TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
BED 2 #Ventilator associated IVF: PNSS 1L at 10cc/hr via peripheral DIAGNOSTICS:
pneumonia cutdown For repeat CBC on day 5 of antibiotics (11/14)
LAROZA. TRINIDAD (Enterobacter Pre HD CBC, Na, K, Creatine, Ca, Alb (11/14 AM – inform RDU nurse)
MILITANTE aerogenes) DIET: OF as ordered
AWAITING:
87/F/RPVD #Bronchial asthma in MEDICATIONS: Blood CS x 2 sites 1st site peripheral, 2nd IJ cath (11/10)
ID: 314049 acute exacerbation 1. Ceftriaxone 2gm IV OD Day 3
DOB: 03/20/32 2. Decrease Hydrocortisone 100mg
DOA: 5/6/19 #PE B prob HF vs CKD IV to q8hr for 3 more doses then REMARKS:
discontinue then start - Defer JP drain for now
CC: dyspnea #CAD VHD AS S/p PCI Budesonide neb Q12hrs - Will optimize HD first
AF SVR NYHA III 3. Decrease Salbutamol + - WOF: dyspnea, desaturation, chest pain
NEURO: Ipatropium neb to q8 hours RTC - Right side lying for 45 mins then 15 minsleft side lying
GCS 10 E4VTM5 #DKD G5D 4. KCl tablet 1 tab q2 x 3 doses then - CPT after neb
1 tab TID for 3 days - Suction secretion as needed
PULMO: #Anemia of chronic 5. Potassium Chloride 750mg/tab 1 - CBG TID AC and record
(+) cough disease tab TID Day 3 - DISCONTINUE RSBI for now (11/13)
(-) dyspnea 6. Salbutamol + Ipratropium 1 neb
(+) whitish to yellowish #T2DM Q8 RTC OTHER SERVICES:
suction per trache 7. Amino acid 7% 500mL during HD ENT:
(-) rhonchi bilateral #Chronic ventilator 8. Humulin R 6 units SQ for CBG Maintain tracheostomy tie tightness to <1 fingerbreath allowance
SCE dependence sec greater than 200mg/dL Daily and proper tracheostomy care
central apnea 9. Lantus 12 units SQ OD Refer back to TCVS for perm cath once stable
CARDIO: 10. Paracetamol 1gm TIV Q12 PRN REFER BACK TO TCVS FOR CTT INSERTION BILATERAL
No palpitations for pain
(-) systolic murmur 11. Lactulose 30cc ODHS hold for BM SURGERY: (6/26/19)
AP, NR, irregular more than 2 TCVS notes (09/11/19)
rhythm 12. ISDN 5mg/tab 1 tab SL PRN for
chest pain RSBI: 248.22 (10/24/19)
GI: 13. Atorvastatin 40mg/tab ODHS
No nausea 14. Montelukast 10mg/tab ODHS
No vomiting 15. Epoeitin 5000 U SC every Tues, MV SETTINGS
No abdominal pain Sat SIMV
Soft, flabby, non- 16. Aspart 4u SQ TID TV 380
tender abdomen, NABS 17. Clonidine 75mg/tab 1 tab SL OD FiO2 40%
for BP >160/90 BUR 16
MS: 18. Telmisartan 40mg/tab 1 tab OD PEEP 8
(+) edematous UE 19. Cefuroxime 750mg/IV OD PS 16
Completed
20. KCl 750mg/tab TID x 3 days Day 3 Decrease BUR by 2 every 3 hours until 8 then decrease PS by 2 every 3 hours until 10
Skin: 21. Omeprazole 40mg/cap ODAC
(-) erythematous 22. Enoxaparin 0.2cc sq OD – HOLD **AC mode for during HD
lesions during HD days
(+) Gr 2 ulcer

DISCONTINUE
Vancomycin 500mg IV q8
Cetirizine, Calamine lotion
Linagliptin 5mg/tab OD
Digoxin 0.25mg/tab, 1/2 tab q36hrs

SHIFTED
Piperacillin-tazobactam
Vancomycin 500mg IV day 7

1
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
BED 3 IVF: none DIAGNOSTICS:
CHIONG, MICHAEL
MALINIS #Sacral ulcer gr IV S/P DIET: 2500 kcal 2:1 dilution banana based with H & H 6 hours post HD
52/M/CP necrosectomy , partial 30cc pre and post flushing, increase in potassium
coccygectomy
ID No: 44956 diet AWAITING:
DOB: 05/14/67 # VAP (Enterobacter
DOA: 07/29/19 agglomerans) - resolving MEDICATIONS: REMARKS:

#Persistent Vegetative state 1. Humulin R 6 units (target CBG <

NEURO:
GCS 9 (E4VTM4), No
seizure, Cervical
hyperextension
PULMO:
SCE, (+) Rhonchi, bilateral,
CARDIO:
Adynamic precordium,
#Chronic ventilator
dependence sec to central
apnea
# Anemia of Chronic
disease
#Pressure ulcer grade II s/p
debridement Right leg
#DKD G5D
#T2DM
For HD tomorrow (11/13/19)
200mg/dL) - WOF: dyspnea, desaturation
2. CaCo3 500 mg 2 tabs in AM, 1 tab lunch,
- Chest physiotherapy every after nebulization
1 tab evening
-Daily PT
3. Valproic acid syrup 250mg/5mL 5mL per
NGT Q12 Day 10 (plan to taper after Day -Maintain negative pressure as previously advised by plastics surgery
15)
4. Amino Acid 7% 500mL post HD REFERRALS/ON BOARD:
5. Citicholine 1g tab 1 tab OD On board GS, IDS, Pulmo, Neuro, Derma
6. Nystatin oral suspension as swab to oral
cavity q4
7. Calcitriol 1 tab BID For trial of Tpiece for 30 minutes
8. Omeprazole 40mg / cap 1 cap OD
9. D50 50 mL vial TIV PRN for CBG ≤80 MV SETTINGS as follows after HD
mg/dL
10. EPO-B 5000 u every T-Th-S post HD
11. Beneprotein 2 scooops to OF OD SIMV

