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UTS HEALTHFamily Name:KumarMRN 1123408Given Name: KamalMale X FemalePROGRESS /CLINICAL NOTESDOB: 22.01.1956M.O. HarrisAddress: 46 Addison Avenue, Concord NSW 2137Location/Ward 1ADate/Time(Use 24 hour clock)NB: All entries must be legible, written in black pen and include healthcare providers[printed name, designation and signatureAdmission NotesHistory present case – Mr Kamal Kumar, 63 year old male admitted to UTS Hospital for a high anteriorXx/xx/xxbowel resection. Had been experiencing episodes of blood in his stools, reviewed by GP and referred forcolonoscopy. Mr Kumar underwent a colonoscopy (10th November 2017). The colorectal specialisedperforming the colonoscopy located a tumour which was biopsied. Biopsy result confirmed a malignanttumour (adenocarcinoma). Scheduled for surgery later today. Further tests including a CT scan show noevidence of any secondary tumours, however the tumour in the bowel had broken through the bowel wall, whichexplained the blood in his stool. ———————————————————————————————–PMHx: . Mr Kumar also has a history of hypercholesterolaemia and hypertension. These both being controlledwith medication (Metoprolol 50mg daily and Atorvastatin 20mg daily). Reports recent trouble controllinghis BP and that when his GP last checked it a week ago it was slightly high despite having taken hismedication. Pt has T2DM for which he takes metformin.Currently weighs 130 Kg in weight and is 168cm in height. BMI at 46.1. He reports having trouble with hisweight for most of his adult life. Exercise very limited, takes short walks but only occasionally. Reports.getting breathless very easily. —————————————————————————————Background: Mr Kumar emigrated from India to Australia with his family 12 years ago. He lives with hiswife and two adult children. Works full time as an IT consultant – up to 55hrs a week. ————————-Plan: Consent and prep for high anterior bowel resection————————————CASE-Dr Case (56123)PerioperativeMr Kumar had a FG 20 cannula inserted in the left Cubital Fossa preoperatively. Anaesthetized, intubatedXx/xx/xxwith a 7.5 ETT (a fibre optic bronchoscope required to safely intubate due to poor vision of the vocal cords).Intermittent positive pressure ventilation (IPPV). 1L of Hartmann’s commenced through a fluid warmer.Temperature probe, a FG 14 Foley IDC, with an hourly urine measure bag and NG tube inserted. Due tocardio vascular history central line inserted to monitor CVP intraoperatively. A forced air warmer applied toboth upper and lower extremities. TED stockings and SCDs placed on legs and a diathermy plate to rightthigh. Fully prepped and draped for the procedure. ——————————————————————–Surgery was uneventful and proceeded without complication. A colostomy was not required. A wound drain(FG 14 Bellovac)inserted——————————————————————– CASE-Dr Case (56123)PACU xx/xx/xxNursing: PACU – BP was high when received from theatres 170/90mmHg. Stabilised followingcommencement PCA of Fentanyl.