COURSE IN THE WARD

July 2, 2017

@1:05 am Patient was transfer from south super hi-way via ambulance
conduction and he was awake and coherent, seen and examined by Dr. Reyes upon
admission in MCP Emergency Room with chief complaint of DOB. Initial Vital Sign were
taken: BP: 120/70mmhg PR: 116bpm RR: 20cpm Temp: 36 C Oxygen saturation: 93%.
Different laboratory test done, consent was secured prior to admission. Patient was
admitted to ICU under the service of Dr. Glen Guce with ongoing IVF of D5W 500 ml
@KVO rate, received with Foley Catheter attached to urine bag. Other medication given
as ordered. Patient was advice for Intra Jugular Catheter insertion Stat, consent are
signed and OR is inform for Stat dialysis to an on-call dialysis nurse in duty.

During admission patient is awake, conscious and coherent at the

operating room for intra jugular catheter insertion with on-going IVF D5NSS 1L x 100 cc
patient was transferred safely to OR bed and monitored regularly, he also received
oxygen by a face mask. Local anesthesia was given by Dr. C. Reyes. @3pm operation
started and ended @3:14pm and well tolerated, post-op care done. He is endorsed to
the Hemodialysis unit, after hemodialysis patient start given NaHCO3 650 mg/1tab BID,
CaCO2 500mg/tab BID, Eposino 400unit SQ 2x, FeSO4 325mg/tab 2tab BID (9am-
3pm). With BP: 120/70mmhg PR: 114bpm RR: 20cpm O2sat: 99%. Consent was
signed for blood transfusion and endorsed to ICU nurse on duty. He was transferred to
ICU, he is awake conscious with GCS 15 given side drip of Sodium Bicarbonate as
ordered, seen and examined by Dr. Guce.

Patient was transferred via stretcher with oxygen inhalation at 8Lpm via
re-breather mask with IVF D5NSS 1L x 100 cc/hr. infusing well and with Foley catheter.
Patient is in low salt low phosphate low potassium @1800kcal/day diet with strict
aspiration precaution. He also hooked to cardiac monitor and pulse oximeter, initial Vital
sign was taken BP: 150/80mmhg PR: 104bpm RR: 18cpm Temp.:36 C Oxygen
saturation: 100%. Medication was given as follows: omeprazole 20mg IV started initiate
NaHCO3 drip, D5W 250 + NaHCO3 1 vial x 8 hrs. Patient complaint Nausea and
vomiting, he is referred to ROD to administer Metoclopramide 1 ampule IV given as
ordered and was encouraged deep breathing exercises. He was transfusing of 3 units of
PRBC for hemodialysis with consent signed. Attending physician updated to continuity
of care @9:10pm BP: was taken 170/90mmhg, amlodipine was given 1 tab OD. @
10:00 pm patient was risk for reoccurrence of Difficulty of Breathing, weak and pale
looking with on-going IVF of D5NSS 1L x 100cc/hr. and ongoing NaHCO3 drip: D5W
250cc + 1 vial NaHCO3 x 8hr, he is still with Oxygen inhalation via re-breather mask at
5Lpm. Patient was placed on high back rest and encouraged deep breathing exercises.
@12 midnight patient was given furosemide 20 mg IV, then CBG taken 219mg/dl. (+)
warm to touch with temperature of 37.8 C, (-) DOB shifted re-breather mask to nasal
cannula at 4Lpm, (+) cough with phlegm, his attending physician is updated.

July 3, 2017

@6am Patient is (+) at vomiting metoclopramide was then again given

with oxygen support via nasal cannula at 4Lpm, ongoing IVF D5NSS 1L x 100cc/hr.
NaHCO3 drip x 8 hour and Foley Catheter attached to urine bag draining well, morning
care rendered and encourage Deep Breathing and verbalization of comport. @7:45am
Dr. Guce and other physician updated no objection. Patient all cleared for trans-out to
regular room safely. Vital signs was taken BP: 140/80mmhg PR: 86bpm RR: 16cpm
Temp: 36 C Oxygen saturation: 99% he is still at nasal cannula at 4Lpm and revised
clonidine to 75 mcg/tab PRN for of BP: 160/100mmhg, wheeled to room 312 station 4
and endorsed to nurse on duty .