Normal rate, regular rhythm, 12. Sevelamer 800mg/tab 1 tab TID

13. Diazepam 5 mg TIV PRN for seizures F8
no murmur, No neck vein
1. Salbutamol + Ipratropium (Duavent) neb
engorgement q8 RTC
PEEP 5
14. KCl 750mg/tab 2 tabs now then 1 tab
NEPHRO TID for 3 days – D2
COMPLETED: VT 500
Cefepime 2g IV OD Day 14
(+) edematous extremities
KCl 750mg/tab TID D3
(+) grade 1 edema PS 10
Tranexamic acid 500mg TIV q8 t/c 6 doses D6/6
Cefepime 1 gm q24h – day 14/14
GI Ciprofloxacin 500mg OD D7 FiO2 30%
(-) ascites Piperacillin-Tazobactam 2.25 gm IV q6 Day 9-10
Soft, non-tender Ertapenem 500mg IV infusion over 3hrs q24hrs - FOR Daily RSBI
Day 14/14
MSK

(+) Edema both upper arms

BED 5 #Acute Respiratory IVF: Heplock DIAGNOSTICS:

failure type I secondary For CBC, Na, K, Crea, BUN (11/15)
ROMERA, EDGARDO to: DIET: OF as ordered 2D echo with DS on call
ESPIRITU 1.HAP
2.Volume Overload MEDICATIONS: AWAITING:
69/M/RPV 1. Ceftriaxone 2g TIV Q24 D3 Cranial ct (11/10)
ID: 06161288 #Uremic PadiatePopathy 2. Continue Paracetamol 1gm IV
DOB:05/19/1950 Q12hr REMARKS:
DOA:11/02/2019 #ACS NSTEMI (lateral 3. Aspirin 80mg ODPC CBG monitoring, TID premeals
wall ischemia) Heart 4. Clopidogrel 75mg 1 tab ODPC Suction secretion regularly
Indang, Cavite score 6 (day 5) 5. Enoxaparin 0.6cc SQ OD day 3 O2 at 2lpm via NC
6. Captopril 25mg/tab ½ tab TID Relatives advised to buy egg tray foam for bed sores
CC: Chest pain #CKD G5D secondary 7. Atorvastatin 80mg/tab ODHS MV SETTINGS
to NSAID induced 8. ISMN 60mg/tab OD
NEURO: nephropathy 9. ISDN 5mg SL for chest pain SIMV
E4VTM5 (GCS 10) 10. TMZ 35mg 1 tab BID BUR 16
(-) sedated #Gouty arthritis 11. Lactulose 30cc ODHS hold for BM Peep 5
(+) restlessness more than 2 PS 16
(-) seizures 12. Omeprazole 40mg/cap ODAC FiO2 40%
13. Hold Amlodipine and ISMN VT400
CARDIO: 14. Norepinephrine drip 12mg in
(-) chest pain 100cc PNSS to run for 12cc/hr Decrease BUR by 2 every 3 hours until 8 then decrease PS by 2 every 3 hours until 10
(-) hypotension (0.4, 60kg) titrate by +/- 3cc/hr to
(-) bradycardia maintain MAP at 65mmhg or less
(-) diaphoresis - STANDBY
AP with no murmurs
D/C / SHIFT:
PULMO: Shift pipt-taz 2.25GM TO Ceftriaxone 2g
(+) whitish to yellowish (11/10-PM)
sputum Midazolam drip discontinued
(+) crackles, bases Norepinephrine drip on standby

GI:
Flabby soft, nontender
(-) No abd pain
(+) nausea
(-) vomiting
(-)jaundince
LBM – 11/05 1x

NEPHRO:
On HD 3x week
BED 7 #CAUTI IVF: Heplock DIAGNOSTICS:
Repeat Mg post correction (11/14 at 1AM)
BAGAPORO, MAGNO #Chronic Ventilator DIET: OF as ordered
BANAGLORIOSO JR. dependence sec to AWAITING:
central apnea MEDICATIONS: CXR results (11/13)
62/M/RPV 1. Start Ertapenem 1gm IV in 50cc PNSS Official cranial CT (9/1)
ID: 95679 #Multiple chronic CVD to run for 2 hours now then Q24hrs
DOB: 10/28/57 Infarcts, left parietal, 2. Start MgSO4 drip: 2.5 gm IV in 90 cc REMARKS:
DOA: 09/01/2019 right frontal lobe MRS PNSS to run for 12hrs Cont. daily RSBI & T piece as tolerated if <105

