PHASE 1

Protacio Marcos a 65 years old, male, married, from Ayusan Norte, Vigan City. Born on November 28,
1955. Was admitted NDH Hospital private room 303, 11/25/2020 AT 10AM. Because he experienced
nape pain, shortness of breath, chest heaviness. History of Coronary heart Disease and Diabetes Mellitus
type 2.

ADMITTING DIAGNOSIS: Cardiovascular Disease

ATTENDING PHYSICAN: CARDIOLOGIST: Dr. Butardo

COMPLAINTS: Nape pain, chest heaviness, shortness of breath

INITIAL VS: BP:160/100 PR: 89 RR:19 TEMP:36.8 o2 saturation: 96%

DOCTOR’S ORDER

COMPLAINTS: Nape pain, chest heaviness, shortness of breath

VS: BP:160/100 PR: 89 RR:19 TEMP:36.8 o2sat: 96%

DIET: LSLF DM DIET

Diagnostics:

CBC, urinalysis, chest xray PA view, BUA, BUN, creatinine, SGOT, SGPT, FBS, Lipid Profile,

12 lead ECG, HBA1C

Treatment: IVF PNSS1L x 16 hours (macroset)

Clonidine 75mg/tab 1 tab sublingual NOW

Amlodipine 10mg/tab 1 tab P.O. OD AM

Metformin 500mg/tab 1 tab P.O BID

Hooked o2 inhalation via nasal cannula 2-3LPM

Monitor BP q shift

At 3PM you visit Mr. Protacio and asked if there is still have nape pain, chest heaviness, and shortness of
breath. He answered that he still have experienced it but the nape pain is now relieved and chest
heaviness and shortness of breath is now tolerable. You also have taken the vital signs: BP: 120/80 PR:
78 RR: 14 TEMP: 36.3 O2 SAT: 98%

Afterwards, you ask the patient intake and output: IVF consumed:312cc Oral intake: 1500cc
Urine:6x(1200cc)
Some of Diagnostics are done:

CBC: normal results of Red blood cells and white blood cells

Urinalysis: Normal results

BUN and Creatinine: Normal results

SGOT and SGPT: Normal results

HBA1C: 12% value. the result is HIGH. The normal value is 4-6%.

LDL: normal result

 DOCTOR’S ORDER
Name:_______________________________________Age/Sex/CS:___________Ward/Room:
Date C A R E D TIME POSTED
And Progress Notes Doctor’s Order AND
SIGNATURE
time
11/25/20 
10AM
COMPLAINTS: Admit to room of choice
Nape pain, chest Secure consent 
heaviness, Vs q shift
shortness of DIET: LSLF DM DIET
breath Diagnostics:
CBC,
Vital Signs:
urinalysis,
BP:160/100
chest xray PA view,
PR: 89
RR:19 BUA, BUN, creatinine,
TEMP:36.8 SGOT, SGPT,
o2 sat: 96% FBS, Lipid Profile,
HBA1C
12 lead ECG

Treatment:
IVF PNSS1L x 16 hours (macroset) Hooked at
10:15AM/CP
Clonidine 75mg/tab 1 tab sublingual NOW
(10:30AM)
Amlodipine 10mg/tab 1 tab P.O. OD AM
(12PM)
Metformin 500mg/tab 1 tab P.O BID (12PM)
Hooked o2 inhalation via nasal cannula 2-
3LPM

C-Carried-out

A-Administered

R- Requested
E-Endorsed D-Discontinued

PHASE 2
Your shift is PM SHIFT (3-11)
At 3PM all laboratories are done:

Chest xray: atherosclerotic aortic knob

ECG: Atrial Fibrillation

BUA: 8mg/dl (high) normal value:3.4-7.0 mg/dl

FBS: 17 mmol/L (high) normal value: 3.85 -6.05 mmol/L

Lipid Profile:

Cholesterol: 5.31 (high) normal value: 3.64-5.2 mmol/L

Triglyceride:8.69 (high) normal value: 0.50-2.26mmol/L

HDL: normal result

LDL: normal result

4PM you follow up IVF (1liter) and then suddenly patient experienced Dizziness, nape pain and chest
pain. Fortunately, Dr. Butardo is available at the hospital and then he seen the pt and examined then
gave Doctor’s order for treatment.

DOCTOR’S ORDER

10/26/2020

4pm

Complaints: Dizziness, Nape pain, chest pain

VS: BP: 200/120 PR:104 RR:17 TEMP:37.1C O2 Sat:99%

TREATMENT:

Start Nicardipine drip 10mg plus 90cc PNSS at 15 ugtts/min until achievable BP OF < 120/80
(started at 4:00pm)

Atorvastatin 40mg /tab 1 tab OD HS (to be given 8PM)

Aspirin 80mg/tab 1 tab OD PM (to be given 7PM)

Trimetazidine 35mg/tab BID (to be given 7pm)

Febuxostat 40mg/tab 1 tab OD (to be given 7pm)

Decrease IVF to 20 hours

 monitor VS q1

refer accordingly

At 11PM latest VS of patient is BP: 120/70 PR:84 RR:12 TEMP:36.3C O2 Sat:98%

you visited patient and asked if how is he now. He replied “okay nak metten nakkong haan nak met
maulawen, haan pay nasakit toy barukong kon ken haan pay nasakit toy lengnges kon.”

