Course in The Ward

 

COURSE IN THE WARD Date and Time

08/12/2011

-Admitted to surgery ward under the care of

11:30pm

Dr. Peralta/Dr. Rasalan -Secure consent -DAT -Labs: CBC Typing, Na, K, ECG, RBS -Drugs: Tramadol 50mg IV q8 -Apply skin testing with 7 lbs. counter weight -Monitor v/s q4

08/13/2011

-IVF PNSS x 30 gtts/ml

1:00am

-Clonidine 75mg 1 tab PRN for BP > 140/90 -Amlodipine 10 mg 1 tab PO -Request for : Lipid Profile and SGPT

08/13/2011

-decrease IVF -Bitagen 500ml for q8 OD

5 am 08/13/2011

-(-) chest pain

8:05am

-(-) dyspnea -BP:90/60 mmHg -Monitor v/s hourly -refer if still hpotensive

08/13/2011

-for BT x 2”u” PRBC PNSS 

8:20 am 08/13/2011

-(+) pain

9:00 am

-for ORIF on tuesday -for cefuroxime -continue medication -still no funds available for skin traction

08/13/2011

-we will do final CP clearance once anemia is

11:30 am

corrected

08/14/2011

-(+) pain on right thigh

 

8am

-still no funds -continue medication -refer

08/15/2011

-(+) pain on right thigh

7am

-follow up post CBC -continue medication -refer

08/15/2011

-Insert IFC

8am 08/15/2011

-BP: 130/90 mmHg

3:40 pm

-(-) chest pain -(-) orthopnea orthopnea -secure ECG done August 12 -request for PT, PTT -relay result

08/15/2011

-NPO

4pm

-prepare for OR use: Midazolam #1, Fentaryl #1, Morphine #1, Eptudru#1, Sensorcairu heavy #1, Profolol #1, Isoflurans 50 cc, syringe( 10 cc, 5 cc, 3cc) #2

08/15/2011

Refer for OR tomorrow

8pm 08/16/2011

-(-) dyspnea/orthopnea/chest pain

7am

-no episodes of BP elevation -BP:130/90mm Hg -decrease IVF for KVO -secure ECG

08/16/2011

-no absolute contraindication to contemplated

4:15pm

procedure, patient is stratified as moderate to develop cardio-pulmonary complication.

08/17/2011

-(+) pain

7:30am

-(+)cast -still no funds

 

-continue medication -refer 08/17/2011

-still no fund for surgery

7:40am

-facilitate referral to social service

08/18/2011

-(+) pain on left thigh

7am

-(+) cast -still for referral to social service

08/18/2011

-BP:140/80

3:45pm

-Clonidine 75mg 1 tab PRN for BP > 140/90 -Amlodipine 5mg 1 tab OD

08/19/2011

-BP: 120/70 mm Hg

5:45 am

-continue Amlodipine 5mg tab OD

08/20/2011

-(+) pain on right thigh

4:40 pm

-(+) skin traction -facillitate referral regarding plan for ORIF

08/21/2011

-(+)pain on right thigh

8:00 am

-still no funds for OR -(+) skin traction -facilitate referral to social service regarding plan for ORIF -maintain skin traction -kindly place pillows between right thigh to maintain alignment -refer

08/22/2011

-(+) pain

7:30pm

-(+) skin traction -refer to social service

08/22/2011

-BP:140/90 mmHg

9am

-CR: 79 -(-) orthopnea, chest pain -continue Amlodipine 10 mg a tab OD

 

-decrease IVF to KVO -repeat creatinine and K 08/22/2011

-patient referred to social service awaiting for

1pm

support.

08/22/2011

-IFC and UB

3pm

-refer to social service for disposition

08/23/2011

-(+) pain

7am

-(+) skin traction -refer

08/24/2011

-(+) pain

7:20am

-(+) skin traction -refer

08/25/2011

-(+)pain at right leg

7:10am

-(+) skin traction -still no fund -follow up referral to social service regarding plan for patient -refer

08/26/2011

-(+)pain

7:15am

-(+)skin traction -still no fund s for OR -refer

08/27/2011

-(+)pain

7:05am

-(+)skin traction -still no fund s for OR -refer -continue medication if available -refer to helping hands

08/28/2011

-(-)pain

8:20am

-(+)skin traction -still no fund s for OR -refer

08/29/2011

-(-)pain

 

8:00am

-(+)skin traction -still no fund s for OR -refer

08/30/2011

-(+)pain

8:05am

-(+)skin traction -still no fund s for OR -refer -maintain traction

09/01/2011

-(+) abdominal pain

7:30 am

-(-)fever -(+) skin traction -Maintain traction -continue medication -refer

09/02/2011

-give tramadol 50mg IV now -(-)pain

7:50am

-(+)skin traction -continue medication -DAT -maintain traction -refer

09/03/2011

-(+)pain

7:30am

-(-)fever -(+)skin traction -maintain traction -refer -no fund for OR

09/05/2011

-(+)pain

7am

-(-) fever -(+)skin traction -Still for ORIF -refer

09/06/2011

-v/s: 120/70mmHg, 93bpm,20cpm,36.3C

 

12:00 pm

-refer Na, K, Crea results once available

09/06/2011

-refer

4:15pm

-continue medication

09/07/2011

-secure consent

7am

-notify OR -NPO -Prepare the following:PD5O #1, Chromic plain #1, sills #1, elastic bandage #3

09/07/2011

-lab results within normal limit

4:50pm

-v/s: 110/80mmHg, 80bpm, 20cpm, 36.9C -no absolute CI to underlying contemplated procedure -risk stratified as moderate risk for developing cardio-pulmonary complication

09/07/2011

-Pre-op orders: NPO after 2am -prepare the following for OR case: PNSS 1L #2, PLRS 1L #1, Syringe(5cc #2, 3cc #4, 1cc #1) -give anti-hypertensive drugs -give pre-meds at OR

09/08/2011

-cefuroxime 1.5g IV

12:30am

-1 hr prior to OR ANST

09/08/2011

-reschedule ORIF at hip first case on Tuesday (09/13/2011) -notify OR -secure consent

09/09/2011

-(+)pain

7am

-continue medication -still for ORIF

09/09/2011

-(-)pain

7:10am

-continue medication -still to ran consent for OR -for ORIF on 9/13/2011

 

-refer 09/12/2011

-(-)pain

7:30 am

-still no consent -continue medication -refer

09/12/2011

-NPO

9am

-Prepare the ff. for OR use: Bupiralarion #1, Ephearion#1, nidazolem #1, Nubain #, BT set #1, Syringe(10cc, 5cc, 3cc, 1cc)#2 -Pre-op meds: Promothazen 50g and Nubain 5g IM prior to OR

09/12/2011

-continue medication

7am

-on NPO -for ORIF -secure consent

09/13/2011

-Post-op orders: to RR, resume diet after 6 hrs starting with liquids -v/s -encourage deep breathing exercise when fully awake -PLR 20gtts/min. -report hgb and hct result after 1 st BT -Ketorolac 30g OD q6hrs -Ranitidine 50g OD q8 hrs -refer accordingly

09/13/2011

-for x-ray right knee

1:30pm

-may transfer to ward

09/13/2011

-(+) bleeding

4:20 pm

-fully soaked dressing -change dressing done