———————————————————-RN COOPER, J Cooper HEALTHFamily Name: KUMARMRN 1123408Given Name: KamalMale X FemalePROGRESS / CLINICALNOTESDOB: 22/01/56M.O. HarrisAddress: 46 Addison Avenue, Concord NSW 2137Location/Ward: 1ADate/Time(Use 24 hour clock)NB: All entries must be legible, written in black pen and include healthcare providers[printed name, designation and signatureXx/xx/xxDay 3 post high anterior resection of the bowel for adenocarcinoma. Patientremains NBM and on 4th hourly NG tube aspirations (last done at 06.00) inresponse to increased aspirate via the NG and nausea along with nil flatus or bowelsounds yesterday. Mr Kumar has reported some discomfort overnight in his right leg.Last pain score was 5/10. PRN S/C morphine was given at 0600hrs. Abdominaldrain was removed last night at 10pm. IV N/saline running at 100mls/hr via theperipheral line. Abdominal wound dressing remains dry and intact. Observationsstable overnight although blood pressure has been slightly elevated. Observations at6.00hrs – HR 92 BPM, BP 157/75 mmHg, Resps. 20 BPM, O2 Sats. 96% RATemp. 37oC. Slept intermittently though getting breathless very easily and notmobilising well. Surgeons to review today.——————-A. King Alice King Attach ADR stickerRegular Medicines Brand substitution not permittea n pBSlnpeS Regular MedicinesFirst prescriber to print patient name and check label correct:Weight(kg):……………… Heisht (cm):………………Brand substitution not permittea ! peslnpgSYearYearSR = Sustained, modifiedor controlled releaseformulation.lf scored tablet, then halfcan be given.Dose must be swallowedwithout crushing.otflAllergies and adverse drug reactions (ADR)J Nil known l,,l Unknown (tick approoriale box or complete details below)Medicine (or other) Reaction ltypeldate lnitialsPrint Date. …. . .. .. URN:Family name:Not a valid prescriptionGiven names:ir’,ir.:11 ,,.i’..t:.1 iil:,* 1 :.1*Address:46 Addison Ave, Concord, NSW 2137Date of birth:22/01/1956Sex: MD FtrXMedicare No:PBS/RPBS Entitlement No.KUMARKamal Ll Concessional ordependent RPBS orU saiety Net Entiilement Card HolderSatety Net Concession Card Holder Variable dose medicineDate and monthSlart DateMedicine (print generic nameyform&ug level z:;>;zaqagE i5E+:> : aE.E ih, i’65^. !-:”qSig=a!! id ooodDate:o ]-rne levelRoule FfeqerAy Prsdibs to ed6 [email protected] tims d t&Jjv;dd [email protected] takenDoselndication Pharmacy PressiberTime toPrescriber signature SAC/MN b€Signature: Stad Date lvledicine (print generic name/formc Eczi;zas,- 6€> ;.a”5.. i93 :a.i6 !5E :.’6oG. :-;: –aE‘tr9idH5-6&Boute Prescriber to erterindMdual dosesTarget INR Rarqe Dosemg mg mg mg MQ mg mIPrescribslndication Pharmacylnitid 118:0OPrescriber signaturelnttial 2Prescriber to enter administration timesJStart Date Medicine (prinl generic nameyform Tick if-::izo6,>ot> :F.9 i-oE a’6“,-o ! o-F gE 8QOOd o RouteDose and Frcquency and now enter tirnes -l’IV1gDaily lndication PharmacyPrescriber signature SAC/AANStart Date l4edicine (print generic name/form!9+i> : aa :65I HpEXbXb.659OOOL o BoutelndicationJ. Perryxx xxIVPERRYDose and Frequency500mgand now enler times -*|*BDPharmacy Prescriber signatureJ Perry SAC/AANPharmaceutical review:Recommendedadministration timesGuidelines onlv N.4orningNightTwicea davThree timesa davRegular6 hourlvMane oB00Nocte1B0O or 2000BDoB002000TDS 0am ‘1400 20w6 hrly 06m 12co 1 800 24co RegularB houdv B hrly 0600 1400 22coFour timsOID 06m 12cD 1 800 22WDate and monthPrescriber to enter administration timesStart Dale Medicine (print generic name)/form:izoqi6 >gt> !!qE i’6E^. !