Name: Paul Mel Faller Age: 19 y/o Gender: M Status: Single Birthday: 1-10-93 Religion: RC Address: Sto.

Tomas, San Luis, Pampanga Time and Date of Admission: 10:40am 3-8-12 Admitting Physician: Dra. Aldaba

Case No. 320065 Bill No. 487-3

History of present illness June 2011- History of Vehicular accident (Motorcycle Accident) ORIF + Plating + M Flap Dec 2011 (+) Nonunion Removal of Implant (ROI) + RAEF done March 8, 2011 (+) Nonunion Admission to OR ILIZA ROV done

Doctor s Order

3/8/12 10:40am Weight 56kg T: 36.7 PR: 104 Bone defect of a non-united fracture of tibia

S/P RAEF application Dec 2011 S/P Plating M Flap June 2011 Please admit it under service of GS III Secure consent for admission and management NPO Midnight CBC with PC Blood Typing 12 Lead ECG Treatment (start of 12 midnight) D5LR 1L x 8hours Cefuroxime 750mg q8 (-) ANST Ranitidine 50mg IV q8 For Eliza Rov Application Secure Consent Informed Anesthesiologist on Duty Refer 2 unit of packed RBC Pre-op Order For OR tom Secure consent for OR and Anesthesia NPO PMN D5LR x 8hours Ranitidine 50mg IV q8 Bromethazine 50mg IV q8 Follow up lab result and refer to AROD

3/9/12

Post Op Order

OR Time Began: 1:57 Time Ended: 4:05

3/10/12

3/11/12

3/12/12

3/13/12

S/P Eliza Applicator under CSE To RR Flat on bed x 12hrs Oxygen 3L/min via Face Mask Diet: May have clear liquids once @ the wards that DAT after 2hrs Meds: Continue antibiotics Ranitidine: 50mg IV q8 x 2 dose Bupivacane For x-ray Left leg V/S q15 x 2hrs Transfer to ward x-ray on left leg on way forward Morphine precautions HxH once at ward Refer result to AROD Follow up HxH DAT GABA Apply traction to counter weight Celecoxib Change Dressing Elevate Right Leg with 1-2 pillows DAT Follow up HxH Maintain Traction Daily Wound Care Transfuse 2unit Packed RBC Pre BT meds Paracetamol Diphenhydramine Maintain Traction Follow up HxH Maintain proper traction

Medication Administration Record 3-8-12 CEFUROXIME 750mg IVq8 (-) ANST RANITIDINE 50mg IVq8 once NPO [discontinued (3/9/12 @ 12N)] PROMETHANINE 50mg on call to OR 3-9-12 KETOROLAC 30mg IV now then q8 x 6 doses CELECOXIB 200mg/tab 1tab BID PO CEFUROXIME 750mg IVq8 (-) ANST BUPIVACAINE 0.1% to 2mg Morphine/10ml 10ml via epidural catheter q12 1st 3-10-12 GABAPENLIN 400mg/cup OD @ night

CELECOXIB 200mg/tab 1tab BID PO RECOPIED 3-12-12 PARACETAMOL 300mg/IV DIPHENHYDRAMINE 1amp Prior BT OR (3-9-12) DIAZEPAM 2.5mg IV DIAZEPAM 5mg IV DIET 3-8-12 NPO PMN 3-9-12 CLEAR LIQUIDS 3-11-12 DAT AFTER 2 hours (BT) BLOOD TRANSFUSION DATE 3-12-12 3-12-12

BLOOD COMPONENT PRBC PRBC

SERIAL NO. 1337 1416

TIME STARTED 6:00am 11:30am

TIME CONSUMED 10:50am 3:45pm

HEMATOLOGY RESULT (3-11-12) Hemoglobin: 77 Hematocrit: 0.23 HEMATOLOGY RESULT (3-12-12) Hemoglobin: 77 Hematocrit: 0.23 HEMATOLOGY RESULT (3-13-12) Hemoglobin: 89 Hematocrit: 0.25 1st HEMATOLOGY RESULT (NO DATE) Blood Type: AB Platelet Count: 316 Hemoglobin: 133 Hematocrit: 0.40 WBC Count: 8.2 Neutrophils: 0.73 Lymphocytes: 0.19 Monocytes: 0.04 Eosinophils: 0.04 X-RAY RESULT No Interpretation No Date