2
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
5 3. Shift Peptamen to Ensure 5 scoops in Relatives reapproval for tracheostomy
Central Bicutan, Taguig ½ glass water BID – coordinated Continue Physical therapy
City #Chronic ICH, (11/13) Maintain MAP 110-130
midbrain, pons, right 4. Sodium Hyaluronate eye drops, 1 Maintain normothermic
NEURO: cerebellum drop to both eyes QID Maintain moderate high back rest
E4VTM5 5. Lacryvis eye drops, 1 drop to both Bed sore and aspiration precaution at all times
(+) resting tremors, L #Seizure disorder sec eyes ODHS Bed turning Q2
UE to PSG 6. NaCl tablet 1 tab TID Suction secretion regularly
No seizures 7. Clonidine 75mg/tabfor BP >160/90 May undergo PT as suggested Defer transout
No new o P ppler #HASCVD, Mild MR, 8. Amlodipine 10mg/tab OD in PM S/P intubation: 10/4/19
(-) febrile episode mild TR, mild 9. Irbesartan 300mg/tab OD Referred to ENT: Dr. Espanto/Jorge
(-) hypotensive episode pulmonary 10.Diazepam 5mg/IV PRN for frank Apply compression stockings once available
hypertension ACC/AHA seizures COD c/o ENT
CARDIO: st. C 11.NAC 600mg/tab BID
No chest pain 12.Rosuvastatin 20mg/tab ODHS MV settings:
No hypotension #Gr. 2 Sacral decubitus 13.Lactulose 30cc ODHS PSV
No diaphoresis ulcer 14.Metformin 500mg/tab TID PS 10
AP, with occasional 15.HR 6u SQ PRN for CBG >200mg/dl FI02: 30%
tachycardia, RR, no s/p tracheostomy 16.Valproic acid 250mg/5ml 10ml q12 PEEP5
murmurs (10/31) 17.Salbu + Ipra neb q8 PRN for dyspnea
18.Omeprazole 40mg/cap ODAC Daily RSBI
PULMO: 19.Enoxaparin 0.4cc OD SQ 3 days post
(+) minimal to whitish op RSBI (11/14):
to yellowish 20.Clopidogrel 75mg/tab ODPC 1wk
suction/trache post op
(+) Occasional rhonchi
bilateral
S/P trache; moderately
soaked dressing 10/31
No dyspnea
No desaturation
RSBI:

GI:
Flabby soft, nontender
No abd pain
No nausea
No vomiting

NEPHRO:
No edema
Msk: (-) edema, (+) gr 2
sacral ulcer, non foul
smelling

BED 8 IVF: PNSS 1L 20cc/hr to maintain cutdown DIAGNOSTICS:

BALLESCAS, #Septic Encephalopathy For repeat CBCPC and CXR on D14 of Minocycline
DULCELINA DIET: regular salt, low fat, low chole, high fiber For H and H 15 minutes post BT Once available
BELANDRES #Vascular Dementia diet at 1800kcal/day, CHON at 0.8g/kg/day, 1.5:1 AWAITING:
83/F/RPVD dilution divided into equal feeding Official WAB utz 10/29
#Chronic CVD infarct MRS Official cranial CT scan 10/10
ID No: 159441 5, bilateral frontal lobe MRS MEDICATIONS
DOB: 04/02/1936 5; lacunar infarcts 1. Minocycline 100mg/tab 2 tabs Q12 Day MV Settings:
DOA: 10/15/2019 11 SIMV
#Cervical CA St. III B s/p 2. Valproic acid 250mg/5ml, 10ml BID VT 400
NEURO: chemotherapy s/p 3. Diazepam 5mg TIV for active seizures FiO2 30%
E1VTM4 brachytherapy 4. Vit C tablet OD PS16
(-) new focal déficit 5. Peptamen 6 scoops in ½ glass water BID F16
(-) seizure #Seizure disorder sec to 6. Omeprazole 40mg/cap ODAC
(-) vomiting PSG 7. Sabutamol + Ipatropium q8 neb RTC REMARKS
(-) lateralizing signs 8. PNSS neb Q8 RTC - HOLD Awaiting GS notes
#Chronic hyponatremia 9. Mupirocin ointment on affected area Apply mupirocin ointment on affected areas
PULMO: 10. Sodium Hyaluronate TID OU WOF: dyspnea, desaturation, hypotension
(-) dyspnea, desaturation #Anemia of chronic disease 11. Digoxin to 0.25mg/tab 1 tab q48 Apply compression stockings once available for dvt prophylaxis
SCE, (-) retractions, (+) 12. Betadine oral antiseptic solution for oral Bed turning q2
crackles, bilateral #Sacral decubitus ulcer gr. 2 care BID Suction secretions
13. Start Clopidogrel 75mg/tab OD after Secure 1 unit PRBC properly typed and crossmatched once available
#Cataract Immature, R, s/p debridement
CARDIO: pseudophakia, L 14. Start n-acetylcysteine 600mg 1 tab in ½ ONBOARD SERVICES
(+) inotropic support glass water ENT
(+) hypotensive episode #Blepharoconjunctivitis, 15. Start: Calmoseptine Cream GS - Dr. Solomon, Dr. Littaua (for wound debridement)
AP, tachycardic, irregular UO – resolved 16. Start Daikins solution on pressure ulcer Ophtha – Dr. Hizon
rhythm, (-) murmur 17. Start: Folic Acid 5mg/tab OD
#Chronic Respiratory 18. Start Vitamin B complex OD
GI: Failure sec to HAP 19. Start Enoxaparin 0.4cc now then OD DNR- renewed waiver 11/1
flabby, NABS, soft, (Burkholderia) Refused HD, CT scan, wound debridement
nontender
#AKI, intrinisic prob sec to
(+) edema, LLE infection
COMPLETED
(+) wound, RUE
1. Amikacin 500mg TIV OD D14/14
(+) Grade 2 sacral ulcer
10/25/19
2. Furosemide 80mg IV q8 10/28/19
3. Meropenem 1g/IV x 3hr infusion
Q8 10/29/19
BED 9 #Acute Decompensated IVF: Amiodarone drip – hold, MgSO4 drip: DIAGNOSTICS:
BUMAGAT , ARTEMIO Heart Failure secondary 250mg in 100cc PNSS x 12hours (2/2) For angiogram 11/14 6:00am at Metro North via ambucon
SUBA to cardiac dysrhythmia
79/M/CP AF with RVR->AVR Diet: LSLF low cholesterol DM diet at AWAITING
ID: 48449 coronary artery disease 1,800kcal/day Na, K
DOB: 10/22/14 2-vessel 2D Echo with Doppler
DOA: 11/11/2019 Disease ACC/AHA St. C Medications: HbA1c
NEURO: NYHA III s/p Pacemaker 1. Enoxaparin 0.4cc SQ OD
GCS 15 E4V5M6 insertion (2003) s/p PCI 2. Losartan 50mg/tab 1 tab OD (AM)- REMARKS
No sepsis (2002,2007) >Losartan 50mg + Amlodipine 5mg combo WOF: Chest pain, dyspnea
#T2DM unknown control tab OD Coronary angiogram scheduling
PULMO: 3. Carvedilol 25mg/tab BID
(-) Dyspnea 4. Spironolactone 25mg/tab OD

