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KARDEX Case 3

This patient was admitted on 8/13/20 at 4:10 PM under the service of Dr. Quijano for left sided weakness and slurring of speech. The patient is being treated with multiple IV medications including Mannitol, Citicoline, Atorvastatin, Pantoprazole, and Levetiracetam. Labs ordered on admission include COVID and PCR testing, CT brain scan, ECG, CBC, renal and liver panels. The patient was intubated on 8/14/20 and transferred to the ICU for further management including ventilation support, cardiac monitoring, and nephrology consultation for chronic kidney disease.

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Juviely Premacio
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641 views3 pages

KARDEX Case 3

This patient was admitted on 8/13/20 at 4:10 PM under the service of Dr. Quijano for left sided weakness and slurring of speech. The patient is being treated with multiple IV medications including Mannitol, Citicoline, Atorvastatin, Pantoprazole, and Levetiracetam. Labs ordered on admission include COVID and PCR testing, CT brain scan, ECG, CBC, renal and liver panels. The patient was intubated on 8/14/20 and transferred to the ICU for further management including ventilation support, cardiac monitoring, and nephrology consultation for chronic kidney disease.

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


8/13/20 @4:01 PM 8/13/20
//Mannitol 200 cc IV bolus q4H @(4 pm , 8 pm,12 am, 4 am) // - Please admit to COVID Unit under the service of Dr.
Citicoline 1 gm IVTT q 8H (4 pm , 12 am , 8 am )// Quijano
//Atorvastatin 80 mg/tab, 1 tab OD per NGT (4:01pm)// - Secure signed consent to care
Pantoprazole 40 mg IVTT now then q 24H (4:01pm)// - TPR q 4 H
//Levetiracetam 500 mg/tab 1 tab BID NGT ( 4:01pm & 5:01pm)// - O₂ at 2-3 LPM via nasal prong
//DKA (Ketobest) ii tabs TID NGT ( 4:01 pm & 5:01 pm and - MHBR
6:01pm)// -Please insert NGT and FBC attach to urobag
8/14/20 - Monitor vital signs hourly to include neuro
Give Paracetamol 500 mg IVTT PRN for fever - I & O q 4H in absolute figures
-Please attach to cardiac monitor
-Will inform Dr. Quijano
-Continue Maintenance Meds
-Please intubate patient and attach to MV c̅ the ff settings ;
AC mode;TV 400;FIO₂ 100 %;BUR 20;PEEP 5
;PL 60 ;PF 45
-Please refer to Dr. Barbosa for RSI
8/14/20 @ 7:00pm
-Please include Neurovital signs
-Refer to Dr. Inting (Nephrologist) and Co- mngt Re:
-CKD (Hypertensive Nephrosclerosis
Vs U. Acid
-Please Facilitate swab Testing
-Repeat ABG now
-Transfer to VSMMC
-Dr. Inting informed of this co-management through phone
call with acknowledgement
-Facilitate Transfer ;
KARDEX
DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS
8/13/20 @4:01 8/14/20
COVID Antibody RTK IVF to 60cc/hr
VOVID RT-PCR c/o SHH Give HRI 3 units SQ now
CT Scan Brain Plain 8/13/20
ECG 12 Leads Venoclysis: PNSS 1L at 20 gtts/min
CBC: S. crea, Na⁺, K⁺, SGPT, BUA, BUN, HBAIC Give HRI 6 unitsSQ now
FBS, Lipid Panel Give 200 mg NaHCO₃with bows now
Urinalysis Nicardipine drip: 10 mg + 90 cc PNSS at 20 cc/hr titrate c̅ BP, to
Protime, APT maintain BP ≤ 140/90 ≥ 90/60
CXR PA
ABG now
8/14/20 @ 7:30 AM
Repeat ABG now
For 2D ECHO with doppler
KARDEX
PATIENT’S NAME:__ Allan , Morales Bernados _ DIET:
AGE_77__ SEX_M______ 8/14/20@6:19 AM
ATTENDING PHYSICIAN___ Dr. Quijano _______ Blenderized Feeding 1500 kcal in 1000cc water in 6 divided
CO-MANAGEMENT________________________ feedings
DATE & TIME ADMITTED _8/13/20 / 4:10 PM__ 8/13/20 @4:01
//NPO temporarily//
ROOM #______ RELIGION:__Roman Catholic ______
HOSPITAL #_____DATE OF BIRTH_ June 12 ,,1943__
DIAGNOSIS/ IMPRESSION:
BLOOD TYPE :_________

CHIEF COMPLAINTS: L sided weakness, slurring of speech

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