL

ELECTROCARDIOGRAPHIC REPORT

DATE PERFORMED: 8/25/10@4:35 pm

 TEST RESULT REFERENCE
Standardization 10mm Rhythm sinus HR. 89/min. (0.670 sec)
PR interval 17 deg ORS interval 0.094 sec. Atrial Rate Ventricular rate
PR interval 0.154 sec. RVS 0.75 mv SV1 (0.92mv) QT/QTCc (0.384 sec/ 0.466)
ORS Complexes Q waves in V1-V2 ST-Segments elevated at V1V3
P-waves normal T-waves upright

Interpretation

Sinus rhythm with acute anteroseptal wall myocardial infarction. Suggest follow-up tracing, cardiac enzyme studies and clinical correction.

CLINICAL CHEMISTRY REPORT

DATE PERFORMED: 8/25/10@6:29 pm

Test Result Reference Unit

CK-MB 21 Up to 25 u/L

CLINICAL CHEMISTRY REPORT

DATE PERFORMED: 8/25/10@6:22 pm

TEST RESULT REFERENCE UNIT

HBA1C (IFCC- New Method) ↑5.5 2.9-4.2 %
HBA1C (DCCT-Old Method) ↑7.2 4.8-5.9 %
Creatinine 1.3 0.6-1.5 mg/dL
SGPT-ALT ↑54 5.0-50.0 u/L
Troponin I (Quantitative) <0.01 Less than 0.11 ng/mL
Sodium (Serum) 135.0 134.0-148.0 µmol/L
Potassium 3.9 3.3-5.3 µmol/L

CHEMISTRY REPORT

DATE PERFORMED: 8/25/10@11:42 AM

Laboratory test Result REFERENCE unit
Urea 16.1 7.0-18.0 mg/dL