Nenita Mendoza

Sto Cristo, Angeles City

Teacher
69 8/20/45
Anita Sagaral niece
Date In 11/5/14 11:45am
VS 150/100 PR 93 RR18 T 37.2
CC Body Malaise
Histore 3rd day PTC fever took paracetamol relieves, (-) CC, vomiting
and DOB
2nd day PTC, general body malaise (+) productive cough with yellowish
sputum took guiafenesin syrup bottle with no relief, afebrile
1 day PTC, (+) body weakness (+) loose watery stool with solid particles
x 1 episode, afebrile, DOB
Medications taken Lantus @10am
PE
(+) wheezes R>L
(+) ronchi R>L
Crackles with wheezes
Grade 3 bipedal edema
Past medical History
(+) DM Insulin 10 units
(-)BA
(+)CKS
Dyslipidemia Rosuvastatin
(+) HPN Lacipil

Family History
Sister Hypertension
Heart Disease Sister
No asthma
DM sis and bro
Cancer prostate father
Review of Systems
Weakness, dyspnea, sputum production
Flabby soft abdomen
1.6 m
49.1kg
Fish, Rice, Fruits/Vegetables, Fats/Oils, No sugar/sweets, Milk daily
Past Medical History
HPN more than 20 years
DM 10 years
Previous Hospitalizations: CKD, HPN, Fistula Placement
Drugs: Rosuvastatin 10mg OD, Lacipidine 6mg AM, Amildone 3mg PM,
Clonidine 75mg TID, Kerosteril TID, Furosemide 40 mg OD,
Ivancadine 5mg BID, Lantus Solustar
Folley Cath 11/5 and 6 (10-6pm, 6-2pm); 11/7 (6-2pm)
Had an emergency tube pericardiostomy insertion with pericardial
biopsy

Doctors Orders
11/5/14
1:32pm
DIET: Diabetc Diet of 1700 kcal/day; 30g/day of CHON; phosphorus of
<800mg/day; Cholesterol <300 mg/day divided into 3 meals 2
snacks in between; Limit fluid intake to <1L/day
IVF: D5w 250ml x 10cc/hr TS: 12:30pm
Dx: Chest xray, CBC, ECG, Na, K, CA, ph, RBS TID premeals (125 mg/dl
@130pm), urinalysis, sputum GS/Cs
DRUGS: Cefepime 1 g, IV infusion (30 ml run for 30 min q 24
Azitromycin 500mg 1 tab OD
N-Acetylcisteine 200 mg 1 sachet glass water BID
Furosemide 40mg TID then q 12
Continue protocol medications:
Rosuvastatin 10mg OD
Lacidipine 1 tab or tab PM
Catapress 75mg 1 tb TID
Ketobest 1 cap TID
Ivabradine 5mg 1 tab
Lantus Solostan 8u AM if RBS >150 mg/dl
*V/S q4hrs
I/O q shift and record quantity
O2 of 2lpm
High back rest
*Inc Furosemide to q 8 hrs
2:12pm

For stat 2d echo with dobbler

For ABG, CT, BT, ApTT, TT
Increase HGT to 96
DRUG Start omeprazole 20 mg 1 tab OD
For pericardiostomy
HR COVERAGE <200-0; 201-250 3units; 251 > - 5 units
3:30pm
EF 70
PE mod to severe 1.9-3cm
(+)RA collapse during diastole
NPO Now
8:30pm
S/P Pericardiostomy Tube insertion
Subphixoid Pericardial Window Creation with Pericardial Biopsy
Intraop
Drained 700cc of Straw fluid
Epi and Pericardium smooth
Keep JP drain on negative pressure at all times and monitor output q6
and record
Monitor CT output with __ Svidu and record
9:10pm
Post Anesthetic Orders
Hook to cardiac monitor with O2 sat

Monitor VS q 15 mins x 1 hr then hourly unitl fully awake/stable

Meds:
Tramadol 50mg IV q 8 hrs x 3 doses then shift to dolcet 1 tab q 8 hrs
10pm: Problem Pain 9/10
Nubain 5mg/IV now
10:30pm
For TBG
Venturi to 50%
High Back Rest
Insert Foley Cath
For 20 mg IV
11:45pm
Condition Critical
Activity: CBR
IVF: D5W 250 ml x 10 cc/hr
NPO temporarily
O2 @ 50% venture
Dx: FF result of pericardial fluid analysis
ABG
Therapeutics:
Tramadol 50 mg TW q 8hrs x 3 doses then shift to dolcet 1 tab q 8hrs
Cefepime 1 gm q 24 hrs via infusion
Furosemide 40mg TW q 8 hrs
Omeprazole 40mg TW OD
Rosuvastatin 1 tb OD

