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  • Kodigs Octavio

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    Sarah Ong Siu
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    The patient was admitted to the hospital from July 25th to July 31st. They presented with a cough, pain in the axillary area and a 10x11 abscess. Diagnostics showed pleural effusion, pneumonia and decreased breath sounds on the right side. They were given clindamycin and paracetamol for treatment. Throughout their stay, vital signs and urine output were monitored. The working impression was pleural effusion and cellulitis in the right axilla.

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    The patient was admitted to the hospital from July 25th to July 31st. They presented with a cough, pain in the axillary area and a 10x11 abscess. Diagnostics showed pleural effusion, pneumonia and decreased breath sounds on the right side. They were given clindamycin and paracetamol for treatment. Throughout their stay, vital signs and urine output were monitored. The working impression was pleural effusion and cellulitis in the right axilla.

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    7 views4 pages

    Kodigs Octavio

    Uploaded by

    Sarah Ong Siu
    The patient was admitted to the hospital from July 25th to July 31st. They presented with a cough, pain in the axillary area and a 10x11 abscess. Diagnostics showed pleural effusion, pneumonia and decreased breath sounds on the right side. They were given clindamycin and paracetamol for treatment. Throughout their stay, vital signs and urine output were monitored. The working impression was pleural effusion and cellulitis in the right axilla.

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    of 4

    DATE 07/25 07/26 07/27 07/28 07/29 07/30 07/31

    HOSPITAL DAY 0 1 2 3 4 5 6
    DAT DAT DAT DAT DAT DAT
    DIET DAT
    HL HL HL HL HL
    IVF HL HL
    (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever, (-) cough (-) DOB, (-) fever,
    SUBJECTIVE colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain, colds (-) vomiting, (+) Pain,
    axillary area axillary area axillary area axillary area axillary area axillary area axillary area
    OBJECTIVE
    Decreased breath sounds, Decreased breath sounds, Decreased breath sounds, Decreased breath sounds, Decreased breath sounds, Decreased breath sounds, Decreased breath sounds,
    Right, (+)10x11 abscess, Right, (+)10x11 abscess, axilla, Right, (+)10x11 abscess, Right, (+)10x11 abscess, Right, (+)10x11 abscess, Right, (+)10x11 abscess, Right, (+)10x11 abscess, axilla,
    axilla, right right axilla, right axilla, right axilla, right axilla, right right
    VS 90/60 110 20 37.5 98% VS 90/60 98 20 37.5 98% VS 90/60 110 20 37.5 98% VS 90/60 110 20 37.5 98% VS 90/60 110 20 37.5 98% VS 90/60 110 20 37.5 98% VS 90/60 110 20 37.5 98%
    CBC 7/22/23(D3
    DIAGNOSTICS
    Clinda) 07/29/23 (D5
    Clinda)

    Hgb: 123 127

    Hct: 3537

    WBC: 13.48.8
    Hgb: 123
    Hct: 35 N: 82.463.6
    WBC: 13.4 Chest Xray:
    N: 82.4 Pleural Effusion, L: 11.026.1
    L: 11.0 Pneumonia, Right. Clear
    lungs, left. M: 6.09.2
    M: 6.0
    E: 0.5 Lateral Decubitus:
    No change on pleural E: 0.5.8
    PC: 393
    eff, pneumonia and
    PC: 393462 CRP D3> D5 CLINDA
    subsegmental atelectasis FOR SPUTUM AFB ON AUGUST
    1, 2023
    CRP D3: 192mg/l Sputum AFB: Negative x2 07/2207/29 (D5 Clinda) 1925.50

    MEDICATIONS
    1. Clindamycin 1. Clindamycin 1. Clindamycin 1. Clindamycin
    300mg/cap 300mg/cap 300mg/cap 300mg/cap 1. Clindamycin
    D4+1 D5+1 D6+1 D7+1 300mg/cap
    1. Clindamycin 300mg/cap 1. Clindamycin 300mg/cap 2.Paracetamol 500mg/tab 2.Paracetamol 500mg/tab 2.Paracetamol 500mg/tab 2.Paracetamol 500mg/tab D7+3
    q6 D2+ 1 D3+1 prn prn prn prn 2.Paracetamol 500mg/tab prn
    2.Paracetamol 500mg/tab 2.Paracetamol 500mg/tab prn
    prn

    OTHERS UO 1.3 UO: 1.1 cc/kg/hr UO: 0.9 cc/kg/hr UO: 1.0cc/kg/hr UO: 1.1cc/kg/hr UO: 0.8cc/kg/hr UO: 1.3 cc/kg/hr
    Pleural Effusion, Right; Pleural Effusion, Pleural Effusion, Pleural Effusion, Pleural Effusion, Pleural Effusion, Right;
    WORKING Pleural Effusion, Cellulitis, Right axilla Right; Cellulitis, Right; Cellulitis, Right; Cellulitis, Right; Cellulitis, Cellulitis, Right axilla
    Right; Cellulitis, Right axilla Right axilla Right axilla Right axilla
    IMPRESSION Right axilla

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