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    Doctor's Order Phase 2

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    Renea Joy Arruejo
    Mrs. Milagros Bautista, a 58-year-old female, was admitted to the hospital for cold clammy skin, chills, dizziness and a blood glucose level of 348 mg/dL. She has a history of diabetes. Doctors ordered various diagnostic tests and started her on insulin and medications to manage her diabetes and blood pressure. Due to a diabetic foot infection and gangrene, she was also referred to surgery and started on antibiotics. Later notes show her heart rhythm was found to be atrial fibrillation and she exhibited signs of acute coronary syndrome, so additional cardiac medications were prescribed.

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    © All Rights Reserved
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    Doctor's Order Phase 2

    Uploaded by

    Renea Joy Arruejo
    63 views5 pages
    Mrs. Milagros Bautista, a 58-year-old female, was admitted to the hospital for cold clammy skin, chills, dizziness and a blood glucose level of 348 mg/dL. She has a history of diabetes. Doctors ordered various diagnostic tests and started her on insulin and medications to manage her diabetes and blood pressure. Due to a diabetic foot infection and gangrene, she was also referred to surgery and started on antibiotics. Later notes show her heart rhythm was found to be atrial fibrillation and she exhibited signs of acute coronary syndrome, so additional cardiac medications were prescribed.

    Original Description:

    CHARTING

    Original Title

    DOCTOR'S ORDER PHASE 2

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    Mrs. Milagros Bautista, a 58-year-old female, was admitted to the hospital for cold clammy skin, chills, dizziness and a blood glucose level of 348 mg/dL. She has a history of diabetes. Doctors ordered various diagnostic tests and started her on insulin and medications to manage her diabetes and blood pressure. Due to a diabetic foot infection and gangrene, she was also referred to surgery and started on antibiotics. Later notes show her heart rhythm was found to be atrial fibrillation and she exhibited signs of acute coronary syndrome, so additional cardiac medications were prescribed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    63 views5 pages

    Doctor's Order Phase 2

    Uploaded by

    Renea Joy Arruejo
    Mrs. Milagros Bautista, a 58-year-old female, was admitted to the hospital for cold clammy skin, chills, dizziness and a blood glucose level of 348 mg/dL. She has a history of diabetes. Doctors ordered various diagnostic tests and started her on insulin and medications to manage her diabetes and blood pressure. Due to a diabetic foot infection and gangrene, she was also referred to surgery and started on antibiotics. Later notes show her heart rhythm was found to be atrial fibrillation and she exhibited signs of acute coronary syndrome, so additional cardiac medications were prescribed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    PHYSICIAN’S ORDER/PROGRESS NOTES

    SURNAME:___BAUTISTA______________M.I.:___A_____ AGE:__58___HOSPITAL NO.:_2021-0000025____


    GIVEN NAME:____MILAGROS__________ SEX:__F___ WARD/ROOM NO.:_MEDICAL WARD -207________

    Progress TIME POSTED


    Date Doctor’s Order C A R E D AND SIGNATURE
    Notes

    1-05- cold clammy  Please admit to Medical Ward, Room of /


    2021 skin, chills Choice, under the service of Dr.
    9:45 AM and dizziness Cabuena
    while on his  Secure consent for admission and /
    work management
     TPR q shift and record /
     LSLF Diet: NPO post midnight /
     Diagnostics:
     FBS /
     Lipid Profile /
     CBC /
     BUN,Creatinine /
     SGPT, SGOT /
     Serum Electrolytes /
     Thyroid Function Test /
     12-L ECG /
     CXR-PA /
     Urine Analysis /
     CBG-348mg/dl /
     IVF: PNSS 1L X 8 hours /
     Treatment:

     Give Regular Insulin 10 units SQ /


    now
     GIve Clonidine 75 mg/tab 1 tad SL /
    now
     Losartan 50mg/tab 1 tab OD (AM) /
     Amlodipine 10mg/tab 1 tab OD /
    (PM)
     Metformin 500 mg/tab 1 tab BID /
     Cinnarizine 10 mg/tab 1 tab TID /
     Atorvastatin 20mg/tab 1 tab OD HS /

     Repeat CBG after 30 minutes then /


    CBG Monitoring TID pre meals
    /
     Monitor VS q 2 hours and record
    /
     I and O q shift and record

    C- Carried A- Administered R- Requested E- Endorsed D- Discontinued


     Inform AP of Admission /
     Refer to Dr. Richard Realin (Surgery) /
    for evaluation re: diabetic foot
    (Sig)
    Dr. Victoria Cabuena R. Arruejo
    ER Physician Stud. No.
    Lic.# 111430 3000052120513

     Give another 5 units Regular Insulin SQ /


    1-05- Repeated now
    2021 CBG: 295  For HbA1C /
    10:15 mg/dl  Add Gliclazide 30 mg tab OD /
    AM  O2 support at 1-2 LPM via nasal cannula /

    Dr. Victoria Cabuena


    ER Physician (Sig)
    Lic.# 111430 R. Arruejo
    Stud. No.
    3000052120513

    SURGERY
    1-06-  For wound culture and sensitivity
    2021 -Diabetic foot  Wound dressing daily on diabetic foot /
    10:00 with signs of with normal saline and apply /
    AM infection Bactroban ointment
    -no sensation  Duplex Ultrasonography on left leg
    on left leg and  Start Amipicillin+ Sulbactam 750mg IV /
    presence of every 8 hours ANST ( ) /
    gangrene leg
    Dr. Richard Realin
    Surgery Specialist (Sig)
    Lic.# 456700 R. Arruejo
    Stud. No.
    3000052120513
     For repeat 12 lead ECG with long lead
    1-06- II
    Impression:
    2021@
    AF to consider
     Stat Trop. T quantitative /
    4:30pm
    ACS  Give 4 tabs of Aspirin 80 mg/tab to be
    chewed now /
    /
    ECG reading:  Atorvastatin 40 mg/tab 1 tab now
    CRBB then OD HS start tomorrow /
    (Complete  Digoxin 0.50 mg IV now
    Right Bundle
     Carvedilol 6.25 mg/tab 1 tab BID
    Block)
     Trimetazidine 35 mg/tab 1 tab BID /
     Captopril 25mg/ tab ½ tab BID with BP /
    precaution
     Pantoprazole 40 mg/tab 1 tab OD /
     Lactulose 15 ml OD HS /
     CBR without BRP
     O2 support at 3LPM via nasal cannula /
     Vital signs q2 and record; close watch
    patient pls. /
     CBG Monitoring q 6 hrs pre meals and /
    relay /
     Secure Insulin 70/30
    /

    Dra. Margarita De Guzman


    Medical Internist
    Lic.# 342754 (Sig)
    R. Arruejo
    Stud. No.
     Discontinue Nicardipine drip. 3000052120513
    120/80mmHg  Increase Losartan 50mg/tab to /
    8:00 PM
    on Nicardipine 100mg/tab, 1 tab OD to start tomorrow
    Drip (8am) /

     For referral to Dr Marjorie Llanes


    (Cardiologist) for cardiac evaluation
    and co.management /
     Start Insulin 70/30, 10 units SQ 30
    minutes before breakfast and 30
    minutes before dinner /

    Dra. Margarita De Guzman


    Medical Internist
    (Sig)
    Lic.# 34275
    R. Arruejo
    Stud. No.
    3000052120513

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