INFECTIOUS AND PULMONARY MEDICINE CENSUS
August 28, 2010 (Saturday)
Consultants-in-Charge: Dr. Lanzona/Dr. Bergsntin
Total no. of patients = 12 Infectious Main = 6
Admission/s = 0
Discharged =0
PATIENT
209A (pulmo)
Domingo, Pilar
83/F
CC: difficulty of
breathing
DOA: 08/24/10
04-47-36
10H00573
DIAGNOSIS
1)
2)
3)
4)
Chronic cough
prob secondary to
lung new growth
t/c CAP
DM type 2
CAD/ASHD,
incomplete RBBB,
HPN stage 2
CIC: GV
Alt: Jae Joyce
221 B (Pulmo)
MIRANDA, Nestor
58/M
CC: Dyspnea
DOA: 07/21/10
06-93-70
10G00466
CIC: Steph
Alt : BInx, Tal
Admitting Diagnosis: Pleural
effusion, right s/p CTT insertion
and removal (June 2010). PTB
on treatment. t/c HAP
Working Diagnosis:
Problems:
1)
Pleural effusion,
right, s/p CTT
insertion (June,
2010)
2)
Acute Respiratory
failure secondary
to Hospital
Acquired
Pneumonia
3)
Pulmonary
Tuberculosis,
Class III, on
treatment
4)
Protein energy
malnutrition
5)
Acute Gastritis (H.
Pylori positive)
6)
Hepatic nodule,
t/c TB
7)
Chronic
Obstructive
Pulmonary
Disorder
Fellows-in-charge: Dr. Jardinico/Herrera/Untalan
Pulmo Main = 6
Transferred = 0
Co-managed = 1
Expired = 0
Residents-in-Charge: Drs. Ramirez/Cuenza/Lim
DAMA = 0
THERAPEUTICS
LABORATORIES AND PROCEDURES
PENDING
Ertapenem 1g/IV
Azithromycin 500mg 1
tab od x 3d
Combivent neb. 1 neb
q6h
Telmisartan 80mg/tab
od
ISDN 5mg/tab 1 tab
sublingual prn
ISMN 30mg/tab od
Actrapid 5units/SC
(hold if CBG
<180mg/dL)
CBG tid & hc
Atorvastatin 20
mg/tab ODHS
Trimetazidine
35mg/tab BID
Fluimucil 600mg/tab
in 100cc water BID
Clopidogrel 75mg/tab
1 tab OD
Omeprazole 20mg/tab
1 tab ODHS
08/25 SGPT/ALT 12.15 normal, Hba1c 6% normal
08/24 CBC Hgb 132 RBC 4.38 HCT 0.39 MCV 89.3 MCH 30.2 MCHC 33.8 RDW 13.8 MPV 7.6 platelet 353 WBC 8.9 neutrophils
0.68 segmented 0.68 lymphocytes 0.30 eosinphils 0.02
08/24 Creatinine 0.87, Na (low) 135.00, K 4.8
08/24 Troponin I 0.03 ng/mL
08/24 ABG: pH 7.38, PCO2, 37.9, PO2 125.3 HCO3 22.4, O2 sat 98.3%, AaDO2 43.7, a/A 0.74, P/F 417.67, DFiO2 6.83
08/24 ECG: incomplete RBBB
08/24: CXR initial read – (+) consolidation on ® middle lobe, (+) opacification on superior segment of ® lower lobe, (+) denities on (B)
apex
2D echo with Doppler
12 L ECG official result done
8/25/2010
Record of hospital admission last
year
CT scan and biopsy results to
chart
UTZ of liver and bone scan – wait
for carry out orders
KCl durule 2 durules
TID x 4 doses
Pre-BT meds
Diphenhydramine 5
mg/cap
Paracetamol 500
mg/tab
Myrin P Forte 3 tabs
pre breakfast (6/2010)
– 1 month
Doripenem 500mg/iv
q8h
Omeprazole 20
mg/tab BID
Vitamin B complex 1
tab OD
Hypermellose
eyedrop 1 gtt OU qid
Budesonide neb q2
Duavent q 6h
Fluimucil 600mg/tab,
2 tabs
Tinzaparine 0.35
ml/SC OD
TMP-SMX
800/160mg/tab 1 tab
q12H for 7 days
Fluconazole
REFERRAL and COMANAGEMENT
Comanaged with CV
Med
Referred to:
Medical Oncology
IR
WOF: chest pain, signs of
respiratory distress
8/25 Hgb 88 Hct 0.26 WBC 29.8 Plt 350 Neutro 0.94 Mono 0 Lym 0.06 Eo 0
8/25 Na 133, K 3.37 low
8/25 PT 13.4 Norm cont 12.0 PT Ratio 1.1 INR 1.1 aPTT 37.8 NC 36.1
8/13 sputum CS staph hemolyticus few; sensitive to cholramphenicol, TMP-SMX, clindamycin, Vancomycin, tetracycline. Resistant to
azithromycin, erythomycin, ciprofloxacin, gentamycin, oxacillin, penicillin
8/13 plueral fluid fungal cs: no growth after 21 days
8/12 Hgb 104 hct 0.31 plt 440 WBC 35.10 Neutro 0.94 bands 0.04 seg 0.90 lympho 0.06 Total protein 6.02 alb 2.14 globulin 3.90 A/G
ratio 0.60 blood culture: no growt after 5 d incubation on both arms
8/10 ET GS: no microorganism, PMNs +3, squamous few
8/9 Crea 0.72 iCa 1.08 Na 142 k 2.76
Hgb 98 rbc 2.95 hct 0.29 wbc 41.8 platelet 229 seg 0.98 lympho 0.02
8/7hbg 123 rbc 2.95 hct 0.29 wbc 41.8 platelet 229 seg 0.98 lympho 0.20
8/4 Na 137 K 4.15
8/4 CBC Hgb 121 RBC 3.55 Hct 0.36 MCV 100.00 MCH 34.10 MCHC 34.10 RDW 18.30 Plt 332 WBC 39.20 Neutrophils 0.96
Segmenters 0.96 Lymphocytes 0.04
8/3 Total Protein 6.83, Albumin 2.42, Globulin 4.40, A/G Ratio 0.50, Na 138, K 3.17
8/3 PT 12.1, Normal Control 12.5,PT ratio 1.0, INR 1.0, aPTT 37.3, Normal Control 34.3
8/2 Pleural fluid fungal CS: no growth after 10 days incubation
7/30 Total Protien 6.74, Albumin 2.29, Globulin 4.40, A/G Ratio 0.50
7/28 Culture and Sensitivity (Pleural fluid): no growth after 5 days of incubation
7/28 Culture and Sensitivity (Blood, Right Arm): No growth after 5 days incubation
7/28 Culture and Sensitivity (Blood, Left Arm): No growth after 5 days of incubation
7/27 PT 14.0, Normal contral 12.4, PT ratio 1.1, INR 1.1; aPTT 52.5, normal control 34.4
7/26 crea 0.52
7/26 CBC Hb 125, RBC 3.72, Hct 0.38, MCV 100.9, MCH 33.6, MCHC 33.2, RDW 17.5, MPV 6.2, Plt 400, WBC 30.8, PMN 0.93, seg
0.93, lymph 0.06, eo 0.01
7/26 ECG Sinus tachycardia, low voltage in all limb leads,right bundle branch block pattern, persistent posterobasal forces
7/26 Portable CXR official reading: Follow-u study when compared to the one done 7/25/10 shows partial resolution of the pleural fluid
on the right. The visualized portions of the right upper lobe shows inhomogenous opacities, with air bronchogram, suggestive of
consolidation. There is slight prominece of the visualized left upper lobe vessels. This may be secondary to patient’s position when film
1
Change IV site q 3 days
Increase K in diet
Transfusion 1 u pRBC 8/26/10
Peripheral smear retrieved
For tracheostomy
For ABG, CT guided biopsy, palliative
RT deferred due to financial
constraints
IR –CT Guided Biopsy DEFERRED
Pulmo –
- For ET aspirate AFB smear
EEG
Request 2D echo
Repeat ABG 8/14
Repeat serum K
For CT-scan guided biopsy –
INFORM FINAL SCHEDULE
Refer to Rad Onco for evaluation &
management (re: SVC)
For SGPT on next blood extraction
TMX-SMX – Antimicrobial sheet
