Date/time Doctor's Order Rationale

Sept. 1,
2018
1. To determine the general status of the pt.
9:21 AM 1. Patient seen and reexamined
2. History reviewed
• 4 days PTA: chestpain (ps 9-
10/10) radiating to the scapular
area
(+) diaphoresis
consult at local hosp, admitted
• 2 days PTA: transferred for
further evaluation
• Hours PTA – admitted
• (+) HPN (2010): Metropolol 50
mg tab OD PO
• (-) Hx of previous admission
4. Diagnostics
• CBC, platelet • Measures several components and features of blood
• Crea, BUN • To evaluate kidney function
• Na, K+, Ca, Mg • Measures level of electrolytes
• Blood culture • Identifies specific bacteria/fungi causing the infection
• Trop I, please facilitate • Measures the levels of troponin T or troponin I in the
blood
• ECG – 12 leads • Measures heart's electrical activity
• 2D echo, please follow up • Ultrasound technique to take pictures of the heart
• Repeat CXR-PAL • Projection radiograph of the chest used to diagnose
tomorrow 6 am conditions affecting the chest
5. Therapeutics
1. increase aspirin to 100 mg tab 1. For mild to moderate pain or fever, to prevent blood clots
OD PO
2. Furosemide 40 mg IV q 8hrs 2. For edema due to heart failure, hepatic impairment or renal
disease. Hypertension
3. continue other meds
3. To continue treatment

6. Ffup requested blood units, to

transfuse 1 unit q 8hrs with BT
precautions
- Furosemide 20 mg IV port BT • prophylactic administration of loop diuretics is common
esp. among pts who are at risk for circulatory overload ,
pulmonary edema, or both
7. Strict I and O q shift 6. To help evaluate pt.'s fluid and electrolyte balance, any imbalance
may affect pt.'s output
8. Moderate high back rest 8. For proper lung expansion and to promote breathing
9. Deck to ICU/CCU depending on
vacancy (Deck 2)
10. Refer accordingly
Sept. 2,
2018
1. For fluid and electrolyte replenishment and caloric supply
7:07 Am 1. IVF: D5W 500 cc @ 10cc/hr
2. Continue other meds 2. To continue treatment
Sept. 3,
2018
1. For fluid and electrolyte replenishment and caloric supply
7:01 AM 1. IVF: D5W 500 cc @ 10cc/hr #4
2. Diagnostics:
• For Trop I
• Hba1c (glycated haemoglobin)
• Blood typing
• CBG q6 (5-11, 5-11)
• For 2D echo w/ Doppler, please
do ffup
3. Therapeutics:
Summary of Meds:
1. Enoxaparin 6cc SQ q12 – D3
2. Aspirin 100mg tab OD PO
3. Clopidogrel 75 mg tab PO OD
4. Atorvastatin 80 mg tab OD PO
@HS
5. Enalapril 5 mg ½ tab OD PO
6. Carvedilol 6. 25 mg ½ tab BID
PO
7. Ceftriaxone 2 g IV q 24
8. Azithromycin 500 mg tab BID
9. N-Acetylcysteine 600 mg tab
BID
10. Start NaHCO3 tab TID PO
11. Omeprazole 40 mg tab OD PO
4. Please do ffup Blood transfusion
• Secure blood units as
previously ordered
• transfuse once available
5. Ffup Decking to CCU as ordered
6. Refer accordingly
7. Strict I and O q shift
8. Moderate high back rest
• Measures the levels of troponin T or troponin I in the blood
• Used to reflect average blood glucose levels
• To tell the type of blood
• Reveals individual patters of blood glucose changes
• Measures the speed and direction of the blood flow within
the heart
1. Used to prevent blood clots in pt.s who are in bedrest. Also
used in combination with aspirin to prevent complications
from angina and heart attacks
2. For mild to moderate pain or fever, to prevent blood clots
3. Reduction of atherosclerotic events in pts at risk for such
events including recent MI or acute coronary syndrome
4. Reduction of risk of stroke an heart attacks
5. For renal hypertension. Reduces systolic and diastolic BP
by 15- 20%
6. For hypertension
7. To prevent growth of bacteria that cause infection
8. Treatment of different types of infections caused by
bacteria (respiratory, skin, ear, and STD)
9. Treatment of respiratory affections by thick & viscous
hypersecretions
10. Management of metabolic acidosis. Used to alkalinize
urine
11. To treat conditions caused by too much acid production in
the stomach
4. to replace lost components of blood
7. To help evaluate pt.'s fluid and electrolyte balance, any imbalance
may affect pt.'s output
8. For proper lung expansion and to promote breathing