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ADMISSION ADMISSION
Please admit to room of choice/near nurses/ ICU under the service of TOB: Please admit to NICU under the service of Dr._____
Dr._____ BW: TPR QHourly and record
Monitor VS Q4H/QHourly and record BL Diet: May have breast feeding
Venoclysis:
Diet: NPO/DAT/Low Salt and Low fat T:
LABS: CBC, APC, Blood typing, Blood CS(PROM), New
Venoclysis: PNSS 1L x __cc/H HC: born screening within 24 hours
LABS: CBC, APC, U/A, S. Na, K, Ca, FBS, Crea, SGPT, Lipid Profile, Uric CC: Meds:
Acid, ECG 12 Leads, Chest Xray, CBG now(routine) AC: Erythromycin eye ointment OU
Meds: AS: Phytomenadione 1mg IM
OBAOG: Hep B vaccine 0.5ml IM
S/O: MIO Qshift and record PAOG: BCG 0.05ml prior to discharge
Stool and vomitus count sheet (diarrhea and vomit) S/O: Routine newborn care
Thermoregulate between 36.5-37.5
Replace GI losses vol/vol w/PLR Maternal
Reweigh px every other day
Relay labs once in BT: Suction secretion prn
Will inform Dr.___ of this admission HBsAg;NR Daily Cord Care
Watch out for any untowards S/Sx RPR:NR Will inform Dr.___ of this admission
Refer accordingly (NR=non Watch out for any untowards S/Sx
Thank you. Reactive) Refer accordingly
Resident/Intern Resident/Intern
PEDIATRICS (ER)
ADMISSION
Please admit to room of choice/ PICU under the service of Dr._____
SKIN TEST ORDER
Monitor VS Q4H/QHourly and record
Diet: NPO/DAT/No Dark colored foods
Venoclysis: (-)erythema *Negative Skin Test(NST) to
LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL (-) induration CEFUROXIME(Zegen)
Meds:
*NST to Generic(Brand)
S/O: MIO Qshift and record
Stool and vomitus count sheet (diarrhea and vomit)
Replace GI losses vol/vol w/PLR IV FOLLOW UP
Relay labs once in
Will inform Dr.___ of this admission (-/+)dry lips *IVF to ff: D5LR 1Lx 100cc/H
Watch out for any untowards S/Sx (-/+)dry tonque Resident/Intern
Refer accordingly
Thank you. (Refer to the latest IV of the
Resident/Intern patient/or ask the nurse)
TRANSOUT ORDERS
T: P: R: BP: *May Transfer Patient Back to Room
SURGERY (-)headache *D/C O2 and Pulse Oximeter
ADMISSION *Monitor VS Qhourly and record
Please admit to room of choice/ SICU under the service of Dr._____ (-) vomiting *MIO QHourly and record, *Refer for
Monitor VS Q4H/QHourly and record UO<30cc/H
Diet: NPO/DAT (+)able to flex *Watch out for any untowards S/Sx
Venoclysis: D5LR/PLR 1L x__cc/H knees=for spinal *Refer Accordingly
LABS: CBC, Protime, APTT, CT, BT, Blood typing S. Na. K, U/A anesthesia *Thank You
Meds:
Resident/Intern
S/O: MIO Qshift and record
Will inform Operating Room
Will inform Dr.___ of this admission
Dr. ___ for anesthesia
Watch out for any untowards S/Sx
Refer accordingly
Thank you.
Resident/Intern
BLOOD TRANSFUSION ORDER/ CP(Cardiopulmonary) Acute Gastroenteritis with Mild/Mod/Severe DHN
ASSESSMENT(IM/SURG/GYNE)
Please admit to room of choice under the service of Dr._____
*CP Status Assessed Monitor VS Q4H and record
T: P: R: BP: *May transfuse available unit of Diet: NPO/DAT
SCE, CBS, RCRR, PRBC/FWD/Modified PRBC/ Platelet Conc of Venoclysis:
(-)DOB patient’s blood type after proper LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL
crossmatching Meds:
Monitor VS Q15min for the 1st hour then *B.Clausii(Erceflora) 1-2 vial TID
Qhourly therafter *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.8-
*Mainline to KVO(Keep vein Open) while on 38.5C(10mg/kg/dose)
BT *Paracetamol__mg prn for fever >38.5C(10mg/kg/dose)
*Watch out for any untowards S/Sx like fever *Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose)
tachypnea, rashes *Metronidazole __mg/ml; __ml Q8H IVTT(30-50mg/kg/day)
*Refer Accordingly S/O: Fast Drip __CC of PLR now
*Thank You MIO Qshift and record
Resident/intern Stool and vomitus count sheet
Replace GI losses vol/vol w/PLR
Relay labs once in
Will inform Dr.___ of this admission
Watch out for any untowards S/Sx
Refer accordingly
Thank you.