Still awaiting for blood culture at 2
different sites
CV
GI
DOTS
Dietary
Ophtha
TCVS
Urology
Interventional
Radiology
8)
Glaucoma
suspect,
Pinguecula
Grade I prostate
enlargement,
asymptomatic
s/p ET intubation
8/8/10
s/p NGT -8/8/10
s/pon mechanical
ventilator -8/8/10
Loculated pleural
effusion
SVC syndrome
DVT LLE>RLE
200mg/cap OD for 14
days
Levofloxacin
750mg/tab, 1 tab OD
D/C Doripenem
Paracetamol
500mg/tab q4 prn for
temp 38.5 and above
Admitting diagnosis:
Acute respiratory failure
secondary to community
acquired pneumonia
Septic shock secondary to CAP
CAP, high risk
Bronchial asthma in acute
excacerbation
HPN Stage 2
Acute gastritis, DM Type 2
Fluimucil 600 mg/tab
in ½ glass water,
BIUD
Hexetidine
mouthwash in padded
tongue depressor,
TID
Paracetamol 500
mg/tab prn
Omeprazole 40
mg/tab, OD
Clarithromycin 500
mg/tab, BID
CaCO3 1 tab OD
Novorapid 8 u/SC
prefeeding q4
Montelukast 10mg/tab
OD
HAA 100mg/IV q8
Levemir 30 u/SC OD
Doxycycline
100mg/cap BID
Dulcolax 200cc
ODHS
KCl sachet 2 durules
QID x 10 doses
Levofloxacin 750
mg/tab OD
ILN with duavent q2
ILN with budesonide
q8
Oral hygiene usi,
HMW TID
Fluimucil 600mg/tab
in ½ glass water BID
Esomeprazole
9)
10)
11)
12)
13)
14)
15)
221 D (Pulmo)
Hababa, Manuel
Sr. Ruiz
61 y.o./M
10H00524
07-11-43
CC: Difficulty of
breathing
DOA: August 23,
2010
CIC: Christine
Alt: Angie, Irish
223-A (ID)
Pingol, Brigida
Segador
77/F
Admitting diagnosis:
Sespsis secondary to CAP
CAP, high risk
Sacral ulcer, Grade IV
ASHD, CAD, t/c ACS NIF Class
was taken. However, beginning pulmonary congestive changes cannot be totally ruled out. There is now minimal blunting of the left
costophrenic sulces, which could be due to minimal pleural fluid. Minimal resolution of the previously noted minimal interstitial infiltrates
is noted at the left paracardiac area.
7/25 Poratble CXR official reading: follow-up examination to 7/22/10 now shows reaccumulation of pleural fluid on the right side.
Minimal interstitial densities are also seen in the left paracardiac area. The rest of the chest findings remain unchanged
7/24 Chest CT with contrast (initial reading): diffuse right pleural thickening inluding the minor and major fissures showing mediastinal
extension, as described, showing confluent soft tissue densities with calcifications in RUL for which the possibilities of pulmonary mass
is not ruled out. Large loculated pneumohydrothorax, Right posterior hemithorax with other loculated pleural fluid connections as
described that can be due to empyema causing relaxation atelectasis of the right mid and lower lobes. Consolidation in the right mid
and lower lobes with interstitial alveolar infiltrates in the RUL that can be pneumonic or granulomatous. Relaxation atelectasis, right mid
and lower lobe.Small bullae, superior basal segment of left lower lobe. Compensatory hyperinfiltration, left. Incidentally, hepatic nodules
as described.
7/23 CBC Hgb 130 RBC 3.82 Hct 0.38 MCV 98.60 MCH 34.0 MCHC 34.50 RDW 17.50 Plt Ct 3.88 WBC 27.10 Neutro 0.90 Lympho
0.10
Na 135 K 3.99
AFB stain: no AFB seen; GS: no microorganism seen KOH: no fungal elements seen
7/23 Pleural fluid: Color yellow, vol 50ml, transparancy slightly turbid with coagulum, supernatant light yellow clear with small red
sediment; microscopic findings: total RBC 250/cu mm, total WBC 200/cu mm, lym 01%, mono 99%
7/23 CXR: Follow up study when compared to the one done on 7/21/10 shows diminution of the right sided pleural effusion. Mixed
interstitial and alveolar infiltrates are now seen in the right lung, which may represent pneumonia. The right parahilar and paracardiac
areas remain obscured, for which a chest CT may more informative. To rule out mass lesion. The rest of the chest findings remain
unchanged.
7/21 HBA1c 5.81
7/21 ABG pH 7.381 pCO2 44.3 pO2 83.6 FIO2 50% HCO3 96.0% AaDO2 222.4 a/A 0.27 dFIO2 49.28 P/F 167.2
7/21 ECG Normal sinus rhythm, incomplete right bundle brancg block, low voltage in all limb leads
7/21 CXR official reading: cardac size can’t be properly evaluated. There is a homogenous density occupying the right mid and lower
lung areas, with ribbon-like density which may represent pleural effusion. A confluent density is seen over the right suprahilar area.
On the lateral view, this is posterior in location. Suggest CT scan correlation to rule out the possiblity of superimposed mass lesion
over the right suprahilar area.
8/27 ET aspirate AFV stain: no acid fast bacilli seen
8/27 SGPT-ALT 78.84, Na 142, K 2.93
8/26 Sputum in suction catheter day 2: no acid fast bacilli seen, PMN 0-5/lpf, sq. epith. Cells 0-5/lpf
8/26 pH 7.420, pCO2 55.2 pO2 234.2 FiO2 60 HCO3 36.4 O2 sat 99.6 dFiO2 24.92 P/F 3.90
8/26 Na 142, K 2.94
8/25 PT 14.6, NC 12, PT Ratio 1.2, INR 1.2
8/25 Crea 1.14, Na 150, K 2.93
8/24: Chol 83.31, Tg 107.44, HDL 27.74, LDL 28.60, iCa, 1.10, Hba1c 6.53
8/23 ET tube C/S: negative for bacterial growth
8/23 Grams stain: gram (+) cocci in pairs: few, PMN leukocytes: +++, squamous epithelial cells: few
8/23: AFB stain: no acid fast bacilli seen
8/23: CXR: Interstitio-alveolar infiltrates are seen on both lung fields, which may be secondary to a pneumonic process.
Cardiomegaly. Sinuses are intact. Ovoid semi-circumscribed densities are seen on the left upper and left paramedian area. This may
be secondary to a confluence, however, pulmonary nodules cannot be totally ruled out. A cystic lucency is seen in the right upper lung
which may represent bullous formation. Tip of ET tube is seen at T3-T4. NGT is seen in place. The main pulmonary artery appears
prominent which may be indicative of pulmonary hypertension. Please correlate clinically.
8/23: 12-L ECG: Sinus tachycardia. Old inferior wall infarct. Premature atrial complexes.
