TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 7, 2019

Admissions: 1 Trans-In: 0
For Trans-Out: 1 Discharge: 0 Mortality: 0
BED 3 IVF: none DIAGNOSTICS:
CHIONG, MICHAEL MALINIS None for today
52/M/CP #Sacral ulcer gr IV S/P necrosectomy , DIET: 2500 kcal 2:1 dilution banana based with 30cc pre and post AWAITING:
ID #: 44956 partial coccygectomy flushing, increase in potassium diet Histopath 10/15/19
DOB: 05/14/67 ETA CS 10/23
DOA: 07/29/19 # VAP (Enterobacter agglomerans) MEDICATIONS: EEG 11/5/19
1. Ertapenem 500mg IV infusion over 3hrs q24hrs - Day 11
#Chronic Vegetative state 1. Carvedilol 6.25/ tab BID (hold before HD) REMARKS:
NEURO: 2. Humulin R 6 units (target CBG < 200mg/dL) - May shift to AC Mode while on HD then shift back to SIMV after HD
GCS 8 (E4VTM4), No seizure, Cervical #Chronic ventilator dependence sec to 3. Paracetamol 1g IV Q* to complete 24 hrs - WOF: dyspnea, desaturation
hyperextension central apnea 4. CaCo3 500 mg 2 tabs in AM, 1 tab lunch, 1 tab evening - Chest physiotherapy every after nebulization
5. Valproic acid syrup 250mg/5mL 5mL per NGT Q12 Day 5 -Daily PT
PULMO: # Anemia of Chronic disease 6. Amino Acid 7% 500mL post HD -Maintain negative pressure as previously advised by plastics surgery
SCE, (+) Rhonchi, bilateral, Decreased breath 7. Cotrimoxazole cream to inguinal area TID -serum Mg from previously extracted blood
sounds, Left base, Minimal sputum per trachea #Pressure ulcer grade II s/p debridement 8. Citicholine 1g tab 1 tab OD -for HD on 11/7/19 1st shift
Right leg 9. Nystatin oral suspension as swab to oral cavity q4 -plan to discontinue Valproic Acid after day 15
CARDIO: 10. Calcitriol 1 tab BID
Adynamic precordium, #DKD G5D 11. Omeprazole 40mg / cap 1 cap OD REFERRALS/ON BOARD:
Normal rate, regular rhythm, no murmur, No neck 12. D50 50 mL vial TIV PRN for CBG ≤80 mg/dL On board GS, IDS, Pulmo, Neuro, Derma
vein engorgement #T2DM 13. EPO-B 5000 u every T-Th-S post HD Refer back to IDS
14. Beneprotein 2 scooops to OF OD Referred to GI
NEPHRO 15. Sevelamer 800mg/tab 1 tab TID Referred to GS- Dr. Cruz/Kiat
(+) edematous extremities 16. Diazepam 5 mg TIV PRN for seizures Referred to dietary (10/07/19
(+) grade 1 edema 2. Salbutamol + Ipratropium (Duavent) neb q8 RTC Refer back to Plastic Surgery if does not collapse on turning on
17. Norepinephrine drip 12mg in 100cc pnss to run at 3cc/hour
GI (0.1mkm, 70kg) MRA for wound deb
(-) ascites 18. KCL tab 1 tab TID x 3 days – Day 2 ongoing Cardio – Intermediate risk
