25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"},{"category":"Physician ","chartdate":"2152-04-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":375159,"text":"Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\n SpO2: 94%\n ABG: ////\n Physical Examination\n Pleasant appears comfortable today\n HEENT no oral ulcers\n Regular S1 S2 no m/r/g\n Lungs clear bilaterally, no wheezing or rales, decreased L base\n Abd soft nontender +bowel sounds\n Extrem warm no edema palpable distal pulses\n Neuro alert and interactive\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n CXR \n 1. Stable post- pneumectomy appearance.\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n 3. Unchanged nodular opacities in the right peripheral lung base.\n Micro urine legionella negative, viral DFA negative, blood cx\n NGTD\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, admitted\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\n and tachycardia.\n # Sepsis: Clinically much improved. Thought likely a reaction to\n gemcitabine. No organisms identified.\n - Continue steroids for Gemcitabine-related inflammatory lung disease\n - Continue home levo, would stop vanc and zosyn today\n - Follow up cultures and reculture if febrile\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem today\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - follow daily, maintain active t+S, transfuse hct>25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"},{"category":"Physician ","chartdate":"2152-04-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":375168,"text":"I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n No events breathing better.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n asa 325\n neurontin 600mg Q 8hr\n advair\n flecinide\n levofloxacin 500Q 24\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n protonix\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 91% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 81 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 81 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -569 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: no film Pending\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Labs pending:\n Micro-DFA negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. Low WBC on high dose steroids may be\n secondary to possible viral etiology if this is not chemo related\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will decrease solumedol 60mg Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow, chemo related\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM Will d\nc central line\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer: PPI steroids\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Floor\n Total time spent:\n"},{"category":"Physician ","chartdate":"2152-04-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":375169,"text":"Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Breathing better today no pain.\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\n SpO2: 94%\n ABG: ////\n Physical Examination\n Pleasant appears comfortable today\n HEENT no oral ulcers\n Regular S1 S2 no m/r/g\n Lungs clear bilaterally, no wheezing or rales, decreased L base\n Abd soft nontender +bowel sounds\n Extrem warm no edema palpable distal pulses\n Neuro alert and interactive\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n Labs above are from \n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n CXR \n 1. Stable post- pneumectomy appearance.\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n 3. Unchanged nodular opacities in the right peripheral lung base.\n Micro urine legionella negative, viral DFA negative, blood cx\n NGTD\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, admitted\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\n and tachycardia.\n # Sepsis: Clinically much improved. Thought likely a reaction to\n gemcitabine. No organisms identified. SOB probably multifactorial with\n COPD, s/p pneumonectomy, gemcitabine effect and ?infection.\n - Continue steroids for Gemcitabine-related inflammatory lung disease.\n Will change to solumedrol 60q6 and plan to taper.\n - Repeat CXR today\n - Continue home levo, would stop vanc and cefepime today\n - Follow up cultures and reculture if febrile. Check sputum if making\n any.\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem today\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - follow daily, maintain active t+S, transfuse hct>25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n Needs CBC with diff today.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"},{"category":"Nursing","chartdate":"2152-04-26 00:00:00.000","description":"Nursing Progress Note","row_id":375134,"text":"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt cont to desat to mid to high 80\ns when wearing only nasal canula.\n Upset about having to wear face mask and about having the door closed\n for droplet precautions.\n Action:\n Pt encouraged many times to wear face tent to keep o2 sat\ns elevated.\n Flu test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"},{"category":"Nursing","chartdate":"2152-04-23 00:00:00.000","description":"Nursing Progress Note","row_id":374827,"text":"Nursing Admission Note\n Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n No pain presently\n Action:\n Prn pain meds available for chronic back and s/p L pneumonectomy pain\n Response:\n As needed\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Pt on sm amt of neo on arrival from ed. Vss. Denies lightheadedness.\n Action:\n Continues on neo. Although apparently documented previous bp are\n 90-105/\n Response:\n Will titrate neo to off\n Plan:\n Titrate neo. Fluid as needed\n"},{"category":"Physician ","chartdate":"2152-04-23 00:00:00.000","description":"Physician Resident Admission Note","row_id":374831,"text":"Chief Complaint: fever\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS:\n ================\n Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H Aspirin 325 mg\n Tablet Sig: One (1) Tablet PO DAILY (Daily).\n Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H\n Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\n One (1) Disk with Device Inhalation (2 times a day).\n Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff\n Inhalation Q6H (every 6 hours) as needed.\n Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3\n times a day).\n Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\n hours) as needed.\n Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at\n bedtime) as needed.\n Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO\n Q6H (every 6 hours) as needed.\n Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:\n One (1) Cap Inhalation DAILY (Daily).\n Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr\n Past medical history:\n Family history:\n Social History:\n PAST ONCOLOGIC HISTORY:\n ======================\n ONC: squamous cell lung cancer T3, N2 s/p L pneumonectomy after\n chemo and XRT; bronchoscopy on revealed erythema and abnormal\n appearance in the L bronchial stump suggesting recurrent disease.\n Recent PET shows some FDG avidity along the pneumonectomy suture line\n with a comment about a foci of avidity in the AP window area. There is\n also circumferential uptake around the pneumonectomy cavity. There is\n also a note of poor anatomic delineation without a contrast CT. There\n was also FDG avidity between the right atrial appendage and the left\n ventricular outflow track without anatomic correlate. No definite bony\n lesions, no subdiaphragmatic lesions. He is being considered for\n radiation therapy\n - He started weekly Taxotere on , and completed two\n cycles.\n - C1D10 of gemcitabine, last dose on \n .\n PAST MEDICAL HISTORY:\n ====================\n - a-flutter s/p ablation in ; not anticoagulated bleeding\n problems while on coumadin for PE in the past\n - PE \n - multiple PNAs, most recently in (as above)\n - + PPD, treated with INH x8 months (completed in )\n - COPD: FEV1 of 1.55 liters or 48% of predicted, an FVC of 2.38\n liters or 53% of predicted, and an FEV1/FVC ratio of 55%\n - Pulmonary embolism \n - L frozen shoulder\n Father died of laryngeal cancer. Does not know what his mother\n died from.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient is divorced and lives with his two daughters. son as\n well. Only rare alcohol use and prior tobacco use (roughly 70 pack\n years); he quit smoking approximately a year ago just prior to be\n diagnosed with lung cancer. He was born in and came to the U.S.\n roughly forty years ago.\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,231 mL\n PO:\n TF:\n IVF:\n 231 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,661 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n Physical Examination\n GENERAL: NAD\n SKIN: warm and well perfused, no excoriations or lesions, no rashes\n HEENT: no JVD, no LAD, no oral ulcers or lesions\n CARDIAC: RRR, S1/S2, no mrg\n LUNG: bilateral high pitched end expiratory wheeze\n ABDOMEN: nondistended, +BS, nontender in all quadrants, no\n rebound/guarding, no hepatosplenomegaly\n M/S: moving all extremities well, no cyanosis, clubbing or edema, no\n obvious deformities\n PULSES: 2+ DP pulses bilaterally\n NEURO: CN II-XII intact\n Labs / Radiology\n 181\n 134\n 0.9\n 14\n 21\n 104\n 4.2\n 136\n 32.7\n 7.2\n [image002.jpg]\n Other labs: Differential-Neuts:98.7, Band:0, Lymph:7.9, Mono:0.6,\n Eos:1.5\n Fluid analysis / Other labs: UA: neg\n lactate 2.9-> 0.6\n pH7.33/ 38/72 HCO3\n Mixed venous O2Sat: 94\n .\n PT: 15.1 PTT: 31.2 INR: 1.3\n .\n Trop< 0.01\n CK 31\n Imaging: CXR: white-out of left side c/w prior pneumonectomy, right\n side with unchanged streaking infiltrates\n Microbiology: UA: neg\n ECG: NSR, no ischemia\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia c/s sepsis.\n .\n # Sepsis: Presents with recent immunosupression but no neutropenia. Pt\n has fever and hypotension refractory to fluids c/w septic shock.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA.\n - wean off neo\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin\n - f/u LFT's\n - recheck CXR to see if infiltrate has developed post-hydration\n - f/u blood and urine Cx\n - obtain sputum cx\n - obtain legionella UA\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - hold diltiazem temporarily\n - neo rather than levo\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n .\n # Disposition: pending resolution of above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: not needed\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2152-04-23 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":374836,"text":"Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient, Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"},{"category":"Physician ","chartdate":"2152-04-23 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":374837,"text":"Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient, Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"},{"category":"Physician ","chartdate":"2152-04-23 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":374840,"text":"Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\n gemcitibine three days PTA. He presented with three days of\n intermittent fever to 102 , weakness and anorexia. He reports mild\n dyspnea and cough at baseline which is not worse. He was referred to\n the ED for evaluation and while there developed SBP to 70s and sinus\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\n was placed and neosynephrine started. CVP=10. He received vanco and\n cefipime and was previously on levaquin\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\n .\n In addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n History obtained from Medical Records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Asa 325\n Neurontin\n Advair\n Flecanide\n Levaquin 500 q24\n Vanco 1 q2 (#2)\n Atrovent nebs\n Morphine\n Heparin SC\n At Home Meds:\n Flecanide\n Cardizem\n Levaquin\n Advair\n Albuterol\n Neurontin\n Dilaudid\n Compazine\n atrovent\n Past medical history:\n Family history:\n Social History:\n T3N2 SCC s/p left pneumonectomy with recurrence in\n hilar stump and left pleura. Had taxotere x 2. gemcitibine x 1.\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\n home. S/P ablation in \n Per RAN\n Quit cigs 1 year ago.\n Review of systems: Reviewed in Detail . Please see RAN of .