200A - M. R.

Sex: Male Age: 48 Address: Laguna Occupation: Retired Factory

or!er

"#: Multiple Myelo$a t%c Acute &idney 'n(ury )A&'* ++: "yspnea ,resent 'llness: ,atient -as diagnosed Multiple Myelo$a ).an. 20/4* -0ic0 $ani1ested 2one pain o3er sternu$4 0e -as prescri2ed -it0 50alido$ide and "exa$et0asone 40$g%ta2 1or 4 days o11 and 4 days on. 4 days prior to ad$ission4 0e 0ad di11iculty o1 2reat0ing -0ile on supine position and relie3ed on standing up or on tripod position. 't -as also acco$panied 2y pain on R lo-er ri2. 5ra$adol -as gi3en -0ic0 a11orded relie1. 'nter3al 0istory re3ealed persistence o1 dyspnea4 non-progressi3e. ,atient -as only a2le to sleep on a sitting position. / day ,5A4 patient $ani1ested dry coug04 di11iculty in urinating descri2ed as only 2eing to urinate t-ice -it0 /60$l. ,ersistence o1 dyspnea cause su2se7uent ad$ission. ,ast 'llness: 859 stage '' )2004* : Losartan 60$g O" +0olecystitis s%p +0olecystecto$y Fa$ily 8istory: Mot0er: 8,9 Fat0er: "M ;randparents: Stro!e : 8eart "isease Li1estyle: S$o!er - 2< pac! years Alco0olic "rin!er - once a year Allergy: '$properly coo!ed c0ic!en%$eat Medications: Losartan : 859 and 50alido$ide4 and "exa$et0asone : MM ,0ysical =xa$ination: 'nitial >ital Signs: ?, : /@0%A0 ,R : 82 RR : /A 5e$p. : @B.2 ;eneral Sur3ey: conscious4 co0erent4 in respiratory distress4 alert4 a$2ulatory S!in: )C* 0yperpig$entation on 2ot0 L=4 -ar$ and $oist4 nails -it0out clu22ing or cyanosis4 )-* ras0es4 petec0iae4 or ecc0y$osis. 8ead: nor$ocep0alic4 no de1or$ities4 )C* dry scalp

=yes: $atted eyelas0es4 pale palpe2ral con(ucti3a4 icteric sclera4 pupils 2-@$$ e7ually reacti3e to lig0t4 exraocular $uscle intact4 1undoscopy: )C* red orange re1lex OD4 )C* -ell de1ined distinct $argins4 cup-disc ratio 0.@4 A> ratio 2:@4 no A> nic!ing4 no 3enous engorge$ent4 OD4 no 0e$orr0ages4 no cotton -ool spots. =ars: no preauricular s!in tags4 no tragal tenderness4 non-0ypere$ic external auditory canal4 no aural disc0arge4 intact L E R ty$panic $e$2rane. 9ose: no disc0arge4 $idline nasal septu$4 no alar 1laring4 no sinus tenderness Mout0: $oist 2uccal $ucosa4 icteric 1renulu$4 icteric posterior p0aryngeal -all4 tonsils not enlarged4 tongue $idline 9ec!: supple nec!4 no anterior nec! $ass4 no palpa2le cer3ical ly$p0 nodes Respiratory: no retractions4 no c0est de1or$ities4 sy$$etrical c0est expansion4 decreased tactile and 3ocal 1re$iti on rig0t lung 5B do-n-ards4 dull on percussion on R lung 2ase 1ro$ 5B do-n-ards. +ardio3ascular: non-distur2ed nec! 3eins4 +A, rapid upstro!e and gradual do-nstro!e4 no 2ruit4 .>, @0c$ at @0 degrees4 adyna$ic precordiu$4 apex 2eat 6t0 L'+S M+LF nondi11used4 non-sustained4 no 0ea3es4 li1ts4 t0rillsF loud4 long4 lo- pitc0ed S/ at t0e apex 1ollo-ed 2y so1t S2F so1t S/ at t0e 2ase 1ollo-ed 2y loud4 s0ort4 0ig0 pitc0ed S24 no $ur$urs4 no gallops. ;astrointestinal: 1la22y4 no 3isi2le pulsations4 no 3isi2le peristalsis4 nor$oacti3e 2o-el sounds )/@*4 ty$panitic on all regions4 )C* direct tenderness on R upper 7uadrant4 no palpa2le $ass4 no 1luid -a3e4 no s0i1ting dullness4 li3er span 8-Ac$ -it0 s$oot0 2orders and !idneys not palpa2le4 5rau2eGs space not o2literated. ;astrourinary: no +>A tenderness =xtre$eties: )C* 2ipedal ede$a4 no clu22ing4 cyanosis4 pal$ar eryt0e$a4 pulses. "iet: 02%/4%/4 /<00 !cal%day4 0.8g%!g%day +8O9 <0H 8?> 26H Fat I 284 9a I 200g +0ole I BH Sat. Fats di3ided 2y @ $eals and 2 snac!s C @ egg -0ites. 02%/6%20/4 9o source o1 & in diet4 9o 1res0 1ruits4 1res0 (uice in diet4 add 2 egg -0ites in eac0 $eal 02%/B%20/4 ,epta$en - 6 scoops in / glass -ater J/2 Medications: 02%/4 : Meropene$ 600g%'> in A0cc ,9SS to run 1or / to 2 0rs )J24* Lactulose @0cc4 8old i1 ?M K @x a day )O"8S* 02%/< : 5ra$adol C ,araceta$ol )+etadol* @B.6%@8.6g%ta2 )J8 ,R9 1or pain* D/C ,araceta$ol 600g%ta2 / ta2 )J< ,R9 1or 2rea!t0roug0 pain* D/C 02%/B : 5ra$adol 60$g%'> )J8 ,R9 1or $od to se3ere pain* 5ra$adol C ,araceta$ol / ta2 )J< R5+* ,antopraLole ),antoloc* 40g%ta2 / ta2 )O" @0 $ins -it0 ?F* 02%/8 : &ali$ate sac0et / sac0et )O"* "60 C /0 u%0r% S'>, )J4 1or 2 doses*

