Date/Time Doctor’s Order Rationale Remark
November 12,2006
12:10 pm
• Admit under white service
• Low salt low fat diet
• Temperature, pulse, respiratory every hour and record
• Venoclysis
D5W 500cc x KVO rate
• Diagnostics:
Complete Blood Count
• Patient is admitted under the white service for close monitoring
• LSLF is ordered for patients with cardiac conditions to decrease the salt and fats that further aggravates the pt’s current condition
• Monitoring of TPR is done to detect any variation or changes from the normal range that would determine an abnormality in the patient’s condition
• It is an isotonic solution that is needed by our body to help regulate the body’s nutrients; it doesn’t swell or shrink the cell. Regulated only at the rate to maintain vein open for
emergency and IVTT meds
• Complete Blood Count offers
necessary information about the kinds and numbers of cells in the blood. This analyzes the 3 major types of cells in the body which are the
• Done
• Done
• Done
• Done
• Done
Platelet
Isosorbide Dinirate (ISDN)
Red Blood Cell, White Blood Cell and Platelet
• Blood test evaluates platelet production
• Detects alterations in glucose metabolism
• For evaluation of renal function
• Evaluates fluid and electrolyte balance as well as renal or adrenal disorders
• This identifies various abnormalities of the lungs and structures in the thorax Also used to identify localize fluid and air in the pleural cavity
• Used to screen for and diagnose a variety of cardiac conditions as well as abnormal heart rhythms, conduction
disturbance,
hypertrophy and other disorders treatment for anginal
• Done
5mg/tab 1 tab now
Metoprolol 50mg/tab ½ tab BID
Captopril 25mg/tab ½ tab OD
Atorvastatin 80mg/tab 1 tab OD
Lactulose 30cc at HS
• Moderate High Back Rest
• Monitor intake and output
• O2 at 4Lpm via nasal cannula
• Hook to cardiac monitor
• Refer accordingly
attacks
• ISDN is the treatment for anginal attacks
• Treat hypertension, management of angina pectoris and prevention of MI
• Treat hypertension and reduce risk of developing congestive heart failure following MI
• Reduction of elevated total and LDL cholesterol and triglycerides
• Determine fluid and electrolyte function and prevent damage to vital organs resulting from inadequate oxygen
12:30 pm
• Retrieve previous 2Decho result c/o
watcher and attach to chart
• Repeat ECG after 6 hours
• Additional meds ASA 80mg/tab OD
Clopidogrel 25mg/tab OD
Enoxaparin 6000 IV every 12 hours
Furosemide 40mg 1 tab OD
Digoxin 0.25 mg/tab OD
• Monitor the patients BP, CR and ECG reading
• It is necessary to refer any unusualities to the physician prevent further complications
• Have a basis of the patient’s current situation base on the result of the previous laboratory exam
• For monitoring of any changes in the result
• Treatment of mild to moderate pain and prophylaxis of MI
• Reduction of atherosclerotic events in patients with atherosclerosis resulted from recent MI
• Prevention of deep vein thrombosis and pulmonary embolism
• Management of edema secondary to CHF and treatment of hypertension
• Used to slow the ventricular rate in tachyarrhythmias such
8:30 pm • Start O2 5Lpm per nasal cannula
• Furosemide 40 mg IVTT now
• Spironolactone 100 mg 1 tab now induced by other diuretics, for edema and hypertension
• Complete bed rest without bathroom privilege
• Refer
• Give Isordil 5mg SL
• If not relieved by Isordil may give Tramadol 1 amp IVTT
• Give Isordil 5g SL now
• Start Isoket drip D5W 500cc + 1 amp Isoket to run out at 10cc/hr
• Avoid valsalva maneuver
• For Pro-time
• Medication needs to be continued for continuity of treatment
• Minimize the workload of the heart and promote rest
• Treatment of moderate to moderately severe pain
• Treatment and prevention of angina pectoris attacks
• Activities that require holding of breath and bearing down can result in bradycardia,
temporarily reduced cardiac output and rebound tachycardia with elevated BP.