3
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
(-) Tachypnea 5. Atorvastatin 80mg/tab 1 tab ODHS
No desaturation 6. Pantoprazole 80mg/tab 1 tab ODAC
No fever 7. Metformin + Linagliptin 500/5mg/tab OD
Clear breath sounds 8. Insulin HR 6 units SQ PRN x CBG
>180mg/dL
CARDIO: 9. Magnesium sulfate 2.5mg/vial, 1 vial in
(+) hypertensive episodes 100cc PNSS
(-)tachycardia 10. KCl 750mg 1 tab 2 tabs now then Q2 x 3
normal rate, irregular doses
rhythm 11. Clonidine 75mcg tab PO now then BID
12. Lactulose 30cc now then ODHS
GI:
No N/v
No GIB
Soft, non-tender

NEPHRO:
Adequate UO

MSK:
(-) Edema
BED 10 #HASCVD, Acute IVF: Heplock Diagnostic:
REYES, RACHAEL Decompensated Heart 2D echo with DS for approval
57/F/CP Failure NYHA IV in SR DIET: Low Salt, low fat, high fiber DM Diet OF KUNP UTZ on nov 18 9am
ID No: 48508 at 1200kcal/day with CHON at 0.8g/kg/day- FOBT x2 determination
DOB: 10/21/1962 Mechanically soft Repeat Trop-I
DOA: 10/15/2019 #CAP-HR DIAGNOSTICS Awaiting:
1. Furosemide 80mg IV Q12hrs UA, ETA GS/CS, Blood CS
NEURO: with BP precaution FBS, BUA, Lipid profile, Ferritin
GCS 15 #Pleural Effusion, Bilateral 2. Ceftriaxone 2gIV OD Remarks:
(-) new focal déficit 3. Azithromycin 500mg IV OD For BT of 1 unit PRBC properly typed and crossmatched once available
(-) seizure #T2DM 4. N-acetylcysteine 600mg/tab 1 Give furosemide 40mg IV Post BT
(-) vomiting tab in ½ glass of H2O ODHS Repeat H&H post BT
(-) lateralizing signs 5. Salbutamol + Ipratropium neb
#DM Foot Right q8hrs PRN for dyspnea
PULMO: 6. Paracetamol 500mg/tab 1 tab
(-) SCE, (-) retractions, (+) q4hrs PRN for temp >37.8
crackles, bilateral #Cardiorenal syndrome type 7. Humulin R GU SC fpr CBG
2 >200mg/dL Referrals
8. Clopidogrel 75mg/tab 1 tab OD
CARDIO: 9. Sevelamer 800mg/tab 1 tab BID
(+) inotropic support 10. Enoxaparin 0.4cc sc now then
(+) hypotensive episode OD
AP, tachycardic, irregular 11. Clonidine 150mcg/tab SL PRN
rhythm, (-) murmur for BP >160/100mmHg
12. Sodium Bicarbonate 650mg/tab
GI: 1 tab TID
Flabby, soft abdomen, non-
tender

EXT:
Grade 2 Bipedal edema
Hyperpigmentation R foot
with ulceration
BED 11 #Chronic ventilator IVF: Heplock Diagnostics:
BENJAMIN, MA. dependence 2 to 1) Diet: Diet: as ordered For CXR once feasible
ASUNCION ESPINO Central Apnea, 2) VAP, 3) 2D echo w/ DS on call
77/F/RPVD PE both sec to a) PNA, b)Medi Medications:
ID: 95626 VO 1. Salbutamol + Ipratropium neb q6 PRN for
Awaiting:
DOB: 8/15/1942 dyspnea
DOA: 7/30/2019 #Chronic CVD infarct PCA 2. Linagliptin 5mg/tab OD Chest map official 10/28
with hemorrhagic MRS 5 3. Amlodipine 10mg/tab OD CXR official 11/02
NEURO: 4. CaCO3 1 tab TID
GCS 10 E4VTM5 #HF sec. to CAD 1VD s/p 5. NAC 600mg/tab in ½ glass H2O Remarks:
No sepsis Angioplasty LAD old 6. Clopidogrel 75mg/tab ODPC For RSBI daily and T piece IF <105
ASWI NYHA Class III 7. Lactulose 30cc after each dose of Calcium Shift to trach mask if tolerated for 2hrs
PULMO: polysterene sulfonate Apply Dakins solution in wet to dry dressing BID
(-) Dyspnea #Anemia of chronic 8. Omeprazole 40mg/cap ODAC
Dec. CBG monitoring to TID pre meals
(-) Tachypnea disease 9. Daikin’s soln wet to dry dressing BID
No desaturation 10. Diabetasol 3 scoops in ½ glass H2O q4 Suction secretions regularly
No fever 11. Insulin glargine 28u SQ in PM Monitor neuro VS QH
(+) Wheezes , on both #T2DM, controlled 12. Ampi-sul 1.5gm TIV OD – completed 11/1 Bed turning Q2H
lung fields #Grade 2 Sacral 13. Clonidine 75mg/tab SL PRN for BP WOF: dyspnea, desaturation, fever
Decubitus Ulcer >160/100
CARDIO: 14. Mupirocin ointment to L wound BID
No hypotensive episodes #COPD in exacerbation 15. Carvedilol 6.25 mg ½ tab BID
MV Settings:
No tachycardia 16. Hold Furosemide for now
V-AC
Normal rate, regular 17. Telmisartan 40mg/tab OD(AM)
rhythm 18. Olodaterol/Tiotropium2.5/2.5mcg 2 F16
puffs OD AM PEEP 5
GI: FiO2 30%
No N/v VT 380
No GIB Maintain O2 sat >92%
Soft, non-tender

