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CAPEGSAN, GARYSON OLAT Nurses Notes Vital Signs

Input and Output Discharge Instructions CBG OR

DOCS PACS Doctor's Order Rx Clinical Summary

Visit History

Patient Information
(ID:
Patient's Name Attending Dr1: DR. FRANCIS
BALLESTEROS YABUT,
2024004489 Attending Dr2: DR. JASON
VIEW OPD/ER: 374609B ) GUINTO NGALOB, MD,
DPBS
CAPEGSAN, GARYSON Attending Dr3: DR. CAESAR
OLAT NOEL ISON PALAGANAS,
MD
Age: 47 Sex: M Room: SH704
Admitting Dr: DR.
Admisson Date: 06/04/2024 EMERSON LAZAGA
03:22 PM Discharge: BENEDITO,
Referring Dr: DR. LOI MARIE
RUMIAS VELASQUEZ, MD,
DPBA, FPSA

New Telephone SMS Verbal Other

Order: Order Order Order Orders
Side Notes Orders

Type here... Course in the Ward

Type here...

SAVE

List of Doctor's Orders

Entered by: Carried out by:
BLACK, DAIME ROSE S.
RALPH EBES | Jun 09,
GERALD R. | 2024 10:48 AM
Jun 09, 2024
09:30 AM

Side Notes Order# 360912 Nurse Compliance

IM GASTRO -
Increase - to give
Save/Update losartan to - noted
100mg in AM. -
Course give amlodipine -
10mg in PM

Dr. Palaganas/ R.
Black

Entered by: Verbal Order: Carried out by:

VELASQUEZ, NGALOB, JASON DAIME ROSE S.
DOMINIQUE G. NOT EBES | Jun 09,
BIANCA G. | CONFIRMED 2024 10:42 AM
Jun 09, 2024
08:58 AM

Side Notes Order# 360884 Nurse Compliance

GS Notes -
For repeat CBC -
Save/Update in AM -
Regular low fat - regulated
Course non oily diet -
IVF to KVO -

Dr. Ngalob

Entered by: Carried out by:

BLACK, GERALDINE L.
RALPH FACTORA | Jun
GERALD R. | 09, 2024 08:53
Jun 09, 2024 AM
07:49 AM

Side Notes Order# 360834 Nurse Compliance

Patient IM RESIDENTS -noted

notes NOTES -consumed
having Current IVF: -hooked as
occasional D5LRS 1L x 16 10th bottle;
PS 5/10 hours ongoing
post op site IVF TF: PLRS 1L -hims updated
pain. The x 16 hrs
patient Diet: LSLF -noted
denies any -
subjective # S/P ERCP and -
complaints open -
such as cholecystectomy -
headache, (06/06/2024) -
dizziness, due to -
Blurring of Obstructive -
vision, jaundice -
nausea, secondary to
vomiting, choledocholithia -
chest pain, ses, galbladder
DOB hydrops, acute -
calculous -
BP: 150- cholecystitis, -?frequency
180/ 90-100 mild acute OD vs BID
(120/100) cholangitis: - to be
HR: 68-80 Cetriaxone instructed
(62) (Xtenda) 2g IV once with d/c
RR: 15-19 now then OD - plan
(15) D5 at 06/09, 12
T: 36.1- PM
36.8 (36.7) Omeprazole
SpO2: 93- 40mg/tab 1 tab -noted
98 (93%) BID 30 mins pre- -noted
BF and pre
I&O (16 dinner
hrs): 2170 Nalbuphine
vs 2300 (Endurpin) 5mg
BM: 1 SIVP PRN for
severe
Patient breakthrough
seen laying pain
on bed Etoricoxib
watching (Arcoxia)
TV, awake, 90mg/tab 1 tab
alert, BID
conversant
Pink #Hypertension
palpebral Amlodipine
conjunctiva 5mg/tab 1 tab
e, anicteric BID
sclerae Losartan
Clear and 50mg/tab 1 tab
equal BD - AM
breath For hypertensive
sounds workup (FBS
Heart rate complete lipid
normal with profile, Na K
regular crea, Uric acid)
rhythm as OPD basis as
Abdomen per patient
globular, request
soft,
nontender , Monitor BP
normoactiv trends and reay
e bowel Inform MROD if
sounds with with persistent
dry and SBP > 160mmHg
intact
dressing R. Black
No pedal
edema

