Date/Time Side Notes Physicians order

February 1, 2019 Cc: Cough  Admit to single

room under Dr. N.
11:15am Luching
Impression:  TPR q4h; soft diet
140/90  Obstructive with aspiration
102 Pneumonia precaution.
22  Lung adeno CA  PLRS 1L x 40cc/h
36.8˚c stage 4 with line
 S/P chemo x Labs:
6cycles (2018)  CBC, plt
 Na, K, BUN, Creat.
 Sputum GS, CS
 SGPT, SGOT
 ECG 12L
 CBG BUN
 CXR (PA)
 ABG
 Urinalysis

Meds:
 Nebulize with 1 neb
ipatropium +
salbutamol q6h
(duavent)
 NAC 600mg tab
dissolve 1 tab in ½
glass of H2O OD
 Paracetamol
500mg tab q4h
PRN for fever
 hydrocortisone
100g IV now then
q8h x 2 more doses
 Cefepime (Axera)
1g IV q8h ANST
 Azithromycin
500mg IV OD ANST
ECG S/O:
 I&O; Qshift, O2 @
2lpm
 Moderate to high
back rest
 Dr. N Luching
informed by call,
gave orders.

|Page
February 1, 2019 Pain meds:
 Morphine so4
2:55pm 10mg, 6 tabs q6h
 Paracetamol
C/O folks 500mg tab, 2 tabs
q8h
 Tramadol 50g tab
q4h PRN for
breakthrough pain
 Pregabalin 150g
cap q8h

 O2 at 2lpm by N.C
 Incorporate 30
February 1, 2019 meqs kcl to present
3:10pm IVF
 Kcl (Kalium durule)
 Infuse azithromycin
over two hours
 inform Dr. Arches of
this new order

 Pain Management
February 2, 2019  Pain meds as
ordered.

 Solucortef 10mg IV
q8h
 ↑ NAC to BID
 Incorporate 20-30
February 2, 2019 meqs kcl to next
11:30pm IVF
 KCL (Kalium durule)
; tab BID
 Omeprazole
(omera) 40mg IV
OD
 IVF to follow: PNSS
1L x 60 cc/hr (2 IV
bottles)

|Page
  Give tramadol 50g
IV now.
February 3, 2019
1:15am

February 3, 2019  Pain management

 Morphine so4
10mg/tab 6tabs
q6h RTC
 Paracetamol
500mg/tab 3 tab
q8h
 Tramadol
50mg/tab q8h PRN
for breakthrough
pain
 Pregabalin
150mg/tab q8h
RTC (75mg/tab
2tabs Gabica)
 Refer accordingly

 PNSS 1L x 40cc/hr +
February 3, 2019 30meqs KCL
3:50pm

|Page
February 4, 2019  Pain management
 Continue pain
meds

(+) Chest pain  For stat ECG

February 4, 2019 (+) Stable vs 12leads
3:10pm CR = 95  Dr. N. Luching & Dr.
Arches updated

 Ketoralac 30mg
IVTT now
February 4, 2019  Dr. Luching & Dr.
3:20pm Arches updated

February 4, 2019  D/C cefepime

5:30pm  meropenem
(meropex) 1g IV
q8hr ANST – infuse
for 2h, increase O2
to 3-4 lpm.

 Trop I, CBC, K+,

Creat- now- pls
relay result to me.

 Increase Igco to
q6h

February 4, 2019  Repeat CXR, AP

portable tomorrow
am
 Provide
urinal/bedside
commode
 Increase
hydrocortisone to
100mg IV q6h

|Page
  Decrease IVF to
February 4, 2019 KVO.
5:30pm

February 4, 2019  May use

8:50pm omeprazole
(omera)

 Carvedilol 6.25mg
February 5, 2019
1tab BID
9am
 Please carry out
yesterday’s order!

 Rely all labs once in

 Shift meropenem
(meropex)

 d/c NAC oral

 NAC (fluimucil)
1amp IV q12h

 Will be OOT be
back tomorrow
am.

 Patient and folks

are informed

February 5, 2019  For bloodtyping

3:35pm  Request for 2 units
of PRBC pts
bloodtype and
xmatch and
transfuse once
available.

|Page
February 5, 2019  Pls. transfuse
10:20pm Pre CP status available 1U PRBC
and pts blood type
after proper
crossmatching.
 Transfuse for 4h
 IVF to KVO while on
BT
 Watch out for signs
of BT reaction

 Refer to oncologist
once with consent.
February 6, 2019 (+) Paralyzed L & R leg
– pt. waiver signed.
(unable to walk)
 Transfuse 2nd unit of
blood after proper
crossmatching
 Refer CBC prior to
BT

