Course in the ER /Hospital Day 0

Admitting Orders:

>Please admit patient to IMCU once cleared

- Secure consent to care and management
>Impression:
1. Cardiogenic shock secondary to dilated cardiomyopathy
2. Covid suspect, gene Xpert done (4/4/2021), awaiting swab test result
>Diet:
>IVF:
- (....) D5W 1L at 10cc/hour (macroset)
- Inotropes: Dobutamine 250mg to make 50cc NSS start at 5mcg/kg/min
>Diagnostics:
- Chest X-ray PA/AP - Na, K, SGPT
- 12L ECG - ProBNP
- HGT - Trop I
- CBC with Plt - Chest UTZ
- Crea, BUN
>Therapeutics:
1. Atorvastatin 40mg/tab, 1tab OD
2. Carvedilol 6.25mg/tab, ½ tab BID PO
>Hook to cardio monitor
>Refer to cardio
>I/O q shift
>Monitor VS q hourly
>Refer accordingly

CBC
WBC: 6.35
RBC: 5.00
HGB: 14.50
HCT: 43.8
MCV: 87.6
MCH: 29.0
MCHC: 33.10
RDW: 16.60
PDW: 10.60
MPV: 10.70
PMN: 68.8
Lympho: 17.50
Mono: 9.30
Eosino: 3.80
Baso: 0.60
Platelet: 137

BUN: 12.9mg/dl
Crea: 0.76mg/dl
Na: 147.4mmol/L
K: 3.82mmol/L
SGPT: 30.97
Trop I: <0.01 negative
HGT: 138

12L ECG: sinus arrhythmia, RAD, inferolateral wall ischemia

CT ratio: 0.79
Chest AP Result: Cardiomegaly, multichamber form with beginning pulmonary congestive changes. New
onset minimal left pleural effusion.
Chest UTZ: Minimal pleural effusion with passive atelectasis of the adjacent lung parenchyma, may be
physiologic. Sonographically unremarkable right hemithorax. Negative for pericardial effusion
Swab test result: SARS-COV2 Negative

>Referred to cardio (Dr. Go)

- Revise diagnostics
- Start Digoxin
- Diurese if BP of >/=100/60mmHg (furo drip)
- Start Spironolactone 25 OD

>Working diagnoses:

1. Dilated cardiomyopathy in and cardiogenic shock, NYHA FC IV

2. SARS-COV2 negative 4/4/2021

>Therapeutics: Start

1. Digoxin 0.25mg/tab, ½ tab OD

2. Furosemide drip @ 5cc/hr, hold if BP </= 90/60mmHg
3. Spironolactone 25mg, 1 tab OD
4. Hold Carvedilol for now

>Referred to Pulmo (Dr. Tan-Pastor)

- Cleared for IMCU admission

>Referred to Dr. Capistrano: informed

>Furosemide drip 100mg + 100cc NSS to run @ 5cc/hr, hold if BP </=90/60mmHg

>Dobutamine drip 250mg to make 50cc NSS, @15mcg/kg/hr (9cc/hr), inc/dec by 5cc/hr q hourly to
achieve BP >/=90/60mmHg.

- Facilitate transfer to IMCU

Hospital Day 1 (04/05/2021)
Subjective Objective Assessment Plan
No fever 90/60 70 30 36.3°C 96% Dilated cardiomyopathy Patient was for 2D echo
(+) SOB CBG: 136 in cardiogenic shock with doppler studies,
No chest pain (postpartum) NYHA FC proBNP, I. calcium, Mg,
CVS: dynamic IV Phosphorus, lipid profile
precordium, distinct SARS-COV2 Negative and FBS
heart sounds, no Medications were
murmur, PMI @6th LICS continued
Chest: equal chest Monitor VS qH and I&O
expansion, clear breath qshift
sounds
Abdomen: normoactive
bowel sounds
Extremities: no edema

I.cal: 3.13mmol/L H
Mg: N/A L
Phosphorus: 1.19mg/dl L

Hospital Day 2 (04/06/2021)

Subjective Objective Assessment Plan
No fever 90/60 98 23 36.6°C 95% Diagnostics: CBC with
No SOB I: 1290 Plt, BUN, Crea, Na, K, I.
No chest pain O: 5800 calcium, Mg, CXR PAL,
ANA, HbSAg, Anti-HCV,
Anicteric sclerae, pink albumin and 2D echo
palpebral conjunctiva, with doppler studies
no lymphadenopathies,
dynamic precordium, Summary of
distinct heart sounds, medications:
no murmur, PMI @6th -Dobutamine drip
LICS, equal chest 250mg + 50cc PNSS to
expansion, clear breath run @ 5mcg/kg/hr to
sounds, normoactive achieve BP =/>90/60
bowel sounds, soft -Furosemide drip
@5cc/hr, hold if BP
<90/60
-Atorvastatin 40mg/tab,
1 tab OD
- Digoxin 0.25mg/tab, ½
tab OD
-Lactulose (?)00cc OD at
HS
-Spironolactone
25mg/tab, 1 tab OD

Monitor VS qH and I&O

qshift

IVF: PNSS 500cc

@10cc/hr

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.