Soft, non-tender 19. KCl drip 40mEqs in 100cc PNSS to run for 6hrs via IJ Pulmo – may undergo on contemplated procedure
catheter for 2 cycles Nephro – on HD
MSK
(+) Edema both upper arms HOLD: Wound care 2x/ day and every diaper change
Amlodipine 10mg/ tab 1 tab OD PM Ideally for Chest mapping with Thoracentesis but VAC dressing need continuous suctioning
Telmisartan 80 mg / tab 1 tab OD AM
Levofloxacin 750mg/IV now then Q48- (Day 17) Carvedilol 6.25 mg MV SETTINGS as follows after HD
1tab BID SIMV
F12
COMPLETED: PEEP 5
Cefepime 2g IV OD Day 14 VT 500
KCl 750mg/tab TID D3 PS 10
Tranexamic acid 500mg TIV q8 t/c 6 doses D6/6 FiO2 30%
Cefepime 1 gm q24h – day 14/14
Ciprofloxacin 500mg OD D7 Shift to AC mode during HD (T-Th-S)
Piperacillin-Tazobactam 2.25 gm IV q6 Day 9-10 HD Settings
Duration 4 hours
UE: 2 L + 7 % amino acid + flushing
DISCONTINUE QB 250mL/min
Lactulose 30 cc ODHS hold for BM > 2x QD 500mL/min
HCO3 set to 22
Heparin free
FOR PEG INSERTION
Medical Risk Assessment
Cardio: Intermediate
Pulmo: Class I for post procedure pneumonia
Nephro: Patient is on maintenance HD
BED 6 #Acute CVD infarct right MCA NIHSS IVF PNSS 1L x 80cc/hr DIAGNOSTICS:
VIÑARTA, MARIO Y MAGASO 9 probably cardioembolic
72/M/RPV #CAD ACC/AHA St. B DIET AWAITING:
ID: 45455 Low salt, low fat, high fiber diet at 1800kcal/day Official Cranial CT scan 11/2
DOB: 02/07/47 2D echo with DS scheduling (for approval)
DOA: 11/2/19 Medications: Carotid artery Duplex scan scheduling (for approval)
NEURO: 1. Clopidogrel 75mg/kg 1 tab OD PC - HOLD
GCS 15 E4V5M6 2. Omeprazole 40mg/cap 1 cap ODAC REMARKS:
Oriented to 3 spheres Follows command 3. Atorvastatin 80mg/hr 1 tab ODHS Maintain MAP 110-130mmHg
Shallow left nasolabial fold 4. Lactulose 30cc ODHS hold if BM >2x/day Maintain CBG at 140-180mg/dL
Weak gag 5. Paracetamol 1g IV q12 RTC for headache Maintain O2 at > 94%
Pupils 2-3mm 6. HR units SC for CBG >200mg/dL Moderate – high back rest
MMT: 5/5 on right extremities, 0/5 left upper 7. KCl 750mg/tab 1 tab TID x 3 days Refer to ophtha, ortho, DRM- done
extremities; 3/5 left lower extremities 8. D5050 vial for CBG <80mg/dL Maintain neuroprotection:
(-) Babinski 9. Tramadol 25mg/IV PRN for breakthrough pain MAP: 110/130 mmHg
(-) Nuchal rigidity 10. Clonidine 75mcg/tab SL PRN if MAP > 130mmHg CBG 140mg/dl – 180mg/d;
11. Nicardipine 1mg/IV O2sat > 94%
PULMO: 12. Nicardipine drip 10mg in 100cc PNSS at 5cc/h – HOLD
(-) Dyspnea 13. Mannitol 100cc TIV Q8 D3
(-) Desaturation
CBS