\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\n possibility but so far no infectious source. His respiratory status\n appears intact and is responding to resuscitation. Agree with MICU\n team plan of care and empahsize.\n CV\n 1. wean off pressors. Continue antiarrythmic therapy, not on\n anticoagulation due to bleeding risk.\n PULM\n On 3L NC presently but may not need this. Will wean off. Atrovent q6\n GI\n Full diet\n ID\n Micro w/u. Empiric vanco/cefpime with plan to discontinue if w/u\n negative.\n PPX- heparin SC\n DISPO- FULL code. MICU today for montioring. Possible transfer to\n floor if stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"},{"category":"Physician ","chartdate":"2152-04-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":374946,"text":"I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Spiked to 101\n Weaned off Neo\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g\n atrovent\n cefepime\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100% 50%FM\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\n Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology:\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n BNP-Pending\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -Will Check CTPA to rule out PE and eval for PNA\n -Check BNP\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n -Give fluid if hypotensive\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- will check CTA, per patient had \n problem from chest wound from anticoagulation.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen\n ICU Care\n Nutrition: regluar diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2152-04-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":374953,"text":"I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Spiked to 101\n Weaned off Neo\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g\n atrovent\n cefepime\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100% 50%FM\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\n Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology:\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n BNP-Pending\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -Will Check CTPA to rule out PE and eval for PNA\n -Check BNP\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n -Give fluid if hypotensive\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- will check CTA, per patient had \n problem from chest wound from anticoagulation.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regluar diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 mins\n"},{"category":"Nursing","chartdate":"2152-04-23 00:00:00.000","description":"Nursing Progress Note","row_id":374815,"text":"Nursing Admission Note\n Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2152-04-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":374933,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\n - on levoquin chronically\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2152-04-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":374935,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n - spiked temp to 101, rigors\n resolved with Tylenol, not cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\n - on levoquin chronically\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2152-04-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":374937,"text":"Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n - spiked temp to 101, rigors\n resolved with Tylenol, not cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine.\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - on levoquin chronically\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2152-04-25 00:00:00.000","description":"Nursing Progress Note","row_id":374998,"text":"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Pt alert and oriented. No episodes of dizziness. Bp normotensive. O2\n sat\ns dropping occ to high 80\ns. hr in 90\ns to low 100\ns with occ\n pvc\n Action:\n ,contd cefipime,vanco and levoquin, solumedrol had been given Q8hr\n and has now been inc to q 6/hrs.\n Response:\n No drop in blood pressure, mentaing fine with map>60, urine output\n slowing down.\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt with 5lnc on all shift and will occ drop o2 sat\ns to the high 80\n resp rate in the 20\ns, lung sounds witih insp/exp wheezes. Vss.\n Action:\n Pt receiving nebs and using inhalers. Also receiving steroids which\n have been inc to q 6/hrs. occ will put on face tent to help with\n desaturation.\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n tent.(50%), final read of cta neg for pe.\n Plan:\n cont nebs,solumedrol.\n"},{"category":"Nursing","chartdate":"2152-04-25 00:00:00.000","description":"Nursing Transfer Note","row_id":375086,"text":"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol,02\n wened to 3L NC,ruled out PE with CTA.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,02 weaned to 3L NC\n Response:\n Sats mostly in 92-95%,but does desats to high 80\ns at times,but quckly\n reverts back,also asymptamatic with desats,does gets sob at times with\n exertion which may require high amount of 02 for a brief period of\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"},{"category":"Radiology","chartdate":"2152-04-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1078223,"text":" 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change as remains hypoxic.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with gemcitabine related inflammatory lung disease\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change as remains hypoxic.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DDBc WED 12:19 PM\n PFI: No change from prior day. Nonspecific but progressive right-sided\n process.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with lung cancer on gemcitabine. To further assess.\n\n TECHNIQUE: radiograph was obtained.\n\n COMPARISON: .\n\n REPORT:\n\n Patient is status post pneumonectomy on the left side. A left-sided central\n line is identified in situ. There is evidence of widespread patchy change in\n the right lung, which is nonspecific, but as mentioned before could reflect\n toxic drug damage ,edema or infection. The appearances are certainly not\n changed from prior day, but when compared to multiple prior radiographs have\n demonstrated probable progressive change. The nodular pattern may be\n misleading given the widespread emphysematous change present. Osseous\n structures are grossly unremarkable.\n\n CONCLUSION:\n\n No change from previous day.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2152-04-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077654,"text":" 12:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new L IJ\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with new left IJ. Evaluate line placement.\n\n COMPARISON: at 10:37 p.m.\n\n SINGLE AP VIEW OF THE CHEST: There is a new left internal jugular central\n line, with tip crossing midline and likely extending into the right\n brachiocephalic vein.\n\n Again noted are left pneumonectomy changes, with shift of midline structures\n to the left. Within the right lung are emphysematous changes, with patchy\n nodular and airspace opacities within the right lower lung, as previously\n seen, likely reflecting residual infection. Of note, the right costophrenic\n sulcus is excluded.\n\n IMPRESSION: Left IJ central line tip crossing midline, and crossing over to\n the right brachiocephalic vein.\n\n Dr. was paged at the time of this interpretation.\n\n\n"},{"category":"Radiology","chartdate":"2152-04-24 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1077880,"text":" 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, PEs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 9:31 PM\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\n Increased diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right middle\n lobe nodule slightly increased, likely infectious. Persistent worrisome\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\n ______________________________________________________________________________\n FINAL REPORT\n CTPA INPATIENT\n\n REASON FOR EXAM: 59-year-old men with history of PE, rule out pneumonia, now\n with hypoxia.\n\n TECHNIQUE: Chest MDCT was performed without and following 100 cc of\n intravenous Optiray using 5 mm and 2.5 mm axial slice thickness. Coronal,\n sagittal and oblique reformations were also obtained.\n\n COMPARISON: and priors back to .\n\n FINDINGS: There is no pulmonary embolism to the subsegmental level on the\n right. Left pneumonectomy is again seen. Soft tissue in the left hilar\n region and lateral to the hilar stump is unchanged, worrisome for local\n recurrence, up to 12 mm in thickness lateral to the surgical sutures. Basilar\n pleural nodules are also unchanged, corresponding to areas of FDG avidity on\n the most recent PET/CT. Emphysema is unchanged.\n\n Peribronchial and diffuse opacities in the right lung have increased. Right\n middle lobe peribronchial opacity also slightly increased (3:63). Scattered\n coronary artery calcifications are unchanged. Tiny small right pleural\n effusion is new. Signs of anemia persist. There is no pericardial effusion.\n\n This study was not tailored for subdiaphragmatic evaluation but the upper\n abdomen is unremarkable. There is no bone lesion suspicious for malignancy.\n Left humeral bone infarct or enchondroma is unchanged. Left thoracotomy\n changes are stable.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. Increased peribronchial and diffuse right lung opacities, superimposed\n upon emphysema. The diffuse abnormalities may be due to pulmonary edema,\n especially given a new small right pleural effusion, but diffuse infection is\n (Over)\n\n 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n also possible. Right middle lobe and other peribronchial opacities slightly\n increased, likely infectious, but attention to this region should be paid on\n subsequent followups.\n\n 3. Persistent soft tissue lateral to the hilar pneumonectomy stump, very\n worrisome for local recurrence. Unchanged left basilar pleural nodules,\n suggestive of pleural metastases.\n\n 4. Signs of anemia.\n\n 5. Stable old left humeral bone infarct or enchondroma.\n\n\n"},{"category":"Radiology","chartdate":"2152-04-24 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1077881,"text":", MED MICU-7 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, PEs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\n Increased diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right middle\n lobe nodule slightly increased, likely infectious. Persistent worrisome\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\n\n"},{"category":"Radiology","chartdate":"2152-04-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1078224,"text":", MED MICU-7 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change as remains hypoxic.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with gemcitabine related inflammatory lung disease\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change as remains hypoxic.\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change from prior day. Nonspecific but progressive right-sided\n process.\n\n"},{"category":"Radiology","chartdate":"2152-04-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077661,"text":" 2:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new position of L IJ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with repositioned L IJ\n REASON FOR THIS EXAMINATION:\n ? new position of L IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with repositioned left IJ.\n\n COMPARISON: .\n\n SINGLE AP VIEW OF THE CHEST: The left internal jugular central venous\n catheter tip appears in same position, likely within the right brachiocephalic\n vein. There has been no other interval change.\n\n\n"},{"category":"Radiology","chartdate":"2152-04-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077662,"text":" 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new L IJ\n REASON FOR THIS EXAMINATION:\n ? placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with new left IJ. Evaluate placement.\n\n COMPARISON: at 2:22 a.m.\n\n SINGLE AP VIEW OF THE CHEST: There is a left internal jugular venous\n catheter, which has been retracted, and tip likely lies within the left\n brachiocephalic vein. There have been no other interval changes.