DATE/TIME CVD BLEED
Pls admit under the care of Dr. _
VS: Secure consent to care
T= Diet: NPO
Bp= Please insert NGT
HR= Start IVF PNSS 1L at KVO
RR= Labs:
02 SAT= CBC, Crea, Na, K RBS, ECG, plain cranial CT
scan, CXR
GCS Meds:
1. Nicardipine 2mg IVTT bolus now, repeat
BP after 15 mins
2. Nicardipine drip (10mg + 90PNSS) at 15
cc/ hr, uptitrate at increments of 5cc/hr
to achieve SBP<160
3. Mannitol 150 cc IV drip now
4. Mannitol 100cc IV drip q6hrs
5. Furosemide 40mg IVTT now then OD
6. Diazepam 10mg IVTT now PRN for seizure
7. Ranitidine 50mg IVTT now then q6
8. Citicoline 1g IVTT q8
Insert FBC
Start supplemental O2 to maintain O2 at
>95% or
Elevate head 45degrees
Intubation done with ET size __; level 20
PMhx: (MMASH) S- state of conciousness TV=500 FIO2= 100%
Medical history: P- pupil reactivity AC mode RR=16
Maintenance meds: E- eye movement IE: 1:3 PEEP= 8
Allergies R- respiratory pattern RBS q 2hrs
Surgeries M- motor Monitor VS q 15 for the first hour then q 30
Hospitalizations: for the next hr, then q hourly thereafter
Monitor Neuro VS q 4
PE Monitor I/O q shift
Refer
Thank you.
Atenolol 10/tab od
DATE/TIME CONGESTIVE HEART FAILURE
VS: Please admit under the care of __
T= Please secure consent to care
Bp= Start O2 at 2-4lmp via nasal canula
HR= Diet: Low salt, Low fat when stable; NA
RR= <2gm/day
02 SAT= Limit total fluid intake < 1L/day
IVF: Start D5W 500 cc at KVO
HPI Labs
-CBC -ECG 12 L
PMhx: (MMASH) -UA - CXR-PA
Medical history: - Crea, BUN
Maintenance meds: -K , Na
Allergies > Meds:
Surgeries 1. Furosemide 40 or 20 mg IVTT now then OD or
Hospitalizations: q12
CVS: JVP!!!! 2. Clopidogrel 75/tab, 1 tab OD
C/L: crackles: transudation of fluid; wheezing: 3. Atorvastatin (40 or 80mg) , OD
peribronchial cuffing from congestion 4. ISMN 60/tab, 1 tab OD (if + chest pain)
Ext: peripheral edema 5. Captopril 25-50 mg q 6-12 hours (maximum
50mg TID) – cornerstone of tx
6. Metropolol 150/tab OD – cornerstone of HF
tx
> FBC insertion
> Complete Bed rest with no bath room
privileges
> High Back rest Bisoprolol 5/tab, OD
> Monitor VS q 4 Spironolactone 25/tab, OD
> Monitor I/O q shift TMZ 35/tab, BID
> Refer
A> CHF, FUNCTIONAL CLASS _ SEC TO (I.E. CAD > Thank you
SEC TO CKD/HPN)
Lanoxin 0.25, 1/2 tab, OD
TMZ 35/tab, 1 tab BID
Carvedilol 6.25 tab, BID
D5water 500cc at KVO
DATE/TIME ACUTE APPENDICITIS
VS: Please admit under the care of
T= Please secure consent to care
Bp= Diet: NPO
HR= IVF: Start D5LR at ___
RR= Labs:
02 SAT= CBC CXR
UA UTZ – WA
HPI Blood typing PT
Meds:
PMhx: (MMASH) 1. Omeprazole 40mg IVTT now, then OD
Medical history: Uncomplicated:
Maintenance meds: Cefoxitin 1gm IVTT q8
Allergies Complicated:
Surgeries Metronidazole
Hospitalizations:
For appendectomy
If female: Please endorse surgeon
-LMP Monitor I/O q Shift
-Parity GP(TPAL) Monitor VS q 4
- menstruation (regular, number of pads) Refer
-Always rule OB problems Thank you
ALVARDO SCORING:
DATE/TIME CHRONIC STABLE ANGINA PECTORIS
VS: Please admit under the care of __
T= Please secure consent to care
Bp= Start O2 at 2-4lmp via nasal canula
HR= Diet: Low salt, Low fat when stable; NA
RR= <2gm/day
02 SAT= Limit total fluid intake < 1L/day
IVF: Start D5W 500 cc at KVO
HPI Labs
-CBC -ECG 12 L
PMhx: (MMASH) -UA - CXR-PA
Medical history: - Crea, BUN
Maintenance meds: -K , Na
Allergies -trop I
Surgeries Meds
Hospitalizations: 1. ISMN 30mg/tab, 1 tab now then OD
thereafter – symptomatic relief (se:
CSAP: headache)
Angina- heaviness, pressure squeezing ; crescendo- 2. Metropolol 100mg/tab, 1 tab now then
decrescendo in nature, usually last 2-5 minutes and BID thereafter – cornerstone in angina
relieved with 5-10 min 3. Trimetazidine 35/tab, 1 tab BID
4. Clopidogrel 75/tab, 1 tab OD
5. Atorvastatin 80/tab, 1 tab OD
Complete bed rest without bathroom prv
High back rest
Monitor I/o q shift
Monitor v/s q4
Refer accordingly
Thank you.
