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KARDEX Case 1

The document contains the kardex of patient Feliciano Aranas Bugtay, an 80 year old male admitted to the COVID unit on August 11, 2020 under the service of Dr. Quijano and co-managed by Dr. Fernandez for cough and dyspnea. The kardex details his medications, treatments, laboratory results, diet orders, and notes from daily medical rounds documenting his hospital course and management.

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Juviely Premacio
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0% found this document useful (0 votes)
392 views3 pages

KARDEX Case 1

The document contains the kardex of patient Feliciano Aranas Bugtay, an 80 year old male admitted to the COVID unit on August 11, 2020 under the service of Dr. Quijano and co-managed by Dr. Fernandez for cough and dyspnea. The kardex details his medications, treatments, laboratory results, diet orders, and notes from daily medical rounds documenting his hospital course and management.

Uploaded by

Juviely Premacio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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KARDEX

DATE/ TIME MEDICATIONS DATE TREATMENT/ MANAGEMENT


8/11/20 @4pm
//Ceftriaxone (Trizeto) 2 gm IV Drip q 24H ANST (4pm) // 8/11/20
//Azithromycin (Zenith) 500 mg/cap, 1 cap OD PO (4pm) // - Please admit to COVID unit under the service of Dr.
//Dexamethasone 6 mg IVTT OD, 1st dose now (4pm) // Quijano, co-managed with Dr. Fernandez
//Colchicine 0.5 g/tab, 1 tab BID ( 4pm & 12 am) // - Secure to care
//Melatonin 3 mg/tab, 2 tabs BID PO ( 4pm & 12 am) // - CBR w/o TP provide commode
//Lopinavir/Ritonavis 200 mg/50g/tab, 2 tabs BID ( 4pm & 12 am) // - NPO temporarily
//Famotidine 20 mg/tab, 2 tabs OD PO may use Ranitidine 150 - V/S q hourly to include O2 Sat
mg/tab, 1 tab BID ( 4pm & 12 am) // - I/O q 4 hours in absolute figure
//Tocilizumab Drip: 400 mg in 100 cc PNSS to run for 2 hours, - Please inform DR. Adlawan once pt. is at the ward
provide consult Pre medicate with; - Refer unusualities
//Paracetamol 300 mg IVTT 30 mins prior // - Dr. Quijano updated
//Diphenhydramine 50 mg IVTT 30 mins prior// - Please insert FBC
//Vitamin C + Zinctab, 1 tab OD (4pm)// - I&O q hourky, refer I&O q 4 to IM ROD
//Trimetazidine (Vastarel MR) 35 mg/tab, 1 tab po BID ( 4pm & 12 - O2 @ 15L via non rebreather mask
am) // - Limit OFI to 800 cc/day
8/12/20 @8am - MHBR at all times
//Start Enoxoparin (Clexane) 0.4 SC OD give one dose now 8/12/20 at 9:00 AM
(8am) // - Rounds with Dr. Fernandez
8/13/20 @8pm - Inform MROD if still w/o stock of Lipo/Rito by
Start Atorvastatin 40 mg/tab 1 tab OD PO give 1 dose now (8pm) noontime
- SO requested to transfer to VSMMC due to financial
constraints; AP updated, no objection
- For transfer
- Dr. Fernandez no objection to transfer
8/13/20 at 7:00 AM
- AP updated
- Defer FBC insertion
- Decrease O2 inhalation to 10 LPM NRM
- APS updated
- Facilitate transfer
- FF up Pro BNP, D-Dimer and Ferritin results
- Please facilitate after hospital letter pro-BND
- Repeat creatinine now
8/13/20 at 11:53 PM
- May transfer to VSMMC
- Dr. Quijano updated
- Please facilitate
KARDEX

DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS


8/11/20 at 4:00 PM
 CBC, UA 8/12/20
 Na, K, Crea, BUN, ALT BUA Lactulose 30 cc OD HS, hold for BM >2x/day
 LDH, CRP, Pro-calcitonin 8/11/20
 Ferritin, D-Dimer, Blood Typing Venoclysis: c ̅ PNSS 1L at 10 cc/hr
 Protime, clotting/ bleeding time
 Blood c/s x 2 sites
 FBS, Lipid Panel
8/11/20 at 4:50 PM
 Repeat ABG after 6 hours
8/11/20 at 10:02 PM
 Repeat ECG 12 L now
 UTZ WAB to include prostrate
 Facilitate 2D ECHO
8/13/20 at 7:00 AM
 Repeat Creatinine now
KARDEX
PATIENT’S NAME:__Feliciano, Aranas Bugtay DIET:
AGE__80_____ SEX__M_____ 8/11/20 at 10:02 pm
ATTENDING PHYSICIAN__DR.Quijano_______ May have a soft diet with aspiration precaution
CO-MANAGEMENT_DR. Fernandez_________ 8/11/20 at 4:00 pm
DATE & TIME ADMITTED ; 8/11/20 / 4:00 PM // NPO temporarily//
ROOM #______ RELIGION:__Roman Catholic __
HOSPITAL #_____DATE OF BIRTH ; September 18, 1939 DIAGNOSIS/ IMPRESSION:
BLOOD TYPE :_________

CHIEF COMPLAINTS: Cough and Dyspnea

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