PGH FormNo P-310010
Revised January 2008
Philippine General Hospital
University of the Philippines Manila
The Health Sciences Center
Taft Avenue, Ermita, Manila
“PHIC Accredited Health Care Provider”
Date Received:
Clinical Abstract
Name of Hospital / Ambulatory Clinic:
Case No. 3403752
Admission:
Date: 1/23/09
Time:
Month/Day/Year
Accreditation No.:
Philippine General Hospital
Address of Hospital / Ambulatory Clinic
am/pm
Barangay:
Taft Avenue
Ermita
Municipality / City:
Province:
Manila
Zip Code:
NCR
1000
Patient’s Clinical Record
1.
Patient Name
Last Name
First Name
2.
GUIAO
FILOMENA
Age
71
3.
Sex
□
■
Male
Female
4.
Middle Name
Printed Name & Signature of Admitting Officer
5.
Admitting Diagnosis
ARF 2 to CAP, BA in AE
NSTEMI
Hypertension St II
CVD with no residuals
Stress Hyperglycemia, t/c Type 2 DM
s/p Cataract Surgery
Present Working Impression
New onset VAP on top of non resolving VAP (Klebsiella, Pseudomonas)
UTI
Bronchial Asthma, controlled
Pulmonary Congestion, resolved
CHF FC II 2 to IHD/HHD with Bilateral Pleural Effusion and Severe MR
DM Type 2, NO, IR
With Retinopathy, Nephropathy, Cystopathy
Hypertension Stage II
Dyslipidemia
Decubitus Ulcer, L buttock and R back
Non- healing wound, left foot
Cardiogenic Shock, resolved, 2 to NSTEMI
Massive LGIB, resolved prob 2 to small intestinal bleeding
Critical Illness Polyneuropathy
ICU depression
s/p endoscopy x 2
s/p Colonoscopy with colonic polyp excision
s/p NSTEMI
s/p CVD with no residuals (1984)
s/p Cataract Surgery (1993)
6.
7.
Chief Complaint transfer from another hospital for difficulty of weaning from ventilator
Reason for Admission Further management
8.
Brief History of Present Illness / OB History:
PROFILE
Pt is a known asthmatic since childhood. Last attack was said to occur >20 years ago, which was also the last use of Salbutamol inhaler. There were no known attacks
of BA / no use of prn Salbutamol since then until only recently.
Pt is a known hypertensive since 1993, highest BP 170/100, UBP 120/80. Maintenance meds unknown to informant.
S/P CVD since 1993, as pt presented with facial asymmetry and slurring of speech. Diagnostics / medications / course unknown to informant. Pt has no residuals.
Allegedly a diabetic, circumstances of diagnosis unknown to informant. Maintenance medications unknown to informant. Pt has undergone laser eye surgery and
cataract operations (total of 3 surgeries) since 1998 at East Avenue Medical Center.
At baseline, pt is awake, ambulatory to ~50meters, and still able to do activities of daily living. Pt able to lie flat on bed.
HISTORY OF PRESENT ILLNESS
21 days PTA – Pt noted episodes of dyspnea after the New Year celebrations. There was also note of easy fatigability. At this time, pt was awake, conversant, and had
no other complaints. The episodes were relieved with Salbutamol nebulization.
18 days PTA – There was increasing dyspnea, accompanied with 3-pillow orthopnea. Pt had decreased functional capacity at this time, and was requiring Salbutamol
nebulization x 4 times a day, still with relief of symptoms.
12 days PTA – Due to persistence of dyspnea, pt then consulted at the MCU ER.
A> ARF; Bronchial asthma in acute exacerbation; CAP, HR; DM, uncontrolled. Pt was intubated and allegedly was told to have a “heart attack”. Added to PWI >
NSTEMI. Trop I = 0.12. P > ASA 80mg OD, Atorvastatin, Enoxaparin.
CXR – pneumonia on (B) lung fields, with increasing infiltrates on serial CXR
ETA revealed Pseudomonas. P> Imipinem + Cilastatin (on 4th HD), and Ceftazidime 2g q8 (on 5th HD). Pt also on Ciprofloxacin 250mg OD, Quinapril 10mg OD,
Omeprazole 40mg OD, Erdosteine 300mg BID, Humulin 70/30 16”u” q12.
Pt never weaned off from MV, as pt had episodes of desaturation during weaning.