 Pain management

February 6, 2019  Insert foley

catheter & MIO q
shift

 Moso4 10mg /tab

6tabs q6h RTC

 Paracetamol
500/tab 2tabs q8h
RTC

 Pregabalin
170mg/tab q8hrs

 Tramadol
50mg/tab q8h PRN
for breakthrough
pain

 Refer accordingly

 Clonazepam
2mg/tab 1/4tab at
H.S for insomnia

|Page
  Furosemide 20mg
February 6, 2019 IV now, Dr. Luching
3:35pm gone order

 Tranfuse 1u PRBC
properly xmatched

 v/s q30mins while

on BT

 BT line: PNSS @ 10 =
cc/hr run for 4-6 hrs

 Refer properly

February 6, 2019  Increase KCL

4:21pm (Kalium Durule)
1tab TID
 Give 2tabs now

February 6,2019 O2S: 85%  Shift O2 to face

10pm mask @ 8lpm

 Turn to sides, q2h

 Doxofylline
(Doxofix) 200mg
1tab BID

 Incorporate
20meqs kcl to
present IVF

 Decrease
hydrocortisone to
75mg IV q8h

 Suction secretion
PRN

 Sputum c/s

 MVT (Trevoca) 1tab

OD

|Page
  Pain management
February 7, 2019  Increase
pregabalin
150mg/tab 2tabs
q12h
 Continue moso4
10mg/tab 6tabs
q6h
 Paracetamol
500mg/tab q8h
RTC
 Refer accordingly

 Ketoralac 30mg IV
February 7, 2019 now
4pm

 IgCo milk 1 sachet

February 8, 2019 in 1 glass of water
BID
 provide turning
schedule at
bedside

 please issue birth

certificate at
February 8, 2019
hospital continent

 pain management
 continue moso4
February 9,2019
10mg/tab 6 tabs
q6h
 pregabalin
75mg/tab 4tabs
q12hrs
 clonazepam
2mg/tab ¼ tab OD
at H.S PRN for
insomnia
 refer accordingly

|Page
February 9, 2019
 Pain management
 Continue pain
meds.

February 9, 2019  Decrease O2 to

6lpm by facemask

 Chest
physiotherapy post
nebulization

February 10, 2019 BP-= 80/60-70/50  Hold carvedilol

 Fastdrip 200cc
PNSS then back @
60cc/h
 Please update dr.
arches for possible
affected of pain
meds
 Repeat CBC

 Decrease
February 10, 2019
morphine so4
7:56am
10/mg, 3tabs q6h
RTC

 No objection for
February 10, 2019 BP= 100/60 discharge once ok
with ap
 Increase moso4
10mg/tab 6tabs
q6h RTC

February 10,2019  Incorporate

1:19pm 20meqs kcl to
present ivf
 Continue kalium
durule 1 tab BID

|Page
February 11, 2019  IVF to ff: PNSS 1L +
12:30am 20meqs kcl xkcl
60cc/h x 2bots

 Relatives appraised
regarding
February 11, 2019 Weak carrying effort tracheostomy (for
11:40am long term
pulmonary)

 Hydrocortisone x 3
doses then d/c

 Chest
physiotherapy after
each neb c/o
pulmonary

 Request sputum c/s

 Cxr ap portable
tomorrow am

February 12, 2019 O2 sat: 85%-92%  Increase O2 at

1pm 8lpm via nasal
cannula

O2sat: 96%  Increase O2

February 12, 2019 inhalation at 10lpm
4:30pm with rebreathing
bag.

February 12, 2019

 Increase neb to
5:00pm
q4h x 3 doses then
q6h
 NPO when dyspnic
 Suction secretion,
provide oral airway

February 12, 2019

7pm  IVF tf: PNSS 1L +
20meqs kcl x
60cc/hr

|Page
  d/c oral pain meds.
Shift to morphine
February 12, 2019 drip: 20mg
7:30pm morphine in 100cc
pnss via soluset x
24hrs

 morphine so4 1mg

SQ q4hr PRN for
breakthrough pain

February 13, 2019  Clonazepam

4:20am (rivatril) ¼ tab now.

February 13, 2019  Midozalam 2.5mg

6:50am IV now then 2mg IV
q4h PRN for
restlessness

 Diphenhydramine
50mg IV now

February 13, 2019  Midozalam 50mg

10:45am IV now
 Start midozalam
drip: midozalam
5omg in 100cc
PNSS in a soluset x
24hrs
 Hold for
desaturation and if
BP <80mmhg

 Okay with above

February 13, 2019
suggestion
10:47am

 Obtain sputum
February 13, 2019 specimen by
11:30pm suctioning after
nebulization

|Page
February 13, 2019  Pain management
 Carry out orders
 Restraint patient
 Refer accordingly

 Patient clinically
February 14, 2019
expired
 Do post mortem
care
 Inform AP

|Page