\n\n"},{"category":"Radiology","chartdate":"2152-04-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077967,"text":" 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 3:13 PM\n Interval increase in reticular nodular opacities in the right mid lung and\n lower lobe concerning for volume overload, infection or, less likely\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male with hypoxia. Evaluate for change.\n\n COMPARISON: Multiple studies including most recent of and CT of\n .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: As before, there is complete opacification\n of the left hemithorax consistent with prior pneumonectomy. Nodular opacities\n in the right peripheral lung base are not significantly changed from prior.\n However, there is increased reticulonodular opacities in the right lung base\n concerning for volume overload, infection or, less likely, post- pneumectomy\n syndrome resulting in impaired lymphatic or venous drainage. The remainder of\n the exam including the left IJ catheter is unchanged.\n\n IMPRESSION:\n 1. Stable post- pneumectomy appearance.\n\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n\n 3. Unchanged nodular opacities in the right peripheral lung base.\n\n"},{"category":"Radiology","chartdate":"2152-04-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077968,"text":", MED MICU-7 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in reticular nodular opacities in the right mid lung and\n lower lobe concerning for volume overload, infection or, less likely\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\n\n"},{"category":"Radiology","chartdate":"2152-04-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077647,"text":" 10:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with squamous cell lung CA, Hypotensive, tachycardic, febrile.\n I s/p L lubectomy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with squamous cell carcinoma, hypotensive,\n tachycardia, status post left pneumonectomy. Evaluate for infiltrate.\n\n COMPARISON: .\n\n SINGLE SUPINE AP VIEW OF THE CHEST: The patient is status post left\n pneumonectomy, with fluid within the left pneumonectomy space. There is\n unchanged leftward shift of mediastinal structures. The right lung contains\n ill-defined patchy and nodular densities, particularly within the right lower\n lung, which may reflect residual areas of consolidation, likely infectious, as\n seen on prior chest CT . Emphysema is also noted. There is no\n pleural effusion or pneumothorax within the right lung.\n\n IMPRESSION:\n 1. Stable post left pneumonectomy changes.\n 2. Patchy nodular densities within the right lower lung, likely reflect\n residual infection, as seen on chest CT .\n 3. Emphysema.\n\n"},{"category":"Radiology","chartdate":"2152-04-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1077729,"text":" 1:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls eval for infiltrate, interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with lung ca, s/p pneumonectomy, now s/p hydration\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: , 3:59 a.m.\n\n FINDINGS: As compared to the previous examination, there is little overall\n change. The left-sided central venous access line is in constant position,\n with its tip projecting over the slightly displaced trachea. The total\n opacification of the left hemithorax is constant (status post pneumonectomy).\n In the right lung, there is a minimal decrease of the diffuse parenchymal\n opacities that remain, however, clearly visible, notably in the periphery of\n the lung.\n\n"},{"category":"ECG","chartdate":"2152-04-22 00:00:00.000","description":"Report","row_id":217629,"text":"Sinus tachycardia. Lateral ST-T wave changes. Cannot rule out myocardial\nischemia. Compared to the previous tracing of atrial fibrillation has\nnow converted to sinus rhythm. Ventricular premature beats have resolved.\nLateral ST-T wave changes are new. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2152-04-23 00:00:00.000","description":"Report","row_id":217628,"text":"Sinus tachycardia\nAnterolateral ST-T changes are nonspecific\nSince previous tracing of , the heart rate has decreased, ST-T wave\nabnormalities are less\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 374934,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n EKG - At 04:00 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 02:33 AM\\n Cefipime - 10:17 AM\\n Levofloxacin - 10:17 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.7\\n HR: 109 (82 - 113) bpm\\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\\n RR: 27 (17 - 27) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 7,234 mL\\n 672 mL\\n PO:\\n 400 mL\\n 200 mL\\n TF:\\n IVF:\\n 834 mL\\n 472 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 2,880 mL\\n Urine:\\n 3,060 mL\\n 2,880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -2,208 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.2 g/dL\\n 161 K/uL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 374936,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Spiked to 101\\n Weaned off Neo\\n EKG - At 04:00 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 02:33 AM\\n Cefipime - 10:17 AM\\n Levofloxacin - 10:17 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g\\n atrovent\\n cefepime\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.7\\n HR: 109 (82 - 113) bpm\\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\\n RR: 27 (17 - 27) insp/min\\n SpO2: 100% 50%FM\\n Heart rhythm: ST (Sinus Tachycardia)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 7,234 mL\\n 672 mL\\n PO:\\n 400 mL\\n 200 mL\\n TF:\\n IVF:\\n 834 mL\\n 472 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 2,880 mL\\n Urine:\\n 3,060 mL\\n 2,880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -2,208 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS BS on left, no crackles/wheezes\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology:\\n 9.2 g/dL\\n 161 K/uL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n BNP-Pending\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. Agree with MICU team plan of care and empahsize:\\n HoTN\\n -gemcitabine vs. sepsis vs. cardiac vs. PE\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n -Will Check CTPA to rule out PE and eval for PNA\\n -Check BNP\\n -Continue antiarrythmic therapy\\n -not on anticoagulation due to bleeding risk.\\n -Give fluid if hypotensive\\n Hypoxemia\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- will check CTA.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen\\n ICU Care\\n Nutrition: regluar diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ heprin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375211,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\\n ?infection.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n Taper steroids solumedrol 60q6\\n Follow CXR\\n Continue home levo, would stop vanc and cefepime today\\n Follow up cultures and reculture if febrile.\\n Obtain sputum if making any.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 375212,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\\n ?infection.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n Taper steroids solumedrol 60q6\\n Follow CXR\\n Continue home levo, would stop vanc and cefepime today\\n Follow up cultures and reculture if febrile.\\n Obtain sputum if making any.\\n Called out to floor Hem Onc.\\n Transferred via ambulance\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n SEPSIS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 78.8 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: COPD\\n CV-PMH: Arrhythmias\\n Additional history: nsmlca, sq cell ca, l pneumonectomy, afib/flutter\\n s/p ablasion, hx of pe NOT on anticoagulation, +ppd in past\\n treated\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:111\\n D:59\\n Temperature:\\n 97\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 24 insp/min\\n Heart Rate:\\n 96 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 90% %\\n O2 flow:\\n 5 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 223 mL\\n 24h total out:\\n 950 mL\\n Pertinent Lab Results:\\n Sodium:\\n 145 mEq/L\\n 10:23 AM\\n Potassium:\\n 3.6 mEq/L\\n 10:23 AM\\n Chloride:\\n 108 mEq/L\\n 10:23 AM\\n CO2:\\n 26 mEq/L\\n 10:23 AM\\n BUN:\\n 21 mg/dL\\n 10:23 AM\\n Creatinine:\\n 0.7 mg/dL\\n 10:23 AM\\n Glucose:\\n 150 mg/dL\\n 10:23 AM\\n Hematocrit:\\n 31.6 %\\n 10:23 AM\\n Finger Stick Glucose:\\n 164\\n 12:00 PM\\n Valuables / Signature\\n Patient valuables: clothes, sneakers,\\n Other valuables:\\n Clothes: Sent with pt\\n / Money:\\n No money / \\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU7\\n Transferred to: 1184\\n Date & time of Transfer: 1830\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375213,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\\n ?infection.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n Taper steroids solumedrol 60q6\\n Follow CXR\\n Continue home levo, would stop vanc and cefepime today\\n Follow up cultures and reculture if febrile.\\n Obtain sputum if making any.\\n Called out to . Reis1184 transport via transfer note faxed\\n report to RN.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374863,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\\n gemcitibine three days PTA. He presented with three days of\\n intermittent fever to 102 , weakness and anorexia. He reports mild\\n dyspnea and cough at baseline which is not worse. He was referred to\\n the ED for evaluation and while there developed SBP to 70s and sinus\\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\\n was placed and neosynephrine started. CVP=10. He received vanco and\\n cefipime and was previously on levaquin\\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\\n .\\n In addition, lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n History obtained from Medical Records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Cefepime\\n levaquin\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Asa 325\\n Neurontin\\n Advair\\n Flecanide\\n Levaquin 500 q24\\n Vanco 1 q2 (#2)\\n Atrovent nebs\\n Morphine\\n Heparin SC\\n At Home Meds:\\n Flecanide\\n Cardizem\\n Levaquin\\n Advair\\n Albuterol\\n Neurontin\\n Dilaudid\\n Compazine\\n atrovent\\n Past medical history:\\n Family history:\\n Social History:\\n Squamous cell Ca lung\\no dx , T3N2 (L mainstem bronchus)\\no tumor debridement, stent placement, \\no chemotherapy, XRT /30/08: Cisplatin etoposide\\no L pneumonectomy, mediastinal LN dissection, \\no bronchial washings + (brushings -) \\no PET : uptake at pneumonectomy suture line, around cavity,\\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\\n home. S/P ablation in \\n COPD\\n Pulmonary embolism \\n L frozen shoulder\\n Per RAN\\n Quit cigs 1 year ago.\\n Review of systems: Reviewed in Detail . Please see RAN of .\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS BS on left, no crackles/wheezes\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology\\n CBC, Chem 7 wnl\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\\n possibility but so far no infectious source. His oxygen requirement\\n appear to be declining slowly and may reflect SIRS, PNA, and poor pulm\\n reserve. There may be a component of underlying pulm HTN given the\\n pneumoectomy and the prior PE. Agree with MICU team plan of care and\\n empahsize:\\n Will wean off pressors as tolerated. Continue antiarrythmic\\n therapy, not on anticoagulation due to bleeding risk.\\n On 4-3L NC presently and will wean as tolerated. Atrovent q6\\n Full diet\\n Empiric vanco/cefpime/levaquin with plan to discontinue if\\n w/u negative.\\n PPX- heparin SC\\n DISPO- FULL code. MICU today for montioring. Possible\\n transfer to floor if stable.\\n ICU Care\\n Nutrition: PO diet\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT: Heparin SC\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: FULL CODE\\n Disposition: MICU\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374873,\n \"text\": \"Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\\n pain. Lchest pain @ 1530 received Morphine 15 PO\\n Action:\\n Received Morphine 15mg PO x2. Received Neutrotin per routine.