7/18/18

Patient was seen and assessed with the following vital signs: BP=110/70, CR=72, RR=20, Temp= 36.5,
O2sat=100%. Patient was unconscious with a GCS score of 8 (E2V1M5). Physical Examination revealed
bilateral rhonchi upon auscultation of the chest. Diet includes Glucorna 5 scoops in 1 glass of water every
4 hours with 30cc pre and post flushing and IVF of PNSS x 60cc/hour. Medications included Polymixin B
150 mg TIV q12, Noripenem 500mg TIV q8, Amlodipine + Indapamide 10/1.5 mg/tab, 1 tablet OD,
Rosuvastatin 10 mg/tab, 1 tablet OD at night, Lactiracetam 100 mg/mL, 10 mL every 12 hours, Duavent
½ +2cc NSS every 6 hours, NAC 600 mg/tab, 1 tab BID, Hexetidine swab q6, Theophylline 125 mg/tab BID,
Nebivolol 5mg/tab, 1 tablet OD, CaCO3 tab, OD, Conzace tab, 1 tablet OD, Paracetamol 500 mg/tab, 1
tablet every 4 hours PRN, Diazepam 5 mg TIV PRN, Insulin glargine 20 units SQ OD. Patient was seen by
ENT-OHNS, and Neuro services and was advised to continue present medications and management.
Patient was also seen by the pulmo service in which they modified the MV setup to FiO2= 30%, PEEP= 14,
VT= 350 mL BVR= 14. Additional procedures advised by the pulmo service included suctioning of
secretions as well as to watch out for Hypotension and desaturation.

7/19/18

Patient was seen and assessed with the following vital signs: BP=100/60, CR=88, RR=20, Temp= 36.5,
O2sat=98%. Patient had no febrile episodes as well as desaturation and hypotension. On evaluation,
patient was unconscious with a GCS score of 10 (E4V1M5). Pertinent findings on physical examination
revealed 3mm pupillary light reflex, bilateral rhonchi upon auscultation of the chest and +2 deep tendon
reflexes. Diet includes Glucorna 5 scoops in 1 glass of water every 4 hours with 30cc pre and post flushing.
CBG monitoring in the morning was requested as part of diagnostics. Medications included Polymixin B
150 mg TIV q12, Noripenem 500mg TIV q8, Amlodipine + Indapamide 10/1.5 mg/tab, 1 tablet OD,
Rosuvastatin 10 mg/tab, 1 tablet OD at night, Lactiracetam 100 mg/mL, 10 mL every 12 hours, Duavent
½ +2cc NSS every 6 hours, NAC 600 mg/tab, 1 tab BID, Hexetidine swab q6, Theophylline 125 mg/tab BID,
Nebivolol 5mg/tab, 1 tablet OD, CaCO3 tab, OD, Conzace tab, 1 tablet OD, Paracetamol 500 mg/tab, 1
tablet every 4 hours PRN, Diazepam 5 mg TIV PRN, Insulin glargine 20 units SQ OD. Patient was seen by
ENT-OHNS service and was advised to continue present medications and management. Additional
instructions include suctioning of secretions as well as to watch out for Hypotension, fever and
desaturation