Republic of the Philippines

Department of Health

Date and Time Noted PHYSICIAN’S ORDER SHEET

February 5, 2021 ⮚ Please admit to medical ward Private room under the white service
7:30 am ⮚ TPR q shift and record
⮚ Secure consent for admission
V/S: ⮚ NPO temporarily
T° = 39.8°C Dx: CBC, CXR-APL, U/A
RR = 67 cpm Tx: PNSS 1L x 24°
PR = 156 bpm − Cefazolin 1 gm IV every 6° ANST ( )
WT = 75 kg − Amikacin 50 mg IV OD ANST ( )
− Salbutamol 1 nebule + 2cc PNSS every 15 minutes for three doses then every 4
hours
− Paracetamol 900 mg per IV every 4 hours RTC
10 am
− Suction secretion PRN
T° = 39°C
− Oxygen inhalation at 3-4 LPM/NC
RR = 62 cpm
− Vital signs every 4 hours and record
PR = 148 bpm
− TSB PRN for fever
− Increase OFI.
− Watch out for DOB, dizziness
⮚ Refer accordingly
Signed:

Dr. Angel Liban

2pm ⮚ IVF to follow PNSS 1L x 12 hours
T° = 38°C ⮚ For sputum culture this AM.
RR = 56 cpm ⮚ Continue meds
PR = 140 bpm ⮚ Follow up lab results.
⮚ Refer accordingly
Signed:

Dr. Angel Liban

February 6, 2021 ⮚ Shift cefazolin to cefuroxime 750 mg IV every 8 hours ANST ( )
10am ⮚ Discontinue Amikacin
⮚ Decrease Salbutamol nebulization to every 6 hours
⮚ Decrease paracetamol 600 mg every 4 hours RTC to every 4 hours then PRN for fever
⮚ Refer accordingly
Signed:

Dr. Angel Liban

DIAGNOSIS: PNEUMONIA( BACTERIAL)

Name of Patient: STEVE ROGERS Hospital Number: 010110

Ward: MEDICAL WARD ( PRIVATE ROOM) Bed No. 12