MI -it0 Sal2uta$ol )J4* '>F S0eet : 80cc% 0our )0old -0ile ongoing ?5* M M/ M2 M@ M4 M6 M< '>F "ate E 5i$e Started ,9SS /L 2%/4 - @p$ ,9SS /L 2%/6 - 2p$ ,9SS /L 2%/< - //a$ ,9SS /L 2%/< - //p$ ,9SS /L 2%/B ,9SS /L 2%/8 : <a$ "ate E 5i$e =nded or "%+ 2%/6 - 2p$ 2%/< - //a$ 2%/< - //p$ 2%/B 2%/8 - <a$

'nput and Output 'nput 02%/4 /000$l /@00$l 420$l 2B00$l 02%/6 /@00$l /420$l 600$l @220$l /400$l /000$l /600$l @A00$l //00$l B00$l //00$l 2A00$l //00$l

Output /<0$l A00$l @00$l /@<0$l 800$l 600$l 400$l /B00$l B60$l 400$l 400$l /600$l 640$l 460$l 4/0$l /@A0$l /6@0$l

02%/<

02%/B

La2oratory E ,rocedures: Feb. 14, 2014 Blood Chemistry: Drea 9itrogen : 60.A6 $g%dL )A to 2@* 'norganic ,0osp0ate : 4.B@ $g%dL )2.4 to 4.B* +reatinine : @. 6 $g%dL )0.8 to /.4* Sodiu$ : //A.00 $$ol%L )/@6 to /46* ,otassiu$ : 6.<2 $$ol%L )@.6 to 6.0* 'oniLed +alciu$ : /.// $g%dL )/./2 to /.@2*

Complete Blood Count: 8;? : BB g%L )/40 to /B4* 8+5 : 0.22 )0.42 to 0.62* ,latelet : <2 )/@0 to 400 x /0NA%L* ?+ : 4.80 )4 to /0 x /0NA%L* ABG: p8 : B.4/6 )B.@4 to B.44* p+O2 : @<.@ )@6 to 46 $$8g* pO2 : B@.@ )B6 to /00 $$8g* FiO2 : @2H )40H to /00H* 8+O : 2@.2 )22 to 2< $=7%L* O2 Sat : A4.A )A6 to /00H* Chest X-ray: ,at0ologic 1racture 4t0 and Bt0 le1t aspect o1 posterior ri2 Osteolytic c0anges to @rd L posterior ri2 L scapula Anterior -edge co$pression o1 5< 3erte2ral 2ody Feb. 15, 2014 Ultrasound Guided Thoracentesis (Feb. 1 ! "#1$% ,re- and ,ost-Op "iagnosis: ,leural =11usion R ,arapneu$onic is Malignant Started: A:/6 AM =nded: /0:00 AM Mapping o1 R 0e$it0orax done. /. Selected site 1or anest0etic agent 2. Asepsis and anti-asepsis @. 'n(ection o1 6cc Lidocaine 2H on c0osen side 4. ;auge /A needle -as inserted at dept0 o1 @.4c$ at le3el /A 6. Aspiration o1 1luid done <. Re$o3al o1 needle and dressing done Outco$e: ,atient tolerated -ell and returned to roo$. Findings: R $apping 0e$it0orax s0o-ed approx. 460cc o1 loculated % sepated 1luid O2tained total o1 460cc o1 2loody4 serosanguinous 1luid =nd point: O2tained ade7uate a$ount o1 1luid4 9o $ore 1luid to aspirate. Blood Chemistry: ,otassiu$ : 6.<8 $$ol%L Feb. 16, 2014 Complete Blood Count: 8;? : A/ g%L )/40 to /B4* 8+5 : 0.2< )0.42 to 0.62*

