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Date/ shift Aug 10, 2010 6:00am-2:00pm

Physicians order 9:20am - Please admit to pedia ward B - Please secure consent for admission management - TRP q4 include Bp and record please - Monitor I&O cc/cc q shift record please - Diet as Tolerated - IVF D5 0.3 NaCl 1liter to run KVO - Diagnostics: Chest x-ray CBC Urinalysis ECG - Place water out for respiratory distress and any informed s/sx and please refer to PROD - Please inform PROD readmission once at ward. - Please Refer accordingly - Therapeutics: Furosemide 25mg thru IV q8 Cefuroxime 750mg TIV q8

Nurses intervention 10:20am - Admitted a 13y/o girl with a chief complaint of edema on low extremities - Conscious - Vital signs taken and recorded - Seen and examined - Consent for admission and management secured - D50.3NaCl 1L to run at KVO hooked and regulated at desired rate - DAT die - CXR PA follow up results - CBC P follow up results - Urinalysis Follow up results - ECG don result attached to chart - Medication prescribed - Monitor Vital signs include Bp and record - Monitor I&O cc/cc q shift and record - Pedia ward nurse on duty informed

Patient Response

10:40am - Include egg whites 3 egg whites to be mixed with milk 3x/day - Strict I &O monitoring cc/cc - Lab results BUN, CREA

2:00pm-10:00pm

Fixed and brought to ward - Needs attended - Endorsement 12:30pm - Trans. in patient PROD per via stretcher accompanied by NOD - w/ IVF 900cc - Conscious - O2 inhaler 3-4 LAM via face mask - Cont. on DAT diet - CXR PA follow up results - CBC P follow up results - Urinalysis Follow up results - ECG don result attached to chart - endorsed 2:45pm - received patient on bed with IVF @ 50cc - conscious - on DAT diet - O2 inhalation w/ ongoing @3lpm via facemask - CXR PA ff up results - CBC PC ff up results - Urinalysis ff up results

ECG tracing attached to chart for efficient reading Vital signs take and recorded afebrile Due meds given Needs attended endorsed

10:40pm - received on bed w/ IVF @940cc - conscious - DAT diet; include 3 egg whites to be mixed with milk 3x a day - O2 inhalation ongoing @ 3-4LPM via facemask - endorsed - CXR PA ff up results - CBC PC ff up results - Urinalysis ff up results - ECG tracing attached to chart for efficient reading - BUN, CREA for w/ request - Vital signs take and recorded - Due meds given - Needs attended

Aug. 11,2010 6:00am-2:00pm

10:15 am - May mean off to O2 inhalation - Please facilitate pending labs - Continue present meds and management - Please refer

2:00pm-10:00pm

7:00am - Received o bed w/ ongoing IVF 800cc - Conscious - DATT diet include 3 egg whites 3x a day to be mixed w/ milk - w/O2 inhalation 34Lpm via facemask - CXR PA ff up results - ECG tracing attached to chart - BUN, CREA ff up results 2:50pm - Received o bed w/ ongoing IVF 110cc - Conscious - DATT diet include 3 egg whites 3x a day to be mixed w/ milk - w/O2 inhalation 34Lpm via facemask - CXR PA ff up results - ECG tracing attached to chart - BUN, CREA ff up results - Vital signs recorded needs attended - Endorsed 10:00pm - Received o bed w/ ongoing IVF 780cc - Conscious - DAT diet include 3

Aug 12, 2010 6:00am-2:00pm

9:00 am - Revised present Iv to PNSS 500cc + 30mcg NaCl to run for 24hrs x 2 doses - Continue present meds and management - Please refer

2:00pm-10:00pm

egg whites 3x a day to be mixed w/ milk - w/O2 inhalation 34Lpm via facemask - CXR PA ff up results - ECG tracing attached to chart - BUN, CREA ff up results - Vital signs recorded - afebrile - due meds given - needs attended - Endorsed 6:25am - Received o bed w/ ongoing IVF 720cc - Conscious - DAT diet include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing attached to chart - BUN, CREA ff up results - Seen and examined by Dr. Velasco 2:30pm - Received o bed w/ ongoing IVF 720cc - Conscious - DAT diet include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing attached to chart