REVIEW OF SYSTEMS
(-) fever
(-) chest pain
(-) abdominal pain
(-) urinary and bowel changes
(-) cough
(-) colds
(-) behavioral changes
(-) vomiting
PAST MEDICAL HISTORY
As mentioned above. No known history of PTB or CA.
No known drug or food allergies.
FAMILY MEDICAL HISTORY
(+) bronchial asthma – siblings, son
(-) HPN DM CA in the family
PERSONAL/SOCIAL HISTORY
Pt is a nonsmoker, and a is not an alcoholic beverage drinker. Pt is a high school graduate and previously worked in a factory.
OBGyne: G6P6
9.
Physical Examination (Pertinent Findings per System)
General Survey:
Awake, comfortable, not in respiratory distress, communicates via gestures, follows commands, (-) retractions,
Vital Signs:
BP 110/70
HR 90
RR 20
Temp 36.8C
HEENT:
Chest/Lungs:
CVS:
Abdomen:
GU/IE:
Skin/Extremities:
Pink conjunctivae, anicteric sclerae, (-)neck vein engorgement
Equal chest expansion, (+) bibasal crackles, (+) occasional wheezes
Adynamic precordium, (-)heaves/lifts, distinct heart sounds, normal rate, regular rhythm (-) murmurs
Flabby, soft, normoactive bowel sounds, (-) organomegaly/tenderness
Essentially normal
Full and equal pulses, pink nailbeds, no cyanosis/edema
Neurologic:
10. Course in the ER/Wards
01-23-09: Pt received at MICU intubated, with spontaneous eye opening, and communicates with gestures. Mech vent settings> AC mode, TV 400mL, FiO2 40%, IFR 60, PEEP 5, BUR 14.
01-24-09: Noted one hypoglycemic episode (CBG 63), still with note of crackles, tight air entry, no wheezing. Weaning was tried, as pt was put on Inspiron with FiO2 35% and O2 at 5LPM.
After 15 minutes, pt was noted to appear dyspneic, with episodes of desaturation to 60-70%. There was note of tight air entry and wheezing on all lung fields. Pt was also tachycardic. Thus,
pt was given Hydrocortisone 200mg IV and Salbutamol nebulization.
Pt was also noted to have elevated CBG at 490mg/dL, prompting administration of SAI 8”U”. insulin regimen was also shifted to Humulin 70/30 21”u” pre breakfast and predinner. Urine ketones were negative.
01-25-09: Pt awake and comfortable. Pt seen by Pulmo, to maintain current MV settings, FiO2 at 30%. No events.
01-26-09: ET tube displaced, patient was then extubated, was put on O2 mask at 10 lpm and nebulized with salbutamol. After 10 mins 02 sats
-92%, with note of diaphoresis and
tachycardia, patient was then reintubated. Seen by CVS, suggested to increase Omeprazole to 40 mg 1 tab BID, and agreed to defer ACE due to hyperK. Also seen by IDS, agreed with current
Ceftazidime and Levofloxacin medications. Service consultant suggested to decrease TV to stimulate respiration.
01-27-09: Patient had an episode of chest tightness and chest pain. Patient was found to be tachycardic, no crackles with occasional rhonchi on left basal lung field. She was given 2 doses of
ISDN 5 mg SL with relief of symptoms. Stat ECG showed no significant changes from previous. CKMB and CK total also requested. Chest UTZ was done and revealed 590 cc fluid at the right
thorax and 630 cc at the Left. Needle may be inserted 4.5-6.5 cm deep perpendicular to the mark. Patient scheduled for UTZ guided thoracentesis c/o Pulmo. Patient also for 2D-echo with
Doppler studies and for possible tracheostomy.
01-28-09: Pt awake and comfortable, still with minimal secretions via ET. There were still crackles on the (R) basal lung fields, with occasional inspiratory wheezes and rhonchi. Pt had no
complaints of chest pain. Pt has good response to dieresis, with pt maintained on negative balance and is clinically dry. Repeat CXR showed some resolution of the haziness present earlier,
together with decreasing WBC and neutrophils. Pt still noted to be breathing at ventilator BUR, but at times with efforts to breathe on her own. Pt underwent 2D-echo, results pending. Pt
seen by Pulmonary, and is for repeat chest UTZ and possible thoracentesis. Pt seen by CVS and awaits 2D echo results. Pt seen by IDS and recommends continuing current meds.