\\n Response:\\n Pain relief w/meds\\n Plan:\\n Pain assessment\\n Pain med PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\\n R, Dypneic with activity. Dry cough 02 sats 90-95% O2 3L/min increased\\n to 4L/min desats to 88 when off 02. @ 1530 ^ dypneia RR>30 anxious dry\\n cough Sats 90% on 4l/min stat EKG demand ischemia. Feeling cold Temp\\n 07.9 rigor received Tylenol 650.\\n Action:\\n Cont Pressor slow to wean, afebrile received Tylenol for Rigors. Triple\\n Abx vanco/cefepine/Levofloxicin.\\n Response:\\n BP cont labile off neo Goal Map>55 and SBP>90\\n Plan:\\n wean off neo resume for hypotension.\\n keep MAP 55 or SPB>85\\n monitor CXR for infiltrate has developed post-hydration\\n f/u blood and urine Cx\\n obtain sputum cx\\n Continue flecainide, aspirin. hold diltiazem temporarily\\n Followup EKG and cardiac enzymes.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374861,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\\n gemcitibine three days PTA. He presented with three days of\\n intermittent fever to 102 , weakness and anorexia. He reports mild\\n dyspnea and cough at baseline which is not worse. He was referred to\\n the ED for evaluation and while there developed SBP to 70s and sinus\\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\\n was placed and neosynephrine started. CVP=10. He received vanco and\\n cefipime and was previously on levaquin\\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\\n .\\n In addition, lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n History obtained from Medical Records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Cefepime\\n levaquin\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Asa 325\\n Neurontin\\n Advair\\n Flecanide\\n Levaquin 500 q24\\n Vanco 1 q2 (#2)\\n Atrovent nebs\\n Morphine\\n Heparin SC\\n At Home Meds:\\n Flecanide\\n Cardizem\\n Levaquin\\n Advair\\n Albuterol\\n Neurontin\\n Dilaudid\\n Compazine\\n atrovent\\n Past medical history:\\n Family history:\\n Social History:\\n T3N2 SCC s/p left pneumonectomy with recurrence in\\n hilar stump and left pleura. Had taxotere x 2. gemcitibine x 1.\\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\\n home. S/P ablation in \\n COPD\\n Pulmonary embolism \\n L frozen shoulder\\n Per RAN\\n Quit cigs 1 year ago.\\n Review of systems: Reviewed in Detail . Please see RAN of .\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS BS on left, no crackles/wheezes\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology\\n [image002.jpg]\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\\n possibility but so far no infectious source. His respiratory status\\n appears intact and is responding to resuscitation. Agree with MICU\\n team plan of care and empahsize.\\n CV\\n 1. wean off pressors. Continue antiarrythmic therapy, not on\\n anticoagulation due to bleeding risk.\\n PULM\\n On 3L NC presently but may not need this. Will wean off. Atrovent q6\\n GI\\n Full diet\\n ID\\n Micro w/u. Empiric vanco/cefpime with plan to discontinue if w/u\\n negative.\\n PPX- heparin SC\\n DISPO- FULL code. MICU today for montioring. Possible transfer to\\n floor if stable.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374864,\n \"text\": \"Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\\n pain\\n Action:\\n Received Morphine 15mg PO. Received Neutrotin per routine.\\n Response:\\n Pain relief w/meds\\n Plan:\\n Pain assessment\\n Pain med PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\\n R, Dypneic with activity. 02 sats 90-95% O2 3L/min increased to 4L/min\\n desats to 88 when off 02.\\n Action:\\n Cont Pressor slow to wean, afebrile. Ripple Abx vanco/cefepine/azythro\\n Response:\\n BP cont labile off neo Goal Map>55 and SBP>90\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374968,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Rceievd the pt on 0.4mcg on neo,sbp in 100\\ns,map 70\\ns,uop\\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\\n Action:\\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\\n Response:\\n Sbp mostly in 90-100\\ns,but does drops to 80\\ns at times,but mentaing\\n fine with map>60,currently autodiuresing\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,?if no evolving\\n PNA on CT,plan to dc abx.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 70% face tent with 6L\\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\\n 100-120 sinus tachy\\n Action:\\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE\\n Response:\\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\\n comfortable on 5L nc mostly and intermittent sob is manged with face\\n tent.(50%)\\n Plan:\\n Follow up on CTA,cont nebs,solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374865,\n \"text\": \"Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\\n pain\\n Action:\\n Received Morphine 15mg PO. Received Neutrotin per routine.\\n Response:\\n Pain relief w/meds\\n Plan:\\n Pain assessment\\n Pain med PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\\n R, Dypneic with activity. 02 sats 90-95% O2 3L/min increased to 4L/min\\n desats to 88 when off 02.\\n Action:\\n Cont Pressor slow to wean, afebrile. Ripple Abx vanco/cefepine/azythro\\n Response:\\n BP cont labile off neo Goal Map>55 and SBP>90\\n Plan:\\n wean off neo\\n keep MAP 60 or SPB>85\\n monitor CVP and urine output\\n recheck CXR to see if infiltrate has developed post-hydration\\n f/u blood and urine Cx\\n obtain sputum cx\\n obtain legionella UA.\\n Continue flecainide, aspirin. hold diltiazem temporarily\\n neo rather than levo\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374862,\n \"text\": \"Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\\n pain\\n Action:\\n Received Morphine 15mg PO. Received Neutrotin per routine.\\n Response:\\n Pain relief w/meds\\n Plan:\\n Pain assessment\\n Pain med PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\\n Neo .5mcg/kg/min Pt on sm amt of neo on arrival from ed. Vss. Denies\\n lightheadedness.\\n Action:\\n Continues on neo. Although apparently documented previous bp are\\n 90-105/\\n Response:\\n Will titrate neo to off\\n Plan:\\n Titrate neo. Fluid as needed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374969,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Rceievd the pt on 0.4mcg on neo,sbp in 100\\ns,map 70\\ns,uop\\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\\n Action:\\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\\n Response:\\n Sbp mostly in 90-100\\ns,but does drops to 80\\ns at times,but mentaing\\n fine with map>60,currently autodiuresing\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 70% face tent with 6L\\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\\n 100-120 sinus tachy\\n Action:\\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE,received morphine\\n for pain and compazine for nausea\\n Response:\\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\\n comfortable on 5L nc mostly and intermittent sob is manged with face\\n tent.(50%),CTA prelim without any PE,but s/o diffuse parenchymal\\n disease.\\n Plan:\\n Follow up on final read of CTA,cont nebs,solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375053,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,02 weaned to 3L NC\\n Response:\\n Sats mostly in 92-95%,but does desats to high 80\\ns at times,but quckly\\n reverts back,also asymptamatic with desats,does gets sob at times with\\n exertion which may require high amount of 02 for a brief period of\\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374962,\n \"text\": \"HPI:59 yr old male with recurrent squmal cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose received was on .At the\\n time of presentation to ED BP was 116/76 but subsequently HR went up to\\n 120\\ns and dropped BP to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Rceievd the pt on 04mcg on neo,sbp in 100\\ns,map 70\\ns,uop\\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\\n Action:\\n Neo weaned off,started on solumedrol\\n Response:\\n Sbp mostly in 90-100\\ns,but does drops to 80\\ns at times,but mentaing\\n fine with map>60,currently autodiuresing\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375019,\n \"text\": \"Chief Complaint: Hypoxia\\n Hypotension\\n Fever\\n 24 Hour Events:\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.1\\nC (97\\n HR: 96 (92 - 113) bpm\\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\\n RR: 26 (16 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 1,349 mL\\n 277 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 395 mL\\n Urine:\\n 4,270 mL\\n 395 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -118 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine.\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\\n - on levoquin chronically\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375020,\n \"text\": \"Chief Complaint: Hypoxia\\n Hypotension\\n Fever\\n 24 Hour Events:\\n - weaned off Neo\\n - BNP 1000\\n - started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\\n inflammatory lung disease\\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\\n diffuse right lung opacities and new small right pleural effusion,\\n could be due to superimposed edema on infection and emphysema. Right\\n middle lobe nodule slightly increased, likely infectious. Persistent\\n worrisome thickening of the left hilar stump and pleural nodules. Signs\\n of anemia.\\n - continued Antibiotics overnight\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.1\\nC (97\\n HR: 96 (92 - 113) bpm\\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\\n RR: 26 (16 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 1,349 mL\\n 277 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 395 mL\\n Urine:\\n 4,270 mL\\n 395 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -118 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine.\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\\n - on levoquin chronically\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375024,\n \"text\": \"Chief Complaint: Hypoxia\\n Hypotension\\n Fever\\n 24 Hour Events:\\n - weaned off Neo\\n - BNP 1000\\n - started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\\n inflammatory lung disease\\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\\n diffuse right lung opacities and new small right pleural effusion,\\n could be due to superimposed edema on infection and emphysema. Right\\n middle lobe nodule slightly increased, likely infectious. Persistent\\n worrisome thickening of the left hilar stump and pleural nodules. Signs\\n of anemia.\\n - continued Antibiotics overnight\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.1\\nC (97\\n HR: 96 (92 - 113) bpm\\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\\n RR: 26 (16 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 1,349 mL\\n 277 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 395 mL\\n Urine:\\n 4,270 mL\\n 395 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -118 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///24/\\n Physical Examination\\n GEN: A&O, mildly tachypneic when speaking\\n HEENT: mmm, no op lesions\\n CV: reg, no g/m/r, nl s1, s2\\n Pulm: coarse breath sounds over R lung\\n Abd: Soft, nt, nd, nabs, no hsm\\n Ext: no edema\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine.\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\\n - on levoquin chronically\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375027,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 35.6\\nC (96\\n HR: 98 (91 - 113) bpm\\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\\n RR: 20 (16 - 29) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,349 mL\\n 295 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 295 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 635 mL\\n Urine:\\n 4,270 mL\\n 635 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -340 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375028,\n \"text\": \"Chief Complaint:\\n 1. Hypoxia\\n 2. Hypotension\\n 3. Fever\\n 24 Hour Events:\\n - Weaned off Neo ( at 8am)\\n - BNP 1000\\n - Started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\\n inflammatory lung disease\\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\\n diffuse right lung opacities and new small right pleural effusion,\\n could be due to superimposed edema on infection and emphysema. Right\\n middle lobe nodule slightly increased, likely infectious. Persistent\\n worrisome thickening of the left hilar stump and pleural nodules. Signs\\n of anemia.