KARDEX

NAME: Anthony V. Cortez AGE: 73 SEX: M HOSPITAL NO.: 2021-10002

ADDRESS: Cabasaan, Vigan City, Ilocos Sur. CLASSIFICATION: Private WEIGHT: 81kg
ADMITTING PHYSICIAN: Dr. Ivan D. Magtira DATE/TIME ADMITTED: 5/3/2021 BLOOD TYPE: O
+
ATTENDING PHYSICIAN: Dr. Ivan D. Magtira/ Dr. Markus A. Llanes (CP clearance) / Dr. Leo M. Nunez (anesthesiologist)
COMPLAINT: Increasing size of a lump over left hip and has been causing pain and discomfort for over the past two weeks; Skin
around the lump is red and swollen; Fever with 38.3ºC temperature.
IMPRESSION DIAGNOSIS: Left hip Abscess, to rule out DVT vs Reoccurring left Hip Osteomyelitis
SURGERY DONE: Needle aspiration (5/3); DATE/TIME OF 05/5/2021
surgical incision and drainage @ 10am 05/05 SURGERY: @10AM

MENTAL STATUS: ACTIVITIES: DIET: TUBES: Special Info:

 Conscious  Ambulant  NPO  Foley Catheter  Weigh Daily
 Drowsy  Dangle and sit up  DAT  Thoracic tube  BP q shif
 Stupor  Bedrest with BRP  Soft  NGT  Neuro V/S q1
 Unconscious  CBR w/o BRP  Clear liquids  CVP  Abdominal girth
 Comatose Others:  Gen. liquids Others: Others:
Others: PICC line @ left TPR q shift and record
LSLF Diet brachial vein.
NPO post-midnight HemoVac Drain Keep PICC area/line clean
Gradual Diet if Dry sterile dressing to left
Flatus hip daily

Date Date Date and Time

Medication IV Fluids/Blood Transfusion
Ordered Ordered Discontinued
5/3/2021 Start Fondaparinux 2.5 mg SQ OD 5/3/2021 PNSS 1L x 12h 27-28gtts/min
5/3/2021 Give Acetaminophen 325-650 mg tab
q4hr PRN for Mild to Moderate Pain
5/3/2021 Start Docusate sodium 300mg cap PO
OD
5/3/2021 Start Linezolid 600mg/300mL IV OD,
ANST ( )
5/5/2021 Ketorolac 30 mg/ml IV q6hr, ANST (-)
5/5/2021 Omeprazole 40mg IV OD
5/5/2021 Hydrocodone bitartrate/ Acetaminophen
10mg/300mg tab PO 30min to dressing
change
5/16/2021 Aspirin 80mg tab OD
5/16/2021 Acetaminophen 325-650 mg tab q4hr
PRN for Mild to Moderate Pain

5/16/2021 Docusate sodium 300mg cap OD

Date Medical Treatment/

Date Done
Ordered Laboratories/Diagnostics

5/3/2021 CBC 5/3/2021

5/3/2021 FBS, Lipid Profile 5/4/2021
5/3/2021 BUN, Crea 5/4/2021
5/3/2021 SGPT, SGOT 5/4/2021
5/3/2021 CXR-PA 5/3/2021
 5/3/2021 12 Lead ECG 5/3/2021
5/3/2021 Culture and sensitivity 5/10/2021
5/3/2021 Xray Left arm 5/3/2021

KARDEX
NAME: AGE: SEX: HOSPITAL NO.:
ADDRESS: CLASSIFICATION: WEIGHT:
ADMITTING PHYSICIAN: DATE/TIME ADMITTED: BLOOD TYPE:
ATTENDING PHYSICIAN:
COMPLAINT:
IMPRESSION DIAGNOSIS:
SURGERY DONE: DATE/TIME OF
SURGERY:

MENTAL STATUS: ACTIVITIES: DIET: TUBES: Special Info:

 Conscious  Ambulant  NPO  Foley Catheter  Weigh Daily
 Drowsy  Dangle and sit up  DAT  Thoracic tube  BP q shif
 Stupor  Bedrest with BRP  Soft  NGT  Neuro V/S
 Unconscious  CBR w/o BRP  Clear liquids  CVP  Abdominal girth
 Comatose Others:  Gen. liquids Others: Others:
Others:

Date Date Date and Time

Medication IV Fluids/Blood Transfusion
Ordered Ordered Discontinued

Date Medical Treatment/

Date Done
Ordered Laboratories/Diagnostics