Endorsing patient 1 at Room 241A, Patient Salud, Felimon Bautista, 82 y/o, Male, Weight: 90 kg; Height: 170 cm

Admitted: July 8, 2021; at 12:05 PM under the service of Dr. Cosme, Dr. Pilit, Dr. Aswat and Dr. Fernando

Came in due to Soft tissue mass, ulcerating at right lower leg

Patient Underwent excision of tumor, right lower leg under SAB (subarachnoid block) with femoral nerve and
sciatic nerve block (Analgesia) at 7 am today (July 09, 2021)

Activity - Flat on bed (until 2 pm) may have 1 pillow, carried out na to

Diet – DAT resumed at 2 pm

No known allergies

All diagnostic tests had been carried out as of today: CBC, CXR, ECG, RT PCR, APTT/PTPA (activated partial
thromboplastin time), HbA1c all done na (pasecure nalang po ng results, if meron pang wala sa chart ng patient)

IVF

- Endorsing IVF of PNSS 1Li to run for 12 hrs endorsing 500 cc level
- IVF to follow: PNSS 1Li to run for 12 hrs

Following medications

- Paracetamol (Primol) (100 mg) IV q 6 hours RTC (round the clock) x 4 doses, started kaninang 8 am, done
na rin yung 2 pm. To administer nalang yung 3rd dose ng 8 pm and 4th dose ng 2 am
- Paracetamol + Tramadol 1-tab q 8 once IV paracetamol consumed

For PRN meds

- Tramadol 50 mg slow IV push q 8 hours as needed for breakthrough pain

Special endorsements:

Monitor Vital signs q 15 mins x 2H, q 30 mins x 2H then hourly thereafter until stable

Watch for bleeding, hypotension, desaturation, nausea and vomiting

Patient is on post- nerve block precautions

- Do not apply hot or cold compress on right lower extremities

- Do not cross legs
- Provide assistance during sitting/standing

REFER T0 DR. ASWAT FOR Cardio-pulmonary(CP)clearance

Once again, endorsing patient 1, Salud, Felimon Bautista

With latest BP of: 130/80, IV level of 500 cc

NEXT

Endorsing patient 2 at Room 241B, Alodia, Anastacia Santos, 31 y/o, female, Weight: 63 kg; Height: 165 cm

Admitted: August 1, 2021; at 9:30 AM under the service of Dr. Ngalob

Diagnosis: Came in due to Puncture wound

Operation Performed: Underwent wound exploration and debridement -right arm at 10 am today (08/04/21)
Activity - On moderate high back rest

Diet - Diet may resume once fully awake - DAT

No known allergies

IVF:

- Endorsing the 3rd IVF of D5LRS 1Li to run for 8 hours hooked post-operatively, endorsing 400cc level

IVF To follow:

-4) na IV- D5NR 1L to run for 8 hours then KVO once on diet

-5) na IV- PLRS 1L to run for 5 hours

All diagnostic tests had been carried out as of today (08/04/21): CBC, XRAY (forearm APL jugular), RT PCR c/o
parkway (pasecure nalang po ng results, if meron pang wala sa chart ng patient)

Following medications

-Ketorolac 30 mg IV Q6 X 4 doses – 1st dose given na ng 1 pm (pabigay nalang po ng 2nd dose which is
schedules ng 7 pm)

-Etoricoxib (Arcoxia) 90 mg/tab, 1 tab BID PO PC to start after IV ketorolac

-Continue Cefoxitin 1g IV q8h (given napo kaninang 8 am, pabigay nalang po ng 4 pm yung next dose)

For PRN Meds

- (08/03) Cefoxitin 2g IV now then 1g IV Q8H

- (08/03) Ketorolac 30 mg IV q8 for breakthrough pain
- (08/04) Tramadol 50 mg Slow IV Push q8 PRN for severe breakthrough pain

Special endorsements:

- TPR I & O record every shift

- O2 inhalation at 2-3 lpm/nc until fully awake lang si patient
- Monitor VS q 15 for the first 2H, q 30 for the next 2H, then hourly na until stable
- WOF bleeding, DOB and nausea and vomiting
- Keep patient warm
- REFER TO DR. VELASQUEZ FOR JOINT MANAGEMENT

Once again endorsing patient 2, Alodia, Anastacia Santos

With latest BP of 120/80, IV level of 400cc

NEXT

Endorsing patient 3, at Room 103 A Cosme, Prince Espiritu, 56 y/o, male, Weight: 56 kg; Height: 157.5 cm

