Date Admitted: ________________ Address: ______________________Religion: _____
Attending Physician: _____________________ Chief Complaint: __________________ Admitting Diagnosis: _________________________ Diet: _________ Room No. _____ Case No. _________ Membership: _________ Date of Birth: ______________________
Date Treatment Medications IVF
11-30-09 >TPR q Shift >Paracetamol 325\tab 1 tab q >#1 D5.03 >Labs: CBC, Plt, U\A 4 for fever Nacl 1 L @ >V\S q 2 & Record >Ampicillin 500 mg IVTT q 100 cc\hr >Repeat Plt, Hct, Tom AM 6 ANST >#2 D5NSS 1 @ lab >Paracetamol 200\5 mL 1 tsp L + 1 amp >Refer for persistent q4 PRN for fever BNC @ SR- epistaxis & other >Paracetamol 300 mg IVTT available unusualities now then PRN for T>39 C Name: _________________________________ Age: ____ Sex: ____ Civil Status: ____ Date Admitted: ________________ Address: ______________________Religion: _____ Attending Physician: _____________________ Chief Complaint: __________________ Admitting Diagnosis: _________________________ Diet: _________ Room No. _____ Case No. _________ Membership: _________ Date of Birth: ______________________
Date Treatment Medications IVF
11-28-09 >VS q 4 > Lanoxin 25 mg ½ tab OD >#1 PNSS 1 L >Labs: >NaHCO3 325 mg 1 tab OD @ KVO rate RBS, CBC, U\A, ECG, >K 1 tab TID >#2 PNSS 1 L CXR-PA, FBS, Na., K., >Vit. B Complex 1 tab q 12 + 100cc NaCl SUA >Celecoxib 200 mg 1 cap @ 20 gtts/min >CBR w/o BRP BID >Will inform AP >Domperidome10 mg 1 tab >Refer to M. Lasala for co- TID mgt >Endostine 1 cap BID >R.A. >Plasil 1 amp IV now 11-29-09 >For Endoscopy >(+) Vomiting >(+) on\off epigastric pain >(+) anemia >schedule for UGI endoscopy now c/o GMCH
11-30-09 >maintain in NPO
Dr. Gay Hernandez for sedation Facilitate transfer ASAP inform M. Molina Name: _________________________________ Age: ____ Sex: ____ Civil Status: ____ Date Admitted: ________________ Address: ______________________Religion: _____ Attending Physician: _____________________ Chief Complaint: __________________ Admitting Diagnosis: _________________________ Diet: _________ Room No. _____ Case No. _________ Membership: _________ Date of Birth: ______________________
Date Treatment Medications IVF
11-30-09 >Admit under Dr. Balazo >Dilantin 100/ tab 1 tab TID >#1 D5W >High Caloric Diet >Combivent Now q 8 500cc @ KVO >TPR q Shift >Cefurexime 80 mg IVTT q >Labs: CBC, U/A, CXR- 8 ANST PA view- Follow up result >Essentiale forte 1 tab TID >Retrieve chart of previous admission >inform AP