CARDIO:
(-) Chest Pain
(-) Hypotension

1
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 7, 2019
Admissions: 1 Trans-In: 0
For Trans-Out: 1 Discharge: 0 Mortality: 0
GI:
(-) Abdominal pain
(-) Diarrhea

NEPHRO:
Adequate UO

MSK
(-) Edema

BED 8 #Septic shock sec to VAP IVF: Amiodarone drip: 360mg in 250cc D5W x 6 hours then DIAGNOSTICS:
Amiodarone 540mg in 250cc D5W x 18 hrs; NE 10mg in 100cc PNSS
BALLESCAS, DULCELINA BELANDRES #ARF, secondary to HAP x 11cc/hr (0.3mkm, 60kg) ± 4cc/hr to maintain MAP >/= 65mmHg as AWAITING:
(E. coli); Type IV sec to Septic shock ordered Official WAB utz 10/29
83/F/RPVD ETA CS 10/29
ID No. 159441 #Septic Encephalopathy DIET: regular salt, low fat, low chole, high fiber diet at 1800kcal/day, Official cranial CT scan 10/10
DOB: 04/02/1936 revise to 2:1 dilution with 60 cc pre and post flushing
DOA: 10/15/2019 #Vascular Dementia MV Settings:
MEDICATIONS AC
NEURO: #Chronic CVD infarct MRS 5, bilateral 1. Amiodarone 150mg/IV slow push now VT 400
E1VTM4 frontal lobe MRS 5; lacunar infarcts 2. Amiodarone drip: 360mg in 250cc D5W x 6 FiO2 30%
(-) new focal déficit 3. Minocycline 100mg/tab 2 tabs Q12 Day 5 PEEP 5
(-) seizure #Cervical CA St. III B s/p 4. Valproic acid 250mg/5ml, 10ml BID F16
(-) vomiting chemotherapy s/p brachytherapy 5. Diazepam 5mg TIV for active seizures
(-) lateralizing signs 6. Vit C tablet OD REMARKS
#Seizure disorder sec to PSG 7. Peptamen 6 scoops in ½ glass water BID Refused HD & extraction only
PULMO: 8. Omeprazole 40mg/cap ODAC Apply mupirocin ointment on affected areas
(-) dyspnea, desaturation #AKI, multifactorial on top of CKD 9. Duavent neb q8 prn for dyspnea For wound debridement once with consent
SCE, (-) retractions, (+) occ crackles, bilateral 10. PNSS neb Q8 RTC Monitor CBG TID AC and record
(+) yellowish sputum #Chronic hyponatremia 11. Mupirocin ointment on affected area WOF: dyspnea, desaturation, hypotension
12. Sodium Hyaluronate TID OU Apply compression stockings once available for dvt prophylaxis
CARDIO: #Anemia of chronic disease 13. hours then Amiodarone 540mg in 250cc D5W x 18 hrs
(+) inotropic support 14. KCl 2 tabs now then 1 tab TID x 2 days ONBOARD SERVICES
(+) hypotensive episode #Coagulopathy secondary to sepsis 15. Norepinephrine drip 4mg/amp 4amps in 100cc GS- Dr. Solomon
AP, tachycardic, irregular rhythm, (-) murmur PNSS to run at 2cc/hr Ophtha – Dr. Hizon
#Sacral decubitus ulcer gr. 2 16. Digoxin 0.25mg ½ tab OD
GI:
flabby, NABS, soft, nontender #Cataract Immature, R, s/p DISCONTINUED DNR- renewed waiver 11/1
pseudophakia, L Human Albumin + Furosemide infusion; Spironolactone 10/15 Refused HD, refused extraction, CT scan, wound debridement
(+) edema, LLE Maalox x 10cc TID Daily wound care
(+) wound, RUE #Blepharoconjunctivitis, UO - resolved Metoclopramide
(+) Grade 2 sacral ulcer NAC

COMPLETED
17. Amikacin 500mg TIV OD D14/14 10/25/19
18. Furosemide 80mg IV q8 10/28/19
Meropenem 1g/IV x 3hr infusion Q8 10/29/19
BED 9 #Anemia probably secondary to IVF: to consume then shift to heplock DIAGNOSTICS:
TAMANI, JOSE PAUIG
67/M/RPV 1. Iron Deficiency 2. Thalassemia DIET:
Follow up ferritin studies, fecal occult immunochemical test
#071620255 3. R/o Occult GI bleeding MEDICATIONS
DOB: 10/27/1951 1. Amlodipine 5mg/tab 1 tab OD
DOA: 11/05/2019 2. Omeprazole 40mg/cap 1 cap OD - HOLD
#HASCVD NYHA Class 1 in ST 3. ISMN 60mg/tab 1 tab ODHS AWAITING
Cardio: 4. Start ferrous sulfate 325mg/tab 1 tab TID 30 mins
Adynamic precordium, normal rate, regular rhythm, before meals REMARKS
with intermittent palpitation, no chest pain, no neck Complete bed rest for now
vein engorgement Maintain O2 supplementation at 2-3 LPM via nasal cannula
Still for blood transfusion of 2 units prbc once available
Pulmo: REFERRALS
No dyspnea, clear breath sounds