8/23: Hgb 138, Hct 0.43, Plt 255, WBC 11.30, Neutrophils 0.75, Na 141, K 3.12, Cr 1.22, Urea Nitrogen 29.79, SGPT – ALT 77.55
8/23: pH 7.454, pCO2 58.6, pO2 86.8, FiO2 60%, HCO3 41.1, O2 sat 96.9%, dFiO2 57.02, P/F 1.44
8/26 PT 14.3, NC 12, INR 1.2
8/25: CBC Hgb 90 RBC 2.60 Hct 0.27 MCV 105.40 MCH 34.70 MCHC 32.90 RDW 18 Plt Ct 364 WBC 31.60 Neutro 0.97 Lympho 0.03
8/25: BUN 31.73, Crea 0.95, SGPT 10.81, Na 134, K 4.04, Troponin I 0.30
8/25: Portable CXR (initial): reticulo-nodular infiltrates diffusely over both lung fileds more predominately on the right basal area. Heart
is not enlarged. Diaphragm and sinuses are intact. Aorta is sclerotic. ET tube is noted with its tip at T4. NGT is noted. There is
2
Pending:
2D echo with Doppler
For pulmo parameters (8/28)
Referred to:
GI Med
Endo
Ophtha (when stable)
DM center (upon
discharge)
Repeat ABG (8/26/2010 AM)
For TPAG
For strict COD BID
For 2-D echo c Doppler once stable
For cranial CT scan once stable
Co-managed:
CV Med
Referral:
GS
10H00591
05-78-54
III C
DD: Difficulty of
breathing
DOA: August 25,
2010
CIC: Christine
Alt: Angie, Irish
223 A (pulmo)
SISON, Rosalinda
77/f
CC: difficulty of
breathing
DOA: 8/27/10
CAP, in pt non ICU
ASHD, HCVD, CAD, CHF,
Class III-C
AKI probably secondary to
decreased ECV on top of CKD
secondary to a.)
HPN
nephrosclerosis
b.)
DM
nephropathy
CIC: steph
ALT: TAL, BINX
223 B (Pulmo)
Interior, Yolanda
Villafuerte
69/F
CC: Difficulty of
breathing
DOA: 7/10/10
10G00219
CIC: Jae
Alt: GV Joyce
Working Diagnosis
Pleural Effusion Right s/p
thoracentesis UTZ guided with
attempted pleural biopsy (June
29, 2010) s/p CTT with pleural
biopsy (7/12/10) probably
secondary to
1.
PTB
2.
Malignancy
Cervical CA Stage IIB s/p
Chemotherapy 10 cycles s/p
Radiotherapy 20 sessions,
Brachytherapy 4 sessions
(2006)
Hypertension Stage 2
Dyslipedimia
Hospital acquired pneumonia,
resolved
Cutaneous candidiasis left
posterior axillary line , can’t rule
out secondary bacterial infection
40mg/tab OD
Pip-Tazobactam
2.25gm/IV Q8
Atorvastatin 80mg/tab
ODHS
NaHCO3 tab TID
Trimetazidine
35mg/tab BID
ILW with combivent
neb Q4
Budesonide neb Q12
Ceftriaxone 1g/IV
Azithromycin
500mg/tab 1 tab OD
Combivent
nebulizaton 1 neb q6h
Paracetamol
500mg/tab 1 tab q4
prn for temp ≥ 38.5c
Furosemide 40mg/tab
1 tab BID
Losartan + HCTZ
50/125 mg tab 1 tab
OD
Amlodipine 5 mg/tab
1 tab OD
Simvastatin 40mg/tab
1 tab ODHS
Hexetidine
mouthwash q6
Vit B complex 1 tab
OD
Mosegor Vita tab
ODHS
Omeprazole 40
mg/cap OD
NaCl tab 2 tab TID
Fluimucil 60mg/tab
BID
Clindamycin 300
mg/cap, 1 cap Q6
Clobetasol
proprionate ointment,
BID over affected
areas x 7 days
Coumadin 5 mg/tab
OD
Maalox 10 cc prn for
epigastric pain
HRZE (Myrin P) tab
1tab 30 mins
premeals TID
Symbicort inhaler 1
click gargle after bath
use BID
Combiven neb q 6
angioprominence of left hilar shadow. Visualized osseus structures show evidence of osteoporosis.
8/25 12-L ECG: Non-specific St-T wave elevation
8/25 ABG: pH 7.306, PCO2, 27.0, PO2 359.7 HCO3 13.5, O2 sat 99.8%, AaDO2 324.1, a/A 0.53, P/F 3.597, DFiO2 0.043%
For AFB sputum x 3 days
For lipid profile, FBS
Neuro
Pulmo
8/27: ABG : pH: 7.403; pCO2: 29.3; pO2:53.7; FiO2 28%; HCO3 27.1; O2 sat: 87.8%; a/A: 0.33; dFiO2: 31.91; P/F: 192
8/27 CBC plt: hb 118; RBC 3.80; hct 0.35; MCV 92.80; MCH 31.10; MCHC 33.50; RDW 13; MPV 7.40; plt 245; WBC 9.40; high neut
0.79; bands 0.02; high segmenter 0.77; lymphocytes 0.21
8/27 high crea 2.65; SGPT 12.43; low Na 132; low K 3.46; high HbA1c 10.40%
8/27 ECG: complete right bundle branch block
8/27 CXR: initial reading: patchy confluent densities at the right middle and bot lower lung areas atheromatous aorta magnified cardiac
size diaphragm and sinuses intact
refer to cardio present to dra simon
refer to nephro present to dr balili
refer to dietary
refer to ophtha for further evaluation
and mgt
refer to DM ctr for modules 1-2
for lipid profile
for repeat creatinine (8/28 am)
for 2D echo with doppler
for UTZ KUB
refer if CBG is < 80 or > 200mg/dl
Endocrinology
cardiology
8/21 Discontinued Pregabalin and Acyclovir
8/20 WOF: Fever and respiratory distress; GS and KOH: no microorganisms/fungal elements seen
8/22 Pregabalin and Acyclovir were discontinued. Clindamcycin 300mg/tab 1 tab OD was started. Esomeprazole 40mg/tab was also
given.
8/18 Acyclovir IV 250mg/vial, 1vial every 8 hours was started
8/12 SGPT 18.17
8/2 CXR AP Sitting Initial: Complete opacification of R hemithorax with obstruction of R hemidiaphragm, R cardiac border with
ipsilateral mediastinal shift, CT noted
7/29 CXR: Compared to 7-17-10, shows progression of homogenous density on the right lung. R sided thoracostomy tube still seen.
Rest of the chest findings unchanged.
7/29 SGPT 51.22 U/L
7/28 Initial Chest X-ray complete opacification of entire right pneumothorax/ipsilateral deviation tracheal air colums; TT Seem lun
7/27 Na 133 K 4.73
7/26 6PM Na 131.66, K 4.62
7/26 5AM Na 132, K 4.66
7/25 9:45PM Na 135.2 K 4.86
7/25 4:16AM Na 131 K 4.39
7/25 Hgb 124 RBC 4.05 Hct 0.37 MCV 92 MCH 30.5 MCHC 33.2 RDW 12 MPV 6.7 Plt 375 WBC 10.8 neutrophil 0.75 lymphocytes
0.23 monocytes 0.01 eosinophils 0.01
7/22 Albumin 2.58 globulin 3.70 A/o ratio 0.70 total protein 6.25
7/22 Defer 2D Echo: Technically difficult study due to poor echo window, visualized study show normal LV and good wall motion and
contractility
7/21 Crea 0.75
7/20 pleural fluid C&S- no growth after 5 days of incubation
7/19 pH 7.415, pCO2 46.3 PO2 130.5 FiO2 80.0% a/A 0.25 p/F 163.13 dFiO2 53%
7/19 Official Reading Chest CT with contrast: consider multiple loculated pneumohydrothorax, right. Minimal pleural effusion, left.