01-29-09: Pt had no new complaints, and was still breathing at ventilator backup rate, although there were some episodes of efforts to breathe spontaneously. Pt had one episode of
hypoglycemia to 47mg/dL for which pt was fed and the hypoglycemia resolved. Pt underwent ultrasound guided thoracentesis, for which there was note of fluid in the (R) spanning 3
ICS; and fluid in the(L) spanning 2½ ICS. With drainage of 500cc of hazy, straw colored free flowing fluid, nonpurulent, non-sanguinous. No episodes of desaturation nor dyspnea, and pt
was able to tolerate the procedure. Samples sent for chemistry, Q/Q, cultures, and cell block. Pt seen by ORL, with plans for tracheostomy but still no consent.
01-30-09: Pt was seen awake, with an episode of chest pain, assessed to be costochondritic in nature. No interventions were done, with relief of chest pain. Thoracentesis of contralateral
side not yet done. Pt seen by CVS, impression revised: not highly considering LV dysfunction. Pt seen by Pulmonary, assessed the pleural fluid to be transudative, and plans for repeat
thoracentesis. Pt referred to the ROD for one episode of respiratory distress - no desaturations noted, with note of sticky blood-tinged secretions. Pt was suctioned and was comfortable
thereafter.
01-31-09: Pt was seen status quo, comfortable, still breathing at mechanical ventilator backup rate. There were note of rhonchi on (B) lung fields and decreased breath sounds on the (L)
lung base. Pulmonary did chest ultrasound on the (R), where there was note of hypoechoic area spanning 1½ ICS above the (R) hemidiaphragm, with note of atelectasis, but with no safe
window for thoracentesis. Ultrasound of the (L) showed <½ ICS hypoechoic area. CVS suggested correcting potassium first before attempting weaning as this may be the cause for the
difficulty. CVS service signed out of the case. Pt was also noted to have hyperkalemia (7.1mmol/L) and thus GI solution was started. No dynamic ECG changes noted.
02-01-09: Pt seen awake, neurologically status quo. No episodes of dyspnea nor chest pain, no other complaints. Pt’s CBG was noted to be low at 54, and thus GI solution was held. Plans for
the hyperkalemia include increasing Salbutamol nebulization to q6. Pt was shifted to pressure support ventilation (P supp 18cm H2O). Pt comfortable, with no retractions nor labored
breathing. No desaturations noted. Pressure support decreased to 16cm H2O.
02-02-09: Patient was responsive and communicated through gestures. Patient was seen by IDS, occasional rales was noted. Last dose of Ceftazidime was given. Patient was also seen by
Pulmo, and they advised continue weaning/spontaneous mode as long as tolerated. They also requested for repeat ABG, and stand-by intubation as the patient’s family refused
tracheostomy. At the start, patient tolerated weaning (dec pressure support), currently comfortable with good O2 Sats at PS 6 cm H2O. Plan initially was to hook the patient to Inspiron and if
possible, further extubation. However, before these were executed, the patient became tachycardic so extubation was deferred. Patient also had 2 episodes of vomiting after feeding, thus
she was placed on NPO with tight CBG monitoring and stopping of Humulin 70/30. Abdominal findings were unremarkable. Blood chemistry revealed normal K levels, decrease glucose levels
and elevated Crea, probably due to dehydration and not necessarily renal pathology since this was the first time the patient had elevated Crea. Pleural fluid culture showed no growth after 4
days of incubation.
02-03-09: Patient noted to tolerate weaning via spontaneous mode, although there was note of increased heart rate and RR at pressure support of 8. There were no episodes of respiratory
distress, chest pain, or desaturations. Pressure support was maintained from 10 to 8 cmH2O. Patient is planned for extubation if tolerated.
02-04-09: Patient continued to tolerate PS of 8 cmH2O with no dyspnea or signs of respiratory distress. She was seen by IDS, and they advised oxygen mask at 6 lpm after extubation. The
patient was extubated in the afternoon and VS at that time were HR 100s, RR 20-28, O2 Sat of 99%. There was also note of rhonchi BLF. Nebulization with Symbicort was done for 3x 15 min
apart then q4h. IV fluids were also resumed, given D5NR to run for 8 hours. The relatives were informed of the need to do tracheostomy, and the son was advised to coach the patient to
breathe. Hydrocortisone 100 mg IV was given q8 with Symbicort 2 puffs BID. Budesonide nebulization was discontinued. Oral feeding was resumed but with strict aspiration precautions.