BED 10 #Sub acute Subarachnoid IVF: 0.30 NaCl 1L x 80cc/hr DIAGNOSTICS:

TAN, LOURDES MERLAN hemorrhage sec to ruptured basilar Diet: NPO For CXR
77/F/CP tip aneurysm with intraventicular For 12 L ECG
ID:48297 extension, Hunt and Hess 4, acute Medications:
DOB: 6/1/42 hydrocephalus secondary 1. Piperacillin-Tazobactam 4.5gIV q6 D2-3 AWAITING:
DOA: 11/5/2019 2. Paracetamol 300mg TIV q4 RTC Blood CS x 2
#Acute Respiratory Failure Type I 3. Salbutamol neb q8 RTC ETA CS
sec HAP, Type II sec to SAH 4. Mannitol 150cc TIV q6
NEURO: 5. Nimodipine 30mg/tab 2 tabs q4 REMARKS:
GCS 6 E2VTM4 #HAP 6. Acetazolamide 250mg/tab 1 tab TID For VP shunt
asleep 7. Citicoline 1g/IV q12 CBG q4 while on NPO
No preferential gaze #HASCVD ACC/AHA St B 8. Valproic acid 500mg/IV q12 WOF: dyspnea, neurodetoriation
Intact gag reflex
(+) Bilateral Babinski #Hypernatremia

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 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 7, 2019
Admissions: 1 Trans-In: 0
For Trans-Out: 1 Discharge: 0 Mortality: 0
MMT: 0/5 on right upper extremity, 1/5 on right 9. Omeprazole 40mg TIV OD
lower ext, 0/5 left upper extremitys; 1/5 left #Hypokalemia drug induced 10.Give 1 more cycle KCl drip: 40mEqs in PNSS 90cc x 8h MV settings:
lower extremity 11.Lactulose 30cc ODHS AC
12.KCl 750mg/tab 2 tabs now then 2 tabs Q2 x 3 doses TV 310
PULMO: F12
(+) crackles on R base, occ rhonchi, SCE Pre-op meds PEEP5
1. Hydrocortisone 25mgTIV 30mins prior to OW FiO2: 30%
CARDIO: 2. Duavent neb 30 mins prior to procedure
(-) Hypotension
AP, tachycardia, regular rhythm Maintain O2 sat >95%

GI:
Flabby, non-tender

EXT:
(+) Grade 2 edema

BED 11 #Chronic ventilator dependence 2 IVF: d/c Diagnostics:

