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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
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
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