Station 4: Received from ICU patient was transferred to room safely via
stretcher with GCS15 with Intra Jugular Catheter at Right and Oxygen support via Nasal
Cannula at 4Lpm with ongoing IVF infusing well with NaHCO3 drip x 8hrs, Foley
Catheter attached to urine bag. Diet instructed with strict aspiration precaution and
patient position to side and encourage to verbalized discomfort. Endorsed to
hemodialysis @ 12:45pm, the NaHCO3 vial are out of stock to consume side drip differ
2 vials of NaHCO3 if serum bicarbonate 16mmoll/L monitor accordingly.

Hemodialysis Unit: Patient received from station 4 via Bed with Foley
Catheter attached to urine bag, IVF infusing well and NaHCO2 drip via infusion pump
with intra Jugular catheter. Hemodialysis started @5:00pm with following prescription
UF: 0 Heparin: 3:1 QB: 200 QD: 500cc/hr., @5:30pm 2nd unit of blood transfusion
started and monitored for any hemodialysis complication, seen and examined by Dr.
Guce. @6:20pm repeat CBC 6hrs, after 4th unit PRBC administration, he is referred to
surgery service for AVF creation, the patient receive permanent dialysis schedule at
own unit (3x/week) M-W-T. The patient ordered to repeat creatinine, potassium with
CBG. IVF to follow D5NSS 1L x 80cc/hr., patient advice oral fluid intake 2L/day.
@7:00pm on the same day. Blood transfusion of 3rd unit started post hemodialysis, Vital
sign was taken BP: 130/70mmhg PR: 88bpm endorsed the patient to station 4. Shift
omeprazole IV to oral at 20 mg PO OD patient was referred to 2D echo unit.
July 4, 2017

@6:00am Patient is awake with ongoing IVF infusing well and Foley
catheter attached to urine bag that draining well, intra jugular catheter with diet
instructed, patient was keep rested and comfortable. @6:44am patient was seen and
examine by Dr. Guce, IVF transferred to Intra Jugular catheter site; save both arms to
be seen for AVF creation at intervals. @6:45am patient has productive cough decrease
IVF to KVO, the patient started bladder training and remove Foley catheter, defer CBC
post Blood transfusion repeat CBC, Creatinine, Potassium and given Flumucil 600
mg/tab dissolved in 1 glass. Dialysis prescription duration: 4hrs. UF: 1L QB: 250 QD:
500, NaHCO3, heparin: 3:1 dialysate Na 138 his Temp. 36, increase omeprazole
40mg/tab 1 tab 30mins. before dialysis. @9:00am vital sign was taken and noted, he is
for AVF creation (July 5, 2017) under local anesthesia patient was in NPO after 5am.
Informed Operating room secured consent and informed other physician may use intra
jugular catheter for intravenous fluids. @2:10pm during rounds patient is awake,
conscious and coherent with patent intra jugular catheter, ongoing IVF infusion well,
Foley catheter attached to urine bag draining well. Diet was instructed to patient and
kept rested and comfortable. @3:25pm PR: 80bpm decrease coralan 50 mg/tab OD
every other day. @7:00pm Foley catheter remove an aseptically monitored accordingly
voiding freely without complaint (-) dizziness (-) DOB.