BENJAMIN, MA. ASUNCION ESPINO to 1) Central Apnea, 2) VAP, 3) PE
77/F/RPVD both sec to a) PNA, b) VO Diet: As ordered Awaiting:
ID: 95626 Chest map official 10/22
DOB: 8/15/1942 #Chronic CVD infarct B cerebellar IVF: Heplock Chest map official 10/28
DOA: 7/30/2019 with hem conv MRS 5 Diet: as ordered: d/c Ensure milk and give Diebetasal instead Chest map official 11/02
San Pedro, Laguna Medications: RSBI: 122.07
#HF sec. to CAD 1VD s/p 13.Revise Salbu + Ipra neb q8 PRN Remarks:
NEURO: Angioplasty LAD old ASWI NYHA 14.Linagliptin 5mg/tab OD For RSBI daily and T piece IF <105
GCS 10 E4VTM5 Class III 15.Amlodipine 10mg/tab OD Shift to trach mask if tolerated for 2hrs
16.CaCO3 1 tab TID Apply Dakins solution in wet to dry dressing BID
No sepsis
17.NAC 600mg/tab in ½ glass H2O Dec. CBG monitoring to TID pre meals
#Anemia of chronic disease 18.Clopidogrel 75mg/tab ODPC
PULMO: Suction secretions regularly
19.Lactulose 30cc ODHS
(+) Dyspnea 20.Omeprazole 40mg/cap ODAC Refer to Endo: Dr. Ligon/Dr. Naval
(+) Tachypnea #T2DM, controlled 21.Daikin’s soln wet to dry dressing BID WOF: dyspnea, desaturation, fever
No desaturation #Grade 2 Sacral Decubitus Ulcer 22.Diabetasol 3 scoops in ½ glass H2O q4 Monitor neuro VS QH
No fever 23.Insulin glargine 28u SQ in PM Bed turning Q2H
#Non-obstructing Nephrolithiases, 24.To consume stocks of Calcium polysterene sulfonate then Referred to Derma 10/14
(+) Wheezes
d/c Refer to GS for cutdown- Dr. Bartolome/Ocampo
right
25.Lactulose 30cc after each dose of Calcium polysterene For BT of 1 u PRBS
CARDIO: sulfonate
No hypotensive episodes #COPD suspect 26.Ampi-sul 1.5gm TIV OD – completed 11/1
27.Clonidine 75mg/tab SL PRN for BP >160/100 S/P INTUBATION 7/31/19
No tachycardia
28.Mupirocin ointment to L wound BID Referred to GI
Normal rate, regular rhythm
29.Carvedilol 6.25 mg ½ tab BID Refer back to IDS
30.Hold Furosemide for now
GI:
31. Salbutamol + Ipratropium neb q6 Hooked back to Mech vent, Tracheostomy mask not tolerated
No N/v 32.Hydrocortisone 100mg IV Q8 RTC
No GIB 33. Duavent Q6 RTC MV Settings:
Soft, non-tender
V-AC
VT 380ml
NEPHRO:
F12
Adequate UO
PEEP5
Hypervolemic
Fi02: 30%

MSK:
(+) Edema B UE & LE

CBG: 138
BED 13 #Cardiogenic shock secondary to IVF: 1. Dobutamine Drip: 100mg in 100cc PNSS at 6cc/hr [50kg, DIAGNOSTICS:
acute decompensated heart failure, 20mkm] TFT
BRILLO, SHIRLEY ZOSA low output, cold and wet 2. Norepinephrine Drip: 16mg/amp in100cc PNSS at 22cc/hr FBS, Lipid profile in A, include HbA1C
59/F/RPVD [50kg, 1.2mkm] Still for Blood CS x2
ID #:071917230 #Heart Failure with rEF 21% 3. Dopamine Drip: 800mg in 100cc PNSS to run at 18cc/hr Still for CXR
DOB:01/08/60 secondary to cardiomyopathy [50kg, 20mkm] ABG
DOA: 11/6/19 NYHIH Class III 4. PNSS 100 cc bolus TIV now then Q6 2D echo DS
for BUN, crea,Na, K, Cl today, inc SGPT, SGOT
#Hypertensive Atherosclerotic Diet: as ordered

3
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 7, 2019
Admissions: 1 Trans-In: 0
For Trans-Out: 1 Discharge: 0 Mortality: 0
GCS 11 E4VTM6, (-) seizures, (-) headache cardiovascular disease, Atrial AWAITING:
Fibrillation with RVR CHA2DS2VASC MEDICATIONS: Sputum GS/CS
5, HASBLED 1 1. Enoxaparin 0.2cc SC OD-resume ETA GS/CS
PULMO (-) dyspnea, (+) fine crackles
2. Digoxin 0.25mg/tab 1 tab OD
#Type 2 DM, controlled 3. Ceftriaxone 2g/IV Q24 D2
CARDIO fast rate, irregular rhythm, (-) murmurs 4. Azithromycin 500mg/tab 1 tab Q24
#CAP-MR 5. Insulin 6u HR for CBG > 200mg/dL REMARKS:
6. Amiodorone drip: 540mg/500ml D5W Retrieve 2D echo
GI (+) residual feeding
#ARF type IV sec to shock to run X 18hrs CBG monitoring q4
Intubation –done
NEPHRO adequate UO, (+) gross hematuria Venous cut down, left
Monitor VS q1 and record
MSK (+) bipedal edema Monitor I and O and record
WOF: dyspnea, fever, desaturation