BLOOD TRANSFUSION ORDER/ CP(Cardiopulmonary)
ASSESSMENT(PEDIATRICS)
ACUTE TONSILLOPHARYNGITIS EXUDATIVE/NON-EXUDATIVE
*CP Status Assessed
T: P: R: *May transfuse ___cc of PRBC/FWD/Modified Please admit to room of choice under the service of Dr._____
Bmkko0gP: PRBC/ Platelet Conc of patient’s blood type after Monitor VS Q4H and record
SCE, CBS, RCRR, proper crossmatching Diet: NPO/DAT
(-)dyspnea Monitor VS Q15min for the 1st hour then Qhourly Venoclysis:
therafter LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL
*Mainline to KVO(Keep vein Open) while on BT Meds:
*Watch out for any untowards S/Sx like fever *Cefuroxime 20-40mg/kg/day(ORAL) or 50-100mg/kg/day(IV) TID
tachypnea, rashes *or Co-amoxiclav 30-50mg/kg/day TID
*Refer Accordingly *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.8-
*Thank You 38.5C(10mg/kg/dose)
Resident/intern *Paracetamol__mg prn for fever >38.5C(10mg/kg/dose)
*Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose)
S/O: MIO Qshift and record
Replace GI losses vol/vol w/PLR
Relay labs once in
Will inform Dr.___ of this admission
CO-MANAGEMENT Watch out for any untowards S/Sx
Refer accordingly
*Surg/IM/Pedia/Gyne Notes Thank you.
*Thank You for this referral
*Patient seen and Examined
*History and PE reviewed
*Will inform Dr.____ of this referral
*Watch out for any untowards S/Sx
*Refer accordingly
Resident/Intern
C.W.O Dr(consultant)/Resident/Intern
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA C or D BENIGN FEBRILE CONVULSION
Please admit to room of choice under the service of Dr._____ Please admit to room of choice/PICU under the service of Dr._____
Monitor VS Q4H and record Monitor VS Q4H and record
Diet: NPO/DAT Diet: NPO temp
Venoclysis: Venoclysis:
LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL
Meds: Meds:
*Antibiotic(Refer to table for PCAP) *Diazepam(0.2mg/kg/dose)
*Paracetamol __mg/__ml;__ml Q4H prn for fever 37.8- *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.8-
38.5C(10mg/kg/dose) 38.5C(15mg/kg/dose)
*Paracetamol__mg prn for fever >38.5C(10mg/kg/dose) *Paracetamol__mg prn for fever >38.5C(15mg/kg/dose)
*Salbutamol ½ nebule +2cc of PNSS; PAI 1 nebule x 3 doses every S/O: MIO Qshift and record
15mins(DOB) Seizure precautions at bedside
*Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose) Stand by O2 at bedside
S/O: MIO Qshift and record Relay labs once in
Relay labs once in Will inform Dr.___ of this admission
Will inform Dr.___ of this admission Watch out for any untowards S/Sx
Watch out for any untowards S/Sx Refer accordingly
Refer accordingly Thank you.
Thank you.
Partially Compensated
VACCINATION
Vaccine Age of # of Dose Route SIte Completely Compensated N
1st doses
dose Respiratory Alkalosis (Change in pCO2 is greater than change in HCO3) (pCO2 is
BCG Birth 1 0.05ml ID R deltoid decreased)
R buttocks Uncompensated N N
DPT 6 3(6th, 0.5ml IM Upper thigh
weeks 10th,14th Vastus Partially Compensated
month) lateralis
OPV 6 3(6th, 2- Oral Mouth Completely Compensated N
weeks 10th, 14th 3drops
month)
COMON MEDICATIONS THAT ARE USED
Hepa B Birth 3(0,4th, 0.5ml IM Vastus
8th week) lateralis Anti-emetic/Anti-vomiting
Measles 9 1 0.5ml SQ R deltoid *Metoclopramide-dopamine receptor blocker
month Recommended Dose:
MMR 12-15th 2 (12th - 0.5ml SQ R deltoid 0.5mg/kg/dose- ORAL
month 15th R buttock 0.2mg/kg/dose- IV
month, Preparation:
4-6Y.O) Ampule:10mg/2ml Syrup: 5mg/ml
5mg/2ml Tab: 10mg
Anto-Spasmodic
*Dicycloverine-anticholinergic activity
Recommended Dose:
2.5-5mg/kg/day-TID
Preparation:
Drops: 5mg/ml Syrup:2mg/ml
15mg/ml Tab: 10mg