Lacidipine 1 tab in AM tab in PM

Clonidine 75 ml 1 tab TID PO
Ivabrodine 5 mg 1 tab BID
HR coverage same before but hold lantus while on NPO
VS q 1 hr
I&O; maintain UO to >+ 0.5cc/kg/hr
4:43am
2 tabs of paracetamol 500 mg PO with sips of water
11/6/14
5:20am for CBC and K today
7:21pm
Resume diabetic diet
Shift to O2 cannule @ 3lpm
11/6/14
8:15am I 140 Output 510
Start nephrosteril 500ml x 8hrs OD
For CBC
If Hgb is <100 or Hct <30% transfuse PRBC
May have regular diet
For T3, T4, TIA And ANA
3pm IVFF: D5w 250 ml x 10 cc/hr
Hold main line whole on nephrosteril

4:15pm
Review of Meds:
Suggest Epo 4000 u SC 2 x a week
FESO4 with FA 1 tab BID (Iboret)
Riemezin 2gm/sachet 1 sachet TID with meals
Lantus 8u SC in AM
Furo 40 mg/IV q8
Dolcet tab 1 tab TID q8
Omep 40mg/IV OD
Nephrosteril 50ml x 8 hrs OD
Cefepime 1 gm IV infusion 1 24
Clonidine 75 mgs 1 tab TID HOB
Rosuvastatin 10mg HOB OD
Lacidipine 1 tab in am tab In PM
Ivabradine 5mg HOB BID
DIET: DM DIET
IVFL D5w 250ml x 10cc/hr
4:55pm
IV omeprazole to 40mg/tab 1 tab OD
-may transfer
11/7/14
7:40am
BP 130/70
HR 56
O2 sar 99%

EGFR 11.6
No objection to TROG
9:50am
D/C IV Furosemide
Continue HGT monitoring
Dec CBG monitoring BID (premeals)
IF CBG results is <120mg/dl, dc HGT monitoring
Continue lantus
Dec Lacipil to 6mg HOB, OD
Limit visitors
Okay for troc
Start Flumucil 1 tab in 50cc H20 BID
Start Clexan 0.4cc OD (deltoid area)
10:10am
TROC Orders
Problem: 1. DOB > peri effusion
Dx: 1. Pericardial effusion prob 2 to
a. Metabolic (uremia)
b. R/O autoimmune etiology
2. CKD St V 2 to DM nephropathy
3. DM type 2
4. Hypertensive cardiovascular disease
Condition: Stable
Activity: CBR and may sit up on bed
For repeat crea
IVF: D5w x 250ml x 10 cc/hr

Therapeutics:
1. Cefepime 1gm IV infusion q 24
2. Dolcet tab, 1 tab q8
3. Epo 4ku SC2x a week
4. Ricmezin 2gms 1 sachet, 1 sachet TID
5. FESO4+FA (Iberet) 1 tab BID
6. nephrosteril 500ml x 8 hrs OD (off mainline)
7 Lantus 8units SC OD
8. HR sliding scale same
9. Clonidine 75 mg/tab 1 tab TID
10. lacidipine 6mg/tab, 1 tab OD
11. Rosuvastatin 10 mg/tab, 1 tab OD
12. Clexane 0.4cc SC OF
12. Ivabradine 5mg/tab 1 tab BID
13. Flumucil 600mg/tab, 1 tab in 50cc H20 BID
14. Omeprazole 40 mg/tab 1 tab OD
Monitor VS q 4
Monitor I&O q shift then quantify record including CTT and JP drain
O2 support via NC at 2lpm
Limit visitors
5:11pm ftf: D5w 500 cc >10cc/hr
11/8/14
12:10pm
D/C Nephrosterol, Dolct, Iberet, Rosuvastatin, CBC Monitoring
Ok to start NaHCO and CaCO3 if no vomiting episodes for 8 hrs