Heterogenous enhancement of the RUL, with abrupt truncation of the RUL bronchus. Possibility of mass lesion cannot be totally ruled
out. Atelectasis and consolidation, right middlle and lower lobe. Multiple parenchymal and subpleural nodules, left lung as described.
Multiple mediastinal and supraclavicular lymphadenopathies, as described. Solitary hepatic nodule, segment 2, left lobe, suggest,
ultrasound correlation. Minimal subdiaphragmatic ascites. Multiple bony sclerotic foci, thoracic vertebral bodies.
7/17 CXR Followup study when compared to the one done on 7/12/10 shows partial re-expansion of the right lung and partial
regression of the previously noted pneumpthorax. There is a homogenous opacification of the right mid and lower hemithorax, most
likely representing pleural effusion. Aa right sided chest tube is seen in place, with its tip at the level of the 7th posterior rib. There is
kinking of the right sided thoracostomy tube, with its tip at the level of the 9tth posterior rib. The rest of the chest findings remain
stationary.
7/12 Pleural tissue and pleural fluid pathologic diagnosis: Pleural tissue, CTT: fibrocollagenous tissue with no evidence of granuloma or
malignancy; pleural fluid cytology: negative for malignant cells.
7/18 ABG 7.42, PC02 41.7, P02 59.3, Temp 37.0C, Fi02 80.0%, HC03 27.3, 02 Sat 91.3%, a/A 0.11, P/F 74.125, Dfi02 82.90
7/12 post CTT Cxray initial reading: pleural effusion on right side. Largerounded density is now seen occupying most of the right middle
lung field. Mediastinal structure shifted right sid. Pleural effusion right consider large pulmonary mass right.
MGH
Referral
Surgery TCVS
CV Med
Med Oncology
GI
Nephrology
Pathology
Ophthalmology
Dietary Service
Anesthesiology
Pain Management
Dermatology
ID
3
Monitoring: VS q2, no BP taking on
the upper extremities
223 C (Pulmo)
GUIANG,
Magdalena
10H00580
DOA: 8/25/10
CC: dyspnea
Admitting Dx:
Community acquired
pneumonia, moderate risk
Diabetes Mellitus, Type II
CAD, at risk
CIC: Crystal
Alt: BInx, Steph
Ceftriaxone 1g/IV OD
Digoxin 0.25 mg/tab 1
tab OD
Fluimucil 200 mg/tab
1 tab in 1 glass water
q8
Clarithromycin 500
mg/cap 1 cap BID
KCl durule TIDx4
doses
Atorvastatin 20
mg/tab 1 tab ODHS
Bisoprolol 2.5mg/tab
1 tab OD
7/12 MTB culture (Bactet MGIT 960) pleural fluid with tissue – no growth after 14 days.
7/11 initial ultrasound report 970cc pleural fluid right with no septations no internal echoes
7/10 CXR There is homogenous opacifications of the right lung obstructing the cardiac border, hemidiaphragm and sulcus, almost
unachanged when compared with the 6/24/10 (outside film study). Incidentally, there are degenerative changes of the thoracic spine.
CBC Hgb 137, RBC 4.38, Hct0.41, MCV 93.10, MCH 31.20, MCHC 33.50, RDW 12.10, MPV Plt 355, WBC 9.70, Neutro 0.76,
Metamylocytes 0, Segmenter 0.76, bands, lymphocytes 0.24), PT (11.1, normal control 12.6, PR 0.9, PR 0.9, aPTT 34.3, Normal
Control 33.1), ABG partially compensated respiratory alkalosis (dFiO2 29%, P/F 195, pH 7.576, pCO2 25.7, PO2 58.6, Temp 37.0,
FiO2 30%, BP 759.7 mmHg, HCO3 23.9, O2 sat 94.3%, BE 4.6, TCO2 24.7, O2CT 19.8%, BB 52.6, SBE 3.0, AaDO2 125 mmHg, a/A
0.32, RI 2.1)
8/25 Troponin 0.09
8/25 ECG- atrial fibrillation in rapid ventricular response, persistent posterobasal forces, nonspecific ST-T wave changes
8/25 ABG pH 7.458, PCO2 33.5, PO2 74.3, FIO2 21%, HCO3 23.7 mmol/L, O2 sat 95.6%, dFiO2 22.37
8/25 Hgb 116, Hct 0.35, Plt 400, WBC 18.40, Neut 0.81, lym 0.19
8/25 Crea 0.80, SGPT-ALT 18.58, Na 141, K 3.69, Mg 2.16, Hba1c 5.53
8/25 CXR initial read: consolidation R upper lung field, interstitial infiltrates R LLF, suspicious infiltrates R apex, atheromatous aorta,
cardiomegaly, suggest apicolordotic view
Decrease CBG monitoring to BID
AFBx3 days
Co-management:
Rheuma
For arthrocentesis (8/28), specimen
for gram stain and culture
sensitivity; suggest blood culture
and sensitivity at 2 different sites
Referral:
CV
For 2d Echocardiogram with Doppler
Complete bed rest with no bathroom
privileges
Cold compress on R leg
Ideally for ICU admission
Maintain on O2 supplementation
Retrieve previous admission records
223 D(ID)
RAMOS, Leonor
69/F
10G00352
DOA: 7/16/10
CC: Altered
sensorium
CIC: Angie
Alt: Irish, Christine
Admitting Dx:
Septic shock with multiorgan
failure (renal, cv, pulmo) sec. to
urosepsis, AKI sec. to urosepsis
and septic shock on top of
probable CKD sec. to DM
nephropathy vs. HPN
nephrosclerosis in uremia, s/p
femoral catheter injection and
hemodialysis (SLED); Acute
respiratory failure sec. to central
cause to septic encephalopathy;
hyperglycemia sec. to 1) DM
Type 2 2)compounded by stress
of sepsis and hospitalization;
ASHD, CAD, SVT  AF RVR
 sinus NSTEMI not in failure,
class IVD; cerebral infarct L&R
frontal lobe with contusion
hematoma R frontal; UGIB sec.