02-05-09: Patient tolerated extubation overnight, with stable VS. Rhonchi BLF, wheezes BLF, occasional crackles L mid-lung were noted but there were no retractions. She is for possible
transfer to W1 if with vacancy however, around 8am, the patient had respiratory distress, initially starting out as tachypnea then severe dyspnea, prompting re-intubation. There was note of
retractions, coarse crackles, wheezes and rhonchi on BLF. Mech Vent settings were shifted to AC mode. Pre and post ABG values revealed respiratory acidosis and respiratory alkalosis,
respectively but the patient had good oxygenation. CBC with PC and DC, Na, K, Cl, BUN, Crea, ETA GS/CS, blood GSCS and Chest X-ray were done because there was a consideration of new
onset VAP, and the patient is on Salbutamol nebulization. Patient was seen by IDS and they agreed with the plan of shifting Levofloxacin to Piper-Tazo 4.5 g q8. Latest blood chemistry values
revealed increased BUN/Crea of 24 with A> Prerenal Azotemia secondary to sepsis or dehydration. Latest CBC findings revealed a further increase in WBC counts while latest chest x-ray
showed increasing infiltrates especially in the RLF, which support the consideration of new onset VAP.
02-06-09: Patient was seen by ORL for possible tracheostomy and they advised that Aspirin and Heparin be discontinued 3 days prior to OR. She also had bloody secretions per suction on ET
and 200 cc of residuals per NGT. Oral feeding was held, as well as aspirin and heparin. ABG values revealed respiratory alkalosis and hypoxemia but with good oxygenation so IER was changed
to 1:2. Furosemide was also discontinued. Chest physiotherapy was instructed, and Pulmo Rehab was continued.
02-07-09: Patient was stable, with no respiratory distress and appeared comfortable. The patient was seen by IDS and bed sore precautions were advised. Hydrocortisone was discharged
because asthma was controlled. ABG results showed compensated metabolic acidosis with improving oxygenation. Blood chemistry values revealed BUN: Crea of 35 and hypokalemia.
Salbutamol nebulization was then decreased to q12 instead of q6. There was also moderate growth of Klebsiella pneumonia ESBL which was resistant to Pip-Tazo but sensitive to Meropenem
and Ertapenem. A consideration of shifting of antibiotics is warranted.
02-08-09: The patient was asleep most of the time but arousable. She was seen by Pulmo, and they suggested shifting of mech vent settings from AC mode to SIMV mode. IDS suggested
shifting of Pip-Tazo to Ertapenem 1g IV OD to cover the pathogen. Goals for this patient were to shift antibiotics and to finally wean off the patient from vent support by tracheostomy. The
patient is also for inclusion in the Doripenem study of IDS. Patient was also seen by ORL, and they requested clearance for Tracheostomy/GA, repeat PT/PTT and neck STAPL. The patient had
another episode of hypoglycemia (48) with stable vital signs, drowsy but awakens when tapped. She was given 1 vial of D50-50 which improved CBG values to 99. Humulin was put on hold
and to be shifted to NPH. Patient was also referred for 0 urine output for 1 shift but abdominal findings. She was given Furosemide 20 mg IV and response was observed. Blood CS revealed
no growth after 2 days.
02-09-09: The patient was seen comfortable, mostly sleeping but arousable. Oral feeding was started 1.5: 1 dilution. Humulin was held because of hypoglycemia (55) and CBG monitoring was
done BID premeals. Clearance for tracheostomy will be secured as soon as the patient has been off Aspirin for 7 days. Oral KCl 10% solution was started 30 cc TID for 3 doses because of
hypokalemia and Salbutamol nebulization of the patient. Co-managing services just advised continuation of present medications and management.
02-10-09: Patient was awake and alert most of the day. IDS advised that the patient be placed on high back rest and if tolerated, be shifted to Inspiron. ORL scheduled the operation possibly
on February 11, 2009 and asked that heparin be withheld. Since CBG values remained normal despite the absence of Humulin, it was temporarily discontinued. CBC revealed a hemoglobin
value of 85 so PBS with reticulocyte count, FOBT, blood typing, cross-matching and repeat ETA GSCS were ordered to rule out occult gastrointestinal bleed and work-up on the cause of
anemia. Because of this, the patient is for transfusion of 2 units pRBC for 4 hours and for post-blood transfusion CBC. Clearance for tracheostomy will be given once the patient has been 7
days off aspirin as there is an increased risk of hematoma formation, thus, OR rescheduling was done. Patient was referred again for poor urine output and increased flushing volume to 50
cc/flushing was done. Bladder training was also recommended. The patient was also referred for chest pain: (-) point tenderness, found on the L anterior chest wall. Stat ECG was done which
revealed sinus tachycardia, normal axis and non-specific ST wave changes. Patient was given Tramadol 50 mg IV which relieved the pain. Patient was stable afterwards.
