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  • KARDEX (Admission)

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    JA Berzabal
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    Mr. Fernandez, a 23 year old female, was admitted to the hospital on November 19, 2020 with a chief complaint of yellowish vaginal discharge and right lower quadrant pain. She underwent an exploratory laparotomy with a pre-operative diagnosis of tubo-ovarian abscess. Her post-operative medications included cefuroxime 1.5gm IV every 8, 4, and 12 hours and paracetamol 300mg IV as needed. Diagnostic tests performed included a chest x-ray, CBC, and urinalysis on the day of admission and surgery.

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    Mr. Fernandez, a 23 year old female, was admitted to the hospital on November 19, 2020 with a chief complaint of yellowish vaginal discharge and right lower quadrant pain. She underwent an exploratory laparotomy with a pre-operative diagnosis of tubo-ovarian abscess. Her post-operative medications included cefuroxime 1.5gm IV every 8, 4, and 12 hours and paracetamol 300mg IV as needed. Diagnostic tests performed included a chest x-ray, CBC, and urinalysis on the day of admission and surgery.

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    460 views1 page

    KARDEX (Admission)

    Uploaded by

    JA Berzabal
    Mr. Fernandez, a 23 year old female, was admitted to the hospital on November 19, 2020 with a chief complaint of yellowish vaginal discharge and right lower quadrant pain. She underwent an exploratory laparotomy with a pre-operative diagnosis of tubo-ovarian abscess. Her post-operative medications included cefuroxime 1.5gm IV every 8, 4, and 12 hours and paracetamol 300mg IV as needed. Diagnostic tests performed included a chest x-ray, CBC, and urinalysis on the day of admission and surgery.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    KARDEX

    Patient's Name: Mr. Fernandez Age: 23 y/o Sex: F Weight: Room: Bed: 69 Date of Admission: 11/19/20
    Attending Physician: Dr. X Chief complaint: Yellowish vaginal discharge and right lower quadrant pain Operation: TAHBSO (exploratory laparotomy)
    Admitting diagnosis: Tubo Ovarian Abscess Date and Time of Operation: 11/19/20 at 10am
    Date Ordered Oral Medications Time Precautions: Allergy () OR aware () Consent
    Drugs/ Dosage/ Route Date Ordered: Medical Treatments/ Procedures () CP Clearance ___w/ cardiac monitor __w/o cardiac monitor
    () Pre-anesthesia assessment form
    () OR Checklist

    Diet: NPO post-midnight


    Date Ordered Parenteral Medications Time Diagnostic and Laboratory Tests IV Fluid Special Endorsement
    Drugs/ Dosage/ Route 11/19/20 UTZ now D5LRS 1L x 8
    11/19/20 Cefuroxime 1.5gm IV 8, 4, 12 11/19/20 Chest X-ray done
    11/19/20 Paracetamol 300mg VI PRN 11/19/20 CBC done
    11/19/20 Urinalysis done

    IVF Side drip/ Blood Transfusion Admit to Gyne ward


    Inform OR under Dr. X,
    Anesthesiology Dr. Z and
    assist
    Insert D5LRS 1L q8

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