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Mariano Marcos State University: College of Health Sciences

The doctor's order is for a patient admitted to the hospital with laryngitis. The order includes admitting the patient to a room of their choice, obtaining consent for care and management, monitoring vital signs, starting the patient on a soft diet, and performing diagnostic tests including a CBC, throat swab for culture and sensitivity, and neck ultrasound. Treatment ordered includes IV fluids, antibiotics, pain medication, and gargling with an antiseptic solution. The patient is also instructed to rest their voice, increase fluid intake, and avoid certain drinks.

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Joshua Gonzales
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116 views

Mariano Marcos State University: College of Health Sciences

The doctor's order is for a patient admitted to the hospital with laryngitis. The order includes admitting the patient to a room of their choice, obtaining consent for care and management, monitoring vital signs, starting the patient on a soft diet, and performing diagnostic tests including a CBC, throat swab for culture and sensitivity, and neck ultrasound. Treatment ordered includes IV fluids, antibiotics, pain medication, and gargling with an antiseptic solution. The patient is also instructed to rest their voice, increase fluid intake, and avoid certain drinks.

Uploaded by

Joshua Gonzales
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

DOCTOR’S ORDER

SURNAME:____________________ AGE: ______ HOSP.NO.: _____________

GIVEN: ________________________ MI: ______________ SEX: _________ WARD: ______

PROGRESS NOTES ORDER ACTION TIME/SIG


11/14/2021 8:00  Admit to room of choice
AM  Secure consent to care and management
Hoarseness of voice  TPR q shift and record
almost 6 months  Soft diet
Pain upon  Diagnostics:
swallowing 3  CBC, ESR
months ago  Throat swab for C/S
BP: 110/70  Neck ultrasound
PR: 80  For Laryngoscopy
RR: 20  Treatment:
BT: 36.8 C  Start IVF D5LR 1L for 10 hrs, TF : IVF
D5NM1L for 12 hrs
Dx: Laryngitis  Ampicillin 1000 mg IV q 6 hrs ANST
 MIbuprofen 500 mg p.o TID
 Bactidol 1 ml in a glass of water for
gargle TID
 Rest voice as much as possible
 Increase fluid intake
 Avoid coffee and alcohol
 Daily weighing
 Report progress of symptoms
 Refer accordingly

Dr. Galvez

Name Age/ Sex Ward Rm. No.

Nurses Action Legend:


C – Carried A – Administered R – Requested E – Endorsed D – Discontinue

DOCTOR’S ORDER
MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

SURNAME:____________________ AGE: ______ HOSP.NO.: _____________

GIVEN: ________________________ MI: ______________ SEX: _________ WARD: ______

PROGRESS NOTES ORDER ACTION TIME/SIG


11/14/2021 8:00  Admit to Room of choice
AM  V/S q 15 mins until stable
Nape pan  On low salt low fat diet
Dizziness  I& O monitoring q shift
BP: 160/100  CBR w/BPR s
PR: 86  Diagnostics:
RR: 18  CBC, UA
BT: 37. C  Blood chem-FBS, BUN, Crea, Na, K
 lipid profile-total cholesterol,
Dx: HTN, Stage 1 LDL,HDL
 ECG
 Treatment:
 IVF D5LR 1L for 6 hrs
 TF : IVF D5NM1L for 8 hrs
 Clonidine 150 mcg tab SL Now
 Spirinolactone 25mg tab OD AM
 Irbesartan 150 mg tab OD
 Amlodipine 10 mg tab HS
 Observe for any untoward manifestation
 Refer accordingly
Dr. Dela Cruz

Name Age/ Sex Ward Rm. No.

Nurses Action Legend:


C – Carried A – Administered R – Requested E – Endorsed D – Discontinue

DOCTOR’S ORDER
MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

SURNAME:____________________ AGE: ______ HOSP.NO.: _____________

GIVEN: ________________________ MI: ______________ SEX: _________ WARD: ______

PROGRESS NOTES ORDER ACTION TIME/SIG


10/06/2021 8:00 AM -Please admit room of choice
Difficuty swallowing -Secure consent for the admission R 8:05
Dry cough -Diet: Soft diet R 8:05
Sore throat -IVF: Start IVF D5LR 1L to run for 8 hrs R 8:05
TF: IVF D5NM 1L for 6 hrs
Meds: C 8:06
Temp: 37.5oC -Ampicillin 500mg IV q 6 hrs
PR: 76 bpm -Paracetamol 300 mg IV for body temperature 38.5 and up C 8:01
RR: 22 breaths/min -Mefenamic Acid 250mg tab TID P.O for headache
BP: 100/60mmHg A 8:02
-Warm saline gargle TID A 8:03
Dx: Pharyngitis -TSB PRN A 12:03
-Watchout for progress of symptoms A 8:04
-Monitor VS q 4 and record C 8:07
-Refer accordingly C 8:07
Dr. Baytec C 8:10

Name Age/ Sex Ward Rm. No.

Nurses Action Legend:


C – Carried A – Administered R – Requested E – Endorsed D – Discontinue

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