COURSE IN THE WARD

03 August 2019 (4th day of Hospitalization)

At 1300H, BVP was transferred to Service Wing from SICU via stretcher and
ushered to the room. Transferred to bed safely and comfortably. He was conscious and
coherent with initial vital signs of BP: 130/80 mmHg, PR: 88 beats per minute, RR: 18
cycles per minute, Temperature: 36.5 degree celsius and Oxygen saturation: 97%, with
healing wound at occipital area and abrasions on forehead. BVP has ongoing IV fluid of
PNSS 1L x 12 hours at left arm infusing well, and with post mold cast at left leg fastened
with elastic bandage with pain at left hip with pain scale of 7/10. BVP was encouraged
to do deep breathing exercises and was given due pain medication. He was maintained
on compressive stockings at right leg. At around 1400H, BVP pain scale decreased to
4/10.

04 August 2019 (5th day of Hospitalization)

BVP was observed to have high fever around 1630H with temperature of 38.2
degree Celsius and skin is red and warm to touch. Assessed IV site for any signs of
phlebitis then tepid sponge bath rendered and encouraged to increase oral fluid intake.
BP was referred to CPT Ortega of Ortho service with orders made and carried out.
Paracetamol 300 mg IV now given as ordered. Monitored temperature and at around
1730H BP’s temperature dropped to 36.4 degree Celsius.

At 2230H, CPT Ortega ordered for repeat FBS. BP was referred to General
Medicine and Anesthesia service for pre op risk evaluation prior to contemplate surgery
procedure of Partial hip arthroplasty left under SAB.

05 August 2019 (6th day of Hospitalization)

Around 0800H, BVP was conscious and coherent, still with post mold cast at left
leg. BVP complained of on and off pain at left hip with pain scale of 6/10. Pain meds
given as ordered and encouraged patient to verbalize feelings. At the end of shift ,
BVP’s pain scale decreased to 3/10.

At 1336H, Ortho service ordered for repeat CBC with QPC and follow up official
result of CXR and 12 lead ECG. In additional, Ortho ordered to prepare materials for
application of skin traction. Around 1630H, assisted CPT Lim of Ortho service in
application of skin traction of left leg. After the procedure, patient verbalized difficulty
regarding the traction. The doctor explained the after effect of skin traction and
encourage BVP verbalization of feelings . BVP was placed on a comfortable position
and started Diclofenac 75 mg IV every 8 hours for 3 days and Tramadol 50 mg IV every
8 hour for pain as ordered. Referred to General Medicine for pre op risk evaluation prior
to OR.
06 August 2019 (7th day of Hospitalization)

CBC with QPC results of 93g/L and relayed to CPT Lim with orders made at
0115H to secure 2 units of Fresh Whole Blood for possible blood transfusion. No noted
hypotension .BP was maintained on skin traction and IV fluids of PNSS 1L x KVO for 48
hours. At 1040H, CPT Lim informed availability of 1 unit of FWB and ordered for repeat
CBC with QPC 6 hours post BT. Around 1900H, 1 unit of PRBC was ordered to
transfuse to run for 4 hours. Pre BT medications ordered to be given prior to blood
transfusion.

At 2105H, hooked 1 unit of PRBC properly typed and crossmatched to run for 4
hours with initial vital signs of BP: 120/80 mmHg, PR: 88 beats per minute, RR: 21
cycles per minute, Temperature: 36.6 degree Celsius and Oxygen saturation of 98%.
Diphenhydramine 50 mg IV and Furosemide 20 mg IV was given 30 minutes before
blood transfusion. Patient was monitored for any blood transfusion reactions. Blood
transfusion ended at 2300H, no noted blood transfusion reactions, for CBC with QPC 6
hours post BT.

07 August 2019 (8th day of Hospitalization)

At 1100H, endo and cardio service made rounds. Portable 2D echo was
coordinated and done. Pre op risk evaluation of endo is available, no contraindication
for the contemplated surgery. At 1700H, Ortho service made rounds and ordered for
partial hip arthroplasty left under SAB on 13 Aug 2019. Repeat CBC post blood
transfusion result is 114 g/L.

08 August 2019 (9th day of Hospitalization)

At 0820H, seen and examined by CPT Lim of Ortho service. BVP is still for OR
on 13 August 2019, awaiting cardio clearance prior to surgery. Requested 3 units Fresh
Whole Blood for OR use. Pulmo clearance available indicated intermediate risk for
procedure. Potassium result is 3.48 and relayed to CPT Lim with orders to start Kalium
durule tab 1 tab TID for 3 days, instructed BVP to include banana on diet. For repeat
CBC, serum electrolytes, PT, PTT, CT, BT, PBS and reticulocyte count tomorrow.