D/C omep shift to Pantoloc 40 mg/IV OD x 2 doses then Pravacin

30mg/tab 1 tab OD
Kremezin 2gms 1 sachet TID
Dulcolax syrup 2 tsp OD on HS
CTT removed
May ambulate with assistance
11/9/14
10am
IVFtf D5NM x 20c/hr
Remove JP Drain
2:09pm
D/C FC
Start Triocef 200mg/tab BID
Regular diet
D/C Cefepime
D/C Pantoloc
11/10/14
d/c clexane
Dec lacidipine to 4 mg/tab
Review of meds
1. Cefixime 200 mg/tab BID
2. Dulcolax syrup 2 tsp OD HS
3. Lansoprazole (Prevacid) 30 mg/tab OD

4. NAHCO3 650mg 1-1-1

5. CaCO3 500mg 1-1-1
6. Kremazin 2 gm 1 sachet TID
7. Epo 4kunits Sq 2x a week
8. Lantus 8 u SQ OD
9. Clonidine 75 mcg 1 tab TID
10. Lasidipine 6mg 1 tab OD
11. Clexane 0.4c AQ OD
12. Ivabradine 5mg/tab BID
13. Flumucil 600mg/tab BID
11/11/14
Eltroxin 50mg OD
Pred 20 1 tab OD x 2 dats then tab OD x 2 days then
S>
No DOB, chest pain, body malaise and loss of appetite
O>
Conscious and chorent; 120/80
Pink palpebral conjunctiva, anicteric sclera
(-) murmurs
SLE, (-) retractions
Normal RR and rhythm
Take Home Meds
Feso4 500mg 1-0-1
NahCO3 TID 1-1-1

CaCo3 500mg 1-1-1

Kremazin 20mg 1-1-1
Ketoconazole 300 mg 3-3-3
Kobuyostat 40 mg 1-0-0
Epoeitin4k uit 2x a week
Ff up BUN, Crea, UA, HLB, Ca, BUA, CBC
6/16/14
Normal left ventricular size with hypertrophied walls with adequate
wall motion and contractility
Normal right ventricular size with adequate wall moion and contractility
Dilated left atrium without visible thrombus
Normal right atrium
Thickened mitral valve leaflets without restriction of motion; mitral
annular calcification extending to posterior mitral valve leaflet
Thickened aortic cusps with calcification along non coronary cusp
without restriction of motion; aortic annular calcification
Structurally normal tricuspid and pulmonic valves
Normal main pulmonary artery
Calcified aortic walls; raised plaques along sinotubular junction
Echo free space surrounding the heart more prominent along the
posterior left ventricle
Doppler: Tricuspid regurgitation mild
Normal estimated pulmonary artery systolic pressure of 28 mmHG by
tricuspid regurgitation jet method
Reversed mitral inflow pattern

Conclusion:
Concentric left ventricular hypertrophy with normal overall left
ventricular resting regional systolic function; calculated ejection
fraction of 73% by Cube Method
Normal right ventricular size and systolic function
Dilated left atrium consistent with relaxation abnormality
Mitral valve thickening without evidence of prolapse nor diastolic
doming motion
Aortic valve thickening with annular calcification
Atherosclerotic aorta; raised plaques along sinotubular junction
Mild to moderate pericardial effusion; no signs of tamponade
physiology
No evidence of elevated pulmonary artery systolic pressure
11/5/14
Chest Ap/Lateral
Follow up chest radiograph after 9 hours shows decrease in the size of
the cardiac silhouette. Pericardiostomy drainage tube is noted at
the anterior aspect of the right ventricle.
Subsegmental atelectasis is noted at the inferior lingual. The rest of the
lungs are clear. Other chest structures are not remarkable.
Chest PA
Follow up chest radiograph since June 17, 2013 shows clear lungs. True
cardiac size cannot be ascertained. Aorta is still atheromatous.

Admission

11/6

11/7

11/8

11/9

11/10

Discharge

Nursing Problems
Deficient Fluid
Volume
Risk for Spread of
Infection
Impaired Skin
Integrity