to stress, resolved, s/p
cholecystectomy (2006),
comminuted fracture, R
humerus
CaCO3 500 mg/tab TID
Citicholine 500 mg/tab 1
tab q8
Esomeprazole 40
mg/tab 1 tab OD
Duoderm patch over
sacral ulcer
Folic Acid 5 mg/tab 1
tab OD
Vitamin B Complex 1
tab BID
Metoprolol 100 mg/tab 1
tab BID
Dulcolax 20 ml ODHS
Amlodipine 10 mg/tab
BID
Enalapril 5 mg/tab 1 tab
OD
Fluimucil 600mg/tab in
½ glass H2O BID
Novorapid 5 U/sc OD
Lantus 20 U/sc OD
Estriol Cream once a
week
Sitagliptin 50mg/tab OD
Cutasept to trache site
TID
8/27 pH 7.428 PCO2 29.3 PO2 87,5 FiO2 35 HCO3 19.3 O2 sat 96.8 dFiO2 29.42 P/F 250
8/26 pH 7.470 PCO2 31.1 PO2 177.2 FiO2 40 HCO3 22.6 O2 sat 99.3 dFiO2 19.5 P/F 443
8/25 ABG pH 7.437, PCO2 35.1, PO2 160, FiO2 40, HCO3 23.6, O2 sat 99.1, a/A 0.66, aAOO2 84.1, dfiO2 21%, P/F 400
8/24: CBC Hgb 113 Hct 0.34 Plt 448 Wbc 10.50 Neutro 0.75 Lym 0.19 Eo 0.06
08/22 sugar ++; Pus cells 20-30/hpf; few Squamous cell; Bacteria +++
08/21 CBC HGB 98 RBC 3.11 HCT 0.30 MCV 95.20 MCH 31.40 MCHC 33.00 RDW 13.70 MPV 6.80 Platelet 398 WBC 14.10
neutrophils 0.83 lymphocytes 0.16 eosinophils 0.01
8/16 Na 128.04 K 4.21
8/16 hgb 103 rbc 3.30 hct 0.31 plt 478 wbc 13.10 neutro 0.83 meta 0.02 bands 0.01 seg 0.80 lumph 0.14 mono 0.01 eosino 0.02
8/14/ UA Yellow,Turbid, pH6.0,Spec Grav1.015,Albumin-Negative,Sug+++,RBC2-5/hpf,Pus20-30/hpf, SQcell++,Bacteria++++
8/12 Crea O.91 Na 123.47 K 3.74 iPO4 4.25
8/11 yellow turbid 6.0 1.015 albumin (+) sugar (++) pus>100/hpf SC + bacteria ++++ Crea 1.03 Hgb 90 RBC 2.83 hct 0.27 Plt 478
WBC 14.40 N 0.81 L 0.17 M 0.01 E 0.01
8/10 Na 137.0 K 3.95
8/7 Urine C/S: E. Coli >100,000 CFU/ml sensitive to nitrofurantoin, amikacin, norfloxacin, meropenem, imipenem, pi-tazo,
ciprofloxacin
8/7 Crea 1.37, SGPT-ALT 195.05, Na 127.00, K 3.79
8/6: Gram Stain Gram (-) bacilli(-): Uncentrifuged – Few; Centrifuged +
8/5: Crea 1.27, Na 129, K 3.61
8/5 CBC: Hgb 98,RBC 3.12, Hct 0.29, MCV 94.0, MCH 31.50, RDW 14.20, MPV 7.30, Plt 473, WBC 13.40, Neu 0.90, Metamyelo
0.02, Bands 0.02, Lym 0.08, Mono 0.02
8/4 Femcath culture and senitivuity no growth after 3 days incubation.
8/3 UA yellow turbid 7.0 1.010 alb + sug +++ pus cells over 100/hpf sq.cell + renal cell few bacteria ++ calcium oxalate few
8/3 CBC Hgb 90 RBC 2.85 Hct 0.27 MCV 95 MCH 31.60 MCHC 33.20 RDW 14.1 MPV 7.20 Plt 570 WBC 10.6 Neutrophils 0.79
Segmenters 0.79 Lymphocytes 0.18 monocytes 0.01 eosinophils 0.02
8/3 Na 130.92 K 4.41
8/2 Na 131 K 3.86
8/2 Crea 1.48, Na 130, K 3.66
8/2 ABG pH 7.491, PCO2 30.6, PO2 159.4, FiO2 40, HCO3 23.3, O2 sat 99.2, a/A 0.64, aAOO2 91, dfiO2 22.89%, P/F 398.5
7/31 Na 135, K 3.43, iPO4 3.35, iCa 1.02
7/31 CBC Hgb 103 RBC 3.28 Hct 0.31 MCV 95.10 MCH 31.40 MCHC 33.00 RDW 14.00 MPV 7.40 Plt 666 WBC 9.10 Neutrophils
0.76 Segmenters 0.76 Lymphocytes 0.23 Eosinophils 0.01
7/21 CXR: ff up study when compared to the one done on 7/19 shows resolution of the bilateral perihilar haziness, blunting of the
costophrenic sulci, heart not enlarged, tip of endotracheal tube is at T4 (A> bilateral pleural effusion)
7/19 ECG sinus rhythm, non-specific ST-T wave changes
4
Retrieve any previous result of 2d
Echo and 12L ECG
MGH from ID & pulmo standpoint,
inform other referrals
Co-management:
Nephro
Endo
Pulmo
Neuro
CV
Referral:
Ortho surg
Rehab Med
Dietary
GI
Gyne
Hema
Derma
Urology
GS
7/21: Crea 5.03
7/19: CXR: compared findings last 7/14, there is slight clearing of the previously noted bilateral pulmo densities, (+) residual infiltrates
at both lower lung fields, heart is enlarged, aorta is atherosclerotic; right humerus- complete fracture in the right humeral neck
7/19: CBC Hgb 114 RBC 3.63, Hct 0.33, RDW: 13.60, MPV: 8.10, PLT: 287, WBC: 6.90, neutro 0.77, lymphos 0.21
7/19: Na 137, K 4.02
7/18 ABG 10:30PM: pH 7.508, pCO2 33.9, pO2 387.6, Temp 36.4, FiO2 100, BP 758.2, HCO3 26.8, O2 sat 99.9, BE 4.9, TCO2 27.9,
O2 CT 16.6, BB 51.3, SBE 4.5, AaDO2 289.8, a/A 0.57, RI 0.7, dFiO2 23.41, P/F 387.6
7/18 ABG 4PM: pH 7.502, pCO2 34.3, pO2 226.2, Temp 36.3, FiO2 80, BP 757.3, HCO3 26.8, O2 sat 99.6, BE 4.7, TCO2 27.8, O2
CT 16.1, BB 51.1, SBE 4.3, AaDO2 306, a/A 0.43, RI 1.4, dFiO2 79.78, P/F 282.75
7/18 CBC: Hgb 111, RBC 3.57, Hct 0.33, Plt 221, WBC 9.90, neutro 0.89, lym 0.11
7/17 Blood Chem: Crea 3.58, TP 5.91, Alb 3.14, Glob 2.8, A/G 1.10, Na 144, K 4.5
7/17 Blood Type: A+
7/17 ET aspirate C/S (aerobic): Pseudomonas aeruginosa few, yeast isolate heavy growth
7/13 blood C/S Right femoral line – no growth after 5 days
7/13 blood C/S Left foot – no growth after 5 days
223 –E (ID)
Motin, Reina
25/F
10G00443
06-93-22
DOA: 7/20/10
CIC: Irish
Alternate: Christine,
Angie
223 F (Pulmo)
Dioquino, Marie
Len
24/F
Disseminated tuberculosis
s/p Endometrial biopsy 7/27
s/p Lumbar puncture 7/27
Tubo-ovarian abscess, bilateral
Hyponatremia 2o to poor oral
intake
Acute behavioral changes
probably secondary to 1) Fever
2o to general medical condition
2) Multiple electrolyte imbalance
3) Lack of Sleep
HRZE 3tabs OD
prebreakfast to
complete 56 days
Vit B complex OD
NaCl 2 taqbs TID
Myrin 3 tabs OD
Admitting Dx: Massive pleural
effusion probably secondary to
1.) parapneumonic process 2.)