*Hyoscine-N-Butyl Bromide(HNBB)-anticholinergic activity
Recommended Dose:
0.15mg/kg/dose-TID
Preparation:
Ampule: 20mg/ml Tab:10mg
Promotility(For Dyspepsia)
*Domperidone
Recommended Dose:
0.3mg/kg/dose
MULTIVITAMINS: ANTIHISTAMINE(H1-receptor blocker)
Preparation: 1st generation
Drops: 100mg/ml Syrup: 100mg/ml *Hydroxyzine HCl(Iterax)-1mg/kg/day, Q12H
Syrup: 2mg/ml
Dosage: <3 months=0.3ml. Increase dosage proportionately to Tab: 10mg, 25mg
the patient’s age base on months *Chlorphenamine maleate-0.2mg/kg/dose, Q8H
6months 0.6ml Ampule:10mg/ml
1y.o 1ml Syrup: 2mg/5ml
1y 6mos 1.5ml *DIphenhydramine- 3-5mg/kg/dose-oral
2y 2ml 1mg/kg/dose-IV
IRON: Syrup: 12.5mg/5ml
Prophylactic dose: 1mg/kg/day OD Cap:25mg/50mg
Therapeutic dose: 3-6mg/kg/day BID IV:50mg/ml
Vitamin A: 2nd generation
6-11mos:100,000 IU-1 dose *Cetirizine-0.25-0.27mg/kg/dose(OD-BID)
12-71mos:200,00 IU Drops: 10mg/ml, 2.5mg/ml
Zinc: Sol’n: 1mg/ml
10mg:infants Syrup:5mg/5ml
20mg:2y.o+ Tab:10mg
*Desloratidine:
6-11mo-2ml
1-5yo-2.5ml
6-11y.o-5ml
ANTIPYRETIC/ANALGESIC >12y.o- 10ml
*Paracetamol-COX inhibitor Syrup: 2.5mg/5ml
Recommended Dose:
10-15mg/kg/dose(Q4H) MUCOLYTIC
Preparation:
Drops: 100mg/ml Tab: 250mg, 325mg,
Syrup:125mg/5ml 500mg
250mg/5ml
Ampule:300mg/ml
*Ibuprofen-prostaglandin synthesis inhibitor
Recommended Dose:
5-10mg/kg/dose(Q6-8H)
Preparation:
Suspension: 100mg/5ml
Capsule:200mg/cap
*Aluminum/Magnesium Hydroxide
(Q6H)
*Omeprazole 40mg/OD(Proton pump inhibitor)
*Pantoprazole 40mg/OD(Proton-pump inhibitor)
*Esomeprazole 40mg/OD(Proton-Pump inhibitor)
History and PE reviewed
Laboratory Tests requested
Medications given
Patient managed well
Urinalysis:
Sugar RBC
Albumin Pus
Squamous Spec.gravity
Suture Choice:
Nylon 4.0 and 5.0- Face or less muscular area
Nylon 3.0-Extremeties
Suture Removal:
COMMONLY USED TERMS/ PHRASES/ SYMBOLS IN INTERNSHIP Face: 3-5 days
*Physical Examination Extremeties 7-10 days
AS-Anicteric Sclerae
PC-Pinkish Conjunctiva
CLADS-Cervical Lymphadenopathy
SCE-Symmetrical Chest Expansion
CBS-Clear Breath Sounds
AP-Adynamic Precordium *Animal Bite(only dogs and cats- if rodents NO HRIG or verorab
RCRR-Regular Cardiac Rate and Rhythm required)
NVE-Neck vein Engorgement Plans:
*For Xray of ___, ___ view
*Internal Examination *TT 0.5ml/amp via deep IM now
I-Introitus (Admits 2 fingers) *HTIG 250IU/Amp via deep IM now
C-Cervix (Smooth, soft) *HRIG 300IU/amp (dosage), ½ to be infiltrated
U-Uterus (level of umbilicus/symphysis pubis) surrounding the bite site; ½ via deep IM
A-Adnexa (No adnexal mass nor tenderness) *Verorab 0.5ml/amp via deep IM now, then on Day 3, 7, 14, 28
D-Discharges (Minimal bloody discharge) *Patient opted for HRIG injection at WVMC(very expensive)
E-Episiotomy( well-coaptated episiotomy site *Sultamicillin tosylate (dosage) BID x7 days
*FF. Up Official Xray result after 3 days
*Digital Rectal Exam *Watch out for any untowards S/Sx
No external mass *Advised
No internal masses/haemorrhoids *Thank You
No tenderness
No discharges Rabies Immunoglobulin dosage:
No blood/Minimal fecal material HRIG: 20IU/kg
ERIG: 40IU/kg
*Cellulitis
Plans:
*TT 0.5ml/amp via deep IM now(situational)
*HTIG 250IU/Amp via deep IM now(situational)
*Sultamicillin (dosage) BID x7 days
*Daily wound care
*Watch out for any untowards S/Sx
*Advised
GRADING OF MURMURS
1 – Faint
2 – Audible
3 – Moderately Loud
4 – Loud with palpable thrill
5 – Loud with thrill, stet partially off
6 – Loud with thrill, w/o stet
MUSCLE STRENGTH
O – No muscular contraction
1 – Trace contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity & slight resistance
5 – Against full resistance