Acute Pain

Anxiety

Vital Signs
Temperature
Pulse
Rate
Respiratory
Rate
Blood Pressure

37.2

36.8

37

36.7

36.6

36.5

36.5

93

73

80

81

78

65

68

18

17

24

23

21

20

18

150
100

140
70

160
70

150
60

140
60

160
70

150
90

Diagnostics
Complete
Blood
Count
-Hemoglobin

106

109

102

-Hematocrit

.33

.34

.31

135
.39
35.8

-WBC count

7.21

11.54

9.5

-Neutrophils

.68

.86

.78

-Lymphocytes

.25

.09

.13

.92
.08
338
-Platelets

252

Fasting
Blood
Sugar

5.51

293

302
5.51
4.20
6.4

BUA

6.4

Creatinine

81.7

331.2

339.8

Sodium

134.9

140.8

132.2

0.56
81.7
134.9
4.47

Potassium

4.47

4.77

3.61

99.2
Albumin

99.2

23.41

Calcium

1.07

1.07

Phosphorus

1.34

1.34

Chest Xray

99.2

Atherosclerotic
aorta; clear
lungs

ECG

NSR

HGT

90

Urinalysis
-Color

Yellow

-Appearance

Turbid

-pH

6.0

-Specific Gravity

1.015

-Sugar

Negative

-Albumin

4+

-Pus Cells

2-4/hpf

-Red Cells

0-2/hpf

-Epithelial Cells

Moderate

-Bacteria

Rare

Atherosclerotic
aorta;
clear
lungs
NSR

132

121

104

Yellow

Yellow

Yellow

Turbid

Turbid

Turbid

6.0

6.0

6.0

1.015

1.015

1.020

Negative

Negative

1+

4+

4+

3+

2-4/hpf

2-4/hpf

2-3/hpf

0-2/hpf

0-2/hpf

0-2/hpf

Moderate

Moderate

Few

Rare

Rare

Rare
many

-Amorphous
Urates
Arterial Blood
Gas
-pH

7.33

-pCO2

39

-pO2

83

7.33

7.33

39

39

83

83

-HCO3

20

-BE

-5.5

-SO2

95%

20

20

-5.5

-5.5

95%

95%

36.3 sec

36.3 sec
31.8843.68 sec

APTT
-patient value

36.3 sec

-normal patient
value

31.8843.68 sec

31.8843.68
sec

-control value

34.8sec

34.8sec

-normal control
value

28.7-36.5
sec

28.7-36.5
sec

34.8sec

PTT
-patient value

28.7-36.5
sec

11.1 sec
11.1 sec

11.1 sec

-normal patient
value

10-14 sec

10-14
sec

-control value

11.7 sec

-normal control
value

10.3-13.1
sec

-INR

0.93

10-14 sec

11.7 sec
11.7 sec
10.3-13.1
sec

10.3-13.1
sec
0.93

0.93
5 mins
Bleeding Time

5 mins
5 mins

Clotting Time

7 mins
30sec

7 mins
30sec

Radioimmunoassay Result
-TSH

7.18

-Total T4

105.12

-Total T3

0.69

Grams Stain
Sputum

7 mins
30se
Gram (+)
baccil,
cocci in
singles
and cocci
in pairs
are rare;
pus cells
are 1015/lpf;
epithelial
cells are
few

IVF
D5W x 250ml x
10cc/hr
D5W x 500ml x
>10cc/hr

/
/

Drugs
Cefepime 1g IV
infusion 30 ml for
30 min q 24
Furosemide 40 mg
TID then q 12
Rosuvastatin 10 mg
1 tab OD

D/C

D/C

/
Dec
to
6mg
OD

Dec to 4mg
OD

shifted

D/C

D/C

Lacidipine 1 tab Am
and 1/2 tab PM
Clonidine 75 mg 1
tab TID
Ivabradine 5 mg 1
tab BID
Lantus 8u AM
Omeprazole 20 mg
1 tab OD
Tramadol 50 mg IV
q8 hrs x 3 doses
Dolcet 1 tab q8 hrs
Nephrosteril 500 ml
x 8hrs OD
Epoetin 4000u SC
2x a week
FESO4 with FA 1
tab BID
FESO4 with FA 1
tab OD
Kremezin 2
gm/sachet 1 sachet
TID with meals
Flumucil 600 mg 1
tab in 50 cc H20
BID
Enoxaparine
(Clexane) 0.4cc OD
deltoid
Pantoloc 40 mg IV

/
/

inc to 40

D/C

/
/

/
/

D/C

Hold

D/C

OD x 2 doses
Prevacid 30 mg 1
tab
NaHCO3 1 tab TID
CaCO3 500mg/tab
TID
Dulcolax syrup 2
tsp OD
Cefixime Triocef
200 mg 1 tab BID
Lansoprazole 30 mg
1 tab OD
Feblixostat 40 mg 1
tab OD

Diet
Diabetic Diet

NPO

Activity
High Back Rest
Complete Bed
Rest
May ambulate
with assistance