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Day 1
February 8, 2015
9:45 PM
Course of Confinement
Vital Signs
BP= 70/40 mmHg
PR= 96 bpm
RR= 21cpm
T=36.2
spO2= 96%



3mm 3mm

Both are briskly reactive to light and with good accommodation
GCS 15/15
Muscle Strength
3
3
3
3
>Admit to ICU






>with D5W 1L x KVO


>Dobutamine Drip
D5W 250cc + Dobutamine 400mg to run initially at 40 ugtts/min to maintain SBP of 90-100 mmHg with increments and decrements of 10 ugtts/min every 30 minutes with maximum titration of 100 ugtts/minute
>Assisted patient transfer from ward to ICU

>Secured consent for management


>Regulated IVF accordingly

>Hooked Dobutamine drip and regulated at 100 ugtts/minute as ordered
>Add remaining 8cc to present dobutamine drip to make it 500mg/250 ml concentration to maintain SBP of 90 mmHg with increments and decrements of 5 ugtts every 30 minutes with maxium titration of 60 ugtts/min

>Start Dopamine drip 400mg/250 cc to run at 18 ugtts and maintain until further orders
>Started Dopamine drip 400mg/250 cc and regulated at 18 ugtts/min as ordered
Day 2
February 9, 2015
12:20 AM
(+) Chest pain 8/10
(+) Vomiting
BP=70/40 mmHg
PR= 110 -120 bpm
>Give Tramadol ½ amp IV now
>Checked IV patency; noted (+) backflow of blood. Administered Tramadol ½ amp IV as ordered
>Regulated IVF accordingly
February 9, 2015
2:00 AM
(+) Vomiting 2x approximately 50 cc
>Give Metoclopramide 1 amp IV now
> Checked IV patency; noted (+) backflow of blood.
Administered Metoclopramide 1 amp IV as ordered.
>Regulated IVF accordingly
February 9, 2015
2:30 AM
(+) Vomiting 4x
> Give Metoclopramide 1 amp IV now
> Checked IV patency; noted (+) backflow of blood.
Administered Metoclopramide 1 amp IV as ordered.
>Regulated IVF accordingly
February 9, 2015
10:20 AM
Nausea and Vomiting
>Hold Tramadol


>Hold Doxofylline


>Hold Acetylsalicylic acid

>Discontinue Candesartan


>Metoclopramide 1 amp IV every 6 hours
>Hold Tramadol as ordered

>Hold Doxofylline as ordered

>Hold Acetylsalicylic acid as ordered

>Discontinued
Candesartan as ordered

> Checked IV patency; noted (+) backflow of blood.
Administered Metoclopramide 1 amp IV every 6 hours as ordered.
>Regulated IVF accordingly
>For ultrasound of Abdomen once with consent and funds



>Insert IFC; hook to urine bag
>Secured consent for ultrasound of abdomen
>Accompanied patient for ultrasound of abdomen

>Secured consent for IFC insertion
>Prepared necessary materials needed for IFC insertion
>Perineal care done
>Instructed patient to have deep breathes
>Inserted IFC gently and aseptically
February 9, 2015
6:45 PM
Oliguria 10cc/hr for 3 hours
>Suggest referral to nephrologist Dr. Elizabeth Estoesta for co-management and further evaluation if okay with relatives
>Secured consent for referral to Dr. Elizabeth Estoesta for co-management and further evaluation
February 10, 2015
10:35 AM
(+) Crackles on upper and lower lung fields
(+) Difficulty of Breathing
RR: 26 cpm
O2Sat: 98%
February 10, 2015
6:45 PM
(+)Difficulty of Breathing
(+) Copious phlegm
February 11, 2015
12:30 AM
(+) numbness on all extremities and nape
Noted ST segment depression and elevation and isolated premature ventricular contractions
> Hold Doxofylline
>Hold Lanoxin, Clopidogrel, Acetylsalicylic acid


>Increase oxygen to 4lpm


> May have bladder training then remove IFC after two urges
> Hold Doxofylline
>Hold Lanoxin, Clopidogrel, Acetylsalicylic acid


>Increased oxygen inhalation via nasal cannula to 4 lpm

>Facilitated bladder training then removed IFC after two urges
>Shift Ranitidine IV to oral Ranitidine 150 mg 1 tab BID



>For repeat Portable Chest x-ray now
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
ASSESSMENT
>May taper down Dobutamine drip at 40 ugtts/min to 30 ugtts/min

>Start Domperidone (Tozar) 10 mg/tab 1 tab TID x 3 doses





>Titrate Dopamine to 10 mg/kg/min
>Above side drip of Dobutamine drip tapered down at 30 ugtts/min

>Facilitated administration of Domperidone 10mg/tab as ordered
>Maintained on high back rest to prevent aspiration

>Titrated Dopamine to 10 mg/kg/minute
>Give nebulization of Ventolin now then another dose after 15 minutes
>Facilitated nebulization of Ventolin as ordered
>Nebulize with Ventolin now


>Decrease Hydrocortisone 100mg IV TID
> Facilitated nebulization of Ventolin as ordered

>Revised Hydrocortisone to 100mg IV TID
>Checked IV patency; noted (+) backflow of blood
>Administered Hydrocortisone 100mg IV as ordered
February 12, 2015
10:40AM
(+) Difficulty of Breathing
ASSESSMENT
>Increase oxygen to 4lpm




> May have bladder training then remove IFC after two urges


>Shift Ranitidine IV to oral Ranitidine 150 mg 1 tab BID
>Increased oxygen inhalation via nasal cannula to 4 lpm as ordered.


>Facilitated bladder training then removed IFC after two urges


>Facilitated administration of Ranitidine 150 mg 1 tab per orem as ordered
>Maintained on high back rest to prevent aspiration
>For repeat Portable Chest x-ray now
>Secured consent for portable chest x-ray
>Accompanied patient for chest x-ray
February 12, 2015
11:0AM
>Hydrocortisone to consume then discontinue



>Shift Cefuroxime to Levofloxacin 750 mg 1 tab OD


>IV fluid to consume, then shift to heplock
>Facilitated administration of Hydrocortisone until consumed then discontinued

>Shifted Cefuroxime to Levofloxacin 750 mg 1 tab OD

>Regulated present IVF accordingly, consumed then shifted to heplock
February 12, 2015
3:30AM
Day 3
Day 4
Day 5
>May transfer to room of choice.
>Informed 5th floor for the transfer of patient.

>Prepared the patient’s belongings for the transfer.

>Assissted the patient to 5th floor

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