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REID, BRIAN Nurses Notes Vital Signs

Input and Output Discharge Instructions CBG OR

DOCS PACS Doctor's Order Rx Clinical Summary

Visit History

Patient Information
(ID:
Patient's Name Attending Dr1: DR. SOFIA
RELLAMA BLACK, MD, FPCP,
2024004495 FPCC, FPSE
VIEW OPD/ER: 374672B ) Attending Dr2: DR. SHERRY
ONG CUNANAN, MD, FPCS,
REID, BRIAN FPSGS, FPALES, FACS
Age: 84 Sex: M Room: SH703 Attending Dr3: DR. FIDEL JR
ANTONIO BALDOVINO, MD,
Admisson Date: 06/04/2024
FPCS, FPALES
04:45 PM Discharge: Admitting Dr: DR. CHELSEA
RINGOR GABRIEL,
Referring Dr: DR. LOI MARIE
RUMIAS VELASQUEZ, MD,
DPBA, FPSA

New Telephone SMS Verbal Other

Order: Order Order Order Orders
Side Notes Orders

Type here... Course in the Ward

Type here...

SAVE

List of Doctor's Orders

Entered by: Carried out by: |
BLACK,
RALPH
GERALD R. |
Jun 08, 2024
11:13 AM

Side Notes Order# 360167 Nurse Compliance

Crea IM CARDIO Type here...

clearance For ultrasound
55 of hemithoraces
Taper down
Save/Update dopamine drip
Start
Course norepinephrine
8mg in 100cc
PNSS to start at
1mkd
Give dulcolax 2
tablets now
D/c ceftriaxone
Start Piperacillin
Tazobactam
(Bizataz) 4.5g IV
now as loading
dose then
succeeding
doses every 6
hours
Start Bearse 1
tab TID
For PTPA, CBC
APTT, Crea, K
today
Refer to Dr. E.
Ojascastro for
Pulmo joint
management
and possible
thoracentesis

Dr. S. Black/ R.
Black/ Gapuz/
Ulya

Entered by: Carried out by:

GAPUZ, MARIE JOYLYN
NICOLAI C. | A. AGUINALDO
Jun 08, 2024 | Jun 08, 2024
10:22 AM 10:48 AM

Side Notes Order# 360102 Nurse Compliance

S: Patient IM RESIDENT'S -
had good NOTES -noted
sleep but Current IVF: -
with noted PNSS 1L x -
agitation at 80cc/hr -
4am due to DM Diet -
recurrence CBG monitoring -
of low back at 11am-5pm- -
pain. 10pm-6am -
Patient Monitor VS q4 -
given PRN hours and record -
IV -
medication Awaiting repeat -
and now is CXR HTE -
comfortably portable -
resting. -
Patient still #Hypotension -
with poor -Dopamine drip: -
oral intake 1 amp in 250cc -
and still d5w to start at 5 -
with mkd to titrate in -
episodes of increments of -
"choking" 5mkd to -
during maintain sbp of -
administrati >110 ( max of -
on of oral 20) -
medications -Maintain BP of -
. atleast 110 SBP -
-
BP: 90- #Obstructive -
110/60-80 Jaundice s/p -
(100/60) ERCP (6/3/2024) -
HR: 85-108 S/P -
(85) cholecystojejuno -
RR: 17-19 stomy, -
(18) pancreatic mass -
T: 36.0- biopsy with RFS, -
36.5 (36.5) drain placement -
SpO2: 94- (6/5/24) -
98 (98%) at - Ceftriaxone -
3lpm/nc (Xtenda) 2g IV -
OD - 2 days -
I&O (16 completed -
hrs): 1740 - Metronidazole -
vs 1276 500mg IV q8hrs -
- 2 days -
CBG completed -
06/07 - Etoricoxib -
11AM: 126 (Myox) 90 mg -
5PM: 98 tab BID after -
7PM: 104 meals -
10PM: 151 - Tramadol -
50mg/tab 1 tab -
06/08 TID -
6AM: 138 - Tramadol -
50mg IV q12 -
Patient PRN for severe -
examined breakthrough -
asleep pain
jaundiced, - Ketorolac
no pallor 30mg IV Q8 as
Icteric needed for
sclerae, severe pain
pink
palpebral #Type 2 DM,
conjunctiva Insulin requiring
e, - Lantus solostar
Dry lips and OD post-dinner
oral mucosa if CBG is >200
Decreased mg/dl
breath - Jardiance 25
sounds on mg 1 tab OD
left mid to - Pantoprazole
lower lung 40mg IV OD
fields
Normal rate #CAD s/p CABG,
still with HFmrEF
irregular Trimetazidine 35
rhythm mg 1 tab BID
Abdomen Spironolactone
flabby, soft, 25 mg 1 tab BID
dry and
intact #Pleural effusion
dressing, with congestion:
tympanitic, Salbutamol 1
non tender neb TID on
Intact IFC, waking hours
output
noted to be #hypoalbumine
concentrate mia
d dark Albumin 1 vial +
yellow urine 20mg
Grade II Furosemide IV
bipedal OD x 1/3 doses
edema, given
weak but
equal #Hypokalemia
pulses - KCl 750mg/tab
1 tab TID
Save/Update
#BPH:
Course - Duodart 1 tab
ODHS

