MEDICAL MANAGEMENT

Doctors Order
December 3, 2007 @ 6:05 p.m.
1. Please admit

Rationale

1. To properly monitor and provide

medical attention to the patient.
2. Secure Consent
2. To have a proper consent in every
medication and procedure that needs to
be done and for legal purposes.
3. TPR every 4 hours
3. To properly monitor the patients
condition.
4. Diet: NPO for 4 hours.
4. To prevent further irritation in the
affected area and to evaluate more
epigastric pain.
5. Insert NGT open to drain
5. To aspirate gastric secretions.
6. FBC attach to urobag
6. To monitor urinary output accurately
7. Left IVF D5/nm:L @ 40gtts/min
7. For fluid and electrolyte maintenance
Right IVF PNSS MFD 500cc
Use for medication ailment of
@15gtts/min.
compatible blood.
8. Labs:
8.
Chest PA
To evaluate lungs for any problem
Abdominal flat plate
To evaluate abdominal area
CBC & BT
To determine if there are any
abnormalities with the laboratory
results.
9. Blood for stat explore lap c/o Dr. 9. For proper visualization of the
Suan
gastrointestinal organs.
10. Secure consent
10. To have a proper consent in every
medication and procedure that needs to
be done and for legal purposes..
11. Inform OR & Anesthiosiologist
11. To collaborate with the medical team.
12. Meds:
12.
Ranitidine 50/2; amp IVTT q8
For peptic ulcer disease
Cefazolin 1gm IVTT q8 ANST
To treat bacterial infection
Gentamycin 80/2; amp IVTT q8
To treat bacterial infection
ANST
To treat bacterial infection
Metronidazole 50mg IVTT q8
ANST
13. Refer accordingly
13. For further care & management.
14. For Hepa B & C detection
14. To detect any abnormalities in the
liver.
15. May transfer to ward.
15. For proper monitoring & management
16. Resched OR tom a.m. once 16. For thorough operation.
supplies are available.

17. IVTF L D5NM @ 30gtts/min

R PNSS @ 10gtts/min
Dec. 4, 2007 @ 12:02 pm
1. NPO
2. O2 inhalation 4L/min w/ T-piece
3. Suction secretion PRN
4. V/S q 15min; 1hr when stable
5. regulate @ 30gtts/min
6. IVTF Left:
D5Lr;L + 30mg keto @
30gtts/min
D5NSS:L + 30mg keto @ SR
D5LR:L + 30mg keto @ SR
7. Ketorolac 3-mg IVTT now
8. IVTF R @ KVO rate
9. Tramadol 50mg IVTT q4 X 6 doses
then oral for severe pain.
10. Continue meds.
11. I & O qshift
12. DAT when fully awake

17. For fluid and electrolyte replacement

For fluid therapy & compatible w/
blood transfusion
1. In preparation w/ surgery.
2. To provide adequate oxygenation.
3. To prevent furher abdominal infection.
4.To monitor pt closely.
5. For proper fluid therapy
6.
Fluid maintenance & provide relief
of the pain.

7. For fast effect in relieving pain.

8. To provide proper fluid therapy.
9. To relieve severe pain.

10. To continue pharmacologic therapy.

11. To monitor body fluid status.
12. To provide proper nutrients in the
body.
13. Secure 1U of whole blood of 13. replace blood loss
particular blood type.
Dec 5, 2007 @ 9pm
--- 1st post-op day--1. Still NPO
1. To prevent aspiration
2. Pull out FBC
2. To prevent urinary infection
3. Sit up in bed
3. For proper removal of abdominal
drainage
4. IVTF D5LR;L@30gtts/min
4. For fluid replacement therapy.
D5NM;L@SR
D5NSS;L@SR
5. Continue meds
5. To continue pharmacologic therapy.
6. PCM300mg IVTT q4 PRN for fever
6. To relieve fever
Dec 6, 2007 @ 12:40pm
1. IVTF D5NM;;L@SR
1. To continue fluid & electrolyte
maintenance.
2. TWC R arm IVF
2. To use single IV line.
nd
---- 2 post-op day ---3. General liquids
3. Taking slow intake of supplements &
prevent gastric pain.
4. IVTF D5LR;L@30gtts/min
4. Fluid maintenance therapy.
D5NM;L@SR
D5NSS;L@SR

5. Dressing dailly
6. Pull out FBC
7. Continue meds
8. For NGT removal
Dec 7, 2007
1. Repeat Hct now
2. Encourage moving up in bed

5. To provide proper care of abdominal

incision & prevent infection.
6. To prevent urinary infection
7. To continue pharmacologic therapy
8. No longer needed by the pt.

1. For further evaluation & comparison

2. To promote excretion of drainage &
prevent contractures.
3. IVTF D5NM;L@SR
3. To continue fluid replacement therapy
4. Daily dressing
4. To provide proper care of the wound &
prevent infection.
5. General liquid
5. For proper hydration therapy
6. Secure 1u FWB & proper blood 6. To replace blood loss.
typing crossmatched.
Dec. 8, 2007 @ 9:40am
1. Soft diet
1. Can easily be swallowed
2. Follow up transfusion
2. To replace blood loss
3. Continue meds
3. To continue pharmacologic therapy
4. IVTF PNSS;L @ KVO
4. For fluid replacement therapy
5. Daily dressing
5. To provide proper wound care &
prevent infection.

DIAGNOSTIC EXAMINATIONS
Serology (Dec. 3, 2007)
Hepatitis:
HBsAg

Result
: Non reactive

Normal Values
: Non reactive

HCV

: Non reactive

: Non reactive

Significance
: Non reactive for viral
infection in the liver
: Non reactive

Hematology (Dec 3, 2007)

Hematocrit

32.3

42-51vol%

Hemoglobin

10.6

13-18gm

WBC
Differential count
Segmenters
Lymphocytes
Monocytes
Platelet count
Blood type
Rh Type

4,300/cu mm

5,000-10,000

Severe anemia; acute

massive blood loss.
Anemia, severe or
prolonged hemorrhage.
Infection

81
15
04

55-65%
25-35%
2-4%

possible infection

170,000
B
(+)

150,000-450,000

normal range
Type B
Positive w/ antigen

Severe anemia; acute

massive blood loss.
Anemia, severe or
prolonged hemorrhage.

normal range

Hematology (Dec 7, 2007)

Hct

26.0vol%

42-51vol%

Hgb

8.6 g/dl

13-18gm