Good afternoon doctors!

Updating for patient cacayan, Jaime 66/M

Admitted at med 1 hallway

Cc: cough

HPI: Patient is a known case of intracranial mass, probably meningioma. Admitted last 5th July 2019.

3 days PTC, patient started having cough (productive, whitish sputun) with associated occasional DOB,
and decreased appetite.

Hense admitted at med 1

PMHX:

(-)HPN (-)DM (-)PTB

P&S HX:

(+) Smoker 30 packs/year

(+) Alcohol drinker

PE:

conscious, unresponsive but follows command

GCS 11(E4V1M5)

Anictaric sclera, ppc

SCWE, decreased breath sound at right basal lung

AP, NRRR (-) murmur

Abdo: nontender, non distended, NABS

FEP, CRT<2sec

Admitting diagnosis:

Intracranial mass probably meningioma with lung metastases

Plan:

IVF : D5 LRS 1L x12 hrs

Diet: OF 1500kcal in 6 decided food

CHON-50g

CHO-160g

Fat-70g

Dx:

For chest CT scan if ok with main service

For chest x-ray today, CBC, NA, K

Tx:

Please insert NGT

Continue Salbutamul + ipratropium neb q6.

Cefuroxime 750 mg iv q8

Azthromycin 500 mg tab OD

Refer to IM neuro