# Anemia
S/p transfusion
of 1 unit PRBC.
Post furo output
at 150cc

# Dementia
- Quetiapine
200mg/tab 1/2
tab ODHS
- Memantine
10mg/tab 1/2tab
OD
- Donepezil
(Dopezil)
10mg/tab 1/2tab
OD

GAPUZ

Entered by: Carried out by:

BLACK, JANICE C.
RALPH DAO-EY | Jun
GERALD R. | 08, 2024 10:27
Jun 08, 2024 AM
10:12 AM

Side Notes Order# 360087 Nurse Compliance

BP 90/50 IM RESIDENTS -
PR 110s NOTES done
Bibasal Fast drip 100cc -
rales PNSS now -noted

Save/Update R. Black

Course

Entered by: Carried out by:

BLACK, JANICE C.
RALPH DAO-EY | Jun
GERALD R. | 08, 2024 10:24
Jun 08, 2024 AM
09:00 AM

Side Notes Order# 360009 Nurse Compliance

IM CARDIO -
Please continue done/resumed
Save/Update Dopamine at 5mkd then
Fast drip 100cc tritated
Course PNSS now accoprdingly -
-
Dr. S. Black/ R. -
Black -

Entered by: Carried out by:

BLACK, MARIE JOYLYN
RALPH A. AGUINALDO
GERALD R. | | Jun 08, 2024
Jun 08, 2024 10:51 AM
08:46 AM

Side Notes Order# 359993 Nurse Compliance

IM CARDIO -
Please do CPT -requested
Save/Update after every -
Nebulization. -
Course
Dr. S. Black/ R.
Black

Entered by: Carried out by:

BENEDITO, MARIE JOYLYN
EMERSON L. A. AGUINALDO
| Jun 08, | Jun 08, 2024
2024 07:14 07:17 AM
AM

Side Notes Order# 359908 Nurse Compliance

GS notes -
POD 3 -noted
Save/Update wound care -
done -
Course continue -
supportive care -
encourage DBE -
refer -

Dr. Dirige/
Benedito

Entered by: Carried out by:

BLACK, DAIME ROSE S.
RALPH EBES | Jun 07,
GERALD R. | 2024 09:05 PM
Jun 07, 2024
05:49 PM

Side Notes Order# 359547 Nurse Compliance

IM RESIDENTS -
NOTES - noted at 7
Save/Update Check CBG 2 pm, CBG =
hours after 109
Course patient takes -
Kitkat provided -
by relatives -

R. Black

Entered by: Carried out by:

BLACK, DAIME ROSE S.
RALPH EBES | Jun 07,
GERALD R. | 2024 06:12 PM
Jun 07, 2024
05:38 PM

Side Notes Order# 359536 Nurse Compliance

S/P IM RESIDENTS -
cholecystoj NOTES -
ejunostomy, -
pancreatic Current IVF: -
mass PNSS 1L x -
biopsy with 80cc/hr -
RFS, drain DM Diet -
placement CBG monitoring -
(6/5/24) at 11am-5pm- -
10pm-6am -
Patient with Monitor VS q4 -
adequate hours and record -
pain -
control. #Hypotension -
Patient -Dopamine drip: -
noted 1 amp in 250cc -
having d5w to start at 5 -
choking mkd to titrate in -
episodes increments of -
after 5mkd to -
drinking maintain sbp of -
oral >110 ( max of -
maintenanc 20) -
e -Maintain BP of -
medications atleast 110 SBP -
. CXR and -
ABG was -
done. #Obstructive -
CXR Jaundice s/p -
showed ERCP (6/3/2024) -
congestion S/P -
and pleural cholecystojejuno -
effusion. stomy, -
Furosemide pancreatic mass -
was given. biopsy with RFS, -
drain placement -
Patient did (6/5/24) -
not eat - Ceftriaxone -
today and (Xtenda) 2g IV -
does not OD - D2 -
want to - Metronidazole -
drink 500mg IV q8hrs -
medications - D2 -
. Patient - Etoricoxib -
was told to (Myox) 90 mg -
drink tab BID after -
medications meals -
but patient -Tramadol -
complained 500mg/tab 1 tab -
of DOB. TID -
ECG was - Tramadol -
done 50mg IV q12 -
showing A- PRN for severe -
Fib. breakthrough -
BP was pain -
noted to be - Ketorolac -
90/60 CBG 30mg IV Q8 as -
93. needed for -
severe pain - noted IM
Patient is rounds
awake, #Type 2 DM,
conversant, Insulin requiring
Sitting up - Lantus solostar
right on OD post-dinner
high back if CBG is >200
rest mg/dl
Decreased - Jardiance 25
generalized mg 1 tab OD
jaundice - Pantoprazole
compared 40mg IV OD
to
admission, #CAD s/p CABG,
no pallor HFmrEF
Icteric Continue
sclerae, patient's stocks:
pink Trimetazidine 35
palpebral mg 1 tab BID
conjunctiva Spironolactone
e, 25 mg 1 tab BID
Dry lips and
oral mucosa #Pleural effusion
Decreased with congestion:
Breath Salbutamol 1
sounds on neb now then
left mid to TID on waking
lower lung hours
fields
Heart rate
normal with #hypoalbumine
irregular mia
rhythm albumin 1 vial +
Abdomen 20mg
flabby, soft, Furosemide IV
dry and OD x 3 doses
intact
dressing, #Hypokalemia
Noted -KCl 750mg/tab
sanginous 1 tab TID
JP drain
output #BPH:
Intact IFC -Duodart 1 tab
draining, ODHS
Dark yellow
Grade III #Anemia
Bipedal For transfusion
edema of 1u pRBC.
Furosemide
Na 138.20 20mg IV after BT
(136)
Other meds:
Save/Update -Quetiapine
200mg/tab 1/2
Course tab ODHS
-memantine
10mg/tab 1/2tab
OD
-Dopezil
10mg/tab 1/2tab
OD

R. Black

Entered by: Carried out by:

BLACK, DAIME ROSE S.
RALPH EBES | Jun 07,
GERALD R. | 2024 05:26 PM
Jun 07, 2024
05:13 PM

Side Notes Order# 359509 Nurse Compliance

IM CARDIO -
NOTES - noted
Save/Update Regulate IVF -
PNSS to 80cc/hr -
Course
Dr. S. Black/ R.
Black

Entered by: Carried out by:

GAPUZ, DAIME ROSE S.
NICOLAI C. | EBES | Jun 07,
Jun 07, 2024 2024 05:25 PM
04:56 PM

Side Notes Order# 359489 Nurse Compliance

IM CARDIO -
Fast drip 200cc - done
Save/Update PNSS now -
Start Dopamine - hooked at 5:
Course drip as follows: 20 pm
1 amp in 250cc -
d5w to start at 5 -
mkd to titrate in - at 7pm
increments of -
5mkd to -
maintain sbp of
>110 ( max of
20)
Check CBG after
2 hrs
Maintain BP of
atleast 110 SBP
Dr. S.
Black/Gapuz/R.
Black