July 5, 2017

@6:00 AM during rounds, Patient is awake and GCS 15 with ongoing IVF that
infusing well, he was instructed on NPO diet, Morning care we're rendered and kept
patient safe and comfortable. Patient was scheduled for Arterio-Ventricular Fistula
(AVF) Creation @7:00AM his Attending Physician revised (DUPAINOZATIN) to heparin
for Hemodialysis Flushing every 15mins. 100cc PNSS shift piptazobactam (piperacillin/
tazobactam) to cefixime 400mg/tab BID 5 days, D/C levofloxacin shifted to
azithromycin 500mg/tablet 1tablet OD 3 more days.
@10:00 AM Patient is then transferred via stretcher to operating room table
safely and was endorsed to operating room nurse. Patient is awake, not in respiratory
distress, consent signed for the procedure. @10:30 AM, he was then given oxygen via
Nasal Cannula @2 LPM, He is also attached to cardiac monitor with BP: 177/90 PR: 73
RR: 20 OXYGEN SATURATION: 100%. @11:02 PM Local Anesthesia induced by Dr.
C. Reyes, after 2mins. Procedure started at the Left arm. @11:53 AM Procedure ended
and well tolerated, Post-op care done and endorsed with BP: 140/87mmHg PR: 73bpm
RR: 19cpm OXYGEN SATURATION: 100%. @12:00 PM s/p AVF Left under local
anesthesia, patient transferred to hemodialysis via stretcher with left arm precaution.
Cardio medication was prescribed as follows: Trimetazidine 35mg PO BID, Amlodipine
10mg PO OD, Clonidine 75mcg for BP: 160/100mmHg, Coralan 5mg PO OD every
other day, included CBC. @2:30PM patient was seen/examined by Dr. C. Delos Reyes,
@3:10PM patient was also seen/examined by Dr. G. Guce, and ordered the patient may
go home tomorrow (July 6,2017) with the Final Diagnosis: End Stage Renal Disease
Secondary to Hypertensive Nephrosclerosis, he was prescribed with the following
medications:
Cefuroxime 500mg/tablet 1tablet BID 4 more days
Azithromycin 500mg/tablet 1tablet OD 2 more days
Omeprazole 40mg/tablet 1tablet OD 2 more days
Trimetazidine 35mg/tablet 1tablet BID
Amlodipine 10mg/tablet 1tablet OD
Coralan 5mg/tablet 1tablet OD
NaHCO3 650mg/tab 1tablet BID
CaCO3 500mg/tablet 1tablet BID
Ketobest 600mg/tablet 1tablet TID
Eposino 400iu SQ 2/week
Aspirin 80mg/tablet 1tablet OD
Patient was advised with a Low salt, Low phosphate diet at 1600kcal, regular
Hemodialysis 3/week. @5:30PM attending physician clarify regarding order of CBC
may done tomorrow morning (July 6.2017). Post dialysis vital signs was taken BP:
140/70 PR: 82 UF: 2.8 L. received from Hemodialysis unit, patient is conscious and
coherent, complaining of mild discomfort to the newly created IVF on left arm, Vital
signs are within normal range. @6:10PM patient clarify regarding home meds.
Prescribed cefixime 400mg/tablet 1tablet BID for more days instead of cefuroxime
500mg/tablet, D/C furosemide T/C IVF. @6:20PM regular medication resumed with
discontinue as prescribed, Intra Jugular catheter dressing done by the Hemodialysis
nurse, he is on continues oxygen support @2Lpm, for dietician counseling tomorrow
(tentative). All due medication were given.

July 6, 2017

During endorsement @6:00AM, patient is awake with MGH order to day and also
with intra jugular catheter, oxygen inhalation @2Lpm via nasal cannula, AVF on left
arm, diet is instructed to the patient and was encouraged to verbalized discomfort, the
patient has no complaint. @9:50AM Vital Signs was taken within normal, no objection to
discharge, with follow up on Monday (July 10, 2017) room 211 at 4PM. @11:20AM
updated regarding to MGH order. Patient was approved for discharge with medication
Of Soludexide 250 LSU (Lipoprotein Lipase Releasing Unit) BID and follow up Monday
after 2 weeks. @2:00PM endorsement, patient was awake and has no complaints
during rounds @5:00PM patient was transferred to station 2 nurse on duty via
wheelchair from station 4, he was awake, conscious and coherent with intra jugular
catheter, AVF at left arm, diet is also instructed, and patient was kept safe and rested.
@10:00PM Vital signs we're taken and its within normal.

July 7, 2017

@6:00AM patient received awake and still with intra jugular catheter, AVF on left
arm for Hemodialysis with consent signed. @11:30AM patient was endorsed to
Hemodialysis nurse on duty; he was transferred to Hemodialysis unit from station 2 via
wheelchair with right intra jugular catheter. @11:45AM Hemodialysis was started with
duration of 4 hours VF: 1L Heparin: 3:1, Patient is monitored accordingly. @4:15PM
patient was endorsed to station 2 nurse on duty with the Vital signs of BP: 120/70mmHg
PR: 80bpm UF: 1L. @4:40PM patient was discharged via wheelchair safely.