\\n History obtained from Patient\\n Allergies:\\n History obtained from PatientNo Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:44 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.1\\nC (97\\n HR: 96 (92 - 113) bpm\\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\\n RR: 26 (16 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 1,349 mL\\n 277 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 277 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 395 mL\\n Urine:\\n 4,270 mL\\n 395 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -118 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///24/\\n Physical Examination\\n GEN: A&O, mildly tachypneic when speaking\\n HEENT: mmm, no op lesions\\n CV: reg, no g/m/r, nl s1, s2\\n Pulm: coarse breath sounds over R lung\\n Abd: Soft, nt, nd, nabs, no hsm\\n Ext: no edema\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n # Sepsis: Presents with recent immunosupression but no neutropenia. Pt\\n has fever and hypotension refractory to fluids. However, his CVP is 10,\\n he has good urine output and lactate has improved which indicates that\\n he is likely volume rescucitated. In addition, his mixed venous O2 is\\n c/w sepsi at 94s. He has no localizing source at this time with\\n baseline CXR and neg UA. His shock is most likely a distrubtive shock\\n picture and is most likely c/w reaction to gemcitabine.\\n - Continue steroids for Gemcitabine-related inflammatory lung disease\\n - Keep MAP 60 or SPB>85\\n - Monitor CVP and urine output\\n - Continue Vanc/Cefepime/Levofloxacin (Day 1: ) for broad coverage;\\n on levaquin chronically\\n - If Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\\n - F/U blood culture data\\n - Obtain sputum cx if possible\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - Will follow\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - Restart home diltiazem once 24 hrs off pressors\\n # COPD: continue advair, prn albuterol, spiriva\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - Trend for now\\n - Guiac stools\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - Treatment per Onc when infection resolves\\n ICU Care\\n Nutrition: cardiac/heart healthy diet, replete lytes prn\\n Glycemic Control: Check finger sticks while on steroids; if\\n elevated, HISS\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SC heparin\\n Stress ulcer: PPI given steroids\\n VAP: n/a\\n Communication: Daughter (; HCP is son\\n , Phone number: \\n Code status: Full code\\n Disposition: ICU care for now ; possible call-out afternoon \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375029,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Off neo\\n started on solumedol\\n CTA neg PE see report\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 35.6\\nC (96\\n HR: 98 (91 - 113) bpm\\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\\n RR: 20 (16 - 29) insp/min\\n SpO2: 93% 5L\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,349 mL\\n 295 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 295 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 635 mL\\n Urine:\\n 4,270 mL\\n 635 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -340 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\\n Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology: fine interstitial pattern\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n BNP 1000\\n Micro-urine negative\\n -Blood pending\\n -Legionella negative\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation.\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Hypotension\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: NPO will discuss bronch.\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : Will trend vitals if stable will call out.\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374964,\n \"text\": \"HPI:59 yr old male with recurrent squmal cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose received was on .At the\\n time of presentation to ED BP was 116/76 but subsequently HR went up to\\n 120\\ns and dropped BP to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Rceievd the pt on 04mcg on neo,sbp in 100\\ns,map 70\\ns,uop\\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\\n Action:\\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\\n Response:\\n Sbp mostly in 90-100\\ns,but does drops to 80\\ns at times,but mentaing\\n fine with map>60,currently autodiuresing\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,?if no evolving\\n PNA on CT,plan to dc abx.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd,received the pt this am with 70% face tent with 6L\\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\\n left,exp wheeze on rt on exam,non productive cough++,h/o PE in the\\n past,HR 100-120 sinus tachy\\n Action:\\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE\\n Response:\\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\\n comfortable on 5L nc mostly and intermittent sob is manged with face\\n mask\\n Plan:\\n Follow up on CTA,cont nebs,solumedrol,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375107,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\\n Currently off precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Pt cont to desat to mid to high 80\\ns when wearing only nasal canula.\\n Upset about having to wear face mask and about having the door closed\\n for droplet precautions.\\n Action:\\n Pt encouraged many times to wear face tent to keep o2 sat\\ns elevated.\\n Flu test came back neg.\\n Response:\\n Pt refuses to keep face mask on and becoming agitated about being\\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\\n the test was neg and now off precautions.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function. Cont to encourage wearing\\n mask till o2 sat\\ns stable. Cont with antbx and nebs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375083,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,and o2 supplementation\\n Response:\\n Sats mostly 91-95%,but does desats to mid to high 80\\ns with minimal\\n exertion,also does get sob at times,which was managed with 50% face\\n tent. Pt didn\\nt tolerate 3l NC,currently running at 4L,A rapid test for\\n flu is pending.\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375087,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,and o2 supplementation\\n Response:\\n Sats mostly 91-95%,but does desats to mid to high 80\\ns with minimal\\n exertion,also does get sob at times,which was managed with 50% face\\n tent. Pt didn\\nt tolerate 3l NC,currently running at 4L,A rapid test for\\n flu is pending.\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375079,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,and o2 supplementation\\n Response:\\n Sats mostly 91-95%,but does desats to mid to high 80\\ns with minimal\\n exertion,also does get sob at times,which was managed with 50% face\\n tent. Pt didn\\nt tolerate 3l NC,currently running at 4L\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375197,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\\n ?infection.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n Taper steroids solumedrol 60q6\\n Follow CXR\\n Continue home levo, would stop vanc and cefepime today\\n Follow up cultures and reculture if febrile.\\n Obtain sputum if making any.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375201,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n breathing better.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n asa 325\\n neurontin 600mg Q 8hr\\n advair\\n flecinide\\n levofloxacin 500Q 24\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n protonix\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 91% 5L\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 81 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -569 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\\n improved. Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology: no film Pending\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Labs pending:\\n Micro-DFA negative\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. Low WBC on high dose steroids may be\\n secondary to possible viral etiology if this is not chemo related\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will decrease solumedol 60mg Q6 and transition to prednisone with\\n rapid taper over next 5-7 days\\n Hypotension ahs resolved\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow, chemo related\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM Will d\\nc central line\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ heprin\\n Stress ulcer: PPI steroids\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Floor and will need to assess o2 needs pre discharge\\n Total time spent: 25 mins\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374902,\n \"text\": \"Chief Complaint: fever\\n HPI:\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever and dizziness. He called\\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\\n come to ER for counts to r/o febrile neutropenia. He reports that he\\n had fever and rigors with chemotherapy 3 days ago, was told to take\\n tylenol. The following day hie was afebrile. The day of admission, he\\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\\n 102.3., no chills or rigors. He states that he has been pushing fluids\\n and has had nl urine output, btu has had appetitie. He denies any\\n change in cough or sputum production\\n only basein occaisonal thin\\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\\n on levofloxacin as ppx for a long time.\\n .\\n In the ED: He was initially stable with SBP 116/76 but then developed\\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\\n given a central line -which had to be replaced 3 times due to curling\\n of the line. He also was given 6liters NS with improvement of HR to\\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\\n He was mentating well. He was also given Vancomycin and Cefepime. In\\n addition, no lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\\n .\\n Of Note, he was discharged from the CCU one month ago after being\\n admitted for aflutter with RVR. The resolved spontaneously and his\\n medications were not changed\\n Sepsis without organ dysfunction/ Nursing Diagnosis: Impaired Tissue\\n Perfusion\\n Assessment:\\n Pt\\ns sbp approx 80 at beginning of this 12 hours;\\n Pt afebrile at beginning of shift, there was direct a direct\\n correlation between pt temp and O2 sat, when pt\\ns T elevated, pts O2\\n sat decreased, w/ pt requiring increase in nasal cannula O2 delivery;\\n Action:\\n b/p cuff re-cycled a few times at beginning of shift to confirm sbp\\n 80/low 80s, confirmed; therefore neo gtt restarted at low dose;\\n T max 101 at 02:00, not cx\\nd covering MD at that time d/t cx <24\\n hrs;\\n Pt continues to receive IV abx of cefepime and vancomycin;\\n Response:\\n At neo gtt dose level .1 mck/kg/min, pt remained hypotensive below\\n accepted range, sbp adequate w/ neo at .5 mcg/k/min; heart rate also\\n decreased from low 100\\ns down to hi 80\\ns after b/p adequate;\\n Pt\\ns O2 sat successfully increased to acceptable range of mid 90\\ns w/\\n increase of n.c O2 delivery;\\n Plan:\\n Titrate neo gtt to keep MAP >60, sbp >85;\\n Titrate n.c. O2 to keep O2 sat >92;\\n ****next time pt spikes T, pt is to be cultured;\\n Hygiene cares if pt diaphoretic after elevated T\\n Also this noc pt received magnesium and potassium repletion for low\\n serum levels drawn yesterday afternoon; a.m. labs to be drawn at\\n approx. 05:00\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375196,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\\n and may reflect SIRS, PNA, and poor pulm reserve.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375195,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\\n precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\\n Vanco/cepfapine/levoflxicin. Started on spiriva.\\n Response:\\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\\n NC and Face tent.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function.\\n Cont with Abx anf MDI per routine.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375192,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\\n Currently off precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\\n low 90\\n Action:\\n Resp status remains tenuous. Sats low 90\\ns, desats to 80\\ns with\\n activity and RR>25. wean O2 to NC 5l/min . cont to taper steroids. Pt\\n encouraged many times to wear face tent to keep o2 sat\\ns elevated. Flu\\n test came back neg.