February 16, 2011 Please admit

Secure consent
TPR q shift & record
NPO
CBC with BT, urinalysis, CXR, FBS, BUN, Crea,
Lipid profile
IVF: D5LR 1L X8
Meds: Cefuroxime 750 mg IV q8 ANST
For CTT insertion R
Notify OR
Notify Dr. Mallari
Refer to medicine for Co-management
Refer accordingly

Post-op orders:
>to ward
>IVF D5LR 1LXKVO
>DAT
Labs: RPT CXR stat
Meds: Tramadol 5g IV 8 ANST
For CTT Clumping q30 min
For 100 cc of drained fluids

February 17, 2011 Refer to medicine for possible transfer of

service
(9:25 am) >IVF to ff: D5LR X8
>repeat CBC

February 18, 2011 Follow up referral to MROD

(8:30 am)

February 18, 2011 Paracetamol 500 mg PO q4 prn for fever

(5:00 pm)

February 19, 2011 >cont CTT

>IVF: D5LR 1L X KVO
>cont meds

February 19, 2011 For RBS, TPAG

(4:45pm) For CXR, rpt urea
Monitor CTT output
CTT (-) output Record per referral
February 20, 2011 For serum LDH
(-) CTT output For follow up result of CXR
For possible removal of CTT
For Chest UTZ

February 21, 2011 For referral to pulmo

(-) CTT output

February 22, 2011 Follow up referral to pulmo and re co-

(10:00pm) management to Medicine

Co-Amoxiclav 1g BID
Meloxicam 7.5 mg OD

February 23, 2011 Refer back to surologist for quantification of

(10:30 pm) loculated pleural effusion

UTZ chest: loculated pleural effusion R

February 23, 2011 For UTZ

(7:30 pm) Secure consent

February 24, 2011 For TOS to medicine

(9:30 am)

February 24, 2011 For thoracentesis

(2:30 pm) Secure consent

(-) dyspnea

February 25, 2011 SP thoracentesis

(4:30 pm) Approximately 260 cc of yellowish fluid\
Monitor VS q1 & record
BP 110/80 mmHg For rpt CXR
Refer

February 26, 2011 For removal of CTT

(9:15 am) For possible D/C tom
IMH RMP PZA EMB q4 tab OD pre breakfast

(12:30 pm) Possible removal of CTT

Cont meds
February 27, 2011
(11am)
February 28, 2011 For rpt CXR upright
(10:30 am) IVF D5LR X KVO
Cont meds

(2:45 pm) Cont CTT

D5NM 1L X 12
Secure CXR result

For removal of CTT

For possible MGH tom

March 1, 2011 Home meds:

(6:10 am) IMH RMP PZA EMB 4 tabs OD pre breakfast
Vit B complex 1 cap OD

MGH after removal of CTT

February 16, 2011
February 18, 2011
Hemoglobin 12.8 g/dl
Hematocrit 38.1 vol% CBC
WBC count 10, 700/ cumm Hemoglobin 124
Differential count Hematocrit 0.36
Neutrophils 54 (40-60 RBC 3.93 4.5-8 X 10 ^12/L
Lymphocyte 46 (35-40 WBC 8.1 5-10
MCV 91 80-94
FBS 4.6 MCH 31 27-31
BUN 8.6 (5.35-16) MCHC 34% 31-36%
Crea 70.7 ( Segmenters 0.77 0.50-0.56
Total Cholesterol 3.3 (3.46-8.18 mmol/L) Lymphocytes 0.14 0.20-0.40
Triglycerides 1.2 (0.50- 1.86 mmol/L) Monocytes 0.08 0.02-0.08
LDL 2.1 (1.56-4.55 Eosinophils 0.01 0.01-0.04
HDL 0.6 (0.78- 1.95
February 20, 2011
Chest Xray:
To consider hydrothorax, right RBS 152 74- 106 mg/dl
PTB, minimal, left Total protein 5.9 6.3-8.2
Albumin 2.6 3.5- 5.0 g/dl
Chest Xray stat: A/G ratio .8 1.5- 2.5
Hydrothorax, right Globulin 3.3 2.3-3.5 g/dl
Atheromatous aorta
February 20, 2011
February 17, 2011
Follow up chest Xray study after 1 day shows no
Urinalysis radiographic internal change regarding internal
change regarding the right lung field
Cell count
WBC count= 45 cells/uL February 21, 2011
RBC count= 149 cells/uL
Differential count LDH 65.7 80-82.5 IU/L
Segmenters= 0.05
Lymphocytes= 0.95 February 23, 2011
Gram stain
No organism seen Sonogram of the right Hemithorax shows a
Moderate lymphocytes loculated pleural effusion with an approximate
Glucose 103 mg/dl volume of 518 cc
LDH 1230 U/L
Total protein 419 mg/dl February 28, 2011

Far advanced PTB

Consider pleural effusion, right