KARDEX

DATE/ TIME MEDICATIONS DATE TREATMENT/ MANAGEMENT

8/21/20 at 10:52 AM
//Cefuroxime 1.5 gm IV drip q 8H ANST // 8/21/20 at 10:52 AM
//Anthromycin 500 mg/tab, 1 tab OD PO x 6 days (10:52am)// - Please admit to COVID unit under the
//Pantoprazole 40 mg IVTT now then 40 mg/cap 1 cap OD PO ac service of Dr. Yu co-managed by Dr. Hermogenes
breakfast(10:52am)// and Dr. Pizarra
//Citicoline 1 gm IVTT q 6H (10:52am)//
- Secure signed consent
//Atorvastatin 40 mg/tab, I tab OD PO (10:52am)//
- TPR q 4H
//Citirizine 10 mg/tab, 1 tab OD PO q HS (8:00pm)//
//Diphenhydramine 50 mg/amp 1 amp IVTT now (10:52am)// - Monitor vital Signs every 2 hours to
include neuro vital signs
8/22/20@1:27 PM - I & O q 4H in absolute figures
//Alprazolam 500 mg/tab ½ tab now (1:27pm)// - MHBR
8/23/20 @7:26 AM - O₂ at 2-3 LPM via nasal prong
//Memantine (MEMRY) 10 mg/tab½ tab OD (7:26 AM)// - Dr. Yu informed through call, will inform
//Clopidogrel (PLOGREL) 75mg/tab 1 tab OD (7:26 AM)// other Aps – informed through text
- Refer to persistence in BP elevation,
8/24/20 for HAMA meds deterioration of sensorium, dyspnea and other
Memantine 10 mg/tab ½ tab OD PO (8am)
unusualities
Citicoline 1 gm/tab BID PO x 3 months (8 am & 6pm)
Clopidogrel 75 mg/tab, 1 tab OD PO (8am) - Please give D₅₀ W 1 cap slow IV now
Sultamicillin 750 mg/tab, 1 tab BID x 7 days(8 am & 6pm) - Repeat CBG q 1H then raise to 2H until
Losartan 50 mg/tab, 1 tab OD PO (8am) stable
Amlodipine 5 mg/tab 1 tab OD PO (8am) 8/21/20 at 1:33 PM
- Dr. Yu made rounds in ER
Case and Plans discussed
- Suggest refer to Neuro service ( Dr. Pizarra)
- Dr. Hermogenes updated
Case and plans discussed
- Dr. Yu updated through call and conferred
- Decrease HGT Monitoring to q 6 hrs
- Dr. Yu informed through call and conferred
- Fall Precaution
- Please Facilitate CT scan BP tonight
All Aps Updated
8/22/20 at 11:20 AM
- Rounds with Dr. Hermogenes
For Procalcitonin ff with Dr. Yu
For LDH, CRP-HS, Ferritin, D-Dimer if okay
with Dr. Yu
At 11:35 AM
- Suggest referral to neurologist if Ok with
Dr. Yu
At 11:40 AM
- Dr. Yu updated
- Ok to get procalcitonin, LDH, CRP-HS,
Ferritin and D-Dimer
Ok to refer to neurologist under Dr. Pizarra
At 11:50 AM
- Dr. Pizarra called with this referral for co-
 KARDEX
management with conformity and
acknowledgement
- Please facilitate CT scan BP
Will see the patient
8/23/20 at 7:26 AM
- Increase CBG range to q 4H
Please chart all CBGs to chart and relay to
IMROD
8/24/20
- CLIA-refused with signature waiver
- HAMA
- Aps Updated
- Take home meds
- Dr. Yu updated
- Informed of HAMA
- Advised
- Dr. Hermogenes updated
- HAMA
- Advised
- Please provide photocopy of all lab results
- Dr. Hermogenes informed with
confirmation
- Advised
Dr. Pizarra informed
-

DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS

8/21/20@10:52 AM 8/22/20
• CBC, S. crea, Na⁺, K⁺, SGPT, BUA, BUN, BAIC May shift Cefuroxime IV to Ampicillin + Sulbactam 1.5 g
• ECG 12 L, CXR PA, PT, APTT IV drip q6H ANST
• CBG now then TID ac + HS, FBS, Lipid Panel 8/21/20
• Urinalysis Venoclysis: PNSS 1 L at KVO rate
• CT scan BP to start Ampicillin + Sulbactam 1.5 gm IV drip q 6H if okay
with primary service
• COVID Rapid antibody Testing
Please give D₅₀ W 1 cap slow IV now
 KARDEX
• COVID RT PCR c/o CDUH Another dose of Diphenhydramine 50 mg IVTT tonight
8/22/20@9:53 AM prior to CT scan
• For 2D ECHO with doppler Shift IVF to D₅NSS at KVO rate
• For Procalcitonin
• For LDH, CRP – HS, Ferritin, D-Dimer
• For TSH and FT4
• Follow-up checkup after 2 weeks

PATIENT’S NAME:_ Christian , Santos , Nadela _ _ DIET:

AGE_ 87 __ SEX_M______ //8/21/20 at 10:52 AM //
ATTENDING PHYSICIAN___ Dr. Yu co _______ Soft, low salt, low fat DM diet – hypo allergenic
CO-MANAGEMENT___ Dr. Hermogenes ________
DATE & TIME ADMITTED _8/21/20 ; 10:52 AM __ DIAGNOSIS/ IMPRESSION:
ROOM #______ RELIGION:__Roman Catholic ______
HOSPITAL #_____DATE OF BIRTH_ July 20, 1933 __
BLOOD TYPE :_________

CHIEF COMPLAINTS:
Vomiting, Elevated BP, Weakness, Cough