NEPHRO:
Adequate UO

MSK:
(+) Edema B UE & LE

BED 12 #CAD 3VD IVF: D/C DIAGNOSTICS:

MARTINEZ, FERDINAND Repeat Crea in AM
LIWANAG #HF PEF 57% sec to VHD DIET: NPO 4 HRS PRIOR TO PROCEDURE Fecal immunochemical test
65/M/RPV (mod AS)
ID#344898 THERAPEUTICS: AWAITING:
DOB: 03/19/1954 #HASCVD ACC AHA St. C 1. Isoket drip 10g in 90cc PNSS x 10cc/hr Thyroid Function Test
DOA: 11/08/19 2. Ivabardine 7.5mg/tab BID
# PAOD, both 3. Dopamine drip 1 amp in 100cc PNSS to run REMARKS:
CC: CHEST PAIN (1mkm @ 65kg) Start CBG monitoring TID premeals and record pls
#T2DM 4. Enoxaparin 0.4cc SQ q 12 WOF: Hypotension. Chest pain, dyspnea, Desaturation

4
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
CARDIO: 5. ISMN 30mg/tab OD Remove bottom layer of pressure dressing 11/14 11:30am
(-) chest pain #CKD G3bAx sec to DKD 6. NAC 600mg/tab
(+) easy fatigability vs HTNNS 7. Vit C 500mg/tan 1 tab OD
AP, NRRR. Grade 3 8. Amlodipine 10mg/tab 1 tab OD
systolic murmur #OA, Left shoulder 9. Atrovastatin 80mg/tab 1 tab ODHS
10. Clopidogrel 75mf/tab 1 tab ODPC
11. Empogliflozin +Linagliptin 25/50mg 1 tab
OD
12. Gliclazide 80mg/tab 1 tab OD
13. Metropolol 50mg/tan 1 tab BID
14.Cilostoslo 50mg/tab 1 tab BID
15.Gabapentin 30mg/tab 1tab OD
16. Metformin 500mg/tab 1 tab TID -
resume
16. Losartan 50mg/tab 1 tab OD
17. Tramadol 50mg/tab 1 tab q8 PRN for pain

BED 14 #Shock p 1. Septic 2 to IVF: PNSS 1L + NaCl 100meq at 80cc/hr Diagnostics:

Comp UTI vs HAP 2. to consume then shift to ONSS 1L Repeat Na, Cl, Mg (11/14 AM)
AGUILAR, EDUARDO Hypovolemia sec to at 60cc/hr
BUMANLAG poor intake vs GI AWAITING:
Losses (ileostomy) DIET: Revise to regular salt, low fat diet; HBV DNA, HBeAg, Anti-HBe (11/13)
63/M/RPV 70gm CHON/day at 1800kcal/day
ID: 70213 #Chronic Hep B regular diet
DOB: 2/10/56 infection REMARKS:
DOA: 10/30/19 MEDICATIONS: CBG monitoring TID premeals and record
#Complicated UTI 1. Meropenem 1gm IV in 50cc PNSS Maintain O2 supplementation
to run for 2 hours Q8hrs Day 1 Refer back to Nephro and GI
CC: loss of appetite #HAP 2. MgSo4 drip to follow: 2.5gm IV in
90cc PNSS to run for 12hrs
(-) fever #Hypoosmolar 3. NE drip: 10mg in 90cc PNSS to run
(+) colostomy output hypovolemic at 12cc/hr (0.4mkm, 55kg) titrate
(+) Eps of dyspnea and hyponatremia down by 3cc/hr to maintain MAP
chest heaviness > 65mmHg
(+) occ epigastric pain #Anemia p Chronic Dse 4. Start Ensure 5 scoops in 1 glass
and nausea water TID – coordinated (11/13)
(+) poor appetite #AKI resolving on top
(+) hx of watery/loose of p CKD sec to Obs
ileostomy output Uropathy

NEURO: #Invasive urothelial

GCS 15 Cell Ca of the bladed
S/P radical
PULMO: prostatectomy
(-) cough
(-) dyspnea #s/p double barrel
Clear breath sounds ileostomy (10/2019)

CARDIO: #sacral mass r/o

(-) chest pain metastasis
(-) palpitation
(-) diaphoresis #R/O testicular torsion
(-) PND
AP, NR, regular rhythm #R/O ACS
(-) orthopnea
#R/O Cardiogenic
GI: shock
(+) Colostomy
No nausea
No vomiting
No abdominal pain
Soft, flabby, non-
tender abdomen, NABS

