DATE PROGRESS DOCTORS INTERPRETATION

TIME NOTES ORDER

4/8/24 Admit to ROC under the service To assess patient and
84 F of Dr. S. S manage properly
Secure Consent for Admission Free will to subject self of
the possible management
upon admission
Low Salt, Low Fat Diet to manage or reduce to
lower the cholesterol and
reduce the risk of high
blood pressure
CBC Work up labs of DR. S. S.
Urinalysis to rule out the other certain
Na medical conditions.
K
Crea
Hgt
BUA
SGPT
SGOT
C-Xray PA/L
Rapid Antigen Test As per hospital protocols to
identified covid cases.
ECG To check record the
electrical activity of the
heart including abnormal
heart rhythms or heart
attack and angina.
Cranial CT Scan Plain To identify if there is a
damage in a brain and if it’s
a clot or bleeding.
IVF D5Nss 1L x 16h For nutrition Supplement
Mannitol 100ml IV q8 To decrease pressure to the
brain and it helps to reduce
this increased pressure by
drawing excess fluid out of
the brain cells and into the
blood stream. Where it can
be excreted by the kidneys.
Citicoline 1g IV q12 For regeneration of brain or
to lesser the damage of the
brain
Nebulization with Duavent q6 To ease the breathing of the
patient. It helps to loosen if
there is blockage from the
airway.
 Fluimucil 600mg tab in ½ glass To loosen the phlegm
of water BID
O2 inhalation 2-3 LPM via To supply oxygen to the
Nasal Cannula body
Inform Attending physician
Monitor Vital signs q2 For data baseline
Refer For further management
4/9/24 New onset of (R) (R) Extremities weakness Affected body site of the
sided weakness patient base on the
6:30AM with assessment
incomprehensible
Speech, Awake,
Follows
Command

0/5 (+) Body

Weakness
Facilitate Cranial CT Scan
For Fasting Blood Sugar
Lipid Profile
Continue Maintenance
medications
Refer Accordingly
4/9/24 Leg Pain Give Celecoxib 1 cap once.
12:13P
M 2x a day for pain
4/10/24 Re-stroke
12nn
TF: PNSS 1L x 12hrs
Cranial CT Scan Result noted
Start Vessel Due F 300(LSU) IV
q12
Cilostazol 100mg tab BID
Aspirin 80mg 2 tabs now then 2
tabs OD after lunch
To see which part of the
brain was damage if it’s
Infarct or Hemorrhagic.
To Identify if there is a
history of DM or HPN to
know the IVF to be given.
To see the good cholesterol
or bad cholesterol.
To control medical
condition and to prevent
complications or relapses.
For further management
To manage pain
Pt. has a previous history of
stroke
For fluid replacement
(Pls. See on the Diagnostic
parts)
To prevent clotting (It helps
to melt the blood clot)
To reduce leg pain caused
by poor circulation
Nsaids anti-coagulant. This
can decrease the likelihood
of a blood clot blocking a
blood vessel in the heart or
brain.
 (Take with meals To
prevent GI Irritation)
Atorvastatin 80mg tab OD in To lower the cholesterol
PM levels in the blood
For Trop I To determine if there is a
marker/ indication of heart
attack
Increase Mannitol 100cc IV q6 To improve cerebral
perfusion and oxygen
delivery to the affected
areas, thereby reducing the
risk of further neurological
complications. To lessen
the pressure to the brain
Refer Accordingly For further management
4/10/24 Insert NGT Patient is unable to swallow
Diet OF 1500 Kcal For Energy & nutritional
Feeding + 2 scoop of Ensure Content
Gold
Refer Accordingly For further management
4/11/24 TF: PNSS 1L x 12hrs For Fluid replacement
1PM
Continue Meds. To effectively manage the
patient’s health
Refer Accordingly For further management