Course in the Wards

April 28, 2014

9:20
Preliminary x-ray: mild cardiomegaly atheromatous aorta
On Metformin 50g OD
CBG 177
Drowsy, arousable, cannot follow command
BP: 130/80, HR:80, RR:20 Temp 36.8
Patient was admitted to the Medical Intensive Care Unit of DLSUMC.
Diet: DM diet - on NPO temporarily
IVF: Plain NSS x _________
Diagnostics: CBC-PC, Na, K, BUN, Creatinine, ALT, AST, 12 Lead ECG, CXR-PA,
TPAG, Urinalysis, 2D- Echocardiography, CBG monitoring TID, HS, CBG Q4,
NPO, Ammonia, ABG
Therapeutics: Humulin 70/30 (15 units SQ AM with NPO, 11 units SQ AM
with NPO), Ceftriaxone 2g IV now, then 1g IV OD (ANST)
IVF shited to D5 NSS 1L x 12 hours with NPO
Abdominal girth monitoring once a day

10AM
For retention enema
For urine GS/CS
For MICU admission
Hold meals until further order
BM voluminous, hold retention enema for now

2:15 PM
spontaneous eye opening, aphasia, (+) nuchal rigidity, (+) Kernigs, (+) Brudzinski
BP: 120/80, RR 20, CR:81, Temp: 38.5
For Cranial CT Scan and contrast
NGT inserted
Referred to neurologist for co-management
Referred to surgeon for evaluation and co-management of abdominal
distention
Hold Humulin 70/30
Rescue doses: CBG premeals </= 50 1 vial vial D-50-50 and recheck CBG after
CBG after 20 minutes, </=70 vial D-50-50 and recheck CBG after CBG after
20 minutes, >/= 180mg/dL Give 4 units of Humulin R
Blood CS at 2 sites (from neuro)
Increase ceftriaxone to 2 grams IV Q12
.
3:15PM
(-) output per NGT, drowsy GCS 9 (E3V1M5), (+) coarse crackles,bilateral, (+)
globular, tympanitic all over, CBG=224
Facilitate Cranial CT scan
Monitor VS Q1 with NVS and pupillary reaction and abdominal girth
I and O monitoring
Advised MICU but deferred
. Surg
For low flow/ low pressure cleansing enema
No cathartics for now
Suggest whole abdominal CT
6:30PM
May go ahead with whole abdominal CT with contrast (from endo)
IFC inserted
I&O monitored
9PM
For Ionized Ca blood test
On IVF: D5 NSS, 20mEqs Kal/Cal x 12 hours


4/29/14
12AM
Revised rescue dose: CBG premeals </= 50 1 vial vial D-50-50 and recheck
CBG after CBG after 20 minutes, </=70 vial D-50-50 and recheck CBG after
CBG after 20 minutes, >/= 180mg/dL Give 5 units of Humulin R
6:30AM
decreased abdominal girth, still with decreased colic, (+) bowel movement-
spontaneous
cleansing enema done
Still for whole abdominal CT scan with contrast
NPO for now.

Noted 4 episodes of semi-solid stool -> relatives requested enema to be held
Still for CT scan
9AM
Less nuchal rigidity
Responds to questions, with eye opening
BP 130/70, CR 85, RR 21, Temp 37
Continue meds, facilitate whole abdomen CT scan
10:45 AM
awake, conversant, follows command, less nuchal rigidity, (+) BM, CBG 254
Continue meds and still for CT scan
WOF: decrease in sensorium
For BM monitoring and I&O monitoring
WOF: presence of decrease in sensorium, neurologic deficit; progression of
abdominal distention
CBGs noted

4/29/2014
10:30
Continue low flow cleansing enema, . Still persistent abdominal pain. For CT
scan still waiting for the funds to be available. For stool charting.

12:30
Patient is disoriented to date, time, and person, also the patient has delaying of
answers to questions. Pupils reactive to light at 2mm. Full Extra ocular muscles.
Positive Babinski (R). Patient noted to have nuchal rigidity. Review of CBG 3AM 232
mg/dl, 7AM 254 mg/dl, 11am 138 mg/dl.

1pm
pls retrieve old chart, follow up blood CS and urine CS
Resume Humulin R 70/30- 12 units Subcutaeous pre breakfast (4am)
12 units SQ pre dinner (4pm)
Humulin R rescue dose 4 units if CBG is >180mg/dl
Continue CBG monitoring every 4 hours
Carry out whole abdominal CT-scan

4pm
(GS rounds)- Facilitate CT scan with contrast
o -continue cleansing enema OD-BID

5:45
Patient had mild partial GUT obstruction in 2012 but referred further work-
up (retrieved from old chart)

8pm
(Neuro Notes) patient was referred to neurologist due to 2 day fever with
nuchal ridgidity. Patient is awake. Alert, follows commands, pupil 3mm, no
facial asymmetry. tongue is in the midline. Lumbar puncture on hold
temporarily.Motor strength is 3/5 on all extremities. Slight nuchal ridgidity
maybe secondary to cervical spondylosis. Serial CT noted not consisted with
bacterial meningitis
Neuro suggestions: continue current antimicrobial therapy. Observe patient
for any changes in sensorium

4/30/14
VS: BP 140/90, RR 20, T 37, HR 86. CBGs noted 186, 131, 94, 114. Continue present
management.

Surgery notes: Hypo active bowel sounds. Patient has flatus and bowel
movements after cleansing enema. For trans rectal contrast abdominal CT
instead of triple contrast

Neuro/Endo: Patient is awake, alert follows with slight nuchal ridgidity,
tongue midline. Continue present insulin management, faciclitate tranrectal
with contrast abdominal ct scan once with funds. CBG monitoring 11pm 94,
3am 114, 7am 94, 11am 97. Reduce Humulin R to 11 units subcutaneous
4am and 4pm. May start NGT feeding (Nutren) 1200Kcal in 6 equal feedingsif
okay with Endo.





Nurses notes

4/28
7am: received patient with a chief complaint of Fever, brought in via stretcher,
drowsy
715am: CBG 177mg/dl. 12 L ECG, Na, K, BUN, Crea, CBC PC, UA, For CXR portable,
Trop I.
8am: for plain abdomen supine crosst table, lateral portable with request. Plain
abdomen supine upright cant be done because patient cant sit
10am: skin testing for ceftriaxone 2gm will recheck at 1030am. For urine GS/CS. For
retention enema relatives opted to do it at room. ABG done, Ammonia ABG done.
Shifted IVF to D5NSS 1L x12hrs.
1120am: CBG done with a result of 227mg/dl, informed doctor go, hold retention
enema. Plain abdominal lateral decubitus.

4/29
patient awake, continue monitoring

4/30/14
8am: instructed to maintain NPO until further orders
240pm: continued present management kept safe and comfortable
5pm: started feeding with nutren in 1200 kcal 6 divided dose with 5 scoops in
170ml water . Patient cant expectorate phlegm, suggesting for suction