MS
(-) edema

Skin:
(-) erythematous
lesions

5
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
BED 16 #Acutee Coronary IVF: Heplock Diagnostic:
GALEON, FROILAN Syndrome NSTEMI 2D echo with DS On call
ABRIOL anterolateral wall ischemia DIET: Low Salt, low fat, high fiber CHON at KUNP UTZ 11/21/19
782M/RPV HS8 0.8g/Kg/day 2g Na OF at 2100kcal/day 1:5:1 FOBT x2 determination
#0318110933 dilution Repeat Trop-I
DIAGNOSTICS Awaiting:
#ARF Type 2 Secondary to 1. Clopidogrel 75mg/tab ODPC UA, ETA GS/CS, Blood CS
DOB: 07/14/1937
COPD in acute exacerbation 2. Enoxaparin 0.4cc SQ OD FBS, BUA, Lipid profile, Ferritin
3. Captopril 25mg ¼ tab TID Remarks:
DOA: 11/12/2019 4. Atorvastatin 80mg/tab ODHS
#CKD G4A Prob Sec to 5. Omeprazole 40mg ODAC
HTNNS Vs. Senile Kidneys 6. Lactulose 30cc ODHS hold if
NEURO:
E4VTM6 BM >2x/day
7. ISMN 30mg 1 tab OD
#Anemia Prob sec to 1.) 8. ISDN 5mg 1 tab SL PRN for
PULMO: Acute inflammation 2.)
(+) White Sputum, Dec. Chest pain Referrals
Chronic Disease 3.) R/O 9. Budesonide neb Q12
Breath sounds Right base
Occult GI Bleed 10. Salb + Ipra neb q8 RTC and
CARDIO: PRN for Dyspnea
AP, bradycardic, irregular 11. NAC 600mg 1 tab in ½ glass of
#CAP-MR H2O ODHS
rhythm, (-) murmur
12. Furosemide 80mg IV OD
GI: 13. Ceftriaxone 2g IV OD
flabby, NABS, soft, 14. Shift Azithromycin to 500mg in
nontender PNSS 100cc as 2hr IV infusion
OD
MSK:
No gross defromities, full
and equal pulses
BED17 #VAP with pleural effusion, IVF: PNSS at 20cc/hr to maintain cutdown Diagnostics:
VILLARINO, ORNEZA bilateral 2D Echo w/ DS on call
PIZZARAS Diet: regular salt, low cholesterol high fiber diet Chest CBC and xray ap on day 5 of ampicillin-sulbactam
65/F/RPVD #ARF sec to VAP with chon at 1.5g/kg/day OF at 2100 kcal/day, 2:1 Repeat HBA1c after 6 months
dilution divided into 6 equal feeding in 30cc pre For H&H Today 11/13/19 at 7pm
ID No: 019188373 #DKD G5D and post twisting Awaiting:
DOB: 09/01/54 Blood gs/cs
DOA: 10/30/19 #HASCVD Heart Failure MEDICATIONS: Fecal Occult Immunochemical test
ACC/AHA ST B 1. Humulin R 6u SQ PRN for CBG >200mg/dl Official KUB UTZ 10/31
NEURO 3. Linagliptin 5mg/tab 1 tab OD TCVS notes for permanent HD access
GCS 6 E1VTM4 #T2DM 4. Atorvastatin 80mg/tab , 1 tab OD BUN, crea, Na, K,Cl, Mg, alb, Ca
Drowsy, Decreased verbal 5. Clopidogrel 75mg/tab , I tab OD
output #Anemia sec to r/o occult 6. Na HCO3 tab, 1 tab TID Remarks:
(+) Fever 38.6 GI bleeding 8. Caltrate plus tablet For HD tomorrow (11/13/19)
(-) seizures (-) deficits 10. Febuxostat 40mg/tab OD Decrease CBG monitoring to TID premeals & record
11. EPO B 5000 ‘u’ SQ 2x/week WOF: Overt GI bleeding
12. Folic acid 5mg/tab OD Bed turning Q2
PULMO 13. KCL tab 750mg TID for 3 days Suction Secretions as necessary
SCE, decreased crackles, 14. Hydrocortisone 250mg iv WOF: hypotension, desaturation
bilateral, decrease breath 15. Salbutamol+ipratropium neb now then q6 Compression stockings
sounds basal, (+)ronchi hours RTC
basal 20. Paracetamol 1g TIV now MV SETTINGS
21. Paracetamol 500mg/tab 1 tab Q4 for T>37.8C AC mode
26. Omeprazole 80mg IV now F14
CARDIO
29. Ampicillin –sulbactam 3g IV infusion over PEEP 5
AP, NR RR no murmur 1hr post HD then q24 D2 FI02 30%
30. Insulin Glargine 14 units SC ODHS TV 400
GI 31. Start calmoseptine cream to affected area
bid
Flabby, soft, non-tender,