CBC
WBC: 4.15
RBC: 6.61 NEU: 61.40 HbSAg: non reactive
Hgb: 19.0 LYM: 20 HCV: non reactive
Hct: 57.50 MON: 14.20
MCV: 87 EOS: 3.40
MCH: 28.70 BAS: 1.00
MCHC: 33.0
RDW: 17.70 FBS: 45.7 mg/dl
PDW: 13.70
MPV: 11.10
PLT: 154
BUN: 14.6mg/dl
Crea: 1.17mg/dl
K: 4.16mmol/L n
Na: 132.06mmol/L low
I.cal: 1.02mmol/L
Mg: N/A mg/dl low
Albumin: 3.77g/dl low

Lipid profile:
Cholesterol: 206mg/dl H
Triglyceride: 218.2 mg/dl H
HDL-cholesterol: 16.1mg/dl L
LDL- cholesterol:

Hospital Day 4 (4/07/21)

Subjective Objective Assessment Plan
90/60 67 20 36.4C 98% Patient was fo 2D echo
(-) Fever I: 1333.2 and chest Xray PAL
(-) Shortness of breath O: 1550 Medications continued,
(-) chest pain Dobutamine decreased
Anicteric sclerae, pale to 25mcg/kg/min
palpebral conjunctivae Calcium gluconate
adynamic precordium, 1amp given
Distinct heart sounds
Equal chest expansion, IVF: Heplock
Clear breath sounds
Normoactive bowel Monitor V/S and I&O
sounds, tympanitic, (-) qshift
mass

(-)

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.

CBC
HGB: 19.0
HCT: 54.5
WBC: 4.15
PMN: 61.4
Mono: 20
Lympho 14.2
Baso: 3.4
Platelet: 154

ANA: Negative
HBsAg: Nonreactive
HCV: Nonreactive
K: 4.16
Na: 132.06 (dec)
Ionized Calcium: 1.02
Albumin: 3.44

Hospital Day 5 (04/08/21)

Subjective Objective Assessment Plan
90/60 104 Intubated IVF: Heplock
(-) Fever 35.0 C 98% Repeat K after
(-) Shortness of breath I: 814.2 correction
(-) chest pain O: 400 2D echo with doppler

Anicteric sclerae, pale Continue medications

palpebral conjunctivae KCl 20 meqs x 90 cc
adynamic precordium, PNSS to run for 2 hours
Distinct heart sounds x 3 cycles; repeat K after
Equal chest expansion, correction
Clear breath sounds KCl 2 tablets now, then
Normoactive bowel 3x a day
sounds, tympanitic, (-)
mass Monitor V/S and I&O q
shift
(-) edema

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.

Chest Xray (4/07/21): CARDIOMEGALY, MULTICHAMBER FORM WITH RESOLVING PULMONARY

CONGESTIVE CHANGES; NEW ONSET MINIMAL LEFT PLEURAL EFFUSION

BUN: 14.8
Crea: 1.101
K: 3.0 (dec)
Sodium: 127.7 (dec)
Albumin : 3.77

Hospital Day 6 (04/09/21)

Subjective Objective Assessment Plan
 90/60 90 25 36.0 C 98% IVF: PNSS 500cc at 10
(-) Fever I: 1097.2 cc/h
(-) Shortness of breath O: 1500
(-) chest pain Diagnostics: CBC with
Anicteric sclerae, pale platelet, BUN, Crea,
palpebral conjunctivae Sodium, Potassium,
adynamic precordium, Ionized Calcium,
Distinct heart sounds Magnesium
Equal chest expansion, 2D echo with doppler
Clear breath sounds Continue medications
Normoactive bowel Monitor V/S and I&O q
sounds, tympanitic, (-) shift
mass Give O2 at 1-2 LPM in
Nasal Cannula
(-) edema

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.

CBC

Hospital Day 7 (04/10/21)

Subjective Objective Assessment Plan

 90/60 102 26 36.0 C 98% IVF: PNSS 500cc at 10
cc/h
(-) Fever I: 1448

(-) Shortness of O: 2050

breath Diagnostics:

(-) chest pain 2D echo with Doppler

Anicteric sclerae, pale palpebral
conjunctivae CXR PAL

adynamic precordium, Distinct Treatment:

heart sounds
Continue medications
Equal chest expansion, Clear breath
sounds Monitor V/S and I&O q
shift
Normoactive bowel sounds,
tympanitic, (-) mass, (-) edema DIC O2

Refer accordingly

Add: Calcium gluconate 1

amp IV now

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.

