RONDA, JASTYN GRACE G.

GROUP H 02 MAY 2022

Course in the ward

Special
Date Treatment Medication IVF Diet Diagnostics Significance
Endorsement
April 25, 2022  Paracetamol 300  300 cc PNSS as  CBG  Admit to  Patient was admitted
1:00pm mg IV now for fast drip  CBC, pH, BT Emergency for further for
pain then every 6  Blood Department. monitoring,
hours Chemistry:  Refer to GS for management, and
Creatinine, Na, evaluation and evaluation with
K, Cl, Ca, Mg, management of chief complaint pain
BUN left flank mass/ from left flank mass.
 Coagulation: PT, abscess The patient was
INR, aPTT referred to
 Urinalysis Emergency
 Arterial blood Department and
gas later on his clinical
diagnosis of
Diabetic
ketoacidosis, type 2
diabetes mellitus
requiring insulin,
benign prostatic
hyperplasia not in
retention and left
flank abscess.
 Paracetamol 300 mg
IV now and then
every 6 hours was
prescribed for pain.
 IVF PNSS as fast
drip was used for
 hydration and to
facilitate fluid and
electrolyte
replacement and
serve as an access
for IV medication.
 Blood glucose
monitoring was
ordered to observe
for patterns in the
fluctuation of blood
glucose (sugar)
levels that occur in
response to diet,
exercise,
medications, and or
pathological
processes associated
with blood glucose
in diabetes.
 A Complete blood
count or CBC is a
blood test that
measures many
different parts and
features of your
blood. This is a
commonly
performed blood
test that is often
included as part
of a routine
checkup.
 Blood chemistry
tests is a test done
on a sample of blood
 to measure the
amount of certain
substances in the
body. It gives
important
information about
how well a person’s
kidneys, liver, and
other organs are
working.
 Clinicians
frequently order
coagulation tests,
such as the
prothrombin time
(PT), activated
partial
thromboplastin time
(aPTT), and
thrombin time (TT),
to assess blood
clotting function in
patients.
 A urinalysis is a test
of your urine. It's
used to detect and
manage a wide
range of disorders,
such as urinary tract
infections, kidney
disease and diabetes.
A urinalysis
involves checking
the appearance,
concentration and
content of urine.
  An arterial blood
gas (ABG) test is a
blood test that
requires a sample
from an artery in
your body to
measure the levels
of oxygen and
carbon dioxide in
your blood. The test
also checks the
balance of acids and
bases, known as the
pH balance, in your
blood.
April 26, 2022  Secure consent  Incision & drainage
1:00pm  Monitor for was ordered to treat
incision and left plank abscess.
Creatinine: 55.91 drainage Incision refers to the
Potassium: 4.4  Secure consent cut made to reach
for procedure the abscess.
 Refer Drainage refers to
 For soft tissue the release of pus
ultrasound from the body. An
abscess right under
the skin can be
2:00 am  Incision and  Regular  PNSS 1 L x 1  NPO  CBG  Secure consent mostly drained using
Creatinine: 55.91 drainage insulin 10 hour temporarily  ABG for admission this procedure. I&D
Sodium: 133 unites IV now  Creatinine, and is a time-honored
Potassium: 4.11  Piperacillin- Sodium, management method of draining
Chloride: 92.5 tazobactam 4.5 Potassium, abscesses to relieve
 Refer to
Magnesium: 0.55 g IV then Chloride, pain and speed
Endocrine for
AST: 5.0 every 6 hours BUN healing.
co-
ALT: 3.85  Lactulose 30  CBC, Ph, bt  Doctor ordered for
management.
BUN: 3.0 cc ODHS  12 Lead ECG regular insulin
 Refer to GS for
Ionized calcium:  Soft tissue because it is the only
co-
1.08 ultrasound management type of insulin
pH: 7.31 approved for IV use
PCO2: 29 and may be added to
PO2: 82 solutions.
HCO3: 15  Lactulose was
SO2: 95% prescribed for
PT: 12.40 treatment of
ACT: 100% constipation (10
INR: 0.93 days without bowel
APTT: 43.00 movement).
pH: 5.0  Antibiotics were
Specific gravity: prescribed for
1.039 treatment of
Leukocytes: 1+ infection,
Glucose: 4+  Metformin to lower
Ketone: 3+ glucose level,
 Atorvastatin to
(-) bowel x 10 reduce the risk of
days MI/stroke in Type 2
(+) left flank pain diabetes mellitus
(-) abdominal pain patients, and
(-) N/V  Paracetamol as
CBG: 295 mg/dl needed for pain.
 CBG  PNSS is a sterile,
8 pm monitoring nonpyrogenic
every 6 hours solution for fluid
(+) pain on left  Clindamycin  PNSS 1L  Diabetes  Wound GSCS  Refer for CBG and electrolyte
BP: 110/70 600 mg IV regulated to 20 mellitus diet  Blood culture > 300 mg/dl replenishment.
O2Sat: 99% every 8 hours gtts/ min x 2 sites  The patient was first
 Isophane put on NPO
insulin 18 temporarily and then
units SC was transferred to a
prebreakfast; 8 diabetic diet which
units SC ordered by the
predinner physician. This diet
 Metformin helps patient control
 500mg tab his blood sugar
TID (glucose), manage
 Vitamin B his weight and
complex 1 tab control heart disease
od risk factors, such as
 Atorvastatin high blood pressure
40 mg tab and high blood fats.
ODHS  The standard 12-
 Regular lead
insulin 6 units electrocardiogram
SC for CBG > (ECG) is one of the
180 mg/dl; most commonly
Regular used medical studies
insulin 10 in the assessment of
units SC for cardiovascular
CBG > 250 disease. It is the
mg/dl most important test
 Paracetamol for interpretation of
300 mg IV the cardiac rhythm,
now then detection of
every 6 hours myocardial ischemia
as needed for and infarction,
pain conduction system
abnormalities,
preexcitation, long
QT syndromes,
atrial abnormalities,
ventricular
hypertrophy,
pericarditis, and
other conditions.
 Ultrasound provides
information about
the specific soft
tissue structure
being examined, or
 about the blood flow
in vessels within the
soft tissues.
 Wound GSCS was
ordered to detect
and identify the
bacteria causing the
infection.
 Consent of the
patient was secured
to have ethical
considerations and
also to protect
patient's freedom to
make healthcare
decisions.