\\n Response:\\n Pt refuses to keep face mask on and becoming agitated about being\\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\\n the test was neg and now off precautions.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function. Cont to encourage wearing\\n mask till o2 sat\\ns stable. Cont with antbx and nebs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374884,\n \"text\": \"Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\\n pain. Lchest pain @ 1530 received Morphine 15 PO\\n Action:\\n Received Morphine 15mg PO x2. Received Neutrotin per routine.\\n Response:\\n Pain relief w/meds\\n Plan:\\n Pain assessment\\n Pain med PRN\\n Sepsis without organ dysfunction\\n Assessment:\\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\\n R, Dypneic with activity. Dry cough 02 sats 90-95% O2 3L/min increased\\n to 4L/min desats to 88 when off 02. @ 1530 ^ dypneia RR>30 anxious dry\\n cough Sats 90% on 4l/min stat EKG demand ischemia. Feeling cold Temp\\n 07.9 rigor received Tylenol 650.\\n Action:\\n Cont Pressor slow to wean, afebrile received Tylenol for Rigors. Triple\\n Abx vanco/cefepine/Levofloxicin.\\n Response:\\n BP cont labile off neo Goal Map>55 and SBP>90\\n Plan:\\n wean off neo resume for hypotension.\\n keep MAP 55 or SPB>85\\n monitor CXR for infiltrate has developed post-hydration\\n f/u blood and urine Cx\\n obtain sputum cx\\n Continue flecainide, aspirin. hold diltiazem temporarily\\n Followup EKG and cardiac enzymes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 375071,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol,02\\n wened to 3L NC,ruled out PE with CTA.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,02 weaned to 3L NC\\n Response:\\n Sats mostly in 92-95%,but does desats to high 80\\ns at times,but quckly\\n reverts back,also asymptamatic with desats,does gets sob at times with\\n exertion which may require high amount of 02 for a brief period of\\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 375068,\n \"text\": \"Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Nasopharyngeal swab (1600)\\n Comments: No nasal bleed noted. Pt with deviated septum difficult to\\n get into right nare,? If enough cells were obtained for that swab.\\n Pt also seen fro neb treatments, Lung sounds clear with diminished\\n bases, pt tolerated treatments well.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375175,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\\n Currently off precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\\n 4L/min. pt feeling SOB anxious about oxygen status. DB&C dry cough.\\n Lungs RUL clear few exp wheezes L lung DIM BS. Pt placerd high fowlers\\n and sitting Side of bed with improved 02 requirement. Desat mid to\\n high 80\\ns with activity. Pt cont to desat to mid to high 80\\ns when\\n wearing only nasal canula. Upset about having to wear face mask and\\n about having the door closed for droplet precautions.\\n Action:\\n Pt encouraged many times to wear face tent to keep o2 sat\\ns elevated.\\n Flu test came back neg.\\n Response:\\n Pt refuses to keep face mask on and becoming agitated about being\\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\\n the test was neg and now off precautions.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function. Cont to encourage wearing\\n mask till o2 sat\\ns stable. Cont with antbx and nebs.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374878,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\\n gemcitibine three days PTA. He presented with three days of\\n intermittent fever to 102 , weakness and anorexia. He reports mild\\n dyspnea and cough at baseline which is not worse. He was referred to\\n the ED for evaluation and while there developed SBP to 70s and sinus\\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\\n was placed and neosynephrine started. CVP=10. He received vanco and\\n cefipime and was previously on levaquin\\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\\n .\\n In addition, lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n History obtained from Medical Records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Cefepime\\n levaquin\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Asa 325\\n Neurontin\\n Advair\\n Flecanide\\n Levaquin 500 q24\\n Vanco 1 q2 (#2)\\n Atrovent nebs\\n Morphine\\n Heparin SC\\n At Home Meds:\\n Flecanide\\n Cardizem\\n Levaquin\\n Advair\\n Albuterol\\n Neurontin\\n Dilaudid\\n Compazine\\n atrovent\\n Past medical history:\\n Family history:\\n Social History:\\n Squamous cell Ca lung\\no dx , T3N2 (L mainstem bronchus)\\no tumor debridement, stent placement, \\no chemotherapy, XRT /30/08: Cisplatin etoposide\\no L pneumonectomy, mediastinal LN dissection, \\no bronchial washings + (brushings -) \\no PET : uptake at pneumonectomy suture line, around cavity,\\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\\n home. S/P ablation in \\n COPD\\n Pulmonary embolism \\n L frozen shoulder\\n Per RAN\\n Quit cigs 1 year ago.\\n Review of systems: Reviewed in Detail . Please see RAN of .\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS BS on left, no crackles/wheezes\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology\\n CBC, Chem 7 wnl\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. Agree with MICU team plan of care and empahsize:\\n HoTN\\n -gemcitabine vs. sepsis vs. cardiac vs. PE\\n -wean off pressors as tolerated\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n Cardiac\\n -Continue antiarrythmic therapy\\n -not on anticoagulation due to bleeding risk.\\n Hypoxemia\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n H/o Pulmonary embolism\\n - not on anticoag due to risk factors and has cancer predisposing\\n - however improving so results of scan not likely to change management\\n at present\\n - consider further w/u for PE once stabilized. Not likely to anticoag\\n given risk though might warrant filter placement if sig clot burden\\n given single lung and already had PE in past\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -MDI\\n For remainder of plan see resident note.\\n ICU Care\\n Nutrition: PO diet\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT: Heparin SC\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: FULL CODE\\n Disposition: MICU\\n Patient is critically ill.\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375059,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Off neo\\n started on solumedol\\n CTA neg PE see report\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 35.6\\nC (96\\n HR: 98 (91 - 113) bpm\\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\\n RR: 20 (16 - 29) insp/min\\n SpO2: 93% 5L\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,349 mL\\n 295 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 295 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 635 mL\\n Urine:\\n 4,270 mL\\n 635 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -340 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\\n improved. Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology: fine interstitial pattern\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n BNP 1000\\n Micro-urine negative\\n -Blood pending\\n -Legionella negative\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation.\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Hypotension\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: NPO will discuss bronch.\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : Will trend vitals if stable will call out.\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375064,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Off neo\\n started on solumedol\\n CTA neg PE see report\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Cefipime - 10:00 PM\\n Vancomycin - 02:35 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 12:30 PM\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 35.6\\nC (96\\n HR: 98 (91 - 113) bpm\\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\\n RR: 20 (16 - 29) insp/min\\n SpO2: 93% 5L\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,349 mL\\n 295 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 849 mL\\n 295 mL\\n Blood products:\\n Total out:\\n 4,270 mL\\n 635 mL\\n Urine:\\n 4,270 mL\\n 635 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,921 mL\\n -340 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\\n improved. Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology: fine interstitial pattern\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n BNP 1000\\n Micro-urine negative\\n -Blood pending\\n -Legionella negative\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. Low WBC on high dose steroids may be\\n secondary to possible viral etiology if this is not chemo related\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Hypotension\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow, chemo related\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: Hep SQ\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : transition to floor today, taper steroids over next week.\\n Total time spent: 25 mins\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375066,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,02 weaned to 3L NC\\n Response:\\n Sats mostly in 92-95%,but does desats to high 80\\ns at times,but quckly\\n reverts back,also asymptamatic with desats,does gets sob at times with\\n exertion which may require high amount of 02 for a brief period of\\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375174,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\\n Currently off precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Pt cont to desat to mid to high 80\\ns when wearing only nasal canula.\\n Upset about having to wear face mask and about having the door closed\\n for droplet precautions.\\n Action:\\n Pt encouraged many times to wear face tent to keep o2 sat\\ns elevated.\\n Flu test came back neg.\\n Response:\\n Pt refuses to keep face mask on and becoming agitated about being\\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\\n the test was neg and now off precautions.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function. Cont to encourage wearing\\n mask till o2 sat\\ns stable. Cont with antbx and nebs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374978,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Rceievd the pt on 0.4mcg on neo,sbp in 100\\ns,map 70\\ns,uop\\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\\n Action:\\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\\n Response:\\n Sbp mostly in 90-100\\ns,but does drops to 80\\ns at times,but mentaing\\n fine with map>60,currently autodiuresing\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 70% face tent with 6L\\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\\n 100-120 sinus tachy\\n Action:\\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE,received morphine\\n for pain and compazine for nausea\\n Response:\\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\\n comfortable on 5L nc mostly and intermittent sob is manged with face\\n tent.(50%),CTA chest prelim without any PE,but s/o diffuse parenchymal\\n disease.\\n Plan:\\n Follow up on final read of CTA,cont nebs,solumedrol.Assess and manage\\n pain.\\n Others:PO intake better today.no episode of vomiting\\n.daughter called\\n ,updated by this RN..family member visited.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375151,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 81 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -569 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375152,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 81 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -569 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\\n improved. Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. Low WBC on high dose steroids may be\\n secondary to possible viral etiology if this is not chemo related\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Hypotension\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow, chemo related\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375156,\n \"text\": \"Chief Complaint: fever\\n 24 Hour Events:\\n - flu sent and was negative\\n - couldn't call out as was still requiring face tent intermittently\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 83 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 83 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -567 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n CANCER (MALIGNANT NEOPLASM), LUNG\\n HYPOTENSION (NOT SHOCK)\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375158,\n \"text\": \"Chief Complaint: fever\\n 24 Hour Events:\\n - flu sent and was negative\\n - couldn't call out as was still requiring face tent intermittently\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 83 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 83 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -567 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Pleasant appears comfortable today\\n HEENT no oral ulcers\\n Regular S1 S2 no m/r/g\\n Lungs clear bilaterally, no wheezing or rales, decreased L base\\n Abd soft nontender +bowel sounds\\n Extrem warm no edema palpable distal pulses\\n Neuro alert and interactive\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Assessment and Plan\\n 59 year old male with recurrent squamous cell lung cancer, admitted\\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\\n and tachycardia.\\n # Sepsis: Clinically much improved. Thought likely a reaction to\\n gemcitabine. No organisms identified.\\n - Continue steroids for Gemcitabine-related inflammatory lung disease\\n - Continue home levo, would stop vanc and zosyn today\\n - Follow up cultures and reculture if febrile\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - Restart home diltiazem once 24 hrs off pressors\\n # COPD: continue advair, prn albuterol, spiriva\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - follow daily, maintain active t+S, transfuse hct>25\\n - Guiac stools\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - Treatment per Onc when infection resolves\\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Dc central line\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: continue PPI\\n VAP: OOB as tolerated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: to floor today\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375159,\n \"text\": \"Chief Complaint: fever\\n 24 Hour Events:\\n - flu sent and was negative\\n - couldn't call out as was still requiring face tent intermittently\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 83 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 83 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -567 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Pleasant appears comfortable today\\n HEENT no oral ulcers\\n Regular S1 S2 no m/r/g\\n Lungs clear bilaterally, no wheezing or rales, decreased L base\\n Abd soft nontender +bowel sounds\\n Extrem warm no edema palpable distal pulses\\n Neuro alert and interactive\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n CXR \\n 1. Stable post- pneumectomy appearance.\\n 2. Increased reticular nodular opacity in the right mid- and lower lung\\n concerning for volume overload, infection or post-pneumectomy syndrome\\n resulting in impairment of lymphatic or venous drainage.\\n 3. Unchanged nodular opacities in the right peripheral lung base.\\n Micro urine legionella negative, viral DFA negative, blood cx\\n NGTD\\n Assessment and Plan\\n 59 year old male with recurrent squamous cell lung cancer, admitted\\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\\n and tachycardia.\\n # Sepsis: Clinically much improved. Thought likely a reaction to\\n gemcitabine. No organisms identified.\\n - Continue steroids for Gemcitabine-related inflammatory lung disease\\n - Continue home levo, would stop vanc and zosyn today\\n - Follow up cultures and reculture if febrile\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - Restart home diltiazem today\\n # COPD: continue advair, prn albuterol, spiriva\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - follow daily, maintain active t+S, transfuse hct>25\\n - Guiac stools\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - Treatment per Onc when infection resolves\\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Dc central line\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: continue PPI\\n VAP: OOB as tolerated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: to floor today\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 375168,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n No events breathing better.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n asa 325\\n neurontin 600mg Q 8hr\\n advair\\n flecinide\\n levofloxacin 500Q 24\\n vanc 1g 12\\n atrovent\\n cefepime 2GQ12\\n Solumedol 125Q6\\n hep TID\\n protonix\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 91% 5L\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 81 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 81 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -569 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\\n improved. Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology: no film Pending\\n 9.4 g/dL\\n 151 K/uL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n Labs pending:\\n Micro-DFA negative\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. Low WBC on high dose steroids may be\\n secondary to possible viral etiology if this is not chemo related\\n Hypoxemia interstitial process\\n -gemcitabine vs. sepsis\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will decrease solumedol 60mg Q6\\n Hypotension\\n -Continue antiarrythmic therapy\\n -Give fluid if hypotensive\\n Pancytopenia\\n -Will follow, chemo related\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- CTA negative, per patient had \\n problem from chest wound from anticoagulation chart reports hemoptysis.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM Will d\\nc central line\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ heprin\\n Stress ulcer: PPI steroids\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 375169,\n \"text\": \"Chief Complaint: fever\\n 24 Hour Events:\\n - flu sent and was negative\\n - couldn't call out as was still requiring face tent intermittently\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:17 AM\\n Vancomycin - 02:20 PM\\n Cefipime - 10:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 12:30 PM\\n Heparin Sodium (Prophylaxis) - 08:09 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Breathing better today no pain.\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.9\\nC (96.6\\n Tcurrent: 35.9\\nC (96.6\\n HR: 91 (91 - 110) bpm\\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\\n RR: 25 (20 - 32) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,240 mL\\n 83 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 740 mL\\n 83 mL\\n Blood products:\\n Total out:\\n 1,555 mL\\n 650 mL\\n Urine:\\n 1,555 mL\\n 650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -315 mL\\n -567 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Pleasant appears comfortable today\\n HEENT no oral ulcers\\n Regular S1 S2 no m/r/g\\n Lungs clear bilaterally, no wheezing or rales, decreased L base\\n Abd soft nontender +bowel sounds\\n Extrem warm no edema palpable distal pulses\\n Neuro alert and interactive\\n Labs / Radiology\\n 151 K/uL\\n 9.4 g/dL\\n 160 mg/dL\\n 0.6 mg/dL\\n 24 mEq/L\\n 3.6 mEq/L\\n 13 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 28.5 %\\n 3.4 K/uL\\n [image002.jpg]\\n Labs above are from \\n 04:06 PM\\n 05:09 AM\\n 04:11 AM\\n WBC\\n 5.6\\n 6.1\\n 3.4\\n Hct\\n 29.2\\n 27.5\\n 28.5\\n Plt\\n 147\\n 161\\n 151\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n Glucose\\n 108\\n 103\\n 160\\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\\n mg/dL\\n CXR \\n 1. Stable post- pneumectomy appearance.\\n 2. Increased reticular nodular opacity in the right mid- and lower lung\\n concerning for volume overload, infection or post-pneumectomy syndrome\\n resulting in impairment of lymphatic or venous drainage.\\n 3. Unchanged nodular opacities in the right peripheral lung base.\\n Micro urine legionella negative, viral DFA negative, blood cx\\n NGTD\\n Assessment and Plan\\n 59 year old male with recurrent squamous cell lung cancer, admitted\\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\\n and tachycardia.\\n # Sepsis: Clinically much improved. Thought likely a reaction to\\n gemcitabine. No organisms identified. SOB probably multifactorial with\\n COPD, s/p pneumonectomy, gemcitabine effect and ?infection.\\n - Continue steroids for Gemcitabine-related inflammatory lung disease.\\n Will change to solumedrol 60q6 and plan to taper.\\n - Repeat CXR today\\n - Continue home levo, would stop vanc and cefepime today\\n - Follow up cultures and reculture if febrile. Check sputum if making\\n any.\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - Restart home diltiazem today\\n # COPD: continue advair, prn albuterol, spiriva\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - follow daily, maintain active t+S, transfuse hct>25\\n - Guiac stools\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - Treatment per Onc when infection resolves\\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\\n Needs CBC with diff today.\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Dc central line\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: continue PPI\\n VAP: OOB as tolerated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: to floor today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 375134,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\\n Currently off precautions.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Pt cont to desat to mid to high 80\\ns when wearing only nasal canula.\\n Upset about having to wear face mask and about having the door closed\\n for droplet precautions.\\n Action:\\n Pt encouraged many times to wear face tent to keep o2 sat\\ns elevated.\\n Flu test came back neg.\\n Response:\\n Pt refuses to keep face mask on and becoming agitated about being\\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\\n the test was neg and now off precautions.\\n Plan:\\n Cont to monitor o2 sat\\ns and resp function. Cont to encourage wearing\\n mask till o2 sat\\ns stable. Cont with antbx and nebs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374827,\n \"text\": \"Nursing Admission Note\\n Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n No pain presently\\n Action:\\n Prn pain meds available for chronic back and s/p L pneumonectomy pain\\n Response:\\n As needed\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt on sm amt of neo on arrival from ed. Vss. Denies lightheadedness.\\n Action:\\n Continues on neo. Although apparently documented previous bp are\\n 90-105/\\n Response:\\n Will titrate neo to off\\n Plan:\\n Titrate neo. Fluid as needed\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 374831,\n \"text\": \"Chief Complaint: fever\\n HPI:\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever and dizziness. He called\\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\\n come to ER for counts to r/o febrile neutropenia. He reports that he\\n had fever and rigors with chemotherapy 3 days ago, was told to take\\n tylenol. The following day hie was afebrile. The day of admission, he\\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\\n 102.3., no chills or rigors. He states that he has been pushing fluids\\n and has had nl urine output, btu has had appetitie. He denies any\\n change in cough or sputum production\\n only basein occaisonal thin\\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\\n on levofloxacin as ppx for a long time.\\n .\\n In the ED: He was initially stable with SBP 116/76 but then developed\\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\\n given a central line -which had to be replaced 3 times due to curling\\n of the line. He also was given 6liters NS with improvement of HR to\\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\\n He was mentating well. He was also given Vancomycin and Cefepime. In\\n addition, no lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\\n Vitals on transfer:\\n .\\n Of Note, he was discharged from the CCU one month ago after being\\n admitted for aflutter with RVR. The resolved spontaneously and his\\n medications were not changed.