8/21/20 at 10:52 AM //Cefuroxime 1.5 gm IV drip q 8H ANST // 8/21/20 at 10:52 AM //Anthromycin 500 mg/tab, 1 tab OD PO x 6 days (10:52am)// - Please admit to COVID unit under the //Pantoprazole 40 mg IVTT now then 40 mg/cap 1 cap OD PO ac service of Dr. Yu co-managed by Dr. Hermogenes breakfast(10:52am)// and Dr. Pizarra //Citicoline 1 gm IVTT q 6H (10:52am)// - Secure signed consent //Atorvastatin 40 mg/tab, I tab OD PO (10:52am)// - TPR q 4H //Citirizine 10 mg/tab, 1 tab OD PO q HS (8:00pm)// //Diphenhydramine 50 mg/amp 1 amp IVTT now (10:52am)// - Monitor vital Signs every 2 hours to include neuro vital signs 8/22/20@1:27 PM - I & O q 4H in absolute figures //Alprazolam 500 mg/tab ½ tab now (1:27pm)// - MHBR 8/23/20 @7:26 AM - O₂ at 2-3 LPM via nasal prong //Memantine (MEMRY) 10 mg/tab½ tab OD (7:26 AM)// - Dr. Yu informed through call, will inform //Clopidogrel (PLOGREL) 75mg/tab 1 tab OD (7:26 AM)// other Aps – informed through text - Refer to persistence in BP elevation, 8/24/20 for HAMA meds deterioration of sensorium, dyspnea and other Memantine 10 mg/tab ½ tab OD PO (8am) unusualities Citicoline 1 gm/tab BID PO x 3 months (8 am & 6pm) Clopidogrel 75 mg/tab, 1 tab OD PO (8am) - Please give D₅₀ W 1 cap slow IV now Sultamicillin 750 mg/tab, 1 tab BID x 7 days(8 am & 6pm) - Repeat CBG q 1H then raise to 2H until Losartan 50 mg/tab, 1 tab OD PO (8am) stable Amlodipine 5 mg/tab 1 tab OD PO (8am) 8/21/20 at 1:33 PM - Dr. Yu made rounds in ER Case and Plans discussed - Suggest refer to Neuro service ( Dr. Pizarra) - Dr. Hermogenes updated Case and plans discussed - Dr. Yu updated through call and conferred - Decrease HGT Monitoring to q 6 hrs - Dr. Yu informed through call and conferred - Fall Precaution - Please Facilitate CT scan BP tonight All Aps Updated 8/22/20 at 11:20 AM - Rounds with Dr. Hermogenes For Procalcitonin ff with Dr. Yu For LDH, CRP-HS, Ferritin, D-Dimer if okay with Dr. Yu At 11:35 AM - Suggest referral to neurologist if Ok with Dr. Yu At 11:40 AM - Dr. Yu updated - Ok to get procalcitonin, LDH, CRP-HS, Ferritin and D-Dimer Ok to refer to neurologist under Dr. Pizarra At 11:50 AM - Dr. Pizarra called with this referral for co- KARDEX management with conformity and acknowledgement - Please facilitate CT scan BP Will see the patient 8/23/20 at 7:26 AM - Increase CBG range to q 4H Please chart all CBGs to chart and relay to IMROD 8/24/20 - CLIA-refused with signature waiver - HAMA - Aps Updated - Take home meds - Dr. Yu updated - Informed of HAMA - Advised - Dr. Hermogenes updated - HAMA - Advised - Please provide photocopy of all lab results - Dr. Hermogenes informed with confirmation - Advised Dr. Pizarra informed -
DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS
8/21/20@10:52 AM 8/22/20 • CBC, S. crea, Na⁺, K⁺, SGPT, BUA, BUN, BAIC May shift Cefuroxime IV to Ampicillin + Sulbactam 1.5 g • ECG 12 L, CXR PA, PT, APTT IV drip q6H ANST • CBG now then TID ac + HS, FBS, Lipid Panel 8/21/20 • Urinalysis Venoclysis: PNSS 1 L at KVO rate • CT scan BP to start Ampicillin + Sulbactam 1.5 gm IV drip q 6H if okay with primary service • COVID Rapid antibody Testing Please give D₅₀ W 1 cap slow IV now KARDEX • COVID RT PCR c/o CDUH Another dose of Diphenhydramine 50 mg IVTT tonight 8/22/20@9:53 AM prior to CT scan • For 2D ECHO with doppler Shift IVF to D₅NSS at KVO rate • For Procalcitonin • For LDH, CRP – HS, Ferritin, D-Dimer • For TSH and FT4 • Follow-up checkup after 2 weeks
PATIENT’S NAME:_ Christian , Santos , Nadela _ _ DIET:
AGE_ 87 __ SEX_M______ //8/21/20 at 10:52 AM // ATTENDING PHYSICIAN___ Dr. Yu co _______ Soft, low salt, low fat DM diet – hypo allergenic CO-MANAGEMENT___ Dr. Hermogenes ________ DATE & TIME ADMITTED _8/21/20 ; 10:52 AM __ DIAGNOSIS/ IMPRESSION: ROOM #______ RELIGION:__Roman Catholic ______ HOSPITAL #_____DATE OF BIRTH_ July 20, 1933 __ BLOOD TYPE :_________
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