02-11-09: There was no recurrence of chest pain which was most probably costochondritic in nature. Patient has stable vital signs. Anemia was attributed to iron deficiency because the
peripheral blood smear revealed microcytic, hypochromic RBCs. Patient was then given FeSO4 325 mg/tab 1 tab TID, prefeeding after stool exam. It is to be given 2 hours apart from
Omeprazole because it might cause malabsorption. Diaper is to be weighed and elastic bandage is to be applied since the patient will be off from Heparin. Patient also complained of
abdominal pain which could be secondary to ileus from her diabetes (diabetic gastropathy).
02-12-09: Patient was referred for abdominal pain, no bowel movements for 2 days, (+) residuals per NGT. Patient was placed on NPO and hooked to IVF 1L D5NR x 12 hours x 2 cycles. OR
scheduling can be done as patient has been off aspirin for 7 days, heparin has been discontinued and clearance for OR has been secured. Foley catheter done resulted in a urine output of 1L
so intermittent catheterization was requested. Urine GSCS and urinalysis were also ordered. Patient was only able to defecate once in 2 days so she was given Bisacodyl suppository for 1
dose. FOBT has been deferred until the patient defecates. Blood transfusion was done with 2 units pRBC prior to OR and to address the anemia. Neck STAPL was retrieved and placed at bed
side for viewing of ORL before tracheostomy. The patient did not complain of any other symptoms and seemed more comfortable than she has been the past few days.
02-13-09: The patient did not have complaints of abdominal pain as she was able to move her bowels. FOBT was not sent however, because she was given Ferrous sulfate. CBC, and
electrolytes results were normal. Creatinine was still elevated and showed prerenal azotemia. Urinalysis showed lesser yeast cells after her catheter was removed. Light growth of
Acinetobacter baumanii was noted on the ETA CS which may be a contaminant from the MV tubes.
02-14-09: Patient continued to have stable vital signs. No new problems noted. Crackles, secretions were noted to be decreasing and no febrile episodes were noted.
02-15-09: CBC was done which revealed leucocytosis of 12.87, with neutrophil predominance. Anemia was also noted at 111. Urinalysis revealed proteinuria of +3, and 1+ hyphal
elements/yeast cells with 1-2 RBC and WBC. Occasional bacteria was also seen. Chest x-ray was also done and no apparent changed from previous x ray(last 2/11/09) was noted. ORL
saw the patient and a tentative schedule was arranged 3 days after. Patient remained stable with input of 2512 and output of 800, intermittent cathetherization still done. High back
rest, CPPT and frequent suctioning continued.
02-26-09, Patient had 3 episodes of hematochezia with melena. BP dropped to 80/50 but she was resuscitated with NSS 1500mL and BP went up to 110/70.
02/28/09, Patient referred to GI med and Surgery for EGD and Colonoscopy. EGD revealed (?) ulcers and multiple erosions
03/03/09: Patient is currently being weaned from MV, current settings, SIMV: TV 350, BUR 6, Psupport 6, FiO2 35%, Trigger 2lpm, I:E 1.3.
03/05/09: Patient had 3 episodes of hematochezia w/ melena ~3 moderately soaked diapers. EGD done yesterday, no note of source of bleeding. Patient was transfused with 3 “u” pRBC
and was prescribed Somatostatin 250 mg IV bolus then Somatostatin drip 3 mg in D5W 250 cc x 12̊ but was not able to adhere due to insufficient funds. Patient was referred last night
(8:15pm) for CBG of 381 was given 6 ‘u’ of regular insulin sc  223.
03/07/09: Patient had normal ABG yesterday afternoon. She was put on tracheostomy mask for 1 hr and repeat ABG show uncompensated respiratory acidosis. Patient was then again
hooked to mechanical ventilator, CPAP mode, Psupport of 10, PEEP of 5 and FiO2 0f 35%. No episodes of bleeding. No hematochezia. No melena.
03/09/09. Patient was not able to tolerate inspiron for 5 minutes. (for three consecutive days now) Patient became tachycardic (HR=120s), O2 sats 80’s, in respiratory distress (RR=30’s with
use of accessory muscles). CPAP mode, Psupport of 6, PEEP of 5 and FiO2 0f 35%. No episodes of bleeding. No hematochezia. No melena. Patient’s antibiotics were shifted to ampicillinsulbactam 3g IV q6 and amikacin 750mg OD.