2D echo with Doppler

CXR PAL:

Cardiomegaly, multichamber form with further resolving pulmonary congestive changes

Hospital Day 8 (04/11/21)

Subjective Objective Assessment Plan

 90/60 124 22 36.0 C IVF: PNSS 500cc at 10 cc/h
98%
(-) Fever
I: 1200
(-) Shortness Diagnostics:
of breath O: 600
CBC with pt
(-) chest pain
BUN
Anicteric sclerae, pale
palpebral conjunctivae Crea

adynamic precordium, CXR PAL

Distinct heart sounds
Follow Up echo results
Equal chest
expansion, Clear
breath sounds Treatment:

Normoactive bowel 1. Lactulose 30cc OD 2. Carvedilol 6.25mg

sounds, tympanitic, (-) 1/2tab BID 3. Spironolactone 25mg tab,
mass, (-) edema 1tab OD 4. Digoxin 0.25mg tab, 1/2tab OD
5. Atorvastatin 40mg, 1tab OD

Monitor V/S and I&O q shift

Refer accordingly

Add: Calcium gluconate 1 amp IV now

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.
2D echo with Doppler

CXR PAL

BUN 20.4 mg/dl

Crea 0.73 mg/dl

CBC with Pt:

WBC 10.33 (H)

RBC 7(H)

Hgb 20.40(H)

Hct 58.40(H)

MCV 83.40

MCH 29.10

MCHC 34.90

RDW 20.80

Differential counts:

Neutrophils 74.90

Lyphocytes 17

Monocytes 6.90

Eosinophils 0.20

Basophils 1.0
 Hospital Day 9 (04/12/21)

Subjective Objective Assessment Plan

100/60 82 23 36.5 C 97% IVF: PNSS 1L at 10

cc/h
(-) Fever I:

(-) Shortness of O:
breath Diagnostics:

(-) chest pain None for now

Anicteric sclerae, pale palpebral
conjunctivae

adynamic precordium, (+) spitting Treatment:

heart sounds
Continue meds
Equal chest expansion, Clear breath
sounds Monitor V/S and I&O
q shift
Normoactive bowel sounds,
tympanitic, (-) mass, (-) edema DIC O2

Refer accordingly

***Then if naay labs, test results, imaging results na sa hospital day, i-follow lang after the SOAP table.
Hospital Day 9
April 13
Subjective Objective Assessment Plan

(-)fever V/S Start Dobutamine

(-)DOB BP 96/60 drip 25 mg +50 cc
(-)chest pain HR 90 PNSS +12 at 15
ECG (date:__) RR 15 mg/kg/min to
LBBB
O2 sat 96% maintain a BP of
Inferior Wall Ischemia
I 1093 90/60, decrease to
LVH
O 1500 5cc/hr q hourly to
maintain a BP of
Anicteric Sclerae, PPC >/=90/60
Adynamic Dx:
Precorrdium, Distinct Trop I
Heart Sounds CKMB
Equal Chest IVF:
Expansion, Clear PNSS 1 L at 10cc/hr
Breath Sounds O2 inhalation at 2LPM
Flat, NABS

Troponin I
Result: <0.01
Reference Value <1.0

CKMB
Result 15 U/l
Reference Value 0.0-25 U/L
Hospital Day 10
April 14
Subjective Objective Assessment Plan
Dobutamine drip uptitrated
(-)fever V/S By 5cc/min qHourly to reach
(-)DOB BP 96/60 and maintain a BP >90/60
(-)chest pain HR 90
No subjective RR 15 Digoxin 0.25 g tab ½ tab OD
complaints O2 sat 96%
ECG (date:__) Spironolactone 25 mg 1 tab
NA I OD
T wave inversion O
(V5-V6) Start furosemide drip 100 mg
Anicteric Sclerae, PPC +100cc PNSS to run at 5 cc/hr
Adynamic hold if </= 90/60
Precorrdium, Distinct
Heart Sounds Continue other medications
Equal Chest
Expansion, Clear Limit water intake to >1000
Breath Sounds cc
Flat, NABS

Arterial Blood Gas

pH 7.37 (7.35-7.45)
pCO2 30 (35-45)
pO2 82 (80-100)
Hospital Day 11
April 15
Subjective Objective Assessment Plan
Continue dobutamine
(-)fever BP 90/60 drip
(-)SOB HR 127 Continue furosemide
(-)chest pain RR 24 drip
No subjective Temp 36.7
complaints O2 sat 92% Diagnostics:
CXRay PAL
Anicteric Sclerae, PPC CBC with Plt
Adynamic Sputum GS/CS
Precorrdium, Distinct ECG 12L
Heart Sounds
Equal Chest
Expansion, Clear
Breath Sounds
Flat, NABS