MV settings:
V-AC
Vt350
Peep 5
FiO2 100%
F16
BED15 #Liver cirrhosis sec to chronic hepatitis IVF: PNSS 1L X 70CC/HR Diagnostics:
VALDEZ, ANGELO SARMIENTO #hepatocellular carcinoma DIET: Regular salt, low fat, low cholesterol and high fiber diet at Repeat RBS, NA & Mg in AM
#esophageal varices gr. 2 1800 kcal/day
55/M/RPV #portal hypertension gastropathy Awaiting:
ID #: 93176 #T2DM Medications: Urine NA
#Anemia multifactorial 1.Lactulose 30cc per night odhs hold if with BM >3x/day CBC with PC, BUN, Crea, Na, K, Cl, Ca, AST, ALT, TB, B1, B2
DOB: 12/5/63
2.Entecavir 500mg/tab 1 tab OD Official cranial MRI
DOA: 5/19/19
3. Human albumin 25% 50ml/vial 1 vial IV q12 hours
4. Amino Acid 8% 500ml IV to run for 12 hours q12 hours Remarks:
5. Insulin glargine 16 ‘u’ sc odhs Apply compression stockings once available
6. Humulin R 6’u’ SC PRN for CBG >200mg/dl May sit up at bed and dangle legs with assistance
7. Multivitamin 1 cap OD Measure Abdominal girth OD before breakfast and record
8. Zinc sulfate tab 1 tab OD
BED16 #Acute Respiratory failure sec to IVF: Discontinue NE drip DIAGNOSTICS
JALMASCO, FRANKLIN ESQUELA hospital acquired pneumonia with For 2d echocardiogram approval
60/M/PRV pleural effusion bilateral DIET: LS, LF, Low cholesterol high fiber diabetic renal diet
@2100kcal/day Carbohydrates 45-65% Fats 25-35% CHON AWAITING
#79124 # liver cirrhosis sec to ALD 0.5g/kg/day 1:5:1 dilution divided into 6 equal feeding with 30cc Chest CT 9/19
pre and post flushing ETA AFB x2 10/30
DOB:09/05/1959 #Hypertensive nephrosclerosis G5D Blood CS X2 10/29
MEDICATIONS: Ascitic fluid analysis 10/28
#HASCVD ACC/AHA st. B 1. Meropenem 500mg in 90cc PNSS x 30 OD D7 Ascitic fluid cytology 10/28
DOA:10/28/2019
2. Levofloxacin 500mg IV q48 hours D6 ETA CS 10/29
#Type 2 DM controlled 3. Increase Salbutamol + Ipratropium neb q6 RTC
3. NAC 600mg cap ODHS REMARKS
NEURO #septic shock secondary 4. Paracetamol 500mg tab q4 T >37.8 After HD decrease FI02% BY 10 every hr until 50%
E4VTM6 5. Paracetamol 300mg IV Q4 T> 38.5 CBG monitoring TID premeals and record
No seizure, No neuro deficits #r/o pulmonary new growth 6 Amlodipine 10mg tab ODPM - HOLD Referred to TCVS 10/30
7. Irbesartan 150mg tab ODAM - HOLD For EGD for surveillance once stable
CARDIO 8.Insulin 70/30 25u SQ AM; 10u SQPM For repeat Chest CT scan once PE resolves
(-) chest pain 9.Humulin R 6u SQ for CBG >200mg/d F
(-) NVE 11.EPO Beta 5000u SQ once a week
(-) hypotension 12.Sodium Bicarbonate 500mg tab TID For compression stockings 38mmHg
13. Linagliptin 5mg OD MV SETTINGS
PULMO 14. Omeprazole 40mg cap ODAC AC mode
No dyspnea, Minimal sputum per trache, Decreased 16. Aminoleban 1 sachet per NGT BID- VT 450
breath sounds, Right (+) crackles, Left base 18. Hold Lactulose 30cc ODHS to maintain BM 2-3x/day F16
19. Epoetin Beta 5000units 2x/weekly PEEP 5
GI 20. Give Midazolam 12mg amp now FI02 30%
No nausea/vomiting 21. cont. norepinephrine 4 amps in 100cc PNSS at 36cc/hr
Flabby soft normoactive bowel sounds Dec PS by 2 every 4 hours until PS 10
BM – 7x HOLD
1. Rosuvastatin 10mg ODHS
NEPHRO