PTB
Paracetamol 500
mg/tab for pain & temp
>/= 37.8 q4
Levofloxacin 750
mg/tab OD
Final Diagnosis
Gliclazide 30mg/tab
8/16 Na 128.66↓; 3.48↓
8/12 Hgb 115↓; RBC 3.86↓; RDW 19.10↑; WBC 2.9↓
8/4 Na 122 K 4.66
8/2 Na 121 K 4.01
8/1: Na 120; k 4.08
7/29 Na 131, K 3.83
7/27 Na 135 K 3.58, RBS 119
LP done at L3-L4 obtaining yellowish slow flowing CSF; opening pressure 130mmH20, closing pressure 110 mmH20
cryptococcal antigen (-); AFB stain: no acid fast bacilli seen; Gram stain: no microorganism seen; India ink: none found for
Cryptococcus neoformans
Negative for: Neisseria meningitides B/ E. coli K1, Streptococcus species Grp B, Haemophilus influenzae type B, Strep pneumonia,,
Neisseria meningitides ACY W135
Color: colorless; Vol: 1mL; Transp: clear; Supernatant: colorless, clear; Total RBC: 30/cumm; Non crenated 07%; Crenated 93%;
Total WBC 17/cumm; Lymphocytes 100%
Total Protein 180.04; Glucose in CSF 46.28
7/26: Na 128.69, K 3.33
7/25 Na 128.16 K 3.56
7/25 Na 135, K 3.20
CBC: Hgb 116 Hct 0.35 WBC 8.30 Seg 0.96 Lympho 0.04 PC 578
7/25 Blood CS: no growth after 5 days, L and R arm
7/24 CT scan: Diffuse right hemispheric cerebral edema with leptomeningeal enhancement and mild mass effect as described.
Consider leptomeningitis. Consider acute cerebral infarction from middle cerebral artery thrombosis.
7/24 Na 121 K 3.86
7/23 Urine Na 246, Urine K 40.52
7/23 SGPT 9.38, Na 116, K 3.87, urine Na 246, urine K 40.52
7/22 Na 116 K 3.91
7/22 Na 118 K 4.09
7/21 CXR nodular densities scattered diffusely over both lung fields. Interstitial infiltrates. Impression: interstitial pneumonia, miliary
TB cannot be totally ruled out
7/20 Crea 0.40 Na 126.46 K 4.43
7/20 CBC: Hgb 110 Hct 0.33 Plt 433 WBC 4.50 Seg 0.68 Lymph 0.32
7/20 Na 128 K 4.00 Plasma Osm 289
7/20 ABG pH 7.488 pCO2 34 pO2 79.1 HCO3 25.8 dFiO2 0.21 P/F 376.67
7/20 CBG 133, Na 128, K 4.11
7/19 TVS: Normal sized uterus; thin endometrium; R complex mass 6.53x4.32x5.72cm; L complex mass 5.78x4.53x5.75cm, consider
tubo-ovarian abscess, bilateral.
8/25: Utz of R hemithorax: right-sided pleural effusion with loculations
8/24: CXR-PAL initial read: right sided pleural effusion, suspicious infiltrates over both apices, suggest apicolordotic view
8/24 PT 11.7 aPTT 31.4
8/24 CBC Hgb 111 Hct 0.33 Plt 591 WBC 8.70 Neutro 0.73 Segmented 0.73 Lympho 0.25 Mono 0.01 Eo 0.01
10H0057
07-12-19
CC: fever
DOA: 8/24/10
CIC: Irish
Alt: Christine, Angie
223 G(Pulmo)
7/31 CBG 10pm: 178
5
For Ishihara testing (8/28)
Opt discharge without LP
MGH Final Dx: Disseminated TB;
Tuboovarian
abscess
bilat;
Hyponatremia 20 to SIADH
Clinical Abstract given to mother
Informed other services of MGH
status For repeat Na,
May Go Home anytime;
CTT insertion at 10 am (8/28)
Referral:
Nephro
Neuro-Psych
ID
Pulmo
Gynecology
SS
TCVS
Sol Cruz, Zenaida N
64/F
CC: Difficulty of
breathing
DOA: 6/30/10
06-84-05
10F00685
CIC: Fer
Alt: Bryan Sandy
Acute respiratory failure
secondary to 1) nosocomial
pneumonia 2) bronchial asthma,
severe in exacerbation 3)
pulmonary
congestion secondary to
arrhythmia
s/p extubation (7/27/2010),
Chronic lung disease secondary
to bronchial asthma, severe out
of exacerbation;
ASHD, CAD at risk, MR mild,
TR mild, pulmonic regurgitation,
moderate pulmonary
hypertension Cor Pulmonale
Class IIID;
DM type 2;
Major depressive disorder in
remission;
Cutaneous Candidiasis
resolved,
irritant contact dermatitis
secondary to urine and feces
reaction;
t/c age related macular
degeneration, senile mature
cataract, OU
1tab OD
Montelukast 10 mg/tab
OD
Hexetidine mouthwash
QID
CaCo3+vit D in between
feedings
Clopidogrel 75 mg/tab,
1 tab OD
Diltiazem 30 mg/tab TID
prednisone 10 mg/tab 1
tab OD
Cilostasol 100 mg/tab
BID
Doxyphylline 400
mg/tab ½ tab BID
Travacort cream over
the affected areas BID
Omeprazole 40mg/tab
OD
Fluimucil 600mg/tab in
½ glass of water BID
Symbicort 2 puffs TID
Simvastatin 40 mg/tab
ODHS
Losartan 50 mg/tab ½
tab OD
Gliclazide 30 mg/tab
OD
Sertraline 50 mg/tab OD
Cilostazol 100 mg/tab
BID
Symbicort 1 click BID
Omeprazole 40 mg/cap
until 8/20 OD
Prednisone 5 mg/tab x
5 days then d/c ½ tab
q48
7/30 CBG 10pm: 96
7/27 ABG 7.39, PCO2 42.6, PO2 183.7, HCO3 25.7, O2 Sat 99.2,a/A 0.69, p/f 4.175, dFiO2 23.73
7/18 ABG 7.36, PC02, 54.2 P02 175.6, HC03 31.2, 02 Sat 99.1, a/A 0.95, p/f 501, Dfi02 35.36
7/17 ABG pH 7.459 pCO2 37.4 pO2 117.6 HCO3 26.5 O2 sat 98.4% a/A 0.57 P/F 336 dFIO2 26.24%
7/15 ABG: pH 7.482 pCO2 30.1 pO2 99.1 HCO3 22.5 O2 sat 97.8% a/A 0.46 P/F 283 dFiO2 30%
7/12 Na 137.48, K 3.77
7/11 ECG: Normal sinus rhythm, intraventricular conduction delay, isolated premature ventricular complex, L posterior fascicular
block, non-specific ST-T wave changes
7/11 Blood Chemistry: Crea 0.64, SGPT-ALT 44.57, Na 139, K 3.06, Mg 1.61, iCa 1.14
7/11 Coagulation Assay: PT 11.8, PR 1.0, INR 1.0
7/11 ABG: pH 7.523, pCO2 38.4, O2 129.8, HCO3 31.6 a/A 0.54 dFiO2 27.51% P/F 324.5
7/10 Blood CS: No growth after 5 days incubation
7/10 12L-ECG: Sinus rhythm, anteroseptal wall ischemia
7/10 CBC: Hgb 105, RBC 4.71,Hct 0.37, MCV 77.70, MCH 22.30, MCHC 28.60, Plt 160, WBC 17.70, Neutro 0.9
7/10 Urine G/S Uncentrifuged specimen: No microorganisms seen, Centrifuged Specimen: Gram (+) yeast like cells (few)
7/10 Troponin I: 0.20
7/9 urine c/s: (-) for bacterial growth, yeast isolate 30,000 CFU/mL
7/9 12L-ECG: Sinus beats with different P wave morphologies and frequent premature atrial complexes, frequent episodes of atrial
tachycardia and atrial fibrillation, frequent premature ventricular complexes, left atrial enlargement, nonspecific ST-T wave changes,
left posterior fascucular block (with the above findings, consider RVH with acute pulmonarry hypertension)
7/9 CXR: There is partial regression of the pneumonic infiltrates in both lower lungs, cardiac size is magnified, aortic knob is calcified,
endotracheal and nasigastric tubes are seen in place
7/9 ABG: pH 7.572 pCO2 38.8 O2 119.6 HCO3 35.7 a/A 0.50 dFiO2 29% P/F 299
7/9 Blood chem.: Na 137 K 2.68 Mg 1.56
7/9 U/A: (+) RBC 50-60/hpf, pus cell 55-65/hpf, yeast cell (++++), squamous cell (+), bacteria (+), amorphous urate (+), uric acid (++)
7/9 CBC: Hgb 107 RBC 4.69 Hct 0.37 MCV 77.86 MCH 22.8 MCHC 29.3 Plt 120 WBC 12.9 Neutro 0.95