Save/Update

Course

Entered by: Verbal Order: Carried out by:

None | Jun CASTRO, ALLAN GERALDINE L.
09, 2024 B. NOT FACTORA | Jun
06:56 AM CONFIRMED 09, 2024 08:56
AM

Side Notes Order# 360797 Nurse Compliance

POD 3 -noted
Continue low -noted
Save/Update salt low fat diet -shifted and
shift IVF to PNSS regulated
Course 1L x 16 hrs accordingly
Continue -
supportive care
and
management

Dr. Castro

Entered by: Carried out by:

BLACK, GRETCHEN RIA
RALPH A. CACHO | Jun
GERALD R. | 09, 2024 04:23
Jun 09, 2024 AM
12:50 AM

Side Notes Order# 360676 Nurse Compliance

Clonidine IM GASTRO .
75mcg 1 tab NOTES refused
sublingual Give another
was given dose of
at 10:50PM Clonidine 75mcg
1 tab sublingual
Current BP now
170/100
(180/100)
PR 68
RR 16
T 36.1
98% RA

Save/Update

Course

Entered by: Carried out by:

BLACK, HAZEL M.
RALPH FAYANGCAO |
GERALD R. | Jun 08, 2024
Jun 08, 2024 10:48 PM
10:40 PM

Side Notes Order# 360631 Nurse Compliance

Patient has IM RESIDENTS -

no subject NOTES NOTED
complaints Please give =
except post Clonidine 75mcg =
op site pain 1tab sublingual =
5/10. now. =
Patient Please provide =
denies adequate pain increased
chest pain, control =
nausea For hypertensive =
vomiting, workup (FBS
headache, complete lipid
BOV profile, Na K
crea, Uric acid)
BP 180/100 as OPD basis as
PR 73 per patient
RR 19 request
T 37C Please monitor
93% RA BP and relay
Increase
losartan to
Save/Update 50mg BID

Course Daweg/ R. Black

Entered by: Carried out by:

BLACK, HAZEL M.
RALPH FAYANGCAO |
GERALD R. | Jun 08, 2024
Jun 08, 2024 09:52 PM
09:47 PM

Side Notes Order# 360608 Nurse Compliance

No BOV, IM RESIDENTS -
headache, NOTES -
dizziness, Revise Given
with good Amlodipine =
pain control dosage: noted
at post op Give Amlodipine
site 5mg/tab 1 tab
now then BID
Patient until BP of
claims UBP 130/80 is
at home is achieved
SBP160 and Continue
above. HBP Losartan
recalled is 50mg/tab 1 tab
200+ OD- AM

Patient is R. Black
noncomplia
nt to
maintenanc
e
medication
of
Amlodipine
10mg/tab 1
tab OD
BP: 180/100
HR: 73
RR: 19
T: 37.0
SpO2: 93%
RA

Save/Update

Course

Entered by: Carried out by:

ELLAMIL, MARIE JOYLYN
MARION A. AGUINALDO
NICOL B. | | Jun 08, 2024
Jun 08, 2024 11:16 AM
10:58 AM

Side Notes Order# 360149 Nurse Compliance

GS Notes -
May have -
Save/Update regular low salt -
low fat diet with -
Course water in -
between meals -
Refer
accordingly

Dr. Ngalob /
Ellamil

Entered by: Carried out by:

BLACK, MARIE JOYLYN
RALPH A. AGUINALDO
GERALD R. | | Jun 08, 2024
Jun 08, 2024 10:23 AM
08:15 AM

Side Notes Order# 359971 Nurse Compliance

IM RESIDENTS -
NOTES -noted
Save/Update Give Losartan -and carried
50mg/tab 1 tab out
Course now then 1 tab -
OD in AM -
starting -
tomorrow -
Adjust
amlodipine to
10mg/tab 1 tab
OD in PM
starting
tomorrow

R. Black

Entered by: Carried out by:

BENEDITO, MARIE JOYLYN
EMERSON L. A. AGUINALDO
| Jun 08, | Jun 08, 2024
2024 07:31 07:46 AM
AM

Side Notes Order# 359933 Nurse Compliance

GS notes -
POD 2 -noted
Save/Update wound care -
done -
Course continue -
supportive care -
encourage DBE -
encourage early -
ambulation -
refer

Dr. Dirige/
Benedito

Entered by: Carried out by:

GAPUZ, JHAYJIANN Q.
NICOLAI C. | ORTEGA | Jun
Jun 08, 2024 08, 2024 06:41
06:23 AM AM

Side Notes Order# 359857 Nurse Compliance

S: Patient IM RESIDENT'S -
seen with NOTES - Noted, 9th
adequate Current IVF: bottle
pain D5LRS 1L x 16 - 10 bottle
control, no hours -
nausea/vom IVF TF: PLRS 1L -
iting, no x 16 hrs -
abdominal Diet: Soft diet in -
discomfort, small frequent -
with feedings -
passage of -
flatus but # S/P ERCP and -
no BM yet open -
cholecystectomy -
O: (06/06/2024) -
BP: 120- due to -
160/ 70-100 Obstructive -
(160/100) jaundice -
HR: 68-78 secondary to -
(75) choledocholithia -
RR: 16-20 ses, galbladder -
(16) hydrops, acute -
T: 36.5- calculous -
37.5 (37.0) cholecystitis, -
SpO2: 93- mild acute -
98 (94%) cholangitis:
Cetriaxone
I&O (24 (Xtenda) 2g IV
hrs): 2951 now then OD -
vs 3150 D4 at 06/08, 12
BM: 0 PM
Omeprazole
awake, not 40mg/tab 1 tab
in apparent BID 30 mins pre-
pain BF and pre
pink dinner
palpebral Nalbuphine
conjunctiva, (Endurpin) 5mg
non SIVP PRN for
distended severe
neck veins breakthrough
SCWE, pain
bilateral Etoricoxib
clear and (Arcoxia)
equal 90mg/tab 1 tab
breath BID
sounds
normal rate, #Hypertension
regular Amlodipine
rhythm 10mg/tab 1 tab
Flabby, given
intact and
dry Monitor BP
dressing, trends and
soft, inform MROD if
normoactiv with persistent
e BS, SBP > 160mmHg
tympanitic,
non tender GAPUZ
no bipedal
edema,
FEPP

Save/Update

Course

Entered by: Carried out by:

GAPUZ, JHAYJIANN Q.
NICOLAI C. | ORTEGA | Jun
Jun 08, 2024 08, 2024 06:40
06:21 AM AM

Side Notes Order# 359855 Nurse Compliance

IM NOTES -
IVF TF: PLRS 1L - Noted,
Save/Update x 16 hrs -
#Hypertension - given at
Course Give Amlodipine 6:40am
10mg/tab 1 tab -
now
Gapuz

Entered by: Verbal Order: Carried out by:

None | Jun YABUT, FRANCIS GERLIN C.
07, 2024 B. NOT DEPALOG | Jun
12:20 PM CONFIRMED 07, 2024 02:26
PM

Side Notes Order# 359200 Nurse Compliance

GS NOTES -
-
Save/Update Please apply applied
abdominal updated
Course binder noted
Maintain Soft
diet in small
frequent feeding
Please regulate
IVF to run for 16
hours
Refer
Dr. J Ngalob

Entered by: Carried out by:

