09/30/2018

7:16am

SVI; SLE; AOM with effusion AD
Combivent x 3 doses given at ER
Paracetamol 600mg T IV now.
>Admit to ICU under Dr. Andal.
>Consent.
>NPO temporarily.
>Hook to cardiac monitor and pulse oximeter.
>Hook to 02 via NC at 1-2L/min.
>VS q1 include O2.
>I & O q4.
>TBR with BP
>IVF: PNSS 1L x KVO
>Dx: CBC, SGOT, SGPT, UA, CRP, BUN, CREA, 12 L
ECG, CHEST X RAY, ABO TYPING, FBS, C3, ESR,
>Meds:
Paracetamol 500mg/tab 1 tab q4 for T <
37.8c.
Paracetamol 1 amp IV q4 for T < 38.5c.
Amoxicillin 500mg 1 tab TID.
Pulmodual 1 neb x 3 doses, Q 15 minutes
apart then Q6 do CPT after.
>Continue patient’s meds:
Imuran 50mg BID
Prednisone 10mg 2 tabs BID
Enalapril 10mg 1tab OD
FeSO4 and FA 1 tab OD
Calcium and vitamin D 1 tab OD
Furosemide 40mg 1 tab OD with BP
precaution.
>Omeprazole 40mg IV OD
>Refer to Dr. Villeno for nephrology.
>Consent.
>Dr.
>Accurate I & O
>Relay all labs once available ASAP.
>Refer.

9/30/2018

SLE >For BT 2 units PRBC to run for 4 hours each unit, 2

Pneumonia hours apart.
Anemia >Pre-BT meds:
Paracetamol 500mg/tab, 1 tab per unit of blood.
>Post-BT meds:
Furosemide 20mg IV after each unit of blood,
with BP precaution.
>Suggest to shift Amoxicillin to Cefuroxime 750mg
IV q8.
 >N Acetylcysteine 600mg/tab; 1 tab with ½ glass of
water TID.
>Suggest rheumatology referral.
>For sputum GS CS, Blood CS
>Suggest pulmo referral.
>Update Dr. Villeno accordingly.
>Relay labs once in.
>NPO except meds.

9/30/2018 >May shift antibiotic to cefuroxime.

10:21am >May proceed to blood transfusion as ordered.
>Will see patient later.

9/30/2018
11:25 am

Patient diagnosed with SLE May 2018 >Facilitate BT as ordered.

>Accurate I & O.
Noted on shifting Aprovel to Captopril >Inform undersigned about cross matching.
(+) colds (-) bleeding >Start Nafarin A 1 tab TID
1 day fever, SOB >Atrovent neb q8.
>Refer back to Dr. Lanzon.
(+) Facial edema >Retrieve chart from previous admission.
(+) ear discharge >Refer.
(-)
(+) stridor L,R
(+)
>Hold Enalapril.
>Resume Aprovel 1 tab OD. 150mg/tab.
>Refer.

11:42am >Discontinue pulmodual neb.

9/30/2018
2:00pm >Discontinue prednisone.
>Start Hydrocortisone 100mg IV q8.
>For C3, ANA, Anti ds-DNA
>Will see patient tomorrow

3:22pm

Incompatible on cross matching >Hold BT for now.

>Facilitate steroids as ordered.
>Trial on cross matching tomorrow after 4th dose of
hydrocortisone.
8:35pm >May have general liquid to minimal soft diet with
aspiration precaution.