Surgery Case Scenario 1 - Day 1

I.               Patient Information

Roqu
Name :
Brgy
Address :
26
Age :
Male
Sex :
55kg
Weight :
Octo
Date of Birth :
Singl
Civil Status :
High
Educational Attainment :
None
Occupation :
Bapti
Religion :

II.  Other Information

none
No. of Dependents :
Feb 2
Date & Time of Admission :
 Lace
Chief Complaints :
 Lace
Admitting Diagnosis :
Male
Ward/Bed Admitted :
Dr.Es
Attending physician :

Health History

                        Patient John always play basketball in their barangay and even go play in some nea
hospitalized when he was 10 years old due to asthma. He has inherited this condition from his fa
History of Present Illness

            Two hours prior to admission, at 4am, patient John was jogging along Lacson Street when
identified one person whom he played with a week before in basketball play off and they had an

Patient Endorsement:

DAT
Diet : None
Drains/Attachment :
Precautions : None

Oxygen support : Com

Activity : #1 PN

IV Infusion : Rema
#1 PL
Rema

Laboratory Results

Hematologic Studies

Complete Blood Count

Test
Hematocrit
Hemoglobin
Red Blood Cell Count
White Blood Cell Count
            Segmenters
            Lymphocytes
            Monocytes
Platelets

Coagulation Studies

Test

Prothrombin time
%Activity
INR

Clinical Microscopy
Date and time taken: Jan 23, 2022, 7:00 AM

Urinalysis

Test

Color
Clarity
RBC
Pus
pH
 Specific Gravity
Protein
Glucose
Blood
Ketones
Bacteria

Others:

Date and time taken:

Covid-19 R

Ches
Diagnostic Imaging :

Surgical Procedure/s : Wou

Blood Request/Availability :

Special Endorsement : Mon

Medications : Tetan
 ATS
Cloxa
Dolfe

Blood
Hear
Resp
Latest Vital Signs :
Temp
Pain

 
 
Physician’s Order
 
Day 1
Tetanus toxoid 0.5 ml/amp deep IM now right deltoid
ATS 3,000 IU/amp, 1 ampule IM now ANST left deltoid
For suturing of lacerated wound right arm