Date FOCUS Data

And Action
Time Response
08/26/2021 For D:
thyroidectomy A: It is arranged for Patient to have X-rays of his
chest, pelvis, spine, arms and legs to assess for any
fractures. A computed tomography (CT) scan of his
spine has also been organized. Examined by Dr. Kho
Langot,secure consent for admission, IVF PNSS 1L to
run for 8 hours inserted at right metacarpal vein,
regulated to 41-42 gtts/min. NPO
Dx: CBC 
Serum Electrolytes (Na, K, Mg , Cl) 
Urea, Crea 
PT, PTT  
ECG 
CXR-AP 
Pelvic X-ray 
Left limb X-ray 
Spinal X-ray/ Spinal CT Scan (plain)
TREATMENT: Give Tramadol 50 mg
IV q 8 hours for pain 
Administer Omeprazole 40 mg IV
now then OD in AM
Daily wound dressing 
Start Tranexamic Acid 500 mg IV q8 
Please include blood typing
and cross matching in the
laboratory request  Secure 2
units of PRBC (450cc)
properly blood typed, and
crosses matched and transfuse
1 unit once available. 1 unit
for possible OR use 
Give 10 mg IV Diphenhydramine and
300 mg IV Paracetamol 30 mins prior
to BT. Keep the affected leg immobile
and maintain splint 
Schedule for ORIF Plating 3 PM
today
Skin test Ketorolac 30 mg IV and
Cefuroxime 1.5 grams IV 30 mins prior to ORThen
start Cefuroxime 1.5 grams IV ANST as loading dose
R: Transferred to surgical ward for ORIF plating
scheduled at 3PM………………………………..(PQP)
PRINCESS Q PIMENTEL
UNP-CN STUDENT