COURSE MANAGEMENT DAY 1 On March 11, 2012 at 11:00 am the patient arrived in the ER with the chief complaint

f diffiulty of reating, (+) crackles and (+) wheezes noted. Initial vital signs cheched BP: 130/90mmHg, HR: 130 bpm, RR: 32 b/m, T: 36.4 C nd oxygen saturation of 85%, weight f 50 kgs and with previous CXR result revealed considerations are PTB vs. Lung metastasis. The patient was attented by Dra. Alonto wit orders made and carried out. The problem stated, the patient patient have Bronchial Ashma in Acute Exacerbation, Community Acquired Pneumonia moderate Risk, Pulmonary Tuberculosis v new category I rule out Parenchymal New Growth. With the assessments made and diagnosis noted thus leading to the patients admission to Medicine Ward under the service of orange team ( Dr. Daing, Dr. Mabang, Dra. Alonto and Dr. Dabalus). DOCTORS ORDER
Secure consent to care Intake and Ouput every shift vital signs monitoring every 4 hours and record Moderate High back Rest IVF: PNSS 1L at 30 gtts/min DIET: Diet as Tolerated with aspiration Precaution DIAGNOSTICS: CBC, APC, BT stat DONE CXR PA view stat DONE Sputum AFB x 3takes ECG 12L stat DONE CBG stat DONE (145mg/dL) Chest CT-scan, plain Lipid profile TPAG FBS, BUN, Crea, Uric acid Urinalysis Sputum cytology Medications: Hydrocortisone 100mg IV then q 6hrs Ipratropium + salbutamol, 1 neb up to 3 doses q 20 mins then 1 neb q 6 hrs Ampicillin + Sulbactam 750mg

RATIONALE

NSG. RESPONSIBILITIES
Gather baseline information Do initial assessment (cephalocaudal approach) Vital signs taking Physiacl assessment Subjective and objective Prioritzed patient problem (focus on the chief complaint: difficulty of breathing) Interventions: Position on moderate hih back rest Instructed on deep breathing execise Provided good ventilation Advised to limit activities and have adequate rest All needs attende Encouraged to vervalize feelings and concerns Kept monitored for any signs of unusualities Carried out doctors order Give stat medications with taking consideration of 10 Rs before giving it. Facilitated all labs requested Educated the patient and significant others about the diagnostics to be done

o o o o o o o

IV q 8 hrs ANST Azithomycin 500mg 1 cap OD N-acetylceptine 600mg 1 tab + glass of water OD B complex 1 cap OD HRZE 3 tablets OD ac Hook patient to cardiac monitor then refer oxygen saturation < 90% Refer accordingly

All procedures to be done to the patient should explain first.

At 10:45 pm the patient noted dyspniec with RR: 34b/m, HR: 136 bpm, (+) wheezes all over the chest wall upon auscultatin, BP: 110?70 mmHg, T: 36.7 C, Oxygen saturation of 88%. The following assessments referred to MROD. Dr. Daing seen and examined the patient with orders amde and carried out. The ff orders are:
nebulazation to q4 hydrocortisone 100 mg IV q 4 hr Cont. Other meds Serum Na, K stat ABG Oxygen sat q1 hr, refer if <90% ISMN 60mg tab, 1 tab OD For close monitoring Keep Ivf at 30gtts/min Nebulized patient according to ordered frequency Transcribed hydrocortisone 100mg Iv from q6 to q 4 as ordered Facilitated requested labs and educated patient and significant other about it. Started ISMN 60mg tab as initial dose Regulated IVF at same rate Watched out for any signs of unusualities (oxygen sat <90%) and referred immediately to MROD.

DAY 2 March 12, 2012 at 6:00 am the patient experiencing difficulty of breathing with oxygen saturation of 76%, HR: 135 bpm, RR: 33 b/m, BP: 120/90mmHg, T: 37 C, non productive cough noted, (+) crackles and wheezes noted. The above assessment staed are all referred to dr. Daing with orders made and carried out.
Deck to ICU, transfer once with vacancy (infectious) Aminophylline drip: aminophylline 2 amps + D5W 500cc to run at 10 Informed ICU (decked patient at infectious room) Prepare Aminophylline drip with taking consideration of 10Rs of medication

mgtts/min Prime for possible intubation Follow up official CXR Facilitae other labs

Prime patient (if possible) or the significant others for possible intubation Secured consent (consent to procedure if not consented DNR form will be sign by them) Educated about ET insertion (the procedure, purpose, advantages and disadvantages) Facilitated all labs specifically CXR result

At 10;30 am CXR results in revealed possibility of lung metastasis is considered, however with presence of a mass in the left suprahilar area, primary lung neoplasm with intraparenchymal spred is also entertained. The stated CXR result referred to Dra. Lauban together with Dra. Alonto seen and examined with orders made and carried out.
Shift Ampicillin + Sulbactam to Piperacillin + Tazobactam 4.5g 6 hrs ANST Hold HRZE For Chest CT-scan refer Card out previous antibiotic and transcribed to pip+taz, and hold HRZE Skin test done and started pip+taz (-) ANST

At 2:00 pm the patients is about to undergo Chest CT-scan but the oxygen saturation was 88-89% referred to Dra. Albios with telephone order made and carried out.
Nebulize with Ipratropium + Salbutamol 1 neb now Nebulized patient ordered Turned to sides Back tapping done as

After nebulization the patients oxygen saturation reaches to 96%. The patient wheeled to CT scan room assisted by nurse assigned. At 3:00 pm labs in FBS 6.2 (H), Uric acid 827.1 (H), total CHON 57 (l) AND Albumin 29 (L) referred to Dra. Albios seen and examine d the patient with orders made and carried out.
Kalium durule tab, i tab TID For CBG stat 117mgdL DONE Albumin 1 bottle =20m Furosemide to run in 2hrs OD Checked CBG and referred to MROD Give medication once available in taking consideration of 10 Rs before giving it.

At 3:30 pm the patient tolerated sips of water and can swallow noted referred to Dra. Albios withn telephone order made and carried out.
Change diet into soft diet Informed dietary for changes of diet modification as ordered Enforced to soft diet (eg. Forridge) Instructed on small frequent feedings

At 9:35 pm the patient was experiencing tachycardia with HR of 140-150bpm referred to Dra. Albios with order made and carried out.
Lanoxin .5mg IVTT now Ordered medication given Referred patients outcome to MROD HR: 89bpm

DAY 3 March 13, 2012 at 6:25 am the patients oxygen saturation was 88-89% with (+) wheezes referred to dra. albios with telephone order made and carried out.
Nebulize with Ipratropuim+Salbutamol 1 neb now then q 20 mins x 3 doses Nebulized patient ordered Turned to sides Back tapping done as

At