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Course in the Ward

Day 1 (06/28/16)
A patient who is a woman (1) came to the Emergency Room of San Antonio Medical
Center (2) that was ambulatory accompanied by her relative with the CC of PAIN (R)
distal part of the leg (pain scale? Any cause? Injury? Brief history of present illness?
Physical Assessment?). Vital signs are taken, TEMPERATURE: 37.1 (other VS? BP?
PR? RR?). A consent for admission was secured (immediately? why did the ROD
decide to have the patient admitted in the first place?). She was admitted under
what service? Laboratory and Diagnostics such as CBC, UA (initial results) and Blood
GS/CS before starting antibiotics are requested and medications are given such as
Piperacillin + Tazobactam 2.25 gm/IV q8 ANST if okay with Dr. Valencia and
Keterolac 30 mg/IV q8 ANST PRN. The nurse also started IVF Plain LR 1L @ KVO and
then referred to Dr. Reyes (just state the service, Surgery? IM?) for co-management.
1 What is the age of the patient? Example: A 31 year-old female ambulatory
patient came into the ER
2- Do we really need to divulge the name of the hospital?

Day 2 (06/29/16)
Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
Laboratory orders/ results?
The nurse start to give Celecoxib 200 mg cup BID KTC (what is KTC? Is it RTC or
round the clock?) and the continue to give Piplazo (this is a formal document,
complete the name of medications).

Day 3 (06/30/16)
Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
Laboratory orders/ results?

At 9:50AM, the nurse PLRS IL X KVO was consumed and was shifted to heplock , as
ordered

Day 4 (07/01/16)
Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
Laboratory orders/ results?

Please revise this whole section. Make this narrative. Not timeline.
What was the result of the CP clearance?
Did the patient sign an OR consent?
Is there any pre-op anesthesia note from the doctor?
At 9:10AM, the patient was for Wound Debridement and for once CP evaluated
under the anesthesia and then REFER.
At 2PM, there was a request for serum potassium.
At 3PM, for serum potassium once available and for final clearance once potassium
is in and then REFER.
At 7P, the patient was scheduled for Wound Debridement tomorrow after the 9AM
schedule of Colonoscopy (irrelevant to the patient) and started NPO post midnight.

Day 5 (07/02/16)
Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
Laboratory orders/ results?

Please revise this whole section. Make this narrative. Not timeline.

At 8:10AM, the nurse hooked D5LR 1L and regulated it at 40 gtts/min.


At 8:40AM, there was pre ordered medications. The physician ordered to give
Nubain 10 mg and Promethazine 50 g IM (was it a cocktail dose?) NOW stat and
then hook to O2 inhalation 1-2 LPM via NC (avoid abbreviations/ acronyms).

Please revise this paragraph into a more narrative form, NOT from the direct notes
from the chart:
The anesheologist post orders was patient to recovery room, VS q15 x 2 doses and
NPO. There are medications that was ordered. There were Morphine Sulfate 0.32
Instrospinal fiven and Keterolac 30 mgf q6 x 4 doses, Mefenamic Acid 500 mg cup
TID x 5 doses and Vigocid 2.25 given x 5 doses q8. Also, 1VF D5LR IL X 8 X 3 only.
At 2:30 PM, the physician ordered the D/C of Celecoxib and continue medications.
The patient was also for repeat of CBC, Platelets tomorrow AM and then REFER.
At 3PM, the nurse start IVF D5LR IL at 40 gtts/min.
At 6PM, the patient was now fully awake and advised to have DAT diet.

Day 6 (07/03/16) First Day Post-Operation


Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
This is first day post-op. Were there dressing changes? Is the dressing soaked?
Laboratory orders/ results?

At 7:30AM, physician ordered to continue medications until 10AM and then REFER.
At 1PM, IVF D5LR IL at 40 gtts/min.

Day 07 (07/04/16)

Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
This is second day post-op. Were there dressing changes? Is the dressing soaked?
Laboratory orders/ results?
Health teachings? Diet?

At 8AM, IVF D5LR IL x 40 gtts min at 2 cycles only.


At 5:40PM, IVF to consume and shift to heplock, just continue to give Vigocid to
complete 21 doses then D/C. For discharge by Dr. Reyes and there was no objection
on it.

Day 8 (07/05/16)

Vital Signs?
Physical Assessment?
Goals of Treatment? Is it pain management? Hydration?
This is third day post-op. Were there dressing changes? Is the dressing soaked?
Range of motion?
Laboratory orders/ results?

The patient may go home and there was no home medications until GS/CS result.
The patient was also reminded to have follow up check up on July 9 (Saturday) 8AM10AM at Best Health.
Health teachings for discharge?