CHIONG

11/04/19

S- Patient is an 52/M/CP seen and examined with the ff subjective complaints:

No febrile episodes No seizure No hypertensive episodes No chest pain
No tachycardic episodes No dyspnea (+) Occasional Cough No abdominal pain
No melena/hematochezia (+) Leak on VAC Dressing

O- GCS 8: E4VTM4
BP: 130/90 HR: 81 RR: 19 T: 36.6 O2: 99
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
Hyperextended neck, No neck vein engorgement, No palpable cervical lymphadenopathy
(+) secretions per tracheostomy, Serosanguinous discharge
Pulmo: Symmetrical chest expansion, No retractions, Decreased breath sounds, L, (+) Rhonchi, bilateral
Cardio: Adynamic precordium, normal rate, Regular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft, non-tender, no palpable mass
Ext: No gross deformites, (+) edema, UE; Full and equal pulses,
(+) Grade 2 sacral ulcer (+) blister and ulcerations, both UE

A- #Sacral ulcer gr IV S/P necrosectomy , partial coccygectomy

# VAP (Enterobacter)
#HIE S/P CP Arrest with ROSC
#Chronic ventilator dependence sec to central apnea
# Anemia of Chronic disease
#Pressure ulcer grade II s/p debridement Right leg
#DKD G5D
#T2DM
P- Diet: 2500 kcal 2:1 dilution banana based with 30cc pre and post flushing
Diagnostics:
For repeat EEG (11/5/19)
Repeat K post correction (11/4/19)
CBCPC, BUN, Crea, Na, K, Ca
Therapeutics: 1. Ertapenem 500mg IV infusion over 3hrs q24hrs
2. Salbutamol + Ipratropium (Duavent) neb q8 RTC
3. Decrease Valproic acid syrup 250mg/5mL 8mL to 5mL Q12
4. Citicoline 1g/ tab OD
5. Diazepam 5 mg TIV PRN for active seizures
Refer to neuro regarding dysautonomia
Maintain dressing
Continue other meds
Strict bed turning q2
Continue CBG monitoring TID premeals & record
For HD on Monday
Refer
BALLESCAS
11/04/19

S- Patient is an 83/F/RPVD seen and examined with the ff subjective complaints:

No seizure No abdominal pain No hypertensive episodes
No chest pain (+) tachycardic episodes No melena/hematochezia
No fever No dyspnea No cough
(+) yellowish sputum
O- GCS 3: E1VTM1
BP: 130/70 HR: 115 RR: 19 T: 36.9 O2: 98
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
No neck vein engorgement, No palpable cervical lymphadenopathy
Pulmo: Symmetrical chest expansion, no retractions, (+) crackles, bilateral
Cardio: Adynamic precordium, tachycardic, irregular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft, non-tender, no palpable mass
Ext: No gross deformites, (+) edema, LE; Full and equal pulses,
(+) Grade 2 sacral ulcer (+) blister and ulcerations, UE

A- #Septic shock sec to VAP

#ARF type I sec to HAP (E. coli); Type IV sec to Septic shock
#Septic Encephalopathy
#Vascular Dementia
#Chronic CVD infarct MRS 5, bilateral frontal lobe MRS 5; lacunar infarcts
#Cervical CA St. III B s/p chemotherapy s/p brachytherapy
#Seizure disorder sec to PSG
#AKI, multifactorial on top of CKD
#Chronic hyponatremia
#Anemia of chronic disease
#Coagulopathy secondary to sepsis
#Sacral decubitus ulcer gr. 2
#Cataract Immature, R, s/p pseudophakia, L
#Blepharoconjunctivitis, UO - resolved

P- Diet: regular salt, low fat, low chole, high fiber diet at 1800kcal/day, revise to 2:1 dilution with 60 cc pre
and post flushing
IVF: PNSS 1L at 10cc/hr
Diagnostics: For CBC, PC, serum BUN, Crea, Na, K, Cl, Ca, Mg, ALT, AST, PTPA, INR once with consent
Therapeutics:
Therapeutics: amiodarone drip as ordered
Norepinephrine drip 10mg in 100cc PNSS to run at 6cc/hr (0.2mkm 70kg)
Continue other meds
Maintain mechanical ventilator settings
Refused HD & extraction only
For Emergency Cutdown
Refer
JALMASCO
11/04/19

S- Patient is an 60/M/RPV seen and examined with the ff subjective complaints: No BM as of 8PM.
No seizure No abdominal pain No hypertensive episodes
No chest pain No tachycardic episodes No melena/hematochezia
No fever No dyspnea No cough
O- GCS 10T E4VTM5
BP: 100/60 HR: 82 RR: 20 T: 36.5 O2: 96
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
No neck vein engorgement, No palpable cervical lymphadenopathy, minimal sputum ET
Pulmo: Symmetrical chest expansion, no retractions, (+) decreased breath sounds
Cardio: Adynamic precordium, normal rate, regular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft non-tender, no palpable mass
Ext: No gross deformites, Grade 1 bipedal edema, No cyanosis, full and equal pulses

A- #Acute Respiratory failure sec to hospital acquired pneumonia with pleural effusion bilateral
#Decompensated liver cirrhosis sec to ALD
#Hypertensive nephrosclerosis G5D
#HASCVD ACC/AHA st. B
#Type 2 DM controlled
#septic shock secondary
#r/o pulmonary new growth
P- IVF: Discontinue NE drip
Diet: LS, LF, Low cholesterol high fiber diabetic renal diet @1800kcal/day CHON 1.5g/kg/day
Diagnostics: For Chest Ultrasound
For 2D Echocardiogram
For Chest xray on 11/6/19