MSK
(+) UE edema (-)ulcers
(+) facial edema R

ENDO: 260
BED17 #VAP with pleural effusion, bilateral IVF: Heplock Diagnostics:
2D Echo w/ DS on call
VILLARINO, ORNEZA PIZZARAS #ARF sec to pulmonary congestion Diet: 1500kcal DM diet 2:1 dilution Repeat HBA1c after 6 months
65/F/RPVD MEDICATIONS: BUN, crea,, Na, K,Cl, Mg, alb, Ca
ID# 1019188373 #DKD G5D 1. Humulin R 6u SQ PRN for CBG >200mg/dl
DOB: 09/01/54 2. Amlodipine 5mg/tab 1 tab OD Awaiting:
DOA: 10/30 #HASCVD Heart Failure ACC/AHA 3. Linagliptin 5mg/tab 1 tab OD Official KUB UTZ 10/31
ST B 4. Atorvastatin 80mg/tab , 1 tab OD Blood GS/CS
NEURO 5. Clopidogrel 75mg/tab , I tab OD Sputum GS/CS

4
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 7, 2019
Admissions: 1 Trans-In: 0
For Trans-Out: 1 Discharge: 0 Mortality: 0
GCS 6 E1VTM4 #T2DM 6. Na HCO3 tab, 1 tab TID Fecal Occult Immunochemical test – request given
Drowsy, Decreased verbal output 7. ISMN 30mg/tab 1 tab OD TCVS notes for permanent HD access
(+) Fever 38.6 #Anemia sec to r/o occult GI bleeding 8. Caltrate plus tablet BUN, crea,, Na, K,Cl, Mg, alb, Ca
(-) seizures (-) deficits 9. Carvedilol 6.25mg/tab 1 tab TID - HOLD Remarks:
#Hypokalemia 10. Febuxostat 40mg/tab OD Continue CBG monitoring TID premeals & record
PULMO 11. EPO B 5000 ‘u’ SQ 2x/week May nebulize with Salbutamol + Ipratropium neb, 1 neb q8 PRN for dyspnea
SCE, decreased crackles, bilateral, decrease breath 12. Folic acid 5mg/tab OD Bed turning Q2
sounds basal 13. KCL tab 750mg TID for 3 days Suction Secretions as necessary
14. Hydrocortisone 250mg iv WOF: hypotension, desaturation
CARDIO 15. Salbutamol+ipratropium neb now then q8 hours RTC For possible
AP, NR RR no murmur 16. Piperacillin Tazobactam 4.5g IV infusion over 30mins now then Referred to GS for Emergency cutdown
2.75g IV infusion over 4 hours q8hours- D2 Compression stockings 38mmHg
GI 17. Levofloxacin 500mg IV now then q48hrs-D2
Flabby, soft, non-tender, 18. Give Diazepam 12amp TIV now MV SETTINGS
19. Midazolam 1mg in 90cc PNSS to run - Hold AC mode
Nephro 20. Paracetamol 1g TIV now F16
(+) Edema, decreased 21. Paracetamol 500mg/tab 1 tab Q4 for T>37.8C PEEP 8
Defer hemodialysis for today 22. Captopril, Nifedipine – HOLD FI02 100%
23. start norepinephrine amp 12mg in 100cc pnss to run at 21cc/hr TV 400
titrate by 3cc/hr to maintain MAP 70
24. start dobutamine 4 amps in 100cc PNSS to run at 4.2cc/hr
BED 20 #Ventilator associated Pneumonia IVF: Heplock DIAGNOSTICS:
(Enterobacter), resolving
SANTOS, RENEE ANDRADE DIET: As ordered AWAITING:
87/F/RPVD #Chronic ventilator dependence
ID #: 31328 secondary to central apnea MEDICATIONS: REMARKS:
DOB: 01/06/31 1. Resume Azithromycin 500mg/tab 1 tab OD (M-W-F) after Monitor CBG TID pre-meals
DOA: 05/31/18 #CAUTI (E. Coli) VAP treatment Please hook to cardiac monitor
2. Levetiracetam 250 mg/tab OD Moderate to High back rest
NEURO #Vascular Dementia 3. Lactulose 15cc ODHS Bed turning q2h
GCS 9 E4VTM4 4. Vitamin B Complex 1 tab OD Referred to DRM 10/04
(-) Seizures #HASCVD AF with AVR ACC/AHA St. 5. Salbutamol + Ipratropium neb q8 PRN for dyspnea Daily trache care
B 6. Atorvastatin 40mg/tab ODHS WOF: dyspnea, fever, desaturation
PULMO 7. Omeprazole 40mg/cap ODAC
(-) Dyspnea #COPD GOLD D 8. Oral betadine gargle BID MV settings
(-) Desaturation 9. Drapolene cream BID on sacral ulcers SIMV
SCE, CBS 10. Budesonide neb q12 (hold while on hydrocort) VT 360
11. Carvedilol 6.25 mg/tab, ½ tab BID F16
CARDIO 12. Dabigatran 75mg/tab 1tab BID PS16
AP, NR IR, no murmur 13. Cefepime 2g IV Day 9 PEEP 5
(-) Hypotension 14. Amikacin 250mgIV q12 Day 9 FiO2 30%