10:00pm-6:00am

Vital signs taken and recorded Afebrile Needs attended

Aug. 13,2010 6:00am-2:00pm

8:10am - Continue DAT diet - Lanoxin ).25mg/tab tab 2x a day- hold for HR<80 - Start Salbutamol NEB INED every 12hrs. - Continue present meds and management - Please refer

10:30pm - Received o bed w/ ongoing IVF 200cc - Conscious - DAT diet include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Afebrile - Needs attended 6:00am - Received pt. on bed w/ IVF @ 270cc level - Conscious - On DAT diet to include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing attached to chart - Repeat Na+ correction for request 8:10am - Seen and examined by Dra. Velasco order meds and continue

2:00pm-10:00pm

10:00pm-6:00am

management Vital signs taken and recorded - Needs attended - endorsed 2:40pm - received on bed w/ IVF @ 130cc level - conscious - on DAT diet to include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing for w/ request - Vital signs taken and recorded - #3PNSS 500c+30mcg NaCl X24 hook as to follow - Due meds given - Needs attended - Endorsed 10:00pm - received on bed w/ IVF @ 470cc level - conscious - on DAT diet to include 3 egg whites 3x a day to be mixed w/ milk - ECG tracing for w/ request - Repeat serum Na+ correction -

Aug. 14, 2010 6:00am-2:00pm

8:50am - Continue present meds and management - Please refer

10:30am - Salbutamol neb 1nebule for 1 dose - Re-assessment after 30mins - Please refer

2:00pm-10:00pm

3:10pm

Vital signs taken and recorded - Due meds given - Needs attended - Endorsed 6:00am - Received patient on bed w/ IVF of 390cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Request serum Na+ correction for w/ request 8:50am - Seen and examined by Dr. Macapulay w/ order made and carried out - Vital signs taken and recorded 10:30am - Referred to Dr.Velasco w/ order made and carried out - Due meds given 11:20am - Informed Dr.Velasco - Needs attended 2:30pm

IVF: D5 0.3 NaCl 500cc to run at KVO Refer

Aug. 15,2010

12:00pm - D/c Cefuroxime - Start ceftazidime

received patient on bed w/ IVF @ 200cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Request serum Na+ correction for w/ request - Vital signs taken and recorded - Due meds given - Needs attended 10:00pm - Received pt. on bed @140cc level - Asleep - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat serum Na+ correction for request due @3:30am (8/15/2010) ff up result 6:00am - Received pt. on bed w/ IVF @ 490cc level

770mg TIV q8 ANST Cont. Other meds and management Refer

Conscious On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat serum Na+ correction ff. up result 12:00nn - Seen and examined by Dr. Aganiza w/ new orders made and carried out - Vital signs taken and recorded - Due meds given - Needs attended 2:10pm - Received pt. on bed w/ IVF @ 100cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat serum Na+ correction ff. up result 10:30pm - Received pt. on bed w/ IVF @ 290cc level - Conscious

Aug. 16,2010

9:00am - start with pediasure 2glasses/day - start with multivitamins + Iron cap 1cap daily - rpt CXR(APL) today compare w/ previous result done - cont. Ceftazidime IV & other oral meds - refer

On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat serum Na+ correction ff. up result - Vital signs taken and recorded - Afebrile - Needs attended 7:00am - Received patient on bed w/ IVF @ 400cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk

9:00pm - ECG tracing attached to chart - Seen and examined by Dr. Aganiza w/ order made and carried out - Rpt. CXR for w/ request today; compare w/ previous plate (8/10/10)

2:00pm-10:00pm

Aug.17,2010

ff up rpt CXR (APL) cont. Present meds and management refer

- Afebrile - Due meds given - Needs attended 2:00pm - received pt. on bed w/ IVF @ 340cc level - conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk; include pediasure 2glasses daily - Vital signs taken and recorded - Afebrile - Due meds given - Needs attended 10:00pm - Received patient on bed w/ IVF @ 850cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Afebrile - Due meds given - Needs attended 6:00pm - Received patient on bed w/ IVF @ 400cc level

2:00pm-10:00pm

10:00-6:00pm

Conscious On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given 9:30am - Seen and examined by Dr. Aganiza w/ order made and carried out - Needs attended 2:00pm - received pt. on bed w/ IVF @ 800cc level - conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk; include pediasure 2glasses daily - Vital signs taken and recorded - Afebrile - Due meds given - Needs attended 10:00pm - received pt. on bed w/ IVF @ 300cc level - conscious - On diet as tolerated

