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Physician's Order...

The physician's order sheet documents the treatment for a patient named Steve Rogers admitted to the medical ward with pneumonia. The orders include admitting the patient, administering antibiotics and medications to reduce fever and breathing difficulties, monitoring vital signs, and performing tests. The physician decreases some medications and shifts antibiotics as the patient's condition improves over the next few days.

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Liiza G-Gspr
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758 views2 pages

Physician's Order...

The physician's order sheet documents the treatment for a patient named Steve Rogers admitted to the medical ward with pneumonia. The orders include admitting the patient, administering antibiotics and medications to reduce fever and breathing difficulties, monitoring vital signs, and performing tests. The physician decreases some medications and shifts antibiotics as the patient's condition improves over the next few days.

Uploaded by

Liiza G-Gspr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Health

Date and Time Noted PHYSICIAN’S ORDER SHEET

February 5, 2021 ⮚ Please admit to medical ward Private room under the white service
7:30 am ⮚ TPR q shift and record
⮚ Secure consent for admission
V/S: ⮚ NPO temporarily
T° = 39.8°C Dx: CBC, CXR-APL, U/A
RR = 67 cpm Tx: PNSS 1L x 24°
PR = 156 bpm − Cefazolin 1 gm IV every 6° ANST ( )
WT = 75 kg − Amikacin 50 mg IV OD ANST ( )
− Salbutamol 1 nebule + 2cc PNSS every 15 minutes for three doses then every 4
hours
− Paracetamol 900 mg per IV every 4 hours RTC
10 am
− Suction secretion PRN
T° = 39°C
− Oxygen inhalation at 3-4 LPM/NC
RR = 62 cpm
− Vital signs every 4 hours and record
PR = 148 bpm
− TSB PRN for fever
− Increase OFI.
− Watch out for DOB, dizziness
⮚ Refer accordingly
Signed:

Dr. Angel Liban


2pm ⮚ IVF to follow PNSS 1L x 12 hours
T° = 38°C ⮚ For sputum culture this AM.
RR = 56 cpm ⮚ Continue meds
PR = 140 bpm ⮚ Follow up lab results.
⮚ Refer accordingly
Signed:

Dr. Angel Liban


February 6, 2021 ⮚ Shift cefazolin to cefuroxime 750 mg IV every 8 hours ANST ( )
10am ⮚ Discontinue Amikacin
⮚ Decrease Salbutamol nebulization to every 6 hours
⮚ Decrease paracetamol 600 mg every 4 hours RTC to every 4 hours then PRN for fever
⮚ Refer accordingly
Signed:

Dr. Angel Liban

DIAGNOSIS: PNEUMONIA( BACTERIAL)

Name of Patient: STEVE ROGERS Hospital Number: 010110

Ward: MEDICAL WARD ( PRIVATE ROOM) Bed No. 12

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