FADLEN, GERLIN C.
FRANCES DEPALOG | Jun
LOUISE B. | 07, 2024 09:56
Jun 07, 2024 AM
09:51 AM

Side Notes Order# 359045 Nurse Compliance

Urology noted
Noted
Save/Update developments
Dr. Yabut
Course updated

Entered by: Carried out by:

ACOP, GERLIN C.
MATTHEW DEPALOG | Jun
APOLLO M. | 07, 2024 09:57
Jun 07, 2024 AM
09:38 AM

Side Notes Order# 359022 Nurse Compliance

GS notes diet updated

May have soft
Save/Update diet for lunch
then DAT for
Course dinner if
tolerated
Refer

Entered by: Carried out by:

ELLAMIL, GERLIN C.
MARION DEPALOG | Jun
NICOL B. | 07, 2024 09:59
Jun 07, 2024 AM
08:35 AM

Side Notes Order# 358973 Nurse Compliance

GS Notes for removal

Remove IFC
Save/Update Refer
accordingly
Course
Dr. Ngalob / Dr.
Acop / Ellamil

Entered by: Carried out by:

MUSTHOFA, GERLIN C.
AISHATH U. | DEPALOG | Jun
Jun 07, 2024 07, 2024 09:59
08:11 AM AM

Side Notes Order# 358950 Nurse Compliance

S: tolerable IM RESIDENT -
surgical site NOTES: -
pain, no ROM: -
nausea/vom Current IVF: -
iting, no D5LRS 1L x 8hrs -
abdominal Diet: sips of -
discomfort, water -
with -
passage of # S/P ERCP and -
flatus open -
cholecystectomy -
O: (06/06/2024) -
BP: 110 due to -
(140/ 70-90 Obstructive -
(130/70) jaundice -
HR: 65-84 secondary to -
(65) choledocholithia -
RR: 16-18 ses, galbladder -
(18) hydrops, acute -
T: 36.5- calculous -
36.7 (36.7) cholecystitis, -
SpO2: 94- mild acute noted
98 (94%) cholangitis:
-Cetriaxone
I&O (8 hrs): (Xtenda) 2g IV
800 vs 380 now then OD -
BM: 0 D3 at 06/07, 12
PM
awake, alert -Omeprazole 40
SCWE, mg 1 tab BID, 30
bilateral mins pre
clear and breakfast and
equal pre dinner
breath - Ketorolac
sounds 30mg IV q6 for 3
normal rate, more doses
regular - Paracetamol 1g
rhythm IV q6 for 2 more
globular doses
abdomen, - Nalbuphine
intact dry (Endurpin) 5mg
dressing, SIVP q4 x 2
soft, non doses, then PRN
tender on for severe
superficial breakthrough
palpation, pain
tympanic, -Etoricoxib
hypoactive (Arcoxia)
bowel 90mg/tab 1 tab
sounds BID after IV pain
no edema, meds
FEPP
ULYA
Save/Update

Course

Entered by: Carried out by:

GALAS, GERLIN C.
AMICAH C. | DEPALOG | Jun
Jun 07, 2024 07, 2024 10:00
07:21 AM AM

Side Notes Order# 358907 Nurse Compliance

Anesthesia -
Please extend transcribed
Save/Update Ketorolac 30mg -
IV q6 for 3 more transcribed
Course doses noted
Paracetamol 1g
Patient is IV q6 for 2 more
awake and doses
conversant, Fully recovered
with good from the effects
pain of anesthesia
control. VAS Refer
1/10. No Dr.
complaints Velasquez/Galas
of
headache,
dizziness,
nausea,
vomiting, or
DOB. Able
to tolerate
sips of
water. Able
to sit and
move side
to side on
bed.

Latest VS:
BP: 130/70,
HR: 65, RR:
18, T: 36.7,
SPO2: 94%
at room air
Dry and
intact
dressing
Intact IFC,
adequate
UO

Entered by: ACOP, MATTHEW Carried out by:

ACOP, APOLLO M. DAIME ROSE S.
MATTHEW EBES | Jun 06,
APOLLO M. | 2024 09:01 PM