Digital

Patient
Chart
Patient
No. NW-202100001 Neuro
Ward
Room
No.
18
Last
Name First
Name Middle
Name

Dela Cruz Juan Karlos Santos

Age 49 y.o. Sex Male Civil
Status Married
Address Lanzona Subd. Matina, Davao City
Country/Nationality Philippines / Filipino
Religion:
Roman Catholic Occupation:
Site Manager
Birth
Date:
July 8, 1970 Birth
Place:
Gen. Santos
Attending
Physician: Dr. RJ Tan, MD
Date
of
Admission January 31 2021, 5:55 AM
Admitting
Diagnosis Cerebrovascular Disease
(L) Infarct Cardiovascular
Accident Bleed
Chief
Complaint Decreased Sensorium (E1V1M5)

Procedures
Done Still for surgical correction

of cerebral hemorrhage
Final
Diagnosis Not yet discharged
 Triage
Assessment
Vital
Signs:

Blood
Pressure: HR: RR: Temp:

220/120mmHg 90 bpm 24 37.2C
Pain
Scale Weight: Height: O2
Sat:
220/120mmHg 95 kg 165.5cm 88%

Mode
of
Arrival: on stretcher
Consciousness: response to verbal (E1V1M5)
Triage
Category: 2
Department: Emergency Medicine
Triage
Nurse: Martinez, RN
Other
Remarks:
CC - Inability to feel and move right side of body

Past Hx History - Patient was previously diagnosed with Hypertension and Diabetes Mellitus. Wife of

the patient reports that the patient does not exercise. Food preferences reported: lechon, humba, burger,

frires. Pt. family had history of DMII and HTN, both paternal and maternal grandparents died of

either DMII or HTN. Patient did not comply with HTN/DMII Maintenance.

PHI - 5 PTA, patient experienced vomiting and right sided weakness.

at 5:10AM Patient was rushed to the hospital by wife and cousin because of progressive weakness and

unresponsiveness. CBG - 228 with CT Scan from previous hospital - Rresult: CVD Bleed.

Patient admitted at the ER @ 5:55AM. Pt was pale w/ capillary refill time: 3sec, Pt. has unilateral

facial drooping. Isocoric pupils noted. Pupils are equal, round, reactive to light, accommodation.

Intubated patient due to difficulty breathing and hooked to cardiac monitor. at 6:07AM pt went to

asystole - performed CPR. Given 1 mg epinephrine and 1 amp atropine stat. Pt was revived, inserted

endotracheal and NGT due to impaired swallowing. At 6:55AM pt was endorsed to Neurosurgery

Department for correction of cerebral hemorrhage.

(Signed) ER Resident
 Triage
Assessment
Not oriented to Time, place & person GCS 7 : E1 V1 M5,

Patient cannot identify significant others, cannot talk, or speak when asked

patient opens eyes when stimulated, but hearing and visual acuity is impaired

difficulty breathing, RR 24 clear ET with O1 @ 10L/min

X
X 1 day ago

X 16
X X Urethral

X X X X

X X X not known
X X

X X

R Upper/Lower
X
Extremities

N/A N/A

X
N/A N/A

N/A
Note: Eyes open only in response to pain. muscle strength on L extremities are Normal. R

Extremities Grade (0) muscle strength. a

(Signed) ER Resident
 Doctor's
Order
Dela Cruz Juan Karlos Santos 49 M NW-202100001
Neuro Ward 18 Private Dr. RJ Tan, MD

January - Intubate patient with ET size 7.5cm attach to O2 @ 10 LPM

31 2021, - Give Lidocaine spray 5mL at oral mucosa prior to intubation

5:55 AM - Hook to cardiac monitor

- Give Propofol 6 ml (60mg) slow IV prior to intubation

- Regulate present IVF: PNSS 1 L to run @ KVO

- STAT CBG, ECG, repeat cranial CT Scan

- Other Labs:

- CBC with PC

- Urinalysis

- Chest x-ray

- Serum sodium, potassium, calcium, magnesium

- SGPT

- Creatinine

- Lipid profile

- PT, APTT

- Give Mannitol 100 cc IV bolus now

- Insert NGT

- Mech Vent set up:

AC mode

FiO2: 100%

TV: 370 mL

RR: 16 cpm

- Continue monitoring I&O via FC and attach to urobag

(Signed) ER Resident

Rhythm check: January - Start quality CPR

Asystole noted 31 2021, (Signed) ER Resident

6:07 AM
 Doctor's
Order
Dela Cruz Juan Karlos Santos 49 M NW-202100001
Neuro Ward 18 Private Dr. RJ Tan, MD