-:”“,’o 54ho- [email protected] ds doooc oRoute Dose and Frequency andnowentertimes *1. lndicationIV/POPharmacy1 gQIDPainPrescriber signatureB HarrySAC/MNStart DateMedicine (print generic name/formTick z:i:gi6,>95> :Eo i’6o6. :_!Hdsdo–d RoutelndicationIVDase and Frequency and no,il onter limes –).Pharmacy40mg Daily Prescriber signatureB HarrySAC/AAN20.00Stad Datexx xxMedicine (print generic name)/formMETOPROLOLTr.;ffi]I stow Iletea* |Dose ard Frequerrcy ardnowentertimes –{>08.00PO/NG50mg Daily ziIzoqi6,>Pq Ed*> : a.6 :bE :’6E-. i-3E3E.3=-.c-eF= EF Hii66f, olndication PharmacyPrescriber signature SAC/MNStart Date Medicine (print generic name/form=: i9-g€>:F.A !6r €qoQF9:,’6i-a ‘= ti6 E6.9=pQOOo o Routexx xxDose and Frequercy ardnowentertimes –+ATORVASTATINPO20mg Daily lndication PharmacyPrescriber signature SAC/MNStart Date I/edicine (print generic nameyform Tick ilz1!q:E >s)€>:F.a :t) [email protected]:6b .id’5 IOOOLo RouteDose and Freguencyard now enter times –*lndicationPharmacy Prescriber signalure SAC/AANStart Date Medicine (print generic name)/form Tick ifz .6 *>ai a :tsl’6 oood oFlojie Dose and Frequency andnorrentertimes –+Indication PharmacyPrescriber signature SAC/MNPharmaceutical review:Warfarin education recordPatient educated by:……_………….Sion:Date:Patient supplied Warfarin book: f]Sign:……._._.._.Date:Reason for notadministeringCodes MUST be circled [email protected] On leaveNot available– obtainsupply or contact [email protected] Refused– notify prescriber @Self administeredVomitingWithheld– enter reason inclinical record @SAC: Streamline Authority CodeAAN: Authority Approval NumberXJ Perry PERRY xx/xx/xxxx1123408Kamal Kumar130kg2018xx xx CEFTRIAXONE08.00ProphylaxisPERRY08.0020.00xx xxENOXAPARINxx/xx xx/xx xx/xx xx/xxxx/xx xx/xx xx/xx xx/xxxx/xx xx/xx xx/xx xx/xxMETRONIDAZOLEProphylaxisxx xx PARACETAMOLxx xx PANTOPRAZOLEAcid Reflux06.0012.0018.0024.00HTNB Harry08.00HypercholestrolaemiaB HarryxxxxURN:Family name:Given names:Address:Date of birth:Medicare No:I Concessional or depeniJent RPBS orSafety Net Concession Card Holderi3 C,? :t # ij.rr ; ;+j} t }tt: : at;,, !.!. :ti i t “t ? 1. l;fr: . !,,..’. . i. il” ,r, ‘,., .,.,., iSex: Mtr Fn PBS/RPBS Entitlement No.n Safety Net Entitlement Card HolderA;:pr*vod pharmlcy d*taile:?