Palliative Patients (4-20-21)

FOR OPD PATIENTS (CUT OFF 12 NN)

1. Get the form from nurse on duty
2. Complete the baseline vitals and anthropometrics including the BSA
3. ECG – usually for Dr. Flores’ patients
4. Monitor pre and post chemo
5. Prepare DI and prescription
Room No. BANOS, HEROLD
015-1 RT-PCR and antigen test – negative
Attending Physician: Dr. Calera, Dr. Flores
Age: 71 Sex: M Birthdate: Birthplace:
Current Address: 118 Banget, Ampucao, Itogon, Benguet Date of Admission: April 16, 2021
Occupation:
Clinical Impression: Adenosquamous carcinoma of the lung, left Final Diagnosis: Adenocarcinoma stage IV
Pneumonia in the Immunocompromised; COPDIAE
History: PE:
 Known hx of lung CA (Feb 2021)  04/17/2021:
 3 days PTA:  Vitals: BP 130/80-90 mmHg, HR: 98-99 bpm, RR: 23-24 cpm, Temp: 35.7-
- (+) dyspnea, (+) cough 36.0 C, SpO2: 96-97% at 2 lpm
- (-) dyspnea, (-) paroxysmal nocturnal dyspnea  C/L: symmetric chest wall expansion, (+) subcostal retractions, decreased
- no consult done, no meds breath sounds, (+) left basal crackles, (+) diffuse bilateral wheezing
 Progression of symptoms prompted consult  Heart: NRRR, JVP – 7 cm from right angle, 1-2 cm from the sternal angle
 04/18/2021:
 Vitals: BP: 130/80 mmHg, HR: 101 bpm, RR: 23 cpm, Temp: 36.2 C, SpO2:
94%
 C/L: symmetric chest wall expansion, (-) subcostal retractions, decreased
breath sounds, (-) crackles, (+) diffuse bilateral wheezing but with
improvement of tight air entry
 Heart: (+) prickling chest pain on the left, probably secondary to lung mass; no
ischemic changes on ECG