Nephro

(+) Edema, decreased

Defer hemodialysis for

today

BED 18 #VAP (Klebsiella IVF: Heplock DIAGNOSTICS:

pneumoniae), For HBT UTZ after 6 months (March 2020)
COMENDADOR, JOSE s/p tracheostomy DIET: OF as ordered
BAPTISTA (10/18) AWAITING:
Official HRCT result (11/6)
83/M/RPV #PE, Bilateral prob MEDICATIONS:
ID: 27152 parapneumonic vs 1. Cefoxitin 2g TIV as LD then REMARKS:
DOB: 10/19/36 volume overload (R- 2g TIV Q8 Day 6 Suction secretion regularly
DOA: 8/25/29 130cc, L- 260cc) 2. Amikacin 450mg TIV as LD Bed turning q2hours
TRANS IN: 9/17/19 then 450mg TIV Q12 Day 5 Daily tracheostomy care
#Meningioma, right 3. Duavent neb Q8 RTC HOLD Discontinue CBG monitoring
NEURO: frontal 4. KCl tab TID for 3 days Hold Daikin’s solution
E4VTM6 (GCS 11) D3/3
(+) Follow commands #Chronic multiple CVD 5. Tiotropium + Oladaterol WOF: Dyspnea, desaturation, mucus plug
(-) seizures infarct right 2.5/2.5 mcg 2 sprays OD
(+) agitation on and off frontotemporal area, 6. NAC 600mg/cap to 1 cap in Hooked back to MV
MRS 5 ½ glass water ODHS PSV mode
PULMO: 7. Drapoline cream on PEEP 5
(+) whitish to yellowsih #HASCVD AF c SVR affected area PS 16
discharge on ACC/ AHA St B (CV5 8. Iodosorb powder on FiO2 30%
tracheostomy HB3) affected area
(-) dyspnea, (-) 9. Tramadol 50mg/IV Q6 PRN Pls do chest physiotherapy every 6 hours on L lung field
desaturations #COPD unclassified for pain Pls suction gently every 2 hours and as needed
SCE, (-) retractions, 10. PNSS neb Q8 RTC
decreased BS left lung # Anemia of Chronic 11. Alprazolam 500mcg/tab ½ GS
base, (+) rhonchi, Disease vs tab ODHS PRN for Continue daily wet to dry dressing with Dalkin’s solution.
bilateral Hypoalbuminemia vs agitation Wound debridement not indicated
Nutritional 12. Hialid 1 drop on both eyes Suggestn nutritional buildup
CARDIO: TID
(-) chest pain, (-) #Sacral decubitus ulcer 13. Mupirocin ointment apply ONBOARD SERVICES
hypotension, AP, grade2 on affected area BID Ophtha
normal rate, irregularly 14. Sustagen 3 scoops in 100 Dietary
irregular rhythm, (-) cc H2O OD Onco

6
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
murmur 15. To consume Citicholine at DRM
bedside Pulmo
GI: 16. Gabapentin 300mg/cap GS
Flabby, soft, non- ODHS
tender abdomen 17. Leviteracetam 500mg/tab Pulmo (11/08)
(-) melena BID May continue T piece as tolerated. May hook back to MV if with dyspnea, desaturation and tachypnea
(-) hematochezia 18. Omeprazole 40mg/cap OD SMVT
AC FiO2 30%
(+) less edema, UE 19. Clopidogrel 75mg/tab OD PS 10
(+) gr. 2 sacral ulcer PC (dinner) - HOLD
with good granulation, 20. Betadine gargle oral care 11/9
non foul smelling TID Hooked to Trache Mask at 2-3lpm, WOF for desaturation
21. FeSO4 tablet OD
s/p tracheostomy 22. Tranexamic Acid 500mg/IV
10/18 Q8 for 1/3 days

DISCONTINUE
Ciprofloxacin 400mg/IV
Budesonide neb Q12
Furosemide 40mg IV Q12 x 3 days D3/3 –
completed 10/30
PNSS Q8 RTC Discontinue

COMPLETED
Human albumin 25% + increase to 40mg
Furosemide Q12 x 3 days D3/3
Meropenem 1 g TIV Q8 x 14 days
Ertapenem 1g IV q24 x 7 days
Human albumin 25% + 40mg furosemide
BID x 3 days (10/19/19)
KCl tab TID 10/28/19
Ampicillin-sulbactam 3g/IV Q6 (11/04/19)

BED 19 # Ventilator-Associated IVF: Heplock DIAGNOSTICS:

Pneumonia For Gene Xpert once with adequate sputum
DESPA, NELLY (Pseudomonas DIET: OF as ordered
HARESCO aeruginosa) AWAITING:
MEDICATIONS:
75/F/CPNBB # Chronic Ventilator 1. Start Olodaterol + Tiotropium
ID: 42474 Dependence secondary 2.5/2.5mcg 2puffs OD REMARKS:
DOB: 02/04/44 to deconditioned state 2. Budesonide neb Q12 RTC Strict bed turning q2
DOA: 05/17/19 3. PNSS neb Q8 RTC Suction secretions regularly
# COPD Unclassified 4. Salbutamol + Ipratropium neb Q8 Daily wound care
Estimated height 5’3’’ RTC prn for dyspnea
IBW 51.9 kg #Sacral decubitus ulcer, 5. Calmoseptin cream on sacral ulcer WOF: dyspnea, desaturation, hypotension
grade 3 BID
s/p tracheostomy c/o 6. Lactulose 30cc ODHS Services-on-Board:
ENT (6/11/19) # Lumbar spondylosis 7. Trimetazidine 35mg 1 tab BID -GS
8. Omeprazole 40mg/cap ODAC -Dietary
s/p sacral wound #CAUTI (Klebsiella 9. NAC 600mg/tab 1 tab BID -IDS
debridement c/o GS Pneumonia) 10. Alprazolam 500mcg/tablet BID -ENT
(6/23/19) 11. Beneprotein 2 scoops OD -DRM
#Anemia of Chronic 12. Epoetin alpha 5000U SC 2x/week
NEURO: disease vs 13. Ivabradine 5mg/tablet BID MV Settings
GCS 10 (E4VTM5) Hypoalbuminemia 14. Paracetamol 300mg Ivq4 PRN for SIMV
(+) regard >38.3 PS 12
Does not respond to 15. Paracetamol 500mg/tab q4 PRN VT 360
questions for >37.8 PEEP 5
(-) seizure 16. Daikin’s solution BID on bedsore FiO2 30%
(-) new neurodeficits 17. Continue Budesonide nebulization BUR 8
(-) agitation q12 RTC
UE : WTP RSBI
LE : 0 11/1 - 438
No babinski COMPLETED/SHIFTED/DISCONTINUED 11/2 - 353.10
No seizures - Meropenem 2g IV q8 as 3 hr infusion
(10/02/19)
CARDIO: - Minocycline 100mg/tab 2 tabs q12
(-) tachycardia (D14c 6/20/19)
(-) chestpain - Meropenem 1gm q8 (D14c 6/10)
(-) fever - Colistin 2,000,000 IU in 100 cc PNSS to
(-) murmur run for 1 hr Q12 hrs (D14c 6/25/19)
(-) hypotensiveepisode - Piperacillin-tazobactam 4.5g TIV in 10cc
AP, normal rate, PNSS x 4hrs q6 – completed
regular rhythm, (-) - Omeprazole 40 mg 1 cap ODAC
murmur - Ciprofloxacin 500mg/tab Q12

