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September 15 , 2012 2:00 PM Patient seen and examined at 12:35pm. Triage to critical bed.

For C BG: 195mg/dL Hook to cardiac monitor and pulse oximeter. Start IVF: PNSS 1L x 100cc/hr. Please give lidocaine 50g TIV For intubation now. Using ET tube size 1.5cm, hook to monitor for continuous Ambubag. Mannitol (20%) 250ml Citicoline 2gm TIV now, then ofloxacin Labs: for 12 led ECG CBC, PT, PTT CxR, protein, creatinine, serum NaCl ABG, CT scan, urinalysis. For insertion of NGT, keep end open at bedside bottle. For insertion of individually foley catheter attached to urine bag. Hook to mechanical ventilator with the following set up: FiO2- 100% BUN: 16 TV- 350 mode: AIC NPO temporary CBG q8 while on NPO.

2:00pm -

2:15pm 6:30pm -

Citicoline ASA 80mg/tab 1tab OD Atorvastatin 40mg/tab ODHS Lactulose 30ml ODHS Start of feeding 1750 kcal/day CHO: 218.75gm/day CHON: 131.25 gm/day Fats: 38.9 Ofloxacin 20mg TIV BID (-) ANST Refer for lab results.

Omeprazole 40g TIV OD

Paracetamol 300mg TIV q4 PRN for fever T: 37.8

Kalium durule 75g/tab 1tab BID

September 16, 2012 12:33pm Paracetamol 300mg TIV q4 PRN for fever T: 37.8 Kalium durule 75g/tab 1tab BID

ICU TRANSFER 4:00pm Patient and examined. IVF to ff: PNSS 1L x 40cc/hr.

ROM 1. 2. 3. 4. Citicoline 2gm TIV q8 Atorvastatin 40g/tab 1tab ODHS Omeprazole 40g/tab 1tab ODHS Lactulose 30cc ODHS, hold if BM > 3x/day

Mechanical Ventilator settings as follows: AC mode TV- 350 BUR- 16 PR- 40 PBBP- 5 FiO2- 70%

For repeat ABG prior to ICU transfer. Please inform MROD once results available. Relative informed regarding patients status and prognosis. Monitor and maintain back rest. For carotid duplex 3am once stable. Hook to cardiac monitor and pulse oximeter.

ICU RECEIVING 8:00pm Patient seen and examined. For 12 LED ECG with long LED II. Attach to mechanical ventilator Mode: AC

TV: 360 BUR: 16 TF: 40 Deep: 5 Decrease FiO2 by 10% every hour to reach 30% Repeat ABG in AM out 30% FiO2

9/17/12 7pm -secure official CT scan and CXR CXR noted -decrease BUN to 10 -Strict aspiration precaution -oral care w/ hexi tidine solution swab the oral cavity TID -Refer to rehab medicine 10pm -(+), fowl-smelling, non bloody yellowish stools - for fecalysis 9/18/12 6:30pm -revise lactulose o 30cc prn at bedtime if no BM x 3 days or w/o constipation - moderate high back rest - strict aspiration precaution -ABG in am 9/19/12 4:15 am Please replace current mechanical ventilator bemet or Newport TV : 360 FI O2 : 30% PF : 40 RR: 8 PS: 10 Watch out for desaturation

Facilitate turning of patient Q2 To secure egg crate mattress To secure anti-embolic stocking Watch around patients condition

9/19/12 Please do bronchial tap per shift Revise lactulose to 30cc PRN if no BM x 3 days or if w/ constipation Start mannitol : 9/19 150cc Q6 9/20 150cc Q8 9/21 160cc Q8 9/22 160cc Q12 9/23 discontinue Please continue NVS monitoring Start amlodipine 10mg/tab 1 tab 9/20/12 -IVF PNSS 1L x 40cc/hour x 3 cycles -For ABG today -facilitate undergoing antibiotic and other medications -diet: 1400kcal, blenderized feeding Chon: 56 grams (16%) Cho: 176 grams (50%) Fats: 56 grams (34%) -dilated into 1400c kcal of fluid and divided into 6 equal meals and 30cc flushing post feeding -inform NRD if residual is > to 150ml - Strict aspiration precaution - refer 9/21/12 7pm Please decrease RS to 8, watch out for SPO2 < 92% Watch out for DOB desaturation, hypotension Moderate high back rest IVF PNSS 1L x 40 cc/hour x 2 cycles Strict aspiration precaution Repeat CBC 10pm Patient seen and examined Case receives labs noted Repeat CBC am

Repeat CBG in am Continue medication Refer accordingly 9/23/12 3:15am

Patient seen and examine IV to ff. PNSS 1L x 4cc/ hour 8 Turn patient side to side Shift ciprofloxacine IV to 200mg/tab 1 tab BID x 3 more days Shift citicoline IV to 500mg/ tab 1tab BID -moderate high back rest -refer accordingly 9/24/12 12nn Please apply warm and cold compress to all affected area ABG in arm Discontinue CBG monitoring Give acetycylsitiene Shift omeprazole to pantoprazole cap 40g 1 cap ODHS Continue physical therapy Please do gentle suctioning Refer 6pm Patient extubated because unable to tolerate weaning : diazepam 5mg IV now Re etubated w/ ET tube size 7 at level 22 Hook to mechanical ventilator Hold aspirin