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PUD Admit

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DOCTOR’S ORDER

Name of Patient:_________________________________ Area & Bed No.: _________________ Case No.:_________

DATE TIME PROGRESS NOTES DOCTOR’S ORDER


BP: > Admit patient under the service of Internal Medicine at male medical ward
HR: > Kindly secure consent to care
RR: > Problem: epigastric pain
Temp: > Condition: stable
O2 Sat: > Diet: NPO temporarily
> IVF: PNSS 1L @ 30 gtts/min
> Monitor V/S q 4 hours
> Monitor I & O q shift
> CBS monitoring q 4 hrs while on NPO
> Laboratories:
CBC Blood typing BUN Crea
Serum Na Serum K Amylase Lipase
> Diagnostics:
Esophagogastroduodenoscopy
> Therapeutics:
1. Metoclopramide 10 mg IVTT q 8 hours PRN for nausea and vomiting
2. Omeprazole 20 mg/tab, 1 tab BID PO x 14 days
3. Clarithromycin 500 mg/tab, 1 tab BID PO x 14 days
4. Amoxicillin 1000 mg/tab, 1 tab BID PO x 14 days
5. Sucralfate 1000 mg/tab, 1 tab QID PO X 4 weeks
> O2 inhalation via nasal cannula at 2 lpm PRN for dyspnea
> Activity level: bed rest w/ TP, elevate head of bed to 45 deg
> Family appraised regarding patient’s condition and prognosis
> Case referred to Dr. _______ (Infectious Consultant)
and Dr. ________ (Gastro Consultant)
> Please inform ROD and NOD at ward
> V/S prior transport
> Refer accordingly
> Thank you!

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