7
 TEAM REJANTE|TEAM SAZON|TEAM MONTEFALCON| NOVEMBER 13, 2019

Admission: 0 Trans-In: 0
For Trans-Out: 0 Discharge: 2 Mortality: 1
- Azithromycin
PULMO: -Levofloxacin 750mg IV q24
(-) retractions - Doxyphylline
(-) dyspnea - Cefepime 2g/IV Q8 10/28/10
(-) desaturation - Amikacin 500mg IV Q12
SCE, (+) rhonchi, right

GI:
no nausea/vomiting
flat abdomen soft,
nontender

(+) dependent edema

on B UE

BED 20 #Ventilator associated IVF: Heplock DIAGNOSTICS:

Pneumonia
SANTOS, RENEE (Enterobacter), resolved DIET: As ordered
ANDRADE AWAITING:
87/F/RPVD #Chronic ventilator MEDICATIONS: Urine CS (11/8)
ID #: 31328 dependence secondary 1. Azithromycin 500mg/tab 1 tab OD (M- KUB UTZ official (11/13)
DOB: 01/06/31 to central apnea W-F) –HOLD
DOA: 05/31/18 2. Levetiracetam 250 mg/tab OD REMARKS:
#CAUTI (E. Coli) 3. Lactulose 30cc ODHS Monitor CBG TID pre-meals
NEURO 4. Vitamin B Complex 1 tab OD Please hook to cardiac monitor
GCS 9 E4VTM4 #Vascular Dementia 5. Salbutamol + Ipratropium neb q8 PRN Moderate to High back rest
(-) Seizures for dyspnea Bed turning q2h
#HASCVD AF with AVR 6. Atorvastatin 40mg/tab ODHS Daily trache care
PULMO ACC/AHA St. B 7. Omeprazole 40mg/cap ODAC WOF: dyspnea, fever, desaturation
(-) Dyspnea 8. Oral betadine gargle BID
(-) Desaturation #COPD GOLD D 9. Drapolene cream BID on sacral ulcers MV settings
SCE, (+) Rhonchi bilateral, 10. Budesonide neb q12 (hold while on VSIMV
(+) crackles, left lung field hydrocort) VT 360
11. Carvedilol 6.25 mg/tab, ½ tab BID F8
CARDIO 12. Dabigatran 75mg/tab 1tab BID-resume PS10
AP, NR IR, no murmur tomorrow PEEP 5
(-) Hypotension 13. Ertapenem 1g IV q24 Day 5/5 FiO2 30%

Nephro:
(-) hematuria

MSK
(+) edema B UE, LE
BED21 #Chronic Ventilator IVF: none Diagnostics:
ESPERA, MELITONA Dependence with Central
PEREZ Apnea s/p change of DIET: Low salt low fat + 2 egg whites to diet at Awaiting:
84/F/RPVD tracheostomy 9/9/19 1,800kcal/day
SERVICES ON BOARD:
MEDICATIONS: - DRM (Dr. Mones)
#HASCVD ACC/AHA 1.Cutasept spray to stoma BID - ENT (Dr. Jorge)
ID No: 39134 Stage B 2.Clopidogrel 75mg/tab ODPC - GI for change of PEG
3.Duavent nebule q8 prn
DOB: 03/10/34 #Chronic CVD Infarct 4.Omeprazole 40 mg/cap ODAC Remarks:
(2010, 2018) MRS 5 5.Atorvastatin 40 mg/tab ODHS For change of tracheostomy tube c/o ENT on Mon (09/09)
DOA: 01/28/19 6.Levetiracetam 500mg/tab 1 tab BID Suction secretions PRN
7.Lactulose 30cc ODHS.Hold if BM >2x/day Bed turning Q2
#S/P PEG change June 2019 8.Peptamen 6 scoops in 1 glass of waterTID Chest physiotherapy
9.Bactidol mouthwash TID Mod high back rest
10. Salbutamol + Ipratropium neb now Daily tracheostomy care
COMPLETED: WOF: dyspnea, desaturation, hypotension
Meropenem 2g IV now then 1g IV Q8 Change of catheter weekly
KCl 750mg/tab 1 tab TID x 3 days s/p tracheostomy change (8/14/19)
s/p PEG change 6/28/19
MV Settings:
SIMV
TV 360
PS 10
FiO2 30%
PEEP 5