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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!