,latelet : 62 )/@0 to 400 x /0NA%L* ?+ : 2.80 )4 to /0 x /0NA%L* Blood Chemistry: +reatinine : @.B0 $g%dL Feb. 17, 2014 Blood Chemistry: Sodiu$ : /2< $$ol%L ,otassiu$ : 4.68 $$ol%L Feb. 18, 2014 Blood Chemistry: +reatinine : @.0B $g%dL Sodiu$ : /26 $$ol%L ,otassiu$ : 6.28 $$ol%L Complete Blood Count: 8;? : 8B g%L )/40 to /B4* 8+5 : 0.26 )0.42 to 0.62* ,latelet : 6/ )/@0 to 400 x /0NA%L* ?+ : @.B0 )4 to /0 x /0NA%L* No date laboratories and proced res! Ultrasound o& the 'hole abdomen ((one outside% ,leural =11usion R4 s%p +0olecystecto$y 9or$al li3er4 2iliary tract4 pancreas4 spleen4 L !idney )C* D?4 prox. a2d. aorlL. )O* ,leural Fluid Gram )tain and Culture * )ensiti+ity ;ra$ Stain is 9egati3e AF? Stain is 9egati3e Coa,ulation Assay ,5 : /B.< A,55 : 60.6 '9R : /.4 Urinalysis R?+ : 0 to 2 ,us : 0 to / BU5, : /2.2A ; : //./< A : /./@ A%; : 0./0

9urse 9otes: 02%/4 0/:00 ,M : Ad$ission " : Ad$itted as a case o1 a 48 yrs old $ale -it0 case o1 $ultiple $yelo$a A : "ue to start $edications 1acilitated 2y ad$inistration4 care rendered R : =ndorse 02:00 ,M : =lectrolyte '$2alance " : 9oted 9a P //A4 & P 6.<2 A : Facilitated ne2uliLation and to start $edications. R : Sta2le

atc0ed out 1or any a2nor$al s%sx.

/0:00 ,M : Ris! 1or ?leeding " : 9oted ,L5 P <2 A : Monitored 1or episodes o1 2leeding. Re1erred accordingly. R : Sta2le 02%/6 0<:00 AM : 8yper!ale$ia " : 9oted & : 6.<84 on sal2uta$ol ne2uliLer J4 A : atc0ed out 1or any a2nor$al o1 s%sx. Facilitated ne2uliLation. R : =ndorse 02:00 ,M : For ?5 o1 4 units ,+ t0en / unit o1 ,R?+ " : 9oted order o1 trans1usion o1 4 units ,+ 1ollo-ed 2y / unit ,R?+ A : Facilitated ?5. atc0ed out 1or any a2nor$al s%sx. R : ill 1ollo- up /0:00 ,M : ?5 / unit o1 ,R?+ " : 9oted ?5 /D ,R?+ /$g4 in1use -ell A : Monitored clearly4 >S ta!en and recorded R : ill 1ollo- up 02%/< 0<:60 AM : Ris! 1or 2leeding " : 9oted ,latelet P 62 A : atc0ed out 1or Qso$et0ingR and ordered to re1er i1 t0ere is 2lood%2leeding. R : 9o 2leeding4 endorsed 02:00 ,M : 8yper!ale$ia 9o data /0:00 ,M : Multiple =lectrolyte '$2alance 9o data

02%/B 0B:00 AM : 8yponatre$ia " : 9a P /2< $$ol%L A : Monitored >S4 alteration in sensoriu$. R : ill 1ollo- up 0@:00 ,M : ,ain " : +o$plaint o1 2ac! pain A : Ad3ised di3ersional acti3ities4 pain $edication gi3en. R : ill 1ollo- up /0:00 ,M : 8yponatre$ia 9o data 02%/8 <:60 AM : 8yponatre$ia " : 9a P /2< $$ol%L A : it0 '>F o1 ,9SS /L t%r 80cc%0r R : ill 1ollo- up% Sta2le 02:00 ,M : Ris! 1or 2leeding " : =pisodes o1 epistaxis4 platelet P 6/ A : atc0ed out 1or persistence o1 2leeding4 re1erred to MRO,. R : 9o data