7/8 peripheral smear: hypochromic poikilocytosis, decreased platelet
7/8 CXR enlarged cardiac silhouette, prominent pulmonary vascularity may be secondary to pulmonary congestion, interstitial
infiltrates on both bases, diaphragm and both costophrenic sulci intact
7/8 APTT 42.2
7/8 Na 140, K 2.05
7/7 2D Echo: normal LV w/ good muscle wall contractility and normal resting systolic function & grade1 diastolic dysfunction, dilated
RV w/ symptoms of volume and pressure overload, dilated RA w/ no evidence of thrombus, dilated MV annulus, MR mild, TR mild, PR
moderate, moderate pulmohpn, EF 69%
07/07 Blood Chemistry: Crea 1.01, Na 141, K 2.36
07/07 Coagulation Assay: PT 20.2, PR 1.6, INR 1.6
07/07 ET GS: No microorganisms seen, polymorphonuclear leukocytes ++++, squamous epithelial cells few
07/07 ET CS: Moderate growth of Escherichia coli, sensitive to: cefazolin, pip-tazo, imipenem, ampicillin-sulbactam, tmpsulfamethoxazole, gentamycin, tobramycin, intermediate to: comoxyclav, resistant to: ciprofloxacin
07/07 CXR (3PM, initial reading): Interval progression of the opacities seen in both lung fields, accentuation of the pulmonary vascular
markings, prominence of the right minor fissure t/c interfissural fluid collection, heart is enlarged
07/07 CXR (10PM, initial reading): The heart no longer appears enlarged, interstitial infiltrates still appear on both lower lung fields,
slight decrease in the accentuation of the pulmonary vascular markings, the previously noted fullness of the right hilar area appears to
be a poorly circumscribed pulmonary mass suggesting CT scan correlation if clinically warranted, atheromatous aorta, ET tube at the
level of T5, diaphragm and sinuses intact
07/06 2D-Echo (initial reading): Moderate pulmonary hypertension, RVE, LAE, LVE
7/5 Duplex scan: no evidence of venous thrombosis/insufficiency
07/05 SGPT-ALT 52.27
07/05 12L-ECG: Sinus arrythmia, anterior wall ischemia, poor R wave progression from V1-V6
07/04 CXR (P10-16087) Non-specific interstitial infiltrates, left lung base. Cardiomegaly. Atheromatous aorta. Minimal pleural effusion
and/or thickening, left
07/04 CXR (P10-15759) Heart enlarged. Opacities in both lower lung fields. Consider pneumonia. Previously noted right infrahilar
fullness.
07/04 Reticulocyte count 35, peripheral smear: WBC= no abnormal WBC seen, RBC= hypochromic with anisocytosis and
poikilocytosis. Adequate platelet
07/02 Urine Gram stain: no microorganisms seen on both centrifuged and uncentrifuged sample
07/02 PT 13.4 Normal control 12.8 PT ratio 1.1 INR 1.1
07/02 BUN 65.52 Crea 1.26 SGPT 136.87 Na 136 K 4.80 iCa 1.12 inorganic phosphate 4.87 HbA1c 7.240 total protein 6.17 albumin
3.11 LOW globulin 3.10 A:G ratio 1.00 cholesterol 99.17 LOW triglycerides 62.33 HDL 21.20 LOW LDL 56.59 LOW
07/01 12L ECG 1. Normal sinus rhythm 2. Probable right ventricular hypertrophy 3. Anteroseptal wall ischemia
6/30 12L ECG 1. Sinus rhythm 2.Right axis deviation 3. Predominant R wave in V1 but persistent S wave until V6. Findings are
suspicious for: a.Right ventricular hypertrophy b. True posterior wall infarct
6/30 CXR (P10-15759): Lungfields are clear, normal diaphragm and sinuses, magnified cardiac size, prominent right hilum, suggest
right lateral view, atheromatous aorta
6
MGH
Serum potaasium
For CBG monitoring
TSH Ft3 FT4
Repeat CXR-no funds
CXR after CVP insertion
Sputum graded gram stain
UTZ KUB
Sputum GS, CS
Cranial MRI
D-Dimer
Urinoscopy
12-L ECG
CBC with PC
Serum electrolytes
Creatinine
Urinalysis
Refer to Social Service
Referrals:
Endo
Nephro
Neuro
Psych
Derma
Ophtha
DM center
Dietary
EPS
GS
Hema
Social Service
Bioethics
Co-manage:
CV med
223 H
BERNABE, Lolita
84/F
Adm# 10G00668
Hosp# 05-84-94
DOA: 07/29/10
CC: Anasarca
CIC: Joyce
Alt: GV Jae
Admitting Dx:
Anasarca prob 2 to
hypoalbuminemia, r/o CHF
Tranexamic acid
500mg/IV q8h
D5NSS to run at KVO
Working diagnosis:
Atherosclerotic Heart Disease,
Coronary Artery Disease
NSTEMI, Anasarca probably
secondary to 1. CHF 2.
Hypoalbuminemia
Cor Pulmonale secondary to 1.
COPD 2. Pulmonary embolism;
Central hypoventilation
syndrome secondary to stroke
Febrile episodes probably
sepsis secondary to 1. Hospital
acquired pneumonia 2.
Complicated UTI
Decubitus ulcer on sacral
region, grade 2-3
Acute Kidney Injury secondary
to pre renal cause (3rd space
loss) 2. infection
8/23 Hgb 113, Hct 0.34, Plt 448, WBC 10.5, neutrophils 0.75, segmenterd 0.75, lymphocytes 0.19, eosinophils 0.06
8/22 RBC 20-30/hpf; Pus cells60-70/hpf; Yeast Cell ++; Squamous cell ++; Bacteria ++; Amorphous Urate++
8/19 Na 137; K 3.47
08/18 urea nitrogen 64.64 creatinine 2.02 sodium 148 CBC with platelet HGB 130 RBC 4,27 HCT 0.38 MCV 89.40 MCH 30.40 MCHC
34.00 RDW 22.90 MPV 8.10 platelet 300 WBC 14.80 neutrophils 0.94 bands 0.02 segmented 0.92 Lymphocytes 0.05 eosinophils
0.01
8/16 Na 148.56 K 4.84
8/16 CBC hgb 121 rbc 4.08 hct 0.37 plt 220 wbc 16.10 neut 0.93 bands 0.02 seg 0.91 lymph 0.07
8/16 U/A color dark yellow trans turbid ph 6 sg 1.015 alb ++ sugar _ granular cast 10/coverslip rbc over 100/hpf pus over 100/hpf
bacteria +++
8/14 ph 7.389 pCO2 46.6 pO2 78.4 Temp 37 FiO2 40 HCO3 28.1, O2Sat 95.4 a/A 0.35 dFiO2 39.6 P/F 196
8/13 Plain Film of Abdomen: T/c Nephrolithiasis, left Tubular calcifications may represent calcifications of splenic vessels, irregular
calcifications may be 2 to myoma, calcified aorto-iliac vessels, soft tissue density is noted in the lower pelvic region superimposed in
the iliac vessels. Incidentally, mild osteopenia of the visualized bones
08/7 U/A yellow, turbid. 5.0, ph 1.015, (+) albumin, (-) sugar, granular cast 2/coverslip, rbc 5-10/hpf, ++++yeast cell, +squamous cell,
++ bacteria, + mucus threads, + amorphous urate
08/7 Na 133, K 4.43, Mg 2.59, iCa 1.18
08/7 CBC: Hgb 111 Hct 0.32, Rbc 3.47, Platelet 373, WBC 15.10, Neuto 0.92, metammyelocytes 0.02, bands 0.02, segmented 0.88,
lymphocytes 0.07, eosinophils 0.01
08/7 BUN 68.23, Crea 1.33
08/6 Na 137, K 3.93
08/04 CXR initial reading: Progression of haziness on BL. Tracheostomy tube at T4. Both costophrenic sulci are blunted. The rest of
the remaining findings unchanged.
