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Original Question

01/27/22 2100H Patient: Alfredo, David, Cua Age: 30 Gender: Male Patient ID: 1000879 Birthdate: 02/02/91 Nationality: Filipino Private or Self pay Chief Complaint: Chest Heaviness + Vomiting Admitting Impression: Chronic Heart Failure ; Peptic Ulcer Disease Admitting Physician: Dr Rose Dolendo Attending Physician: Dr. Rowena Chua Wt: 62 kg Ht: 164 cm T: 38 c Pulse: 162 bpm RR: 28cpm BP: 140/96 SPO2: 91% -Please admit under my service. -Secure consent for admission. – V/S every 1hr for the first 4 hrs then every 4 hrs. -Diet Low salt low fat diet. -Labs: *CBC *Platelet count *Urinalysis *CXR PA *ECG 12 Lead *Serum Electrolytes *Complete blood Chemistry -Start Vancomycin w/ D5W 500 cc x KV0 -Meds: * Dobutamine 20 mg + 20cc D5W x 16 cc/hr * Spironolactone 25 mg tab, 1tab OD per orem * Omeprazole 40 mg IV every 12hrs ANST ( ) * Ranitidine 50 mg IV every 8 hrs * Clopidogrel 75 mg tab, 1 tab OD PO * Domperidone 10 mg tab, 1 tab TID PO Atorvastatin 20g tab, 1 tab OD PO -Monitor I&O q4 -Refer 01/28/22 0430H -Temp 38.7 C -Paracetamol (Aeknil) 300mg/cup, 1/2 cup W now then paracetamol 500mg tab PO q4 for temp > 38 C -TSB as needed -advice for increase fluid intake, as tolerated -continue meds -tf labs -monitor VS q2 x 4 then q4 -refer accordingly -additional order > IVTF: PNSS 1L x 80cc/hr MAKE A SOAPIE

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