03/14/09 Patient was maintained on Mechanical Ventilator, AC mode, TV 400mL, FiO2 30%, BUR 14cpm, PEEP 5mmHg. Patient had an episode of hematochezia, ~400mL of soft, reddish
stools, (-) epigastric pain. Vital signs at the time were 140.80mmHg, 82bpm, 18cpm. Patient was awake, able to follow commands, and not in cardiorespiratory distress. CBC was taken and
saline gastric lavage was done, which revealed clear fluids. Assessment at the time was LGIB, probably secondary to angiodysplasia vs diverticulosis vs malignancy, versus heparin-induced.
ASA was put on hold and plan of heparinization was discontinued. Omeprazole was increased to 40mg BID. Patient is currently on MV: Vol - SIMV Mode - TV 400ml BUR 10 PEEP 5 PS 8 FiO2
30%
Patient has been repeatedly tried to be weaned off from mechanical ventilator but has desaturation episodes during weaning.
Patient is being seen by cardio, pulmo, IDS, GI, rehab, hospice care and psychiatry.
At present, family and financial support is very weak.
11. Pertinent Laboratory and Pertinent Diagnostic Findings: (CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc.)
BLOOD TYPING A+
CBC
04/15: Hgb 112, Hct 0.325, Plt 240, WBC 12.84, N 0.575, L 0.231, M 0.125, B 0.067, E 0.002
04/11: Hgb 120, Hct 0.356, Plt 244, WBC 16.02, N 0.634, L 0.212, M 0.074, B 0.072, E 0.002
04/09: Hgb 129, Hct 0.374, Plt 220, WBC 15.3, N 0.677, L 0.153, M 0.077, B 0.070, E 0.001
04/06: hgb 125, hct 0.386, plt 261, wbc 15.50, N.810, L.103
04/05: hgb 73 Hct 0.221
04/01 Hgb 108, Hct 0.335, Plt 337, WBC 14.80, N 0.617, L 0.258
03/29: Hgb 105, Hct 0.318, Plt 349, WBC 15.19, N 0.69, L 0.23
03/26: Hgb 101, Hct 0.312, Plt 247, WBC 13.30, N 0.681, L 0.0218, M 0.092, E 0.004
03/23: Hgb 110, Hct 0.332, Plt 217, WBC 16.55, N 0.591, L 0.335, M 0.069, B 0.001, E 0.004
03/21: Hgb 114, Hct 0.349
03/18: WBC 11.98 Hgb 124 Hct 0.357 Plt 173 N 0.651 L 0.256 M 0.071 E 0.020
03/15: WBC 11.6 Hgb 130 Hct 0.400 Plt 205 N 0.706 L 0.194 M 0.088 E 0.008 B 0.005
03/13: WBC 10.70 Hgb 98 Hct 0.295 Plt 190 N 0.732 L 0.174 M 0.088 E 0.005 B 0.001
03/12: WBC 20.60 Hgb 121 Hct 0.371 Plt 180 N 0.869 L 0.076 M 0.049 E 0.002 B 0.005
03/09: WBC 16.75 Hgb 119 Hct 0.339 Plt 166 N 0.782 L 0.152 M 0.053 E 0.007 B 0.001
BLOOD CHEMISTRY
04/15: Glu 9.72 BUN 8.57 Crea 75 AST 75 ALT 107 Na 121 K 5.7 Cl 88
04/06: BUN 9.08 Crea 79 AST 74 ALT 101 Mg 0.97
03/31: BUN 6.4 crea 76 Alb 15 Mg 0.71 Na 128 K 3.9 Cl 92
03/29: K 4.1
03/28: Mg 0.99, K 5.90
03/26 Crea 95 Alb 16 low, Mg 0.71, na 132 low, Na 132 low, K 3.4 low, Cl 95 low
03/23: plasma K 5.1
03/22: Crea 95 Mg 0.84 Na 136 K 6.5 Cl 100
03/20: Alb 17 low, Ca 1.92 (2.38), Mg 0.88, K 4.4
03/18: Crea 93 N a 138 K 3.1 Alb 16 Mg 0.73 Phos 0.92
03/16: BUN 4.54 Crea 100 Alb 15 L Ca 2.21 Mg 0.97 P 0.84
03/15: Ca 4.98 Na 143 K 4.4 Cl 109
03/14: Trop I: 0.685 ng/mL (20x)
03/12: Trop I: 0.84
03/12: BUN 8.41(H) Crea 122(H) AST 50(H) ALT 56 Ca 1.97(L) Mg 0.89 Na 137 K 3.8 Cl 101