Entered by: Carried out by:

GAPUZ, DAIME ROSE S.
NICOLAI C. | EBES | Jun 07,
Jun 07, 2024 2024 05:30 PM
04:43 PM

Side Notes Order# 359475 Nurse Compliance

Atrial IM CARDIO -
Fibrillation Give Digoxin - given
0.25mg IV now -
Save/Update Dr. S.
Brown/Gapuz
Course

Entered by: Carried out by:

BLACK, GERLIN C.
RALPH DEPALOG | Jun
GERALD R. | 07, 2024 12:49
Jun 07, 2024 PM
10:56 AM

Side Notes Order# 359117 Nurse Compliance

IM CARDIO -
NOTES requested
Save/Update For repeat
portable CXR,
Course HTE tomorrow

Dr. S. Black/ R.
Black/ Gapuz/
Ulya

Entered by: Carried out by:

BLACK, GERLIN C.
RALPH DEPALOG | Jun
GERALD R. | 07, 2024 12:50
Jun 07, 2024 PM
10:53 AM

Side Notes Order# 359111 Nurse Compliance

IM CARDIO -
NOTES transcribed
Save/Update Start Tramadol transcribed
500mg/tab 1 tab -
Course TID decreased
Start Ketorolac -
30mg IV Q8 as noted
needed for
severe pain
Decrease
Quetiapine to 1/2
tab ODHS

Dr. S. Black/ R.
Black/ Gapuz/
Ulya

Entered by: Carried out by:

BLACK, GERLIN C.
RALPH DEPALOG | Jun
GERALD R. | 07, 2024 01:28
Jun 07, 2024 PM
10:47 AM

Side Notes Order# 359104 Nurse Compliance

IM CARDIO -
NOTES transcribed,
Save/Update Start memantine for SP
10mg/tab 1/2tab transcribed
Course OD requested
Start Dopezil given
10mg/tab 1/2tab
OD
For serum Na,
please use
previous serum
today
Ketorolac 1amp
IV now

Dr. S. Black/ R.
Black/ Gapuz/
Ulya

Entered by: Carried out by:

BLACK, GERLIN C.
RALPH DEPALOG | Jun
GERALD R. | 07, 2024 02:07
Jun 07, 2024 PM
10:41 AM

Side Notes Order# 359099 Nurse Compliance

Decreased IM CARDIO -
BS on left NOTES given
lung mid to Give Furosemide now dose
base 20mg IV now given as stat,
CXR: Salbutamol 1 requested
Pleural neb now then green request
effusion on TID on waking form to
left lung hours watcher
Secure and noted
Save/Update transfuse 1 unit transcribed
of pRBC, once transcribed to
Course properly typed start
and -
crossmatched to transcribed
run for 4 hrs. confirmed as
Furosemide tablet
20mg IV after BT -
Resume albumin -
1 vial + 20mg noted
Furosemide IV
OD x 3 doses
Resume
spironolactone
25mg/ tab 1 tab
BID
continue Kcl
infusion while on
Albumin

Dr. S. Black/
Gabriel/ R. Black/
Ulya/ Gapuz

Entered by: Carried out by:

BLACK, GERLIN C.
RALPH DEPALOG | Jun
GERALD R. | 07, 2024 09:30
Jun 07, 2024 AM
09:18 AM

Side Notes Order# 359008 Nurse Compliance

IM CARDIO -
NOTES done as stat
Save/Update For Chest xray done as stat
portable, HTE
Course now
For ABG now

Dr. S. Black/ R.
Black

Entered by: Carried out by:

MUSTHOFA, GERLIN C.
AISHATH U. | DEPALOG | Jun
Jun 07, 2024 07, 2024 09:29
09:18 AM AM

Side Notes Order# 359007 Nurse Compliance

was IM RESIDENT noted,

referred NOTES: instructed
due to strict aspiration watcher
choking precautions