Therapeutics: 1. Meropenem 500mg in 90cc PNSS x 30 OD D5

2. Salbutamol + Ipratropium neb q6 RT
3.NAC 600mg cap ODHS
4. Levofloxacin 500mg IV q48 hours D4
5. Discontinue amino acid 7% 500ml during hd
6. Start Aminoleban 1 sachet per NGT BID
7.Continue Linagliptin
8. Hold Lactulose for now resume tomorrow
Continue other meds
For chest physiotherapy post nebulization
Suction secretions as needed
Maintain mechanical ventilator settings
CBG monitoring as ordered
Refer
VILLARINO
11/04/19

S- Patient is an 65/F/RPV seen and examined with the ff subjective complaints:

No seizure No abdominal pain No hypertensive episodes
No chest pain No tachycardic episodes (-) tachypneic episodes
No desaturation No melena/hematochezia No fever
No dyspnea No cough
O- GCS 15 E4VTM6
BP: 110/70 HR: 69 RR: 18 T: 35.1 O2: 96
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
Supple Neck, No palpable cervical lymphadenopathy, No neck vein engorgement
Pulmo: Symmetrical chest expansion, no retractions, clear breath sounds
Cardio: Adynamic precordium, normal rate, regular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft non-tender, no palpable mass
Ext: No gross deformites, Grade 1 bipedal edema, No cyanosis, full and equal pulses

A- #ARF sec to pulmonary congestion

#DKD G5D
#HASCVD ACC/AHA ST B
#T2DM
#Anemia prob sec to r/o GI bleeding
#Hypokalemia
P- IVF: Heplock
Diet: LSLF, low cholesterol, high fiber, Diet at 2100kcal/day with CHON of 1.2 g/kg/day
Diagnostics: For 2D Echocardiogram
12L ECG to CV Lab for official reading
Repeat HbA1c after 3 months
Therapeutics: Continue present meds
Refer to TCVS for insertion/creation of permanent access for HD
Defer trans out
For Thoracentesis tomorrow
Refer Accordingly
ESPERA
11/04/19

S- Patient is an 85/F/RPV seen and examined with the ff subjective complaints:

No seizure No abdominal pain No hypertensive episodes
No chest pain No tachycardic episodes No melena/hematochezia
No fever No dyspnea No cough
O- GCS 9 E4VTM5
BP: 110/60 HR: 73 RR: 19 T: 36.7 O2: 98
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
Supple Neck, No palpable cervical lymphadenopathy, No neck vein engorgement
Pulmo: Symmetrical chest expansion, no retractions, clear breath sounds
Cardio: Adynamic precordium, normal rate, regular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft non-tender, no palpable mass
Ext: No gross deformites, no cyanosis, full and equal pulses

A- #Chronic Ventilator Dependence with Central Apnea s/p change of tracheostomy 9/9/19
#HASCVD ACC/AHA Stage B#Chronic CVD Infarct (2010, 2018) MRS 5
#S/P PEG change June 2019
P- Diet: Low salt low fat + 2 egg whites to diet at 1,800kcal/day
Diagnostics: 1. Repeat K Post-correction
Therapeutics: Continue present medications
MV Settings:
SIMV
TV 360
F8 FiO2 30%
PS 10 PEEP 5
Refer
PACHECO
11/04/19

S- Patient is an 59/F/CP seen and examined with the ff subjective complaints:

No seizure No abdominal pain No hypertensive episodes
No chest pain (-) tachycardic episodes No melena/hematochezia
No fever No dyspnea No cough
(-) headache (+) yellowish sputum
O- GCS 15
BP: 110/70 HR: 70 RR: 18 T: 36.6 O2: 97
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge
No neck vein engorgement, No palpable cervical lymphadenopathy
Pulmo: Symmetrical chest expansion, no retractions, (+) crackles, bilateral, yellowish sputum
Cardio: Adynamic precordium, normal rate, regular rhythm, No murmurs
GI: Flabby, normoactive bowel sounds, soft, non-tender, no palpable mass
Ext: No gross deformites, (+) edema, LE; Full and equal pulses,
(-)Sacral ulcer, UE

A- NPCA ST IV
HAP WITH PLEURAL EFFUSION
HASCVD AF WITH RVR ACC/AHA ST B
PLEURAL EFFUSION R PROB PARAPNEUMONIC VS MALIGNANCY
SUBCLINICAL HYPERTHYROIDISM PROB DRUG INDUCED
S/P CHEMOTHERAPY X 6 CYCLES
S/P 35 FRACTION OF RT WITH POST RADIATION EXPOSURE
P- Diet: Low salt, low fat, high fiber diet at 1800kcal/day mechanically soft
Diagnostics:Awaiting SPUTUM GS/CS,
Awaiting BLOOD CS
BUN , Crea, Na, K, K, Cl, Ca Mg, Alb
CHEST Ultrasound
Therapeutics:
D/C DIGOXIN 0.25MG 1 TAB OD
START CARVEDILOL 6.25MG ½ TAB BID IN AM
Resume norepinephrine 10mg in 100cc pnss
Case endorsed to dr. ligon
Continue other meds
Refer