**t t*l:tt:y appr$v*i no:Attach ADR stickerSee fron: oage f$r.iet:ilsFirst prescriirer to print patient name e*d check labet corfoct:As required PRN medicines?Brand substitution not permittea E peSlnpSS Yearl-{ospital nanle……….l-lospital Pravicler numbsr. …..t//ard……..Charl valid for: n 1 month n 4 months n 12 months lnitials:Medication chan number………. ofAdditional charts! v nru n BcUinsutin E Acute pain! Putti”tiue“*” ! Chemotherapy fltv heparinflotn”tOCtzot ozozroL-LFzlrJFE F=ozoosz6t =ozozELJFzIJJFtrF=ozoolltTaro6Eq)o=gooo=tog)– ocr{.of)@aIoo!Io q6′o6′foJp+toco I Lg NooIooo33of,o!rJo cgpNooIod6′ : Stad Datexx xxMedicine (prlnt generic name)/formONDANSETRONDateFouteIVDose ard houdy trequencyPRN Timelndication Max PRN dose/24hr ‘NAUSEA/VOMITING 12mgDoseSAC/AANPharmacyBoutePrescriber signatureB HarryStart DateMedicine (print generic name/formDate zi:ZO6 >9 5>.9!F:d’Et’6FEgiit;oood:A o: i>;6,>s5>:FE.a :6) :’65.. :-3oQ-!Pf a!! 66.C=p)oooo o FouteIVDose and houdy frequency10mg6/24lndication Max PRN dose/24hrNAUSEA/VOMITING30mgSAC/MNPharmaryPrescriber signatureB HarryStart Datexx xxMedicine (print generic name)/form PRN nmeDoseBouteDate.=::>;zo6 >9fi> :aE :’66 6. :-:iF 3.F 8ciiSda-6c Foulelndications/cDose and hourty feqrercyMax PRN dose/24hr5mg 3hrlyPRN Tlrne SAC/MNPharmacyRoutrsPrescriber signatureB HarryStart DateMedicine (print generic name)/form z::>izd 5+>EF>A:6i6i-6 5 q:pE as 6OOOC O Routexx xxNebDose and hourly {requeJtcyMax PRN dose/24htPharmacySALBUTAMOL5mg 2hrly30mglndicationSOBSAC/MNPrescriber signatureSignB HarryStart Datei/edicine (print generic name),/form z I b> [email protected]= 5 sqooL oa ORoute Dose and hourly trequenoy PRNlndication Max PRN dose/z4hr DoseSAC/MN Phamacy RotdePrescriber signalureStart Date Medicine (print generic name)/form Datezl :>:6 9E+> :aoc. EAE-a’ ‘.!=6.9a6I=Poooe oFloute Dose and hourt {requency PRN Timelndication lvlax PRN dose/24hr DoseSAC/AAN Pharmacy RoutePrescriber signature SignPharmaceutical review:Authority Prescriptian Numberonce only and nurse initiated medicines and pre-medications/Tele phone ordersBecord of administrationDatdtirneprescribed (print generic name)/formMedicineRoute DoseN1 N2Prescriber/nurse initiatornarne/nurseinithtor Date Time/Given byTime/Given byTime/Given by Given byfime/ PharnracyMedicines taken Fri$r tc pres*ntation to hospitalOwn nredicines in’i Y li N ii ArJn:inisirartion aiC ispecil,) “{Prescribed, cver the counts4 compl*mentary}idedicins Dose ad ?equency Duration Medicine Dcse anC ftr,)qualry DuraticrrGP:Ccmnr:;nity pharmacy:Print: Dinte; kledicirTes *dministerecJPrescriber DetailsPrescriber 1 Prescriber 2 Prescriber 3 Prescriber 4 Prescriber 5 Prescriber 6Name:Prescriber M.Contact NoAddress:Signature:Date:1123408KUMARKamal46 Addison Ave, Concord NSW 213722/01/1956 XKamal KUMARUTS123654Ward 11 1X X2018xx xxMETOCLOPRAMIDEMORPHINEPain (not whilst on PCA) 30mg du;HealtOOc)ONrM.a— –——-lNc9aztiF:-tR=Ro,:f) zcLt Zo-$t: .(9c3o;tzoa-92t!m FAMILY NAMEGIVEN NAMEMRN[] n,tnrE I ren,tnrrM.O.1123408XHarrisKUMARKamalD.O.B.22 01 1956ADDRESS46 Addison Ave Concord, NSW 2137 LOCATIONCOMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HEREFacility:DAILY FLUID tsALANCEDATE: I I INSTRI..IGTIONS:DAILY WEIGI.ITKgINTRAVENEOUS INPUT (mLs) ORAL INPUT t’: : .::: ‘r-,i;‘.,1′;’ OUTPUT (mLs)Time LINE ASite;LINE BSite;LINE CSite;Parenteraltotal(P)ORAL FLUID ENTERAL FLUID Oral/Enteraltotal(oE) Frogressivetotal in(P+OE=X)100Time01 00 Urine Vomitus Gastric /AspirateDrain 1 Drain 2 Other:lFaealProgrbssivetotal outTYJProgressiveFluidBalanceSolution