Admitted: July 2, 2021; 11:00 AM under the service of Dr. Domingo

Came in due to Hiatal Hernia, Cholecystolithiasis

Diet - On low salt, low cholesterol diet

No known allergies
All diagnostic tests had been carried out as of today; CBC, SGPT, SGOT, ALP, TB, Na (Sodium), K (Potassium),
Creatinine, PTPA (BLOOD CHEMISTRY TEST) Urinalysis, ECG, CXR PA, COVID 19 PCR SWAB, UTZ
(pasecure nalang po ng results, if meron pang wala sa chart ng patient)

IVF:

Endorsing the 1st IV of PLRS 1Li x 12 hours, hooked at 11:30 am today (08/02/21) to endorse 550 cc level
For the medications:

- Vocinti 20 mg 1 tab BID; once on NPO

- Omepron 40 mg IV Q 12 Hours (given napo yung 8am, to administer nalang ng 8pm)
- Cotrimoxazole 800/160 mg 1-tab BID (Given na po yung 8 am, to administer nalang yung 6 pm)
- K. Cit tab 1 tab TID (Given napo yung 8 am, 1 pm, to administer nalang ung 6 pm)
- Losartan 50 mg 1 tab OD (Given napo kaninang 8 am)

No PRN meds

Special endorsement

- TPR, I&O q shift then record

- Pre-op antibiotics nya to follow
- Sedation c/o ni Dr. Bangglacan
- Refer to Dr. Ginny Genuino for possible lap-chole, lap fundoplication, joint management
- Refer to Dr. Bacani for CP clearance
- Refer to Dr. Debbie Liquere for e/s (re assessment)

Transfer to PR once may available na room then inform Dr. Domingo nalang din

Once again endorsing patient 3 Cosme, Prince Espiritu

Bp 130/90

IV 750 cc

Endorsing patient 4 at Room 242B, Costes, John Balanza, 75 y/o, male, under the service of Dr. Galleon

Within an ongoing PNSS 1Li x KVO (40 cc/hr) 700 cc and ongoing na TPN x 36 hours (53 cc/hr) infusing at Right
arm

PLRS 1Li + 40 mEqs KCl x 60 cc/hr

- Amiodarone DMP X 36 h (7cc/hr) infusing at Left arm

May resume Nicardipine drip + Titrate accordingly to achieve BP less than or equal to 140/90 mmHg
Transfuse 2 ‘u’ properly tried and cross matched PRBC to run for 4 hours. May use left line for transfusion: 4HFT
IVF & PNSS X 60 cc/hr
s/p Ex-laparotomy

On moderate high back rest

On NPO;

For the diagnostic tests

- For repeat CBC siya sa AM instead of post op

- Intra op wound GSCS (carried out na)
- For postop orders:
For 12L ecg
For Na, K, Ca
For ABGs

(pasecure nalang po ng results, if meron pang wala sa chart ng patient)

For the medications

- Paracetamol (April) 1 gm IV q6H x 24 hours. Then decrease to 600 mg IV q6H (given na ng 8 am, 2 pm,
next dose is 8 pm)
- XXX MSO4 (Morphine sulfate) 2mg IV 10 cc PLSS q12h c/o Anesthesiologist on Duty x 12 days (to
administer nalang yung 10 pm then next 10 am tomorrow) XXX
- Piperacillin – Tazobactam 4-5 gm IV q6h (given na ng 8 am, 2 pm, next dose is 8 pm)
- Metomidate 500 mg IV q6h (given na ng 8 am, 2 pm, next dose is 8 pm)
- Omeprazole 40 mg IV q12h (given na ng 8 am, next dose is 8 pm)

For PRN meds

- Levobupivacaine 0.125% q4h PRN for breakthrough pain

- Tranase 50 mg IV q8h PRN for breakthrough pain

Special endorsements:

Maintain adequate pain control and oxygenation

For post op orders

O2 inhalation at 5-6 LPM/FM until fully awake
Monitor VS q 15 min x 2 h, q 30 min x 2 h, then q 1 hour
On Morphine precaution: Hypotension, bradycardia, N/V, DOB, Nausea, desaturation
Monitor I&O q1 hour and record, refer if less than or equal to 15 – 20 cc/hr
Open NGT to bedside bottle
WOF DOB, desaturation

Once again endorsing patient 4, Costes, John Balanza

IV level of 700 cc

BP 120/80