Aug. 18,2010 6:00am-2:00pm

9:40am - may reinsert IV - continue present meds and management - please refer

2:00pm-10:00pm

3:10pm - IVF to ff: D5 0.3 NaCl 500cc to run at KVO - Please refer

to include 3egg whites TID to be mixed w/ milk; include pediasure 2glasses daily - Vital signs taken and recorded - Afebrile - Due meds given - Needs attended 6:00am - Received patient on bed w/ IVF @ 350cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given 9:00am - Seen and examined by Dr. Aganiza w/ order made and carried out - Needs attended 2:10pm - Received patient on bed w/ IVF @ 100cc level - Conscious - On diet as tolerated

10:00pm-6:00am

Aug.19,2010 6:00am-2:00pm

to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given - Received patient on bed w/ IVF @ 50cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given 12:30am - #5 D5 0.3 NaCl@KVO hooked as to follow - Meds attended 6:00am - Received patient on bed w/ IVF @ 450cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached

2:00pm-10:00pm

8:55pm - For repeat K+ - Cont. meds and management - Please refer

10:00pm-6:00am

to chart Seen and examined by Dra. Velasco w/ orders made and carried out - Repest k+ for request - Vital signs taken and recorded - Due meds given 2:00pm - Received patient on bed w/ IVF @ 400cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given 10:00pm - Received patient on bed w/ IVF @ 340cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Request K+ for -

Aug.20,2010 6:00am-2:00pm

9:35am - Start Vit.B complex 1 tab OD - Cont. meds and management - Please refer

request; result is relayed to Dra. Concepcion - Vital signs taken and recorded - Due meds given 6:15am - Received patient on bed w/ IVF @ 260cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk 9:30am - ECG tracing attached to chart - Seen and examined by Dra. Velasco - Vital signs taken and recorded - Due meds given 2:00pm - Received patient on bed w/ IVF @ 180cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded

Aug.21,2010 6:00am-2:00pm

8:05am - For issuance of clinical abstract - Cont. meds and management - Please refer

- Due meds given 11:15pm - Received patient on bed w/ IVF @ 135cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given - Needs attended 6:00am - Received patient on bed w/ IVF @ 60cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart 8:00am - Seen and examined by Dra. Macapulay w/ orders made and carried out - Vital signs taken and recorded - Due meds given 2:00pm

10:00pm-6:00am

4:00pm - IVF to ff. D50.3NaCl 500cc as KVO

Aug.22,2010

10:30am - For repeat CXR APL tom. 7:00am - Cont. meds and management - Please refer

Received patient on bed w/ IVF @ 10cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given - Needs attended 10:35pm - Received patient on bed w/ IVF @ 490cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Due meds given - Needs attended 6:35am - Received patient on bed w/ IVF @ 450cc level - Conscious - On diet as tolerated to include 3egg

whites TID to be mixed w/ milk ECG tracing attached to chart

2:00pm-10:00pm

10:00pm-6:00pm

10:30am - Seen and examined by Dra. Velasco orders made and carried out - Repeat CXR APL w/ request - Vital signs taken and recorded - Due meds given - Needs attended 2:55pm - Received patient on bed w/ IVF @ 500cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Vital signs taken and recorded - Instructed pt. and mother not to drink colas - Due meds given - Needs attended 10:00pm - Received patient on

Aug.23,2010 6:00pm-2:00pm

6:30am - Cont. meds and management - Please refer

bed w/ IVF @ 340cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat CXR APL tom. @ 7:00am - Vital signs taken and recorded - Afebrile - Due meds given - Needs attended 6:00pm - Received patient on bed w/ IVF @ 500cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat CXR APL for w/ request, due today; done follow 6::30pm - Seen and examined by Dra. Velasco orders made and carried out - Vital signs taken and

2:00pm-10:00pm

recorded - Due meds given - Needs attended 2:35pm - Received patient on bed w/ IVF @ 210cc level - Conscious - On diet as tolerated to include 3egg whites TID to be mixed w/ milk - ECG tracing attached to chart - Repeat CXR APL follow up results - Vital signs taken and recorded - Afebrile - Due meds given - Needs attended