April 27, 2022  Sodium,  Continue CBG  Repeat test of

1:00pm Potassium, monitoring sodium, potassium,
Chloride and chloride ordered
(+) left flank pain  CBC for monitoring of
with pus drainage electrolyte and fluid
CBG: 239 mg/dl balance.
 CBC
 Continue CBG
monitoring to
monitor blood
glucose level of the
patient.
April 28, 2022  Piperacillin-  PNSS 1L  Low salt low  Wound GSCS  Continue CBG  Incision & drainage
4:30 am tazobactam 4.5 regulated at 20 fat diabetic  Blood CS monitoring was ordered to treat
g IV then gtts/ min diet  CBC  Refer to GS for left plank abscess.
BP: 110/70 mmHg every 6 hours  Sodium, definitive  Continue
HR: 80 bpm  Clindamycin Potassium, management of medications for
RR: 18 cpm 600 mg IV Creatinine left flank abscess treatment regimen.
Temp: 35.9 every 8 hours  Whole with possible  PNSS to facilitate
O2Sat: 97%  Isophane Abdomen intraperitoneal fluid and electrolyte
CBG: 171 mg/dl insulin 18 Ultrasound extension (psoas replacement
units SC  Soft tissue abscess)  Low salt low fat
Psoas abscess, left prebreakfast; 8 ultrasound  Vital signs every diabetic diet was
Diabetic units SC 6 hours ordered as adjunct to
ketoacidosis, mild, predinner  Refer drug therapy.
type 2 diabetes  Metformin  Wound GSCS and
mellitus 500mg tab Blood CS was
COVID-19 – TID ordered to detect
negative  Vitamin B and identify the
complex 1 tab bacteria causing the
OD infection.
 Atorvastatin  Repeat test of
40 mg tab sodium, potassium,
ODHS and chloride ordered
for monitoring of
11:40 am  Whole electrolyte and fluid
abdomen CT balance.
(+) left lumbar/ scan with  Ultrasound imaging
flank abscess Incision and triple contrast of the abdomen uses
(+) hipoma left drainage once with  Chest CT scan sound waves to
back CT scan result with IV produce pictures of
(+) mass left lower contrast the structures within
back the upper abdomen.
It is used to help
2:41 pm diagnose pain or
distention
(+) left flank mass, (enlargement) and
purulent evaluate the
kidneys, liver,
gallbladder, bile
ducts, pancreas,
spleen and
abdominal aorta.
 Ultrasound provides
information about
 the specific soft
tissue structure
being examined, or
about the blood flow
in vessels within the
soft tissues.
 A CT scan of the
abdomen may be
performed to assess
the abdomen and its
organs for tumors
and other lesions,
injuries, intra-
abdominal bleeding,
infections,
unexplained
abdominal pain,
obstructions, or
other conditions.
 Vital signs every 6
hours to monitor
condition of the
patient.