You also asked the Input and Output: ORAL: 800cc IVF: (IVF 350 and nicardipine drip 100)
Urine:5x(980cc) stool:once
 DOCTOR’S ORDER
Name:_______________________________________Age/Sex/CS:___________Ward/Room:_______
___76
Date C A R E D TIME POSTED
And Progress Notes Doctor’s Order AND
SIGNATURE
time

12/26/20 
4PM Complaints:
Dizziness, TREATMENT:
Nape pain, >Start Nicardipine drip 10mg plus 90cc PNSS at 15
chest pain ugtts/min until achievable BP OF < 120/80 (started
at 4:05pm)
VS:
BP: 200/120 >Atorvastatin 40mg /tab 1 tab OD HS (to be given
PR:104 8PM)
RR:17 >Aspirin 80mg/tab 1 tab OD PM (to be given 7PM)
TEMP:37.1C >Trimetazidine 35mg/tab BID (to be given 7pm)
O2 Sat:99% >Febuxostat 40mg/tab 1 tab OD (to be given 7pm)
>decrease IVF to 20 hours
>Discontinue o2 inhalation
>monitor VS q1
>refer accordingly

DR. BUTARDO
C-Carried-out
A-Administered
R- Requested
E-Endorsed D-Discontinued
PHASE 3
After 5 days of treatment.
Dated 11/30/20 at 7AM (you are morning shift). You rounds the patient then you get
initial V/S BP:130/90 PR:70 RR:12 TEMP:37.1 O2 SAT:99%. The condition of the
patient is now stable and no further complaints. Exactly 9AM Dr. Butardo visited pt.
Protacio and he ordered for discharge today.

Doctor’s Order
11/30/20
9AM
Status: (-)nape pain, (-) chest pain, (-) shortness of breath
VS: BP:120/70 PR:80 RR:13 TEMP:36.5 O2 SAT:99%
>MGH(May Go Home)
Home Medications:
1. Amlodipine 10mg/tab 1 tab P.O. OD AM for 1 month
2. Metformin 500mg/tab 1 tab P.O BID for 3 months
3. Atorvastatin 40mg /tab 1 tab OD HS for 3 months
4. Aspirin 80mg/tab 1 tab OD PM for 1 month
5. Trimetazidine 35mg/tab BID for 2 weeks
6. Febuxostat 40mg/tab 1 tab OD for 3 months
7. Carvedilol 6.25mg/tab 1 BID (to be given 12PM) for 2 weeks
8. Clopidogrel 75mg/tab 1 OD AM (to be given 1pm) for 2 weeks

>for CBG monitoring at home pre-breakfast and pre-dinner (6am-6pm)

>for 2d ECHO as OPD

>Follow-up after 2 weeks at NDH hospital

>Discontinue IVF at 2PM

>Advised

Dr. Butardo
FINAL DIAGNOSIS: CARDIOVASCULAR DISEASE; CORONARY HEART DISEASE;

DIABETES MELLITUS TYPE 2 UNCONTROLLED

Exactly at 3PM, Patient Protacio went home via wheelchair. The VS before he went home BP:120/80
PR:82 RR:12 TEMP:36.6 O2 SAT:99%
 DOCTOR’S ORDER

Name:_______________________________________Age/Sex/CS:___________Ward/Room:

Date C A R E D TIME POSTED

And Progress Notes Doctor’s Order AND
SIGNATURE
time


Status: 
11/30/20 (-)nape pain, >MGH(May Go Home)
(-) chest pain, Home Medications:
9AM 1. Amlodipine 10mg/tab 1 tab P.O. OD AM
(-) shortness
for 1 month
of breath
2. Metformin 500mg/tab 1 tab P.O BID for 3
month
VS:
3. Atorvastatin 40mg /tab 1 tab OD HS for 3
BP:120/70
months
PR:80 RR:13
4. Aspirin 80mg/tab 1 tab OD PM for 1
TEMP:36.5
month
O2 SAT:99% 5. Trimetazidine 35mg/tab BID for 2 weeks
6. Febuxostat 40mg/tab 1 tab OD for 3
months
7. Carvedilol 6.25mg/tab 1 BID for 2 weeks
(to be given 12pm)
8. Clopidogrel 75mg/tab 1 OD AM for 2
weeks (to be given 1pm)
>for CBG monitoring at home pre-breakfast and
pre-dinner (6am-6pm)
>for 2d ECHO as OPD
>Follow-up after 2 weeks at NDH hospital
>Discontinue IVF at 2PM
>Advised

DR. BUTARDO
C-Carried-out

A-Administered

R- Requested

E-Endorsed D-Discontinued