CKMB 28.5(H)  13.1 CKTot 80  110 (12:44pm  18:24pm)
03/10: Crea 136(H) Alb 19(L) Ca 1.98 (2.4)(L) Mg 1.06(H) Na 136 K 5.8 Cl 100
03/09: Mg 0.65(L) Na 144 K 4.4
PT
04/15: 11.8/12.2/0.8/1.17
04/05: 11.8/12.2/0.80/1.17
03/26:
03/22: 11.8/10.5/>1.0/1.01
03/13:
03/12: 11.7/12.1/0.87/1.16
PTT
35.1/48.4
35.1/48.4
35.3/40.2
36.8/36.8
35.7/51.2
35.7/>240
ABG
04/10: FIO2 30, pH 7.465, PCO2 29.50, PO2 58, HCO3 21.50, BEb -0.8, O2 sat 92.10
04/09: FIO2 40, pH 7.434, PCO2 32.10, PO2 74, HCO3 21.70, BEb -1.2, O2 sat 95.30
03/29: FIO2 35, pH 7.406, PCO2 31.10, PO2 82, HCO3 19.80, BEb -3.5, O2 sat 96.40
03/28: FiO2 35, pH 7.436, PCO2 74, HCO3 22.3, BEb -0.8, O2 sat 95.3
03/25: (7:00pm): FiO2 100%, PH 7.379, PCO2 27.40, PO2 101, HCO3 16.30, BEb -7, O2 st 97.80%
03/24 (7:12pm) RR 26 FiO2 35% pH 7.461 pCO2 33.50 pO2 81 HCO3 24.10 Beb 1.3 O2st 96.60%
03/23: RR 26 FiO2 35, pH 7.421, pCO2 36.5, pO2 75, HCO3 24, Beb 0.4, O2 sat 95.30
03/21: (18:56) RR: 22 FiO2: 35% Hgb 12.40 T 35 pH 7.435 pCO2 40.00 pO2 86 HCO3 27.10 Beb 3.3 O2st 96.40
03/21: (12:08): RR: 24 FiO2: 35% Hgb 14.50 T 37 pH 7.41 pCO2 44 pO2 65 HCO3 28.10 Beb 3.5 O2sat 92.30%
03/18: RR: 18 FiO2: 30% Hgb 12.40 T 36.6 pH 7.460 pCO2 36.90 pO2 78 HCO3 26.60 Beb 3.3 O2st 96.40
03/16: RR: FiO2: 30% Hgb 13 T 36.7 pH 7.446 pCO2 36.0 pO2 76 HCO3 25.1 Beb 1.8 O2 sat 95.90%
03/15: RR: 20 FiO2: 30% Hgb 9.8 T 36.9 pH 7.465 pCO2 36.6 pO2 64 HCO3 26.2 Beb 3.1 O2 sat 93.60%
03/14: RR: 21 FiO2: 30% Hgb 98 T 36.3 pH 7.44 pCO2 29.6 pO2 111 HCO3 20.80 TCO2 21.7 Beb -2.1 O2 sat 98.70%
03/13: pH 7.496 pCO2 32.50 pO2 91 HCO3 25.3 TCO2 26.20 BEb 3.2 O2 sat 97.70%
03/12 (12:28): pH 7.283 pCO2 43.80 pO2 46 HCO3 20.9 TCO2 22.3 BEb -4.9 O2 sat 75.90%
03/12 (10:22): pH 7.406 pCO2 36.80 pO2 36 HCO3 23.4 TCO2 24.5 BEb -0.4 O2 sat 69.90%
03/12 (05:29): pH 7.381 pCO2 37.50 pO2 65 HCO3 22.5 TCO2 23.7 BEb -1.7 O2 sat 92.50%
03/10: pH 7.441 pCO2 37.80 pO2 110 HCO3 26.3 TCO2 27.50 BEb 2.3 O2 sat 98.70%
03/09 (18:43): pH 7.376 pCO2 38.40 pO2 66 HCO3 22.7 TCO2 23.90 BEb -1.6 O2 sat 92.30%
03/13 (13:25): pH 7.463 pCO2 36.50 pO2 68 HCO3 26.1 TCO2 27.90 BEb 3.1 O2 sat 98.50%
URINALYSIS
03/28: yellow, slightly hazy, 1.005, pH 7, sugar 1+, protein 4+, RBC 2-4, WBC 8-12, yeast cells rare, hyaline cast 0-1, crystals negative, EC few, bacteria few, mucuc threads few
03/23: yellow, hazy, sg 1.010. ph 6, sugar (-), prot 2+, rbc abundant, wbc 15-20, EC rare, crystals (-), bac few, MT (-), rbc morph 100% normal
03/22: Yellow, turbid, sg 1.005, pH 8, sugar neg, prot +1, RBC abundant, WBC 5-13, yeast cells few, epith cells few, bac few, MT occ’l, cast (-), crystals (-)
03/13: yellow/turbid/1.010/6.5/CHO(2+)/CHON2+/RBC abundant/WBC3-5/yeast 1+/EC 1+/bac Occ/MT rare/cast coarse granular2-5 fine granular0-3 waxy1-2/crystals (-)
03/10: lt. yellow/clear/1.005/7.0/CHO(-)/CHON1+/RBC 28-31/WBC1-3/yeast occ/EC few/bac rare/MT occ/cast(-)/crystals (-)
URINE STUDIES