08/04 ABG pH 7.345 pCO2 45.7 PO2 65.6 HCO3 27.4 a/A 0.22 O2sat 92% dFiO2 44 % P/F 404
08/02 CBC Hgb 107 rbc 3.42 hct 0.33 mcv 95.40 mch 31.30 mchc 32.90 rdw 15.40 mpv 8.70 PC 250 wbc 10.10 neu 0.91 seg 0.91
lympho 0.09
08/02 Na 131 K 3.86
08/02 CXR initial reading: Tracheostomy tube is seen with its tip at the level ofT5. There isstill evidence of pulmonary congestion with
bilateral pleural effusion. Linear densities are seen at the left lung base suggestive of subsegmental atelectasis. No other significant
changes.
08/02 ABG pH 7.403, pCo2 40.9, pO2 202.3, HCo3 25.5, O2sat 99.4, a/A 0.65 O2sat 99.4% dFiO2 24.4% P/F 404.6
08/01 Blood Chem: Na 138.00, K 4.18, iCa 1.18
08/01 UA: Yellow, Slightly turbid, pH 5.0, SG 1.015, Albumin +, Sugar -, Hyaline cast 01/coverslip, Granular cast 07/coverslip, Pus
cell 1-3/hpf, Yeast cell ++++ (presence of hyphal elements), Squamous cell few, Transitional epithelial cell +, Bacteria ++
7/30 CXR: The follow up study compared to the one done on 7/26 now shows pulmonary congestion. Heart remains enlarged.
Minimal pleural effusion is seen bilaterally. Right paratracheal calcifications are noted may be vascular origin. Endotracheal and
nasogastric tubes are seen. Thoracic cage: No demonstrable radiographic evidence of bone abnormality.
7/30 CBC hgb 131 rbc 4.20 hct 0.21 platelet count 302 wbc 17.20 neu 0.88 seg 0.88 lympho 0.12
7/30 Na 138 K 4.03
7/30 Coag Assay: PT 10.5 s NC 12.6 PR 0.9 INR 0.9 aptt 28.7 NC 34.8
7/30 no acid fast bacilli seen; polymorphonuclear leukocytes more than 25/lpf; squamous epithelial cells 5-10/lpf
7/30 ECG sinus rhythm, nonspecific ST-T wave changes
7/30 ABG pH 7.448, pCo2 42.7 pO2 110.7, HCo3 29.5, a/A 0.36 O2sat 98.1% dFiO2 38.7% P/F 221.4
7/30 ABG pH 7.345, pCo2 52.7, pO2 309.7, HCo3 28.7, a/A 0.47 O2sat 99.7 dFiO2 33.11% P/F 3.097
DNR
Note:
VS, UO and Suction q1 w/GCS; I/O
monitor
Bed turning q2; COD q1 day
Co-manage: CV med
Referral:
Neuro
ENT – HNS
Derma
Dietary
Endo
Surgery
WOF: desaturation, hypotension,
bleeding episodes, hematuria,
CBG <80 or >300
CO-MANAGE
211C
Admitting diagnosis:
Meropenem 500 mg/IV OD
8/20 Urinoscopy: Color: yellow Transparency: clear pH:6 SpGr:1.020 Albumin:++ Sugar- RBC:0-2/hpf PusCells:1-3/hpf Squamous cells: few
NaHCO3 gr X tab 1 tab TID
8/20 BUN 47.37 Crea 2.56 Total protein 5.95 Albumin 2.21 Globulin 3.70 A/G ratio 0.60 Na 136 K 4.12
Atorvastatin 40 mg/tab 1 tab
ODHS
8/20 Hbg 95 RBC 3.49 HCT 0.29 WBC 10.20
For Chest Xray, ABG, and 12L ECG
ID
8/18 urine C&S no growth after 2 days
Vancomycin 1 g/IV in 100
mL PNSS x 2 hours OD
every 7 days
8/17 Blood Chem: Crea 3.10 SGPT-ALT 18.18 iPhosphate 4.26 iCa 1.18 Hba1c 7.83
Relay results of urinsoscopy. Relay CBC
results
Referral:
ISMN 30 mg/tab 1 tab OD
8/15 BUN 55.20 Crea 2.92 Na 134.00 K 4.64 CRP 4.74
2-D echo with Doppler
OrthoSurg
DOA: 8/15/2010
ASA 80 mg/tab 1 tab OD
after lunch
8/15 U/A yellow turbid pH 5.0 spec grav 1.020 albumin ++++ sugar ++ RBC 0-2/hpf pus cell OVER 100/hpf squamous cell ++ renal cell ++ bacteria ++++
amorphous urate FEW
UTZ KUB
Ophtha
CIC: GV
Novorapid 5 ‘U’/SC if CBG
≥ 200mg/dL
8/15 Hgb 104 Hct 0.32 platelet 360 WBC 12.00 neutrophil 0.62 lymphocyte 0.35 eosinophil 0.03 ESR 76.0
Blood C&S 2 sites
8/15 ABG pH 7.326 pCO2 28.4 pO2 167.2 FiO2 32.0% HCO3 14.8 O2sat 98.9% a/A 0.86 dFiO2 18.02% P/F 522.50
Urine C/S
GERONIMO, Melinda
57/F
Hosp # 07-07-14
Adm # 10H00353
Alt: Jae Joyce
AKI 2 to UTI on top of CKD prob 2 to
DM nephropathy; complicated UTI;
DM type 2; non healing wound
Suggest to increase diuresis
Co-managed:
Endo
8/15 Trop I 0.15
CV-Med
Levemir 12 ‘U’/sc OD
8/15 X-ray of legs (initial reading): (-) bone involvement, calcified vessels left lower extremity, otherwise no joint/bone abnormalities
Furosemide 40mg/tab OD
Ciprofloxacin 250mg/tab
1tab BID
8/15 Chest x-ray (initial reading): Cardiomegaly, atheromatous aorta, exaggeration of thoracic curvature, kyphotic spine, suspicious patch of density noted
on LUL, superimposed on bony structures, suggest apico-lordotic view, mild accentuation of pulmonary vascular markings, beginning pulmonary congestion
cannot be ruled out, subsegmental atelectasis, right middle lobe, nodular densities on both lower lobe areas, which may be due to shadow
Clindamycin 300 mg/cap 1
8/15 ECG (initial read): sinus rhythm, old infarct, lateral wall ischemia
7
HbA1c, SGPT
Venous duplex scan of both lower
extremities
Dermatology
cap Q6
Amlodipine 5mg/tab OD
8