Chua, Isabelita 75/F Date of Admission: 7-26-2012 Day 1: - Admit under Dr.

Ayuyao - consent, TPR and I & O - start D5NM 1L x 20 cc/hr - hypoallergenic diet - Dx; CBC, Na, K, SGPT, Crea, ABG, CXR-PA, U/A, sputum GS/CS - Tx; Solumedrol 40mg/IV now then Q6 - Combivent 1 neb Q15min x 3 doses then Q2 RTC - Budesonide 1 neb Q12 - Fluimucil 600mg/tab in glass water BID - Carbocisteine (Solmux) 1 cap TID PO - Omeprazole 40mg/IV now then OD - Hook to NIV now FiO2 40% PS 10 cmH2O PEEP 6cmH2O - ABG after 30 mins hooking to NIV - Refused to NIV w/ waiver - Agreed to hook back to NIV - FiO2 35% PS 9 cmH2O PEEP 5cmH2O - ABG after 30 mins hooking to NIV - Still refused NIV - Hooked to O2 @ 3LPM via NC 11:45 - nebulize w/ Combivent now Day 2: 12:30am - hook to NIV - neb w/ combivent 1 neb now then Q1 - ABG after 30 mins - Stand by intubation 12:30 - S/P intubation - transfer to MICU - to MV w/ ff setting - AC mode TV 400 FiO2 100% PEEP 5 BUR 18 - ABG after 30mins after hooking to MV - CXR AP - ETA GS/CS - Hydrocortisone 100mg/IV now - Combivent 1 neb now x 3 doses Q15 then Q2 RTC - Budesonide 1 neb now then Q12 - Insert FC, for UA - Insert NGT - Start OF 1400kcal LSLF divided into 6 equal feedings - CBG monitoring Q6 pre feeding relay <80 >180 - Continue acetylceisteine BID and carbocisteine TID - Solumedrol 40mg/IV Q6 - Start Doripenem (Doribav) 800mg/IV now then Q8 RTC - Azithromycin (Zithromax) 500mg now then OD

- Blood CS x 2 diff sites - Pre-intubation medication Diazepam 15mg IV - Midozalam 2.5 mg IV - Start percedex drip @ 0.4mcg/kg/hr 3:05pm MV setting FiO2 80% TV 400 BUR 18 -> 22 PEEP 5 - rpt ABG after 30mins - dec. FiO2 to 60% 7:05pm dec. FiO2 to 40% BUR to 20 Day 3 neb w/ combivent 1 neb x 2 more doses (+) DOB give early dose of solumedrol tight airway give early dose of Budesonide (+) wheezes Maintain MV setting - ABG now - Furosemide 40mg/IV now - Start aminophylline drip D5W 1L + 4 amps Aminophylline to run 150 cc for 30mins then regulate @ 25mcgtts/min - Rpt CXR AP - Suction Q30 min please - Inc. FiO2 to 60% Day 4: 7:38am AC mode - FiO2 40% BUR 20 PEEP 5 BUR 20 - ABG after 30 mins O2sat 95% - Start weaning - 6 LTP x 15 min 45 min MV - 6 LTP x 30 min 30 min MV - 6 LTP x 1O 30 MV x cycle - rpt ABG after the 1st cycle of 1hr (-) DOB continue weaning as ordered - relay ABG after 1 hr on T-piece once available Day 5: - give HR 10 u SQ now (+) abd pain give omeprazole 40mg/IV CBG 314 mg/dL 6:58 am - suction secretions (+) wheezes - neb w/ Duavent 1 neb now - continue Duavent neb Q2 - resume weaning this AM - 6 LTP x 15 min, 2 cycles MV x 45 mins - 6 LTP x 30 min, 2 cycles MV x 30 mins - inform PFOD if weaning is tolerable or not 1:15pm - continue weaning as previously ordered (-) DOB - refer if not tolerable 2:35pm- hold weaning (+) DOB - Solumedrol 40mg/IV

(+)tachypnea - combivent neb 1 neb now x 3 doses now then Q1 (+)tight airway- Budesonide 1 neb now O2 sat 88 -> 99% - for CXR portable now - inform PFOD once done - maintain O2sat >= 95% - inc. FiO2 @ 60% - For Na, K, Mg, Phosphorous, Ionized Ca, CBC, BUN, Crea - Will review CXR 3:30pm- FD of 100cc PNSS now 70/25 -> 79/33 - refer to Dr. James Ho for co-mgt - hold Precedex - Inc. IVF to 60 cc/hr 90/76 - FD 100 cc PNSS now - for 12-Lead ECG - for Trop I, CKMB - refer accordingly - for blood CS x 2 sites HOLD 5:30pm- Include TPAG to blood exam - inform CFOD once 12-Lead ecg is done 6:15pm- for 2DED - include PTPA, PTT - start inotropes once w/ persistent hypotension - relay trop I, CKMB result 2pm (late entry) - may not give OF 6:30pm- omeprazole 40mg/IV now (+) abd pain - motilium 1mg/tab 1 tab TID - hold feeding for now (+) DOB - combivent neb x 1 dose now (+) abd pain buscopan 10mg/IV now - open drain NGT