COURSE IN THE WARD

Narrative:
On September 22, 2016 at 12;16am, the patient was admitted at Saint Paul
Hospital of Tuguegarao Mother Benjamin Unit. Upon admission, as ordered by the doctor, she
had undergone CBC with PC and Chest X ray (AP/L). She was hooked with IVF of D5 0.3
NaCl 500 cc to run at 36 ugtts/min. The patients relatives were instructed that she be in a diet for
age. The patient was ordered to take Celestamine syrup 2.5 mL TID and be nebulized every four
hours with Salbutamol. On the same day at 12:40am, the hematology report was released
showing normal results for all parameters except for her WBC, Hematocrit, Lymphocytes,
Monocytes, and Platelet with increased values and her segmenters with decreased value. Along
with this, the Chest X-ray result was also released showing streaky densities in both inner lung
fields thus, having interstitial pneumonia as an impression. During the day, the patient was
reported to be very responsive to the medications and treatment given.

At 8:15am of September 23, 2016, the patient was ordered to start taking
Clarithromycin 125mg/5mL 3.5 mL BID. IVF line was continued. However, the frequency of her
nebulization for Salbutamol was decreased to 1neb for every six hours. D5LRS 1L to run at the
same rate was ordered to follow after infusion of the last IVF line. The patient was ordered to
continue medications.

At 9:10am of September 24, 2016, mainline was decreased to KVO and her IVF
was ordered not to be reinserted once out. The patient was ordered to continue medications.

At around 7:00am of September 25, 2016, the patients IVF line was removed.
The patients SO was instructed that the patient will be discharged the following day.