PHYSICIAN’S ORDER/PROGRESS NOTES

AVILA
SURNAME:_______________________________________ S. AGE:________
M.I.:________ 23 HOSPITAL NO.:_______________
JHON
GIVEN NAME:______________________________________________ MALE WARD/ROOM NO.:______________
SEX:________

TIME POSTED
Progress
Date Doctor’s Order C A R E D AND
Notes SIGNATURE
06/11/2021

6-2 ⮚ Please admit patient to ROC under my

7:30 AM service. /
⮚ Secure consent for admission. /
⮚ NPO Temporarily /
⮚ Diagnostics:
 CBC / /
 U/A / /
 CXR / /
 ECG /
 FBS / /
 BUA /
 BUN
/
/ /
 AST/ALT
 CREA
/ /
 LP / /
/ /
⮚ IVF: D5LRS 1L x 8hrs
/
⮚ Start Omeprazole 40 mg IV Now then OD 7:40 am (KAN)

⮚ Tramadol 50mg IV q8hrs for pain / 7:30 am (KAN)

⮚ Relay H&H once result available / 8:00 am (KAN)

⮚ Refer /
/
Maria Bituka, MD
Gastroenteologist Krizha Nicolas
UNP-CN
Student No.
⮚ Please refer patient to Dr. Mang Butchak 100424050019
11:00 AM for co-management.
⮚ Suggest endoscopic esophageal dilatation /
and PEG creation
⮚ IVF TF: D5LRS 1L x 8hrs (3cycles) /
⮚ May have soft diet
⮚ Refer /
/
Maria Bituka, MD /
Gastroenteologist
Krizha Nicolas
UNP-CN
Student No.
⮚ Please schedule patient for PEG creation 100424050019
under TIVA tomorrow (January 20, 2021)
 7AM.
3:00 PM
⮚ NPO post mid night /
⮚ Inform OR
⮚ Notify Dr. Para Bibineg (Anesthesiologist) /
⮚ Cefuroxime 1.5 gms IV PTOR ANST
/
⮚ Dulcolax 10mg 2tablets at 6pm
/
⮚ Castor Oil 30cc PO x 3 doses (7pm, 9pm, /
6:30 am (KAN)
06/12/2021
11pm) / 6:00 pm (KAN)
⮚ Fleet Enema at 5am
7:00 pm (KAN)
⮚ Refer /
Mang Butchak, MD
General Surgeon 5:00 am (KAN)
/ 06/12/2021
/ Krizha Nicolas
⮚ Transfer to PACU UNP-CN
Student No.
⮚ NPO Temporarily 100424050019
⮚ Position to semi-fowler’s
06/12/2021
⮚ Monitor VS q15 x 2hrs then q1hr until /
6-2
10:00 AM stable /
⮚ O2 support 3LPM per NC /
⮚ IVF TF: PNSS 1L x 8hrs
⮚ Insert IFC
/
⮚ Monitor I&O q1hr
/
⮚ Post-op meds:
 Cefuroxime 500mg IV q8hrs
/
 Metronidazole 500mg IV q6hrs x 2 /
doses ANST /
 Ketorolac 30mg IV q 8hrs x 3doses
ANST
/ 12:00 nn (KAN)
⮚ May transfer patient back to ward if stable
/ 2:00 pm (KAN)
and is already awake.
⮚ OF: 1,500 kcal/day divided into 3 equal
/ 12:00 nn (KAN)
feedings once fully awake and is already at
ward.
/
⮚ Refer
Para Bibineg, MD /
Anesthesiologist

/
Krizha Nicolas
UNP-CN
Student No.
100424050019

** Carried Administered Request Made Endorsed Discontinued