 04/19/2021:
 Vitals: BP: 140/90 mmHg, HR: 115 bpm, RR: 18 cpm, Temp: 36.4 C, SpO2:
98%
 C/L: symmetric chest wall expansion, (-) subcostal retractions, decreased
breath sounds, (-) crackles, (+) diffuse bilateral wheezing but with
improvement of tight air entry
 Heart: (+) prickling chest pain on the left, probably secondary to lung mass;
 04/20/2021:
 Vitals: BP: 170/90 mmHg, HR: 105 bpm, RR: 22 cpm, Temp: 36.5 C, SpO2:
97% at 6lpm
 C/L: symmetric chest wall expansion, (-) subcostal retractions, decreased
breath sounds, (-) crackles, (-) wheezes
 Heart: (-)chest pain
Neuro examination:
Cerebrum: awake, conscious, coherent, drowsy
Cerebellum: (-) nystagmus, (-) tremors
CN I: able to smell
CN II: able to see
CN III, IV, VI: pupils equally round and reactive to light and accommodation,
with preferential gaze to the right
CN V: facial sensory functioning intact, muscles of masticatory intact
CN VII: without facial asymmetry
CN VIII: able to hear
CN IX/X: uvula in midline, no deviation
CN XI: able to turn head from right to left, cannot raise left shoulder
CN XII: midline protrusion of tongue, no fasciculation, deviation to the right
MOTOR: 0/5 motor response on left upper and lower extremities
SENSORY: unable to verbalize sensory testing
REFLEXES: 0 on left upper and lower extremities
 04/21/2021:
 Vitals: BP: 130/80 mmHg, HR: 99 bpm, RR: 24 cpm, Temp: 36.0 C, SpO2:
98%
 C/L, (-) subcostal retractions, decreased breath sounds, (+)crackles, (+) diffuse
bilateral wheezing but with improvement of tight air entry
 Heart: (-)prickling chest pain on the left
 Extremities: No movement of the left upper and lower extremities with
decreased sensation rated as 20%. The right upper and lower extremities
showed normal range of motion, sensation and strength.
 04/22/2021:
 Vitals: BP: 160/90 mmHg, HR: 96 bpm, RR: 25 cpm, Temp: 36.7 C, SpO2:
98%
 C/L, (-) subcostal retractions, decreased breath sounds, (+)crackles, (+) diffuse
bilateral wheezing but with improvement of tight air entry
 Patient had a headache classified as 10/10
 Extremities: No movement of the left upper and lower extremities with
decreased sensation rated as 20%. The right upper and lower extremities
showed normal range of motion, sensation and strength.
 Labs: Other Diagnostics:
 04/16/2021:  01/11/2021:
 CBC  Large pleural based massed with central necrosis at the posterior left
PARAMETER RESULTS PARAMETER RESULTS hemithorax suggestive of a large neoplasm probably a pleural fibroma. An
RBC 4.7 WBC 12.4 (H) abscess is not entirely ruled out, suggest histopathologic correlation. Small
Hemoglobin 124 (L) Neutrophil 82.6 (H) pleural nodular thickening of the infero-psoterio-lateral aspect.
Hematocrit 0.38 (L) Lymphocyte 6.8 (L)  04/15/2021:
Morphology Normo, Normo Eosinophil 2.9  CXR – large homogenous opacity left lung pulmonary mass vs pneumonic
Platelet 267 Monocyte 7.5 consolidation
Atypical cells: Basophil 0.2  CT Scan – mild diffuse fatty liver; few cholelithiasis; multiple renal cortical
 ABG – more than adequate oxygenation cysts, bilateral, Bosniak 1; cystitis vs poorly distended bladder; consider
 BUN – 18.9 varicocele formation, right; agenesis of left common, external and internal iliac
veins, likely congenital; degenerative lumbar spondylosis
 Na – 126.2 (L)
 04/17/2021:
 K – 4.33
 Ultrasound – Mild fatty liver; Multiple gallbladder cholesterol stones with
 Crea – 0.99
probable polyps bilateral; Mild renal medical parenchymal disease with cysts,
 SGOT/AST – 22.75
multiple in the right while solitary in the left; Small cortical nephrocalcinosis,
 SGPT/ALT – 19.76 right; Consider cystitis; Atherosclerotic abdominal aorta; High normal-sized
 iCa – 1.33 (H) prostate gland with minimal central concentrations; Unremarkable sonogram of
 FBS – 215.38 the pancreas and spleen
 Chol – 211, TG – 117, HDL – 37.93, LDL – 149.77  04/19/2021:
FBS, Lipid Profile  CT-scan- Acute infarct, right frontal, temporal, parietal and occipital lobes
(right middle cerebral artery territory), mild microvascular ischemic white
 04/18/2021: matter disease and/ or demyelination, chronic lacunar infarct, left caudate
 CBC body, no acute intracranial hemorrhage, mild cerebro-cerebellar loss,
PARAMETER RESULTS PARAMETER RESULTS atherosclerotic intracranial arteries
RBC 3.5 WBC 3.2 (L)  4/21/2021
Hemoglobin 119 (L) Neutrophil 64  Motor 5/5 right extrem, 0/5 left extrem, decreased sensation (20 %) left
Hematocrit 0.36 (L) Lymphocyte 23 (L) extremeties
Morphology Anisocytosis Eosinophil 3.0  + crackles on right lung
Platelet 312 Monocyte 10 (H) 
Atypical cells: Basophil 0.0  04/22/2021
 ABG – Respiratory Acidosis, partially compensated  CBG pre breakfast
 Crea – 0.5 1. 212 mg/dl
 SGOT/AST – 29.94  Start Methylprednisolone tab 16 mg/tab, 1 tab BID for 5 days
 SGPT/ALT – 55.69 (H)  Decrease budenoside neb to 500 meq/ neb Q12
 O2 inhalation @ 4 lpm
 04/19/2021:  *early dose of salbutamol + ipratropium neb
 X-ray - Large pneumonia consolidation or new growth, left  # for headache give Ketorolac 30 mg 1 amp IV 80 for severe headache
 4/20/21 not relieved by algesia
COMPLETE BLOOD COUNT  May shift citicoline to oral form q6 NGT
RBC 4.6 Platelet 300x 109/L  Refer to Dr. Ambasing for rehab treatment
Hemoglobin 122 (L) WBC 14.5 x 109/L (H)  *patient had headache 10/10 no relieved by algesia around 12 noon
Hematocrit 0.37 (L) Neutrophils 86.5 (H)
MCV 81.5 fL Lymphocytes 5.5 (L)
MCH 26.6pg (L) Eosinophils 2.0
MCHC 326 g/L Monocytes 5.9(H)
RBC morphology Normocytic, Basophils 0.1
Normochromic

BLEEDING PARAMETERS (4/20/21)

Clotting Time 8 mins
Bleeding 3 mins

Bleeding parameters (April 20, 2021)

APTT patient’s plasma 37.90
Patient’s plasma 14.40
Control plasma 13.4
PT activity 78.3
I.N.R. 1.16
Medications:
 Dexamethasone 4 mg IV q8
 Omeprazole 40 mg IV now then OD
o shift to oral 40mg before breakfast (4/21/21)
 Amlodipine 5 mg 1 tab OD
o Put on hold if SBP < 160 – 170 (px SBP= 130) (4/21/21)
 Carvedilol 12.5 mg 1 tab OD
 Flumicil 600 mg OD
 Kiptrix 2g IV OD
 Dilatair 200 mg 1 tab BID – Day 4
 Atorvastatin 20 mg ODHS
 Levofloxacin 500 mg/tab 1 tab OD x 7 days – Day 3
 Salbutamol + Ipratropium bromide neb q 8 hours
 Budesonide neb q 12 hours
 Tiotropium Br + Olodaterol HCl (Spiolto) 1 puff OD
 Tramadol + Paracetamol (Algesia) 1 tab q6h
 Hepatek 1 cap TID
 Mannitol 50cc single dose
  Ketorolac 1 amp I.V single dose
Disposition:
 MVSQ4
 Maintain SpO2 >93%
 Monitor I & O strictly
 Maintain MAP of 110-120
IVF: PNSS 1L x 40cc/hr Diet: NGT WOF: DOB, desaturations, and signs of congestion, and
change in sensorium