Rectal
(+) Constipation
(+)MINIMALBLEEDINGPERANUS
BED21 #Chronic Ventilator Dependence with IVF: none Diagnostics:
ESPERA, MELITONA PEREZ Central Apnea s/p change of
tracheostomy 9/9/19 DIET: Low salt low fat + 2 egg whites to diet at 1,800kcal/day Awaiting:
84/F/RPVD Post correction K
ID #: 39134 #HASCVD ACC/AHA Stage B MEDICATIONS:
DOB: 03/10/34 1.Cutasept spray to stoma BID SERVICES ON BOARD:
DOA: 01/28/19 #Chronic CVD Infarct (2010, 2018) 2.Clopidogrel 75mg/tab ODPC - DRM (Dr. Mones)
MRS 5 3.Duavent nebule q8 prn - ENT (Dr. Jorge)
NEURO: 4.Omeprazole 40 mg/cap ODAC - GI for change of PEG
GCS 8 E4VTM4 #S/P PEG change June 2019 5.Atorvastatin 40 mg/tab ODHS
No seizure No agitation 6.Levetiracetam 500mg/tab 1 tab BID Remarks:
7.Lactulose 30cc ODHS.Hold if BM >2x/day For change of tracheostomy tube c/o ENT on Mon (09/09)
PULMO: 8.Peptamen 6 scoops in 1 glass of waterTID Suction secretions PRN
SCE, CBS, No desat/dyspnea 9.Bactidol mouthwash TID Bed turning Q2
10. Salbutamol + Ipratropium neb now Chest physiotherapy
CARDIO: 11.KCl 750mg/tab 1 tab TID x 3 days - Day 3 ongoing Mod high back rest
Normal rate, regular rhythm, no chest pain, Daily tracheostomy care
COMPLETED: WOF: dyspnea, desaturation, hypotension
GI: Meropenem 2g IV now then 1g IV Q8 Change of catheter weekly
Flabby, soft nontender abdomen, NABS s/p tracheostomy change (8/14/19)
BM MV Settings: s/p PEG change 6/28/19
SIMV
MSK: TV 360
No edema, no ulcers PS10
FiO2 30%
PEEP 5