09 August 2019 (10th day of Hospitalization)

At 1100H, Ortho service made rounds and with pre-operative orders for
Partial Hip arthroplasty left under SAB to be scheduled on 13 August 2019 as 1 st case to
PACU. Requested 5 units platelet concentrate and 3 units Fresh Frozen plasma for OR
use. And to secure following materials for OR use as follows: Indwelling foley catheter
#1, urine bag #1, leukomed medium #3.
10 August 2019 (11th day of Hospitalization)

At 0700H, patient’s skin traction with foam splint was partially removed by ortho
resident as requested by patient. Still on continuous IV fluid of PNSS 1L x KVO.
Awaiting cardio clearance prior to surgery.

At around 1930H, BVP complained pain at left hip with pain scale of 9/10, with
positive chills and temperature of 38.5 degree Celcius. Relayed to ortho resident with
orders made and carried out. Paracetamol 300 mg IV given as ordered. TSB rendered
and put on droplight and provided cooling measures. At the end of shift latest
temperature of BVP was 36.7 degree Celsius.

11 August 2019 (12th day of Hospitalization)

At 0600H, BVP’s temperature was 38.9 degree Celsius, patient’s skin warm to
touch and observed with phlebitis at IV site at right hand. TSB rendered and changed
the IV site. Relayed and seen by ortho resident with orders made and carried out, with
standing order of Paracetamol 300 mg IV was given every 4 hours for temperature of
> 37.8 degree Celsius. Monitored temperature and record.

At 1615H, Anesthesia made rounds and ordered pre-operative instructions, to

PACU on Tuesday at 0600H to PACU. For NPO post midnight prior the procedure and
to hook IV fluid of D5NSS 1Lx 8 once on NPO.

12 August 2019 (13th day of Hospitalization)

At 2400H, BVP was instructed on nothing per orem, and hooked to

D5NSS 1L x 8 using gauge 18 and blood set. Pre-operative medications given as
follows: 1.) Tranexamic acid 1.5 gm IV 30 minutes prior to procedure, 2.) Omeprazole
40 mg IV once on NPO 3.) Cefazolin 1gm ANST (-) 30 minutes prior to procedure.
Routine oral and body hygiene done . Secured consent for the contemplated procedure
and blood availability. At 0600H, patient was endorsed and enroute to PACU via
stretcher accompanied by wardman and relatives.

13 August 2019 ( 14th day of Hospitalization)

At 1545H, BVP was trans in from PACU via stretcher accompanied by wardman
and relatives. S/P Partial Hip Arthroplasty left with cerclage wiring greater trochanter
left. BVP was conscious and coherent, with ongoing IV fluid of D5NSS 1L x 8 infusing
well at right hand, with side drip of Tramadol drip (tramadol 200 mg in 236 cc D5W) at
10 uggts/min with indwelling foley catheter connected to urine bag draining to yellowish
urine output. Patient has post op dressing dry and intact at left hip fastened with elastic
bandage. May resume diet as tolerated once fully awake. Post op Xray of pelvis AP and
crosstable lateral left done. Post op medicines were ordered as follows: 1.) Cefazolin 1g
IV every 8 hours for 3 days then shift to Cefuroxime 500 mg tab 1 tab twice a day for 7
days 2.) Celecoxib 200 mg /cap 1 cap twice a day for 3 days the as needed for pain
3.) Paracetamol 500 mg tab 1 tab every 4 hours for fever >37.5 degree Celsius
4.) Vitamin C 500 mg tab 1 tab once a day 5.) Omeprazole 40 mg tab 1 tab once a day
before breakfast for 3 days 6.) Enoxaparin 0.6 ml SC every 24 hours for 3 days. May
remove IFC once with proper bladder training. Anesthesia post op ordered to
maintained patient flat on bed for 8 hrs due at 1600H. ketorolac 30 mg Iv Q6 for 48 hrs,
Paracetamol 1 gm Iv q6 for 24 hrs and Tramadol 25 mg Iv as rescue dose for
breakthrough pain VAS >4/10 were ordered. Monitored BVP’S vital signs and recorded.
Monitored patient for soaked dressing.

At 2140H, Ortho residents made rounds and ordered to continue IVF of D5NSS
1Lx 8 for 1 cycle. For repeat portable xray pelvis AP bilateral was done.