• Screens for lack of coagulation factors necessary for blood clotting. Measures time required for a fibrin clot to form
• Done
6:30 pm 7:30 pm 8:45 pm (+) chest pain
• Activated Partial Thromboplastin Time
• Refer
• Isordil 5mg SL now
• Increase Isoket drip to 15cc/hr
• Morphine 2mg IVTT now
• Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting
• Management of severe pain,
pulmonary edema and pain associated with MI
• Review of medicines 1. Spironolactone 25mg 1 tab OD
2. Digoxin 0.25 mg/tab OD 3. Carvedilol 6.25mg ½ tab OD
4. Captopril 25mg/tab OD 5. Atorvastatin 80 mg tab OD
6. ASA 80 mg 1 tab OD 7. Clopidogrel 75mg/tab OD
8. Enoxaparin 0.6ml SQ every 12
• Discontinue meds not in review of
medicines
• Refer
• Treatment for essential hypertension
movement
• Senna concentrate 2 tabs at HS
• Refer
• Treatment for constipation
• Diagnostics: repeat ECG 12 leads now
• Repeat Creatinine, Sodium, Potassium
• Continue all meds
• Refer accordingly
• Diagnostics: repeat serum electrolyte
• ISMN 60 mg ½ tab OD
• Continue all other meds
• Not
• Resume Isoket drip (D5W 90cc + 1 amp Isoket) to run at 10cc/hr
• Continue other meds
• Refer
• Continue all meds
• Refer accordingly
• Continue Isoket drip
• Start Warfarin 5mg ½ tab OD
• For stat Complete blood count, Platelet count and Creatinine
• Referred due to dyspnea
• Diagnostics:
• Prophylaxis and treatment of venous thrombosis,
pulmonary embolism, AF with embolization and management MI
• Determine blood
• Done
Hemogluco test now Electrocardigram now Arterial Blood Gas now Creatinine, Sodium, Potassium
• Give D5W 50cc 1 vial slow IVTT now
• Refer once with result
glucose level
• Determine the acid-base balance and/or the respiratory or metabolic status
• A hypertonic solution used for the treatment of
• Review of medicines Spironolactone 20 mg 1 tab OD
Digoxin 0.25 mg ½ tab OD Captopril 25 mg 1 tab OD Atorvastatin 40 mg 1 tab OD
ASA 80 mg 1 tab OD Clopidogrel 75 mg/tab OD Senna concentrate 2 tabs OD
ISMN 60mg ½ tab OD Warfarin 5mg ½ tab OD Enoxaparin 0.6 ml SQ every 12 hours
• Continue all meds
• Refer
• Ceftazidime 1gram IVTT q8 ANST (-)
• Clindamycin 300mg 1cap q6 PO
• Third generation cephalosporins used as treatment for infection
• Anti-infective for infection
• For repeat chest x-ray today
• Continue antibiotics
• Paracetamol 500mg 1tab q4
• Refer
• For mild to moderate pain and fever
• Done
• Done
• Done
CXR was read
• Bibasal pneumonia
• Left sided cardiomegaly
• Underlying minimal pleural effusion
• Pericardial effusion not entirely ruled out
• Omeprazole 40mg IVTT every 12 hours
• please retrieve chest x-ray place on bedside
• hold aspirin, warfarin, enoxaparine temporarily
• Refer
• for STAT 12 lead ECG
• Omeprazole 80mg IVTT now then 40mg IVTT q12
• Rebamipide 100mg 1 tab 3x a day
• Continue Omeprazole and Rebamipide
• retrieve chest x-ray ASAP
• Refer
• Ranitidine 1 ampule IVTT OD
• Vitamin K 1 ampule IVTT OD
• Refer
• Metoclopramide 1
• Management for GERD and duodenal ulcer
• Treatment of gastric mucosal lesions, acute gastritis and gastric ulcer
• Short-term treatment for
duodenal and gastric ulcer and GERD
• Prevention and treatment of hypothrombinemia associated with excessive doses of anticoagulants
• Treatment and prevention of nausea and vomiting
ampule IVTT now November 25,
2006 • Hold clindamycin
• House Omeprazole IV to Pantoprazole 40mg 1 tab OD
• Rebamipide 100mg 1 tab TID
• Repeat CBC, platelet count
• Continue meds
• Refer
• Treatment of mild reflux
Follow up repeat CBC, platelet
Repeat protime, Sodium, Potassium
• Continue all meds
• Consume and
discontinue ceftazidime, start levofloxacin 500mg/cap OD
• Still for repeat protime
• Refer
• Treatment of mild, moderate or severe infection
• Resume Coumadin (Warfarin) 2.5mg ½ tab OD
• Resume Aspirin 80mg 1 tab OD
• Continue Pantoprazole PO
• Repeat chest x-ray today
• Done
• Please retrieve chest x-ray due 11/28/06