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    Doctor's Order Sample 1 IM

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    fujoji92
    A patient was admitted to the department of Internal Medicine under Dr. Velez and Dr. P. Cagimbal for fever, chills, hypertension, uncontrolled diabetes, and left sided paralysis. Initial vitals and labs were taken. Orders were given to admit the patient, start IV antibiotics and insulin drip, insert lines and tubes, monitor vitals and intake/output, and request additional lab tests and imaging. Follow up notes decreased IV fluids and antibiotics and removed a line. Aspirin was also later discontinued.

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    Doctor's Order Sample 1 IM

    Uploaded by

    fujoji92
    11 views2 pages
    A patient was admitted to the department of Internal Medicine under Dr. Velez and Dr. P. Cagimbal for fever, chills, hypertension, uncontrolled diabetes, and left sided paralysis. Initial vitals and labs were taken. Orders were given to admit the patient, start IV antibiotics and insulin drip, insert lines and tubes, monitor vitals and intake/output, and request additional lab tests and imaging. Follow up notes decreased IV fluids and antibiotics and removed a line. Aspirin was also later discontinued.

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    Doctor's order sample 1 IM

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    A patient was admitted to the department of Internal Medicine under Dr. Velez and Dr. P. Cagimbal for fever, chills, hypertension, uncontrolled diabetes, and left sided paralysis. Initial vitals and labs were taken. Orders were given to admit the patient, start IV antibiotics and insulin drip, insert lines and tubes, monitor vitals and intake/output, and request additional lab tests and imaging. Follow up notes decreased IV fluids and antibiotics and removed a line. Aspirin was also later discontinued.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    11 views2 pages

    Doctor's Order Sample 1 IM

    Uploaded by

    fujoji92
    A patient was admitted to the department of Internal Medicine under Dr. Velez and Dr. P. Cagimbal for fever, chills, hypertension, uncontrolled diabetes, and left sided paralysis. Initial vitals and labs were taken. Orders were given to admit the patient, start IV antibiotics and insulin drip, insert lines and tubes, monitor vitals and intake/output, and request additional lab tests and imaging. Follow up notes decreased IV fluids and antibiotics and removed a line. Aspirin was also later discontinued.

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    © All Rights Reserved
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    of 2

    Date/Time Doctor’s Notes Doctor’s Order

    10/27/2021 @3PM BP= 120/80 > Please admit in the department of Internal
    PR:110bpm Medicine under the care of Dr. Velez comanaged by
    RR: 23CPM Dr. P. Cagimbal
    T: 38.0 degC
    >Complaints: Fever and Chills
    Hypertension
    Diabetes Mellitus type 2 uncontrolled
    Left Sided paralysis secondary to TIA

    >Condition: stable
    >Allergies: none
    >Diet: Blenderized Feeding Diabetic diet 1600
    Kcal/day (CHO: 50%, CHON: 20% and FAT: 30%) simple
    sugar ; No Fruits in 1500 cc divided to 4 meals

    >Labs:
    o CBC – taken @ER
    o Crea, BUN – taken @ER
    o Protime– taken @ER
    o Na, K, BUA – taken @ER
    o SGPT
    o HBA1C
    o Lipid Panel w FBS
    o 12L ECG
    o CXR -PAL - taken
    o CT chest plain
    o U/A (save)
    o Blood culture and sensitivity

    >Meds:
    1. Piperacillin- Tazobactam (Piptaz) 1g/vial
    Give 1g IVTT q6H
    2.Paracetamol (Biogesic) 500mg/ tab.
    Give 1 tab q 4h PRN for Temp >/= 38.0deg C/Axilla
    3. metformin (Glucophage XR) 500mg/tab 1 tab BID
    AC
    4. Aspirin 80 mg/tab give 1 tab OD PC @1PM
    5. Pantoprazole (Pantoloc) 40mg IVTT q24H ACBF
    6.Citicholine 1gm/tab give 1 tab TID

    >CBG q hourly and chart separately refer all CBGs to


    MROD
    >Give Supplemental insulin coverage with HRI IVTT:
    o 180 - 200 = 2U
    o 201 - 250 = 4U
    o 251 – 300 = 6U
    o 301 – 350 = 8U
    o 351 – 400 = 10U
    o >400 refer to MROD

    >Start D5LR (2)L @30 gtts/min


    >Please Insert FBC-CDU
    >Please insert NGT
    > CBR without TP
    >Monitor VS q4h
    > I/O q shift
    >Refer for any unusualities
    > Thank you
    TKR, MD
    ****patient wheeled going to your area at 4PM****

    10/27/2021 @6PM Decrease IVF to KVO


    Please insert another line and KSS.(Keep set sterile)
    Decrease Piperacillin- Tazobactam (Piptaz) 1g/vial
    Give 1g IVTT q4H
    Please remove FBC

    Additional Lab request:


    CT scan brain plain

    10/30/2021 at 9AM Discontinue Aspirin 80 mg/tab give 1 tab OD PC


    @1PM
     UTZ -WA
    **** THIS IS JUST A SAMPLE DOCTORS ORDER WHICH IS FOR EDUCATIONAL PURPOSES ONLY ****

    -THE EVENTS MAY NOT BE RELATED TO EACH OTHER BUT THIS WILL FACILITATE PROPER
    DOCUMENATION OF STUDENT’S LEARNING.

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