Rhythm check: PEA January - Continue quality CPR

(Pulseless Electrical 31 2021, (Signed) ER Resident

Activity) 6:10 AM

"- Give Epinephrine 1mg IV now

:12 AM - Rhythm check: Sinus Bradycardia

BP: 60/40

(Signed) ER Resident

Give Atropine 1 amp IV now

BP - Continue Atropine 1 amp IV now

100/70 - Recheck BP
(Signed) ER Resident

January Give Omeprazole 40 mg IV while on NPO

31 2021,
- Give Norepinephrine 8mg plus 92 cc PNSS to run at 34
6:55AM
cc/hr IV now

- Recheck BP after 15 mins

- Please facilitate CT Scan

- Informed neuro surge resident on duty of this case

- Endorse to Neurosurgery for admission

Conferred with DR Castillano: Transfer to neuro surge

(Signed) ER Resident
 Doctor's
Order
Dela Cruz Juan Karlos Santos 49 M NW-202100001
Neuro Ward 18 Private Dr. RJ Tan, MD

January 31
- Please admit under neurosurgery
2021,
- Secure consent
07:30 AM
- IVF: PNSS 140 cc/hr x 4 hours then 120 cc/hr

- NPO Temporary

- VS and NVS q 2 hrs

- I&O q 4 hrs
(Signed) Dr. RJ Tan

January 31 - Labs:
S/P CP Treatment
2021, 7:50 - Blood type,
post 2 cycles
AM - TROP I

epinephrine - HBSAG

- Chest Xray PA

- Meds:

- Paracetamol 1 g IVTT q6

- Omeprazole 40 mg IVTT OD

- Cerebrolyisin 1 g IVTT q8

- Continue norepinephrine done as previously ordered

(Signed) Dr. RJ Tan

 Laboratory
Sheet
Dela Cruz Juan Karlos Santos
NW-202100001

Hematology
Name: Dela Cruz, Juan Karlos Date: January 31, 2021
Age/Sex:49/Male Sample
Type:Blood
Location Emergency Dept. Time
analyzed: 6:45AM
Physician:ER Resident

Measured
Test: Results Reference
Range Status

CBC
+
PLT
Hemoglobin 105.0
g/L 135-175
Low
Hematocrit 0.34 0.40-0.52 Low
RBC
count 3.58
x10^6/uL 4.20-6.10
x10^6/uL Low
WBC
count 16.45
x10^3/uL 5-10
x10^3/uL High
Differential
Count
Neutrophil 75 55-75 Normal
Lymphocyte 18 20-35 Low
Monocytes
Eosinophil 7.0 2-10 Normal
Basophil 0 1-9 Low
Platelet
Count 0
205
x10^3/uL 150-400
x10^3/uL Normal
Prothrombin
Time
PT
patient
PT
Inr 14.2
sec 11.5-14.3
sec Normal
PT
Activity 1.07
PT
control 90.0
14.7
sec 12.0-16.0
sec Normal
 Laboratory
Sheet
Dela Cruz Juan Karlos Santos
NW-202100001

Urinalysis
Name: Dela Cruz, Juan Karlos Date: January 31, 2021
Age/Sex:49/Male Sample
Type:Urine
Location Emergency Dept. Time
analyzed: 6:52AM
Physician:ER Resident

Urine
Examination Results Reference
Range Status

Physical
Exam
Appearance Slightly
Cloudy
Color Yellow

Urine
Chemistry
Protein 3+
Ph 6.0
Specific
Gravity 1.025
Glucose 3+
Micro
Albumin 3+ High
 Laboratory
Sheet
Dela Cruz Juan Karlos Santos
NW-202100001

Chemistry
Name: Dela Cruz, Juan Karlos Date: January 31, 2021
Age/Sex:49/Male Sample
Type:Blood
Location Emergency Dept. Time
analyzed: 6:45AM
Physician:ER Resident

Measured
Test: Results Reference
Range Status

Creatinine 305.10
umol/L 63.6-110.5 High
Sodium 137.00
mmol/L 136-145
Potassium 2.90
mmol/L 3.5-5.1 Low
SGPT/ALT 15.00
U/L 0-55
SGOT/ALT 39.00
U/L 5-34 High
Blood
Uric
Acid 0.35
mmol/L 0.15-0.42
Total
Calcium 2.02
mmol/L 2.10-2.55 Low
Magnesium 0.82
mmol/L 0.66-1.07
 Laboratory
Sheet
Dela Cruz Juan Karlos Santos
NW-202100001

Hematology
Name: Dela Cruz, Juan Karlos Date: January 31, 2021
Age/Sex:49/Male Sample
Type:Blood
Location Emergency Dept. Time
analyzed: 8:15AM
Physician:ER Resident

Measured
Test: Results Reference
Range Status

Blood
Type A+

Troponin
I Negative
Qualitative
Rapid
Test