DOCTORS ORDER

Patient: An-An Alipunga Attending Physician: Dr. Mark G. Sarmiento

Diagnosis: Bacterial Meningitis Date Admitted: August 8, 2015
Date/Time
Aug.8,2015
9:45am

Doctors Order
Rationale
Please admit at female Medical For prompt collaborative care
Ward
and management.
To make sure there is an
approval from the patient as to
Secure consent
take care and treatment that
will be given to her during the
course of admission.

UTI

This implies the presence of

characterisitics symptoms and
significant bacteriurea from
kidneys to bladder.
For further Examination.

R/O Meningitis Vs Migraine

Give to client to tolerate any

food she/he desires that is
nutritious.

DAT

D5LR Il @ 30gtts/min

is
useful
for
daily
maintenance of body fluids
and
nutrition,
and
for
rehydration.

Diagnosis:
CBC with Platelet Count
U/A
Na K Creatinine & BUN
X-Ray of PNS

It is used to demonstrate
the presence or absence of
infection and it is the
process in determining in
the nature of a disease or
disorder and distinguishing
it from other possible
conditions.

To reduce fever

TREATMENT:
1. Paracetamol 5oomg TAB
q4H per Fever
2. Omeprazole 4omg IVTT
q12

Used to treat symptoms of

gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid

To obtain baseline data and

monitor
patients
hemodynamic status

V/S q4

To check whether there is

problem with her kidney
function in excreting fluids

I & O q shift

August
9,2015
12:15pm

V/S q4

Refer if :
BP
HR
RR

Dexamethasone 10mg IVTT

now and 4mg IVTT q6h for
2 days

To obtain baseline data and

monitor
patients
hemodynamic status

For collaborative care to

help in the management
of
patient
medical
condition.

To decrease cerebral
pressure and improve
csf flow thus helps
stabilizing the blood
brain barrier. This leads
to
improvement
in
neurological symptoms.

August
10,2015

Treatment for serious

infections of bacterial
meningitis
Replacement of fluid
and electrolyte.
Cefriaxone 2g IVTT q 12
ANST(-)

PNSS Il 30gtts

For further information

For further Examination
Compliance to medication
ensures
proper
management of existing
medical problems.

August
11,2015
Admitted
7/14/15
for
typhoid fever

To
retrieve
admission chart

previous

For CT scan of brain plain

Continue Meds.

PNSS Il 30gtts/min

S/F CT-Scan-brain plain

FFup CXR

Replacement of
and electrolyte.

fluid

To monitor complications.

This
meds.enhances
actions of the brain and
improves
cerebral
circulation
and
metabolism.
This medication is an
osmotic
diuretic
prescribed for increase
intracranial pressure.

 citicholine 2gm IVTT q 12

Compliance to medication
ensures
proper
management of existing
medical problems.
Mannitol 20% 40cc IVTT q8
x 6boges Hien DC

For collaborative care to

help in the management of
patient medical condition.
Replacement of
and electrolyte.

Continue Meds.

fluid

Compliance to medication
ensures
proper
management of existing
medical problems.

August
12,2015
Still for CT-SCAN

PNSS 1 Liter at 20gtts/min

Continue Meds.

Compliance to medication
ensures
proper
management of existing
medical problems.
For collaborative care to
help in the management of
patient medical condition.

Replacement of
and electrolyte.

fluid

Used
in
relieving
moderate to severe

pain
August
13.2015
Continue all Meds.
Treatment for serious
infections of bacterial
meningitis
Facilitate CT-SCAN

Used to treat symptoms of

gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid

IVF TF C PNSS 1L X
2Ogtts/min

This meds. Enhances

actions of the brain and
improves
cerebral
circulation
and
metabolism.

Paracetamol + tramadol 1
tab q8

To
prevent/reduce
nausea and vomiting

Summary of Meds:
1.Ceftriaxone 2 grams IVTT
q12

To decrease cerebral
pressure and improve
csf flow thus helps
stabilizing the blood
brain barrier. This leads
to
improvement
in
neurological symptoms.

August
14,2015

2.Omeprazole 4omg IVTT

q12

Replacement of
and electrolyte.

fluid

3.Citicholine 1 gram IVTT

q12

4.Metoclopromide
1amp
IVTT now then q8 PRN for
Vomiting

5. Dexametaxone 4mg IVTT

q6 x 48 hrs

Replacement of
and electrolyte.

fluid

For collaborative care to

help in the management
of
patient
medical
condition

Compliance to medication
ensures
proper
management of existing
medical problems.

Neuro imaging can

identify conditions that
may
predispose
to
bacterial
meningitis,
and
to
monitor
complications.
IVF TT C PNSS IL x
20gtts/min x 2
Replacement of
and electrolyte.

August
15,2015
Still
c
difficulty
moving Head
Refer
to
Dr.Sarmiento
PNSS 1 Liter
20gtss/min

at

fluid

Treatment for serious

infections of bacterial
meningitis
Used to treat symptoms of

 Please carry out CT

SCAN
Please refer to Dr.
Sarmiento

August
16,2015

To stimulate metabolic
function and is needed for
cell
reflecation
hematopoises
and
nucleoprotein and myelin
synthesis
It is used to demonstrate
the presence or absence of
infection and it is the
process in determining in
the nature of a disease or
disorder and distinguishing
it from other possible
conditions.

Continue Meds.

S/F CT-SCAN
brain pain

gastro esophageal reflux

disease
and
other
conditions
caused
by
excess stomach acid

of

August
17,2015
10:55am

PNSS @ 20gtss/min
x2

Compliance to medication
ensures
proper
management of existing
medical problems.
Replacement of
and electrolyte.

Reviews of Meds:

fluid

1.Ceftriaxone
grams IVTT q12

2.Omeprazole 40mg
IVTT q24h

Replacement of
and electrolyte.

fluid

Compliance to medication
ensures
proper
management of existing
medical problems.
3. Vit. B-complex tab OD
Maintains muscle tone,
muscle strength,and joint
flexibility

Dx:
CXR
U/A
PNSS Il @
30gtts/min x3

8:30pm

For collaborative care to

help in the management of
patient medical condition.
Compliance to medication
ensures
proper
management of existing
medical problems.
Compliance to medication
ensures
proper
management of existing
medical problems.

Replacement of
and electrolyte.

Continue
Meds.

fluid

August
18,2015

IVF TF: C
PNSS @SR

PNSS 1 Liter @ 15gtts/min

August
19,2015
Continue Meds

August
20,2015

Encourage to sit up and

ambulate slowly

These electrodes detect

the tiny the tiny electrical
changes on the skin that
arise from the heart muscle
depolarizing during each
heartbeat

Treatment
for
uncomplicated UTI or any
infections.
Used to treat symptoms of
gastro esophageal reflux
disease
and
other
conditions
caused
by
excess stomach acid

To stimulate metabolic
function and is needed for
cell
reflecation
hematopoises
and
nucleoprotein and myelin
synthesis

Facilitate CT-Scan

Continue Meds.

To identify any occurring

problems and development

in of health status.

Continue Meds.

IVF TF c PNSS Il @ SR

August
21,2015
For EKG 12 Leads

May go home
1. Home Meds
2.
Cefixine 200mg
Cap I cap
BID
Omeprazole 20g

Patient
was
given
discharged instructions.

cap I OD X 7
Days

Vitamin
Complex
cap OD

Bcap I

FF-up check up at OPD after 1

week

Advised
Consult
neurologist

optha-