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IV. MEDICAL MANAGEMENT

a. Medical Orders with Rationale

09/11/15 Doctor’s Order Rationae

10:00 PM Please admit To properly monitor and provide medical attentionto the patient.

Secure consent to care

To have a proper consent in every medication and

procedure that needs to be done and for leal

purposes.

TPR ! " hours To properly monitor the patient#s condition.

$abs:

%&%&one Marrow &iopsy

'ltrasound%hest ()Ray

To determine if there are any abnormalities withthe laboratory results.

%onfirm a blood cancer dianosis or a bone

marrow disorder 

To detect abnormalities inside the body

To evaluate luns for any problem

*+1,+,01-

Secure 1 unit pac redblood cells with patient#sblood type screenedcrossmatched as stand by

'se to increase R&% count

Repeat %&%To determine if there is a chane in thehematoloic status especially the R&%

/or ntrathecal%hemotherapy withmethotreate

Used to treat or to prevent cancer in theCSF. IT chemotherapy may be administered,as part of a chemotherapy regimen or on anas needed basis.

  Oyen as needed 2ecessary for promotion of normal O, levels

  %ontinue on meds %onstant monitorin by hospital staff  

 3/: 4-$2M1$ 5,0tts+min

/or fluid and electrolyte maintenance. 'se formedication ailment of compatible blood.

 Refer accordinly

/or further care 6 manaement

10

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*+17+1-*:"- am

Start blood transfusion of 1unit PR&% with patient#sblood type screened andcrossmatch

To increase R&% count

Repeat %&%To determine any chanes of the R&% 8to

determine if there is increase in the R&% count9

*+1"+1-:"- pm

 &lood transfusion of 1 unitPR&% crossmatch andscreened

 To increase R&% count

Repeat R&% To determine any chanes in the R&% count

*+1-+,01-1,:0, pm

&lood transfusion of 1 unitPR&% crossmatch andscreened

To increase R&% count

Repeat %&%To determine any chanes in the hematoloicstatus especially the R&% count

*+1;+1-&lood transfusion of 1 unitPR&% crossmatch andscreened

To increase R&% count

Repeat %&%To determine any chanes in the hematoloicstatus especially the R&%

*+,1+1-*:00

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&. $aboratory Results

2ame: >.M Time Re!uested: ,01-)0*)11 10:00 PM

 

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2ame: >.M Time Re!uested: ,01-)0*)17 1:00 PM

 .M Time Re!uested: ,01-)0*)1" ,:00 PM

 

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Physician: 4r. /loirendo

!EMATOLOG" RE#ORT

Test Res$t %nit E&'ected

Va$es

Rationae/Inter'retation

?&% H

13.

10@7+u

$

-=000 A

10=000

ncreased ?&% indicates increased production of ?&% to fiht an

infection. .M Time Re!uested: ,01-)0*)1- *:00 PM

 

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!EMATOLOG" RE#ORT

Test Res$t %nit E&'ected

Va$es

Rationae/Inter'retation

?&% H 15.! 10@7+u$

-=000 A

10=000

ncreased ?&% indicates increased production of ?&% to fiht an

infection.

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Procedure 4ate: *+1B+1- Referrin Physician: /lor = /redeelbert

Patient %lass: npatient

Re'ort Te&t

Relative increase in liver parenchyma echoenicity w+c may relate to normal variance 8"0 E9 or early

non)specific medical blood disease 8B0E9. ?ith uric acid oalate= anthine or metric9 crystals alon the

calyceal walls= both idneys= seen obstructed at present. 2o enlare lymph nodes seen. ?ith enlare

prostate land= approimately 7".-; rams G.

MPRFSSO2:

Mild Splenomealy

Inter'retation)

nfection and diseases can contribute to an enlared spleen. Such as leuemia and lymphoma. The

spleen acts by filterin out and destroys old damaed blood cells and plays a ey role in preventin

infection by producin ?&% called lymphocytes and actin as a first line of defense aainst invadin

pathoens.

1#

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2ame: >.M 4ate of &irth: -+1*+*7