14 August 2019 (15th day of Hospitalization) (1st day post operative)

At 0930H, BVP was seen and examined by ortho residents and explained to
patient and significant others regarding post op care and assisted to sit at bedside.
Patient was instructed to maintain on abduction pillow. Dressings were changed. Ortho
also ordered for repeat CPC with QPC.

At 1115H, Anesthesia made rounds and ordered to consume Tramadol drip then
shift to Tramadol 50 mg IV q6 for 24 hrs. Around 1300H, CBC result revealed 92 g/L
was relayed to ortho resident. Dr Nabong ordered to transfuse 2 units PRBC properly
typed and crossmatched and for repeat CBC 6 hrs post transfusion of 2nd unit.

At 1600H, 1 unit of PRBC properly typed and crossmatched was hooked and to
run for 4 hours. Initial vital signs taken as follows: BP: 110/80 mmHg, RR: 20 cpm, PR:
92 bpm, Temp: 36.6 degree Celsius, O2 sat: 98%. Monitored vital signs and recorded.
BVP was monitored for any BT reactions. Blood transfusion consumed at 2000H, with
no BT reactions noted and with vital signs as follows: BP 120/90 mmHg, RR 20 cpm,
PR 96 bpm, Temp 36.9 degree Celsius, O2 sat of 97%.

Around 0400H, 2nd unit of PRBC was available and hooked. BVP’s initial vital
signs were taken as follows: BP: 130/80 mmHg, RR: 20 cpm, PR: 98 bpm, Temp: 36.9
degree Celsius and O2 sat: 96%. Around 0700H, blood transfusion consumed with no
blood transfusion reactions noted. For repeat CBC after 6 hours of blood tranfusion due
at 15 1300H Aug 2019.
15 August 2019 (16th day of Hospitalization) (2nd day post operative)

At 1000H, BVP complaint of abdominal pain with pain scale of 8/10 and no bowel
movement for the day hence referred to ortho resident. CPT Lim made rounds and
examined patient. BVP’s urine output for 24 hours was checked revealed intake of
1970 ml vs. output of 250 ml. Ordered to give Lactulose 30 cc now, Furosemide 40 mg
IV now and Tramadol 25 mg IV now. Laboratories were ordered as follows crea, BUN,
serum electrolytes and urinalysis. Urine output was monitiored post furosemide. BVP
was also referred to General Medicine for evaluation and management of abdominal
pain.

At 1100H, General medicine suggestions in and relayed to ortho for carry out.
For CXR AP high sitting and 12 lead ECG were done. Dulcolax suppository 2
suppositories per rectum was administered. Patient verbalized to have passed gas and
feel better after. Post BT CBC results revealed 114 g/L and relayed to Ortho resident.
Indwelling foley catheter was removed after proper bladder training. Patient was able to
urinate on his own. No abdominal distention noted.

16 August 2019 (17th day of Hospitalization) (3rd day post operative)

BVP’s vital signs were stable and was encouraged to ambulate and was assisted
by the doctor to sit and stand. Patient tolerated the said activity, with tolerable pain at
operative site.

17 August 2019 (18th day of Hospitalization) (4th day post operative)

BVP was conscious and coherent and tolerated ambulating with assistance using
walker. Repeat urinalysis was done. At 1220H, CPT Geronimo made rounds and
wound care dressing was done.

Around 2000H,BVP’s wound dressing was observed to be soaked with serous

discharge and was relayed to Ortho resident. Seen and examined by CPT Geronimo
and dressing was done using aseptic technique.

18 August 2019 (19th day of Hospitalization) (5th day post operative)

At 0930H, CPT Lim made rounds and ordered May Go home for tomorrow (19
August 2019) with final diagnosis of Fracture, Closed, Comminuted, Intertrochanteric
Femur, Left Secondary to Fall; S/P Partial Hip Arthroplasty, Left with Cerclage Wiring,
Greater Trochanteric Femur, Left. For wound care prior to discharge and encourage
ambulation. Patient was instructed to avoid internal rotation and adduction of left thigh
and to avoid strenuous activities. Also instructed to come back to Ortho OPD c/o Team
Alpha on 27 August 2019 for removal of suture and follow up checkup.
19 August 2019 (20th day of Hospitalization) (6th day post operative)

BVP was conscious and coherent, ambulatory and vital signs were stable.
Wound dressing was changed. At 1000H, discharge home instructions were given to
BVP and verbalized understanding. By 1100H, BVP was discharged in good condition
via wheelchair accompanied by wardman and relatives.