4/10: >100,000 colonies/mL of Citrobacter freundii (S: Imipenem, Meropenem, Nitrofurantoin; I: Pip-Tazo; R: Amikacin, Ampicillin, Ampi-sulbactam, Cefepime, Ceftazidime, Ceftriaxone, Vancomycin)
3/28: No growth after 2 days
03/06: Urine CS 50,000 colonies of A. baumanii per mL of urine (R:Amikacin, Ampicillin-Sulbactam, Cefepime, Ceftazidime, Gentamycin, Imipenem, Meropenem, Piperacillin-Tazobactam, TrimehtroprimSulfamethoxazole, Minocycline 48.0)
03/06: Urine GS PMN >25, Yeast >25
TRACHEAL ASPIRATE CULTURE
4/10: CS: moderate rowth of A. faecalis (MIC: intermediate to Imipinem at 8.0)
4/10: GS:pmn <10, sec <10, gram neg bacilli 3-5
03/23: CS moderate growth Klebsiella ozalnae (S: amikacin, cefepime, imipenem, meropenem, nitrofurantoin; I: pip=tazo; R: ampicillin, ampi sulbactam, ceftazidime, ceftriaxone, cefuroxime, gentamicin, trimesulfa)
CS moderate growth of Psuedomonas auriginosa (S: cefepime, ceftazidime; I: ciprofloxacin, pip-tazo; R: amikacin, gentamicin, imipenem, meropenem)
03/23: PMN 2-15, SEC 0-2, g(+) cocci in chain 0-5, g(-) bac 0-5, g(+) bac 0-10
03/17: MIC of Alk Faecalis: Amikacin > 256 ug/mL and Ceftazidime >128 ug/mL
03/15: Very light growth of alkaligenes faecalis
BLOOD CULTURE
4/10: No growth after 5 days
03/18: No growth after 5 days
03/15: No growth after 2 days
EGD
03/05: Colonic polyp, rectosigmoid colic, external hemorrhoids
CHEST XRAY
03/25: (+) pleural effusion on right lung with note of cephalization on left upper lobe
03/19: (+) decreased pleural effusion compared to previous films; (-) active infiltrates
KUB-UTZ
03/17: To consider renal parenchymal disease, bilateral; Normal ultrasound of the urinary bladde
2D Echo and Doppler Studies
03/26: Provisional Report Concentric Left Ventricular Hypertrophy with good wall motion and contractility and preserved overall systolic function; Aortic sclerosis; severe mitral regurgitation; severe tricuspid
regurgitation; pulmonic regurgitation; pulmonic regurgitation; mild to meoderate pulmonary hypertension; posterior mitral annular classification; minimal pericardial effusion or pericardial fat pad
EF=71%
12.
Surgical Operation:
Date: ____________________
Time: ____________________ am/pm
Printed Name & Signature of Surgeon
(Month/Day/Year)
Type of Anesthesia:
13.
Printed Name & Signature of Anesthesiologist
Discharge:
a. Date: _____________ __
(Month/Day/Year)
b. Time: ____________________ am/pm
c. Final Diagnosis:
__________________________________________________
__________________________________________________________________________________
d. Condition on Discharge:
____________________
e. Signature of Attending Physician:
14.
Signature or Right Thumbmark of Patient or His/Her Representative:
Printed Name & Signature of Patient or His/Her Representative
Right Thumbmark
(In case patient and representative cannot write)
Printed Name & Signature of Witness to Thumbmark
/aljolar2008