Vol Solution Vol Solution Vol Type Volume Type Volume Site: Site: (X’Y)01 00 0200 02000300 03000400 04000500 05000600 06000700 07000800 08000900 09001 000 ‘100011 0011001 12001 300 ‘1300140014001 5001 5001 6001 600170017001 8001 9001 900200021000022002200SubtotalSubtotalTotallnput Output Total Total Balanceo -zPage 2 ot 4Note: Consider insensible losses.Paqe 3 of 4Ward 1xx xx xx450FemoralC/FN/Saline 100100100100100100100100100 NBM200300400500600700800200300400500600700400200110130110640840NBMGIVEN NAME I unlr n reHanlE D.O.B. _/22M.O195601HARRISSTANDARD ADULTADDRESS46 Addison Ave, Concord 2137G ENERAL OBSERVATION CHARTI nttereO Calling CriteriaLOCATIONUTS Ward 1ALL OBSERVATIONS MUST BE GRAPHEDCOMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE DateTimeDateTime-35–30–25–20-– ’15 –-10–5-o(!Et,o(UL oo&.*35–30–25–20–15–10-*5–100–95–90–85-sNoth-100–95–90–85-OzLpm OzLpmDevice /Device / mdalaozIktu to t=aocDxoRA = Room Air, NP = Nasal FM= lacemask, NRB = Non Re-bteathet VM = Venluri Mask-230—l-.220,-210),-200′-190–180–170–160-–‘150–-140–130–120-– 1’10–100–90–80- *70-*60–50-r40-octtq,L.9roact).LE o)ooooEoIo-230-:-220–210–200–190–180–170–160–150–140–130–120-– 110–100–90–80–70–60–50–40-Rhythm Rhythm– 160 –– 150 –-140-–‘130–-120–110-– 100 –-90–80–70–60–50–40-zoE =otrOaoGtLG’oI-160–150–140-* 130 –-120–110-– 100 –-90–80–70–60–50–40- AvAVft,.9ct)oA A AA A A A A A A A A A A A A APP UUozlnitialsEnter appropriate letler, A= Aletl, V= Rousable by voice (conduct onG P= Bousable nnlv hv nain lnondrrcl GCSI [J=PNLGJT PN LQ JF JF LQ PN PN RT LS LS LS JF J F tJf0oclEtlnitialsMRNdUt::lsll!ltulr FAMILY NAME!-‘l$l,!f lHeatthFAMILY NAME MRNHealth:-:- —–N(5;zN ;–” F.; tH=lo2zg;so35CI!e cLZa1IoOrOOta NN [email protected] NAME E vnrE n rruele D.O.B.ADDRESS22M.O.HARRISSTANDARD ADULT011956GEN ERAL OBSERVATION CHARTI RttereO Calling CriteriaLOCATIONUTS Ward 1ALL OBSERVATIONS MUST BE GRAPHEDCOMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE46 Addison Ave, Concord 2137 DateTimeDateTime– 41 –– 40.5 –– 40-– 39.5 –– 39-– 38.5 –– 38-– 37.5 –– J/ –– 36.5 –– 36-– 35.5 –– 35-– 34.5 –– 34-ultr:]ooo.xIJJoooJfiloeE_oF41 –40.5 –40-39,5 –eo38.5 –38-37.5 ,,37-36.5 –36-35.5 –35-34.5 –34-Assess pai n level at rest and with movement. Enter R for at rest, M for movementSevere (7-10)ModerateModerate (+6) (4-6)MitdMird (1-3) lt-3)No pain.g(go.Nillnitials lnitialsDateTimeBGLoooo.po!o-9oDateTimeBGLI Date0);o6DateDateDailyclt‘6=Daten oaityDate Dab‘l’imeTimeSG SGpH pHLeuk LeukBlood BloodNitrite NitriteKetones KetonesBilirubin BilirubinU/BiI U/BiIProtein ProteinGlucose.9,(O(6LfGlucosePage 2 of 4 Page 3 of 4KUMARKamal1123408XJF KUMARKamal1123408XJF PNLG18/05 19/05 20/05 21/05 xx/xx xx/xx xx/xxRTWJT PN LQ JF JF LQ PN PN RT LS LS LS JF J F3L 3L 3L 3L 3L 3L 3L 3L 3L 3L 3L13.30 14.30 15.30 16.30 17.30 21.30 01.30 05.30 09.4515.30 21.30 03.00 06.00 15.00 21.00 03.0006.00 13.30 14.30 15.30 16.30 17.30 21.30 01.30 05.30 09.45 15.30 21.30 03.00 06.00 15.00 21.00 03.00 06.00………….RA RA…. . . . . . . . . .>> >>>>>> > >> >>< < < < <


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