CBC
HGB: 14.30
HCT: 54.43.20
WBC: 11.05
PMN: 83
Mono: 9.30
Lympho 2.20
Baso: 0.20
Platelet: 310
Hospital day Day 12 April 16, 2021

Subjective objective Assessment Plan

-)fever BP: 120/80 IVF: PNSS AT KVO

(-)SOB HR: 81 dx: none so far
(-)chest pain RR:; 21 tx:to consume
No subjective T: 36.6 dobutamine drip
complaints 02 SAT: 96% vs q 4
i and o q shift
Anicteric Sclerae, PPC
Adynamic
Precordium, Distinct
Heart Sounds
Equal Chest
Expansion, Clear
Breath Sounds
Flat, NABS
Hospital day Day 13 April 17, 2021

Subjective objective Assessment Plan

-)fever BP: 100/80 IVF: PNSS AT KVO

(-)SOB HR: 85 dx: none so far
(-)chest pain RR:; 20 tx: continue
No subjective T: 36.5 medications
complaints 02 SAT: 98% vs q 4
i and o q shift
Anicteric Sclerae, PPC
Adynamic
Precordium, Distinct
Heart Sounds
Equal Chest
Expansion, Clear
Breath Sounds
Flat, NABS
Hospital day Day 14 April 18, 2021

Subjective objective Assessme Plan

nt

-)fever BP: MGH today

(-)SOB HR: home medication
(-)chest pain RR:; 1. carvedilol 6.25 mg ½ tab
No subjective T: BID
complaints 02 SAT: 2. spironolactone 25mg tab
BID
Anicteric Sclerae, PPC 3. Digoxin 0.25 tab OD
Adynamic Precordium, 4. atorvastatin 12mg tab OD
Distinct Heart Sounds HS
Equal Chest Expansion,
Clear Breath Sounds follow up at IM OPD after 1 week
Flat, NABS
IMAGINGS
CHEST ULTRASOUND
4/4/2021
Clinical Information: Cardiogenic Shock Secondary to Dilated Cardiomyopathy; R/O Pericardial
Effusion
Comparison: Chest Ultrasound

No fluid collection is seen in the right hemithorax.

Minimal free fluid collection with low-level echoes is noted in the left hemithorax measuring at
least 4.25 x 5.70 x 3.53 cm or 44 mL.
Atelectasis of the adjacent lung parenchyma is noted.
There is no abnormal fluid collection within the pericardial sac.
IMPRESSION:
MINIMAL LEFT PLEURAL EFFUSION WITH PASSIVE ATELECTASIS OF THE ADJACENT LUNG
PARENCHYMA, MAY BE PHYSIOLOGIC.

SONOGRAPHICALLY UNREMARKABLE RIGHT HEMITHORAX.

NEGATIVE FOR PERICARDIAL EFFUSION

-----

Chest AP
4/7/2021
Interval decrease in the degree of accentuation of pulmonary vascular markings with decreasing
perivascular haziness.

No active lung parenchymal opacities.

Same degree of cardiomegaly in multichamber form. (CT ratio of 0.77).
Aorta is unremarkable.
Left costophrenic sulcus is blunted. Diaphragm and right costophrenic sulcus are intact.
The visualized osseous structures are unremarkable.
IMPRESSION:
CARDIOMEGALY, MULTICHAMBER FORM WITH RESOLVING PULMONARY CONGESTIVE CHANGES
NEW ONSET MINIMAL LEFT PLEURAL EFFUSION
----------
Chest AP
4/10/2021
The pulmonary vasculature remain accentuated but in a lesser degree with perivascular
haziness.
Heart is enlarged with a CT ratio of 0.74. The right cardiac border is prominent with splaying of
the carina.
The cardiac apex is rounded and inferolaterally displaced.
The left costophrenic sulcus remains blunted. The diaphragm and right costophrenic sulcus are
intact.
The rest of the findings are unchanged.
IMPRESSION:
CARDIOMEGALY, MULTICHAMBER FORM WITH FURTHER RESOLVING PULMONARY CONGESTIVE
CHANGES
DECREASING LEFT PLEURAL EFFUSION
--------------
Chest AP
4/14/2021
There are now fine reticular densities are seen in the right lower lung zone.
The pulmonary vasculature shows the same degree of accentuation.
The heart is enlarged with inferolateral displacement and rounding of the cardiac apex and
splaying of the carina.
The right cardiac border is prominent with presence of a double density sign.
The diaphragm and costophrenic sulci are intact.
The rest of the findings remain unchanged.

IMPRESSION:
PNEUMONIA. CORRELATE CLINICALLY.
CARDIOMEGALY, MULTICHAMBER FORM WITH PULMONARY CONGESTIVE CHANGES