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    KARDEX Case 2

    Uploaded by

    Juviely Premacio
    This kardex summarizes the hospitalization and treatment of patient Lando Ramos Antigua under the services of Dr. Fernandez and Dr. Esperanza from July 29 to August 1. It includes medications, labs, procedures, assessments, and care plans such as admitting the patient to the COVID unit, monitoring vitals every 2 hours, starting IV antibiotics and steroids, and giving tocilizumab by infusion to treat suspected COVID-19 infection.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    KARDEX Case 2

    Uploaded by

    Juviely Premacio
    112 views3 pages
    This kardex summarizes the hospitalization and treatment of patient Lando Ramos Antigua under the services of Dr. Fernandez and Dr. Esperanza from July 29 to August 1. It includes medications, labs, procedures, assessments, and care plans such as admitting the patient to the COVID unit, monitoring vitals every 2 hours, starting IV antibiotics and steroids, and giving tocilizumab by infusion to treat suspected COVID-19 infection.

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    This kardex summarizes the hospitalization and treatment of patient Lando Ramos Antigua under the services of Dr. Fernandez and Dr. Esperanza from July 29 to August 1. It includes medications, labs, procedures, assessments, and care plans such as admitting the patient to the COVID unit, monitoring vitals every 2 hours, starting IV antibiotics and steroids, and giving tocilizumab by infusion to treat suspected COVID-19 infection.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    112 views3 pages

    KARDEX Case 2

    Uploaded by

    Juviely Premacio
    This kardex summarizes the hospitalization and treatment of patient Lando Ramos Antigua under the services of Dr. Fernandez and Dr. Esperanza from July 29 to August 1. It includes medications, labs, procedures, assessments, and care plans such as admitting the patient to the COVID unit, monitoring vitals every 2 hours, starting IV antibiotics and steroids, and giving tocilizumab by infusion to treat suspected COVID-19 infection.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    KARDEX

    DATE/ TIME MEDICATIONS DATE TREATMENT/ MANAGEMENT

    7/29/20 @ 3:30 PM 7/29/20 at 3:30 pm


    //Piperacillin (Tazobactam (Vigocid) 4.5 gm Iv drip q 6 H ANST - Please admit to COVID unit under the
    (3:30pm-9:30pm)// service of Dr. Fernandez 9D on deck) and
    //Azithromycin (Zenith) 500 mg /tab, 1 tab OD to complete 3 days more Dr. Esperanza (Pulmo on Deck)
    (3:30pm)//
    - Secure signed consent to care
    //Dexamethas 6 mg IVTT OD, 1st dose now` (3:30)//
    //Famotidine 20 mg/tab, 2 tabs O, may use// - TPQ q 4
    Ranitidine 150 mg/tab 1 tab BID is Famotidine is not available - CBR w/o TP, provide commode
    (3:30 pm & 7:30 pm) // - Hook to O2 at 4 LMP via NC
    //Citicholine 1 g/tab, 1 tab OD (3:30pm)// - V/S q 2 hours include O2 Sat
    //Colchicine 0.5 mg/tab, 1 tab BID (3:30 pm & 7:30 pm) // - I/O q 4 hours in absolute figures, don’t
    //Lopinavir/Ritonavir 200 mg/50 mg tab, 2 tabs BID (3:30 pm & estimate
    7:30 pm) // - MHBR
    //Vit. C + Zinc tab, 1 tab OD (3:30pm)// - Dr. Fernandez and Dr. Esperanza informed
    //Vit. B Complex tab, 1 tab OD (3:30pm)//
    of this admission via physical with
    Paracetamol 500 mg/tab, I tabq4 P
    acknowledgement
    RN for fever T: 38 °C
    //Sitagliptin 50 mg/tab a tab OD (4pm)// - Refer accordingly
    //Levofloxacin (Loxeva) 750 mg/tab, 1 tab OD as ordered above, 1st - Increase O2 Inhalation to 6 LPM via face
    dose now (5pm)// mask (late entry)
    7/30/20 10:30 AM - 7/30/20 at 10:30 am
    Atorvastatin 40mg/tab 1 tab OD PO (10:30 AM ) - Rounds with Dr. Fernandez
    Citicholine to 1 gm/tab BID PO (10:30 & 7:30 Pm ) - Case and plans discussed
    Linagliptin 5mg/tab 1 tab OD PO (6:21 PM) - Rounds with Dr. Esperanza
    Norgesic Forte Tab PRN for headache - 7/30/20 at 10:00 pm
    Metoclopramide 10 mg IVTT now (6:21)
    - Decrease O2 inhalation to 3-4 LMP via
    Domeperidone 10 mg tab 1 tabTID x 6 doses (8 am & 1:pm & 6pm
    Nasal Cannula
    Start insulin glargine 15 u SQ at HS
    20-30 min prior pre-medicate with diphenhydramine 50 mg IVTT and - May sit up on bed and ambulation around
    Paracetamol 300 mg IVTT then give Tocilizumab 400mg as IV the room with assistance
    infusion over 2H - Please give HRI 5 units SC now
    - 7/31/20
    - For Tocilizumab infusion
    - Secure consent
    - Monitor closely while on infusion for
    allergic reaction, hypotension, tachycardia
    - 8/01/20
    - HRI 6 u now
    - For transfer to other institution, APS
    update
    - Provide copy of labs prior to transfer
    KARDEX

    DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS


    7/29/20 at 3:30 pm 7/29/20
    - Protime Venocysis: PNSS 1L @ 40 cc/hr
    - Bleeding Time, Clotting time Start Enoxaparin0.6 cc SC q 2H
    - Blood Typing
    - BUN, QCRP, LDUR
    - Lipid Panel
    - D-Dimer, Ferritin
    - Blood C/S x2 sites
    - PCR c/o RESU
    - Rapid Antibody Test for COVID-19
    - CT scan
    - CXR- PA portable
    - ABG
    - FF-up UTZ KUB taken as OPD
    KARDEX
    PATIENT’S NAME:__ Lando , Ramos Antigua DIET:
    AGE_70______ SEX__M_____ 7/29/20
    ATTENDING PHYSICIAN__ Dr. Fernandez ____ Low Salt, Low Fat, full Diabetic diet with SAP
    CO-MANAGEMENT___ Dr. Esperanza ______
    DATE & TIME ADMITTED _7/29/20 / 3:30 Pm ___ DIAGNOSIS/ IMPRESSION:
    ROOM #______ RELIGION:_Roman Catholic______
    HOSPITAL #_____DATE OF BIRTH_ August 17, 1949_
    BLOOD TYPE :_________

    CHIEF COMPLAINTS: Change in sensorium and LBM

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