\\n History obtained from Patient\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n HOME MEDICATIONS:\\n ================\\n Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H Aspirin 325 mg\\n Tablet Sig: One (1) Tablet PO DAILY (Daily).\\n Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H\\n Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\\n One (1) Disk with Device Inhalation (2 times a day).\\n Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff\\n Inhalation Q6H (every 6 hours) as needed.\\n Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3\\n times a day).\\n Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\\n hours) as needed.\\n Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at\\n bedtime) as needed.\\n Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO\\n Q6H (every 6 hours) as needed.\\n Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:\\n One (1) Cap Inhalation DAILY (Daily).\\n Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr\\n Past medical history:\\n Family history:\\n Social History:\\n PAST ONCOLOGIC HISTORY:\\n ======================\\n ONC: squamous cell lung cancer T3, N2 s/p L pneumonectomy after\\n chemo and XRT; bronchoscopy on revealed erythema and abnormal\\n appearance in the L bronchial stump suggesting recurrent disease.\\n Recent PET shows some FDG avidity along the pneumonectomy suture line\\n with a comment about a foci of avidity in the AP window area. There is\\n also circumferential uptake around the pneumonectomy cavity. There is\\n also a note of poor anatomic delineation without a contrast CT. There\\n was also FDG avidity between the right atrial appendage and the left\\n ventricular outflow track without anatomic correlate. No definite bony\\n lesions, no subdiaphragmatic lesions. He is being considered for\\n radiation therapy\\n - He started weekly Taxotere on , and completed two\\n cycles.\\n - C1D10 of gemcitabine, last dose on \\n .\\n PAST MEDICAL HISTORY:\\n ====================\\n - a-flutter s/p ablation in ; not anticoagulated bleeding\\n problems while on coumadin for PE in the past\\n - PE \\n - multiple PNAs, most recently in (as above)\\n - + PPD, treated with INH x8 months (completed in )\\n - COPD: FEV1 of 1.55 liters or 48% of predicted, an FVC of 2.38\\n liters or 53% of predicted, and an FEV1/FVC ratio of 55%\\n - Pulmonary embolism \\n - L frozen shoulder\\n Father died of laryngeal cancer. Does not know what his mother\\n died from.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Patient is divorced and lives with his two daughters. son as\\n well. Only rare alcohol use and prior tobacco use (roughly 70 pack\\n years); he quit smoking approximately a year ago just prior to be\\n diagnosed with lung cancer. He was born in and came to the U.S.\\n roughly forty years ago.\\n Review of systems:\\n Flowsheet Data as of 07:29 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,231 mL\\n PO:\\n TF:\\n IVF:\\n 231 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,661 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n Physical Examination\\n GENERAL: NAD\\n SKIN: warm and well perfused, no excoriations or lesions, no rashes\\n HEENT: no JVD, no LAD, no oral ulcers or lesions\\n CARDIAC: RRR, S1/S2, no mrg\\n LUNG: bilateral high pitched end expiratory wheeze\\n ABDOMEN: nondistended, +BS, nontender in all quadrants, no\\n rebound/guarding, no hepatosplenomegaly\\n M/S: moving all extremities well, no cyanosis, clubbing or edema, no\\n obvious deformities\\n PULSES: 2+ DP pulses bilaterally\\n NEURO: CN II-XII intact\\n Labs / Radiology\\n 181\\n 134\\n 0.9\\n 14\\n 21\\n 104\\n 4.2\\n 136\\n 32.7\\n 7.2\\n [image002.jpg]\\n Other labs: Differential-Neuts:98.7, Band:0, Lymph:7.9, Mono:0.6,\\n Eos:1.5\\n Fluid analysis / Other labs: UA: neg\\n lactate 2.9-> 0.6\\n pH7.33/ 38/72 HCO3\\n Mixed venous O2Sat: 94\\n .\\n PT: 15.1 PTT: 31.2 INR: 1.3\\n .\\n Trop< 0.01\\n CK 31\\n Imaging: CXR: white-out of left side c/w prior pneumonectomy, right\\n side with unchanged streaking infiltrates\\n Microbiology: UA: neg\\n ECG: NSR, no ischemia\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia c/s sepsis.\\n .\\n # Sepsis: Presents with recent immunosupression but no neutropenia. Pt\\n has fever and hypotension refractory to fluids c/w septic shock.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA.\\n - wean off neo\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - cont Vanc/Cefepime/Levofloxacin\\n - f/u LFT's\\n - recheck CXR to see if infiltrate has developed post-hydration\\n - f/u blood and urine Cx\\n - obtain sputum cx\\n - obtain legionella UA\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - hold diltiazem temporarily\\n - neo rather than levo\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n .\\n # Disposition: pending resolution of above\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: heparin\\n Stress ulcer: not needed\\n VAP:\\n Comments:\\n Communication: Family meeting held Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374836,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever and dizziness. He called\\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\\n come to ER for counts to r/o febrile neutropenia. He reports that he\\n had fever and rigors with chemotherapy 3 days ago, was told to take\\n tylenol. The following day hie was afebrile. The day of admission, he\\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\\n 102.3., no chills or rigors. He states that he has been pushing fluids\\n and has had nl urine output, btu has had appetitie. He denies any\\n change in cough or sputum production\\n only basein occaisonal thin\\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\\n on levofloxacin as ppx for a long time.\\n .\\n In the ED: He was initially stable with SBP 116/76 but then developed\\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\\n given a central line -which had to be replaced 3 times due to curling\\n of the line. He also was given 6liters NS with improvement of HR to\\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\\n He was mentating well. He was also given Vancomycin and Cefepime. In\\n addition, no lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\\n Vitals on transfer:\\n .\\n Of Note, he was discharged from the CCU one month ago after being\\n admitted for aflutter with RVR. The resolved spontaneously and his\\n medications were not changed.\\n History obtained from Patient, Interpreter\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374837,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever and dizziness. He called\\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\\n come to ER for counts to r/o febrile neutropenia. He reports that he\\n had fever and rigors with chemotherapy 3 days ago, was told to take\\n tylenol. The following day hie was afebrile. The day of admission, he\\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\\n 102.3., no chills or rigors. He states that he has been pushing fluids\\n and has had nl urine output, btu has had appetitie. He denies any\\n change in cough or sputum production\\n only basein occaisonal thin\\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\\n on levofloxacin as ppx for a long time.\\n .\\n In the ED: He was initially stable with SBP 116/76 but then developed\\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\\n given a central line -which had to be replaced 3 times due to curling\\n of the line. He also was given 6liters NS with improvement of HR to\\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\\n He was mentating well. He was also given Vancomycin and Cefepime. In\\n addition, no lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\\n Vitals on transfer:\\n .\\n Of Note, he was discharged from the CCU one month ago after being\\n admitted for aflutter with RVR. The resolved spontaneously and his\\n medications were not changed.\\n History obtained from Patient, Interpreter\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 374840,\n \"text\": \"Chief Complaint: Fever, tachycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\\n gemcitibine three days PTA. He presented with three days of\\n intermittent fever to 102 , weakness and anorexia. He reports mild\\n dyspnea and cough at baseline which is not worse. He was referred to\\n the ED for evaluation and while there developed SBP to 70s and sinus\\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\\n was placed and neosynephrine started. CVP=10. He received vanco and\\n cefipime and was previously on levaquin\\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\\n .\\n In addition, no lateral ST depressions were noted in V4-V6; cardiac\\n enzymes negative in the ED.\\n History obtained from Medical Records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:08 AM\\n Infusions:\\n Phenylephrine - 0.5 mcg/Kg/min\\n Other ICU medications:\\n Asa 325\\n Neurontin\\n Advair\\n Flecanide\\n Levaquin 500 q24\\n Vanco 1 q2 (#2)\\n Atrovent nebs\\n Morphine\\n Heparin SC\\n At Home Meds:\\n Flecanide\\n Cardizem\\n Levaquin\\n Advair\\n Albuterol\\n Neurontin\\n Dilaudid\\n Compazine\\n atrovent\\n Past medical history:\\n Family history:\\n Social History:\\n T3N2 SCC s/p left pneumonectomy with recurrence in\\n hilar stump and left pleura. Had taxotere x 2. gemcitibine x 1.\\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\\n home. S/P ablation in \\n Per RAN\\n Quit cigs 1 year ago.\\n Review of systems: Reviewed in Detail . Please see RAN of .\\n Flowsheet Data as of 08:01 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 36.2\\nC (97.1\\n HR: 85 (85 - 85) bpm\\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 6,243 mL\\n PO:\\n TF:\\n IVF:\\n 243 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,570 mL\\n Urine:\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,673 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ////\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\\n possibility but so far no infectious source. His respiratory status\\n appears intact and is responding to resuscitation. Agree with MICU\\n team plan of care and empahsize.\\n CV\\n 1. wean off pressors. Continue antiarrythmic therapy, not on\\n anticoagulation due to bleeding risk.\\n PULM\\n On 3L NC presently but may not need this. Will wean off. Atrovent q6\\n GI\\n Full diet\\n ID\\n Micro w/u. Empiric vanco/cefpime with plan to discontinue if w/u\\n negative.\\n PPX- heparin SC\\n DISPO- FULL code. MICU today for montioring. Possible transfer to\\n floor if stable.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 374946,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Spiked to 101\\n Weaned off Neo\\n EKG - At 04:00 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 02:33 AM\\n Cefipime - 10:17 AM\\n Levofloxacin - 10:17 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g\\n atrovent\\n cefepime\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.7\\n HR: 109 (82 - 113) bpm\\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\\n RR: 27 (17 - 27) insp/min\\n SpO2: 100% 50%FM\\n Heart rhythm: ST (Sinus Tachycardia)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 7,234 mL\\n 672 mL\\n PO:\\n 400 mL\\n 200 mL\\n TF:\\n IVF:\\n 834 mL\\n 472 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 2,880 mL\\n Urine:\\n 3,060 mL\\n 2,880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -2,208 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\\n Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology:\\n 9.2 g/dL\\n 161 K/uL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n BNP-Pending\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. Agree with MICU team plan of care and empahsize:\\n HoTN\\n -gemcitabine vs. sepsis vs. cardiac vs. PE\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -Will Check CTPA to rule out PE and eval for PNA\\n -Check BNP\\n -Continue antiarrythmic therapy\\n -not on anticoagulation due to bleeding risk.\\n -Give fluid if hypotensive\\n Hypoxemia\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- will check CTA, per patient had \\n problem from chest wound from anticoagulation.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen\\n ICU Care\\n Nutrition: regluar diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ heprin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 374953,\n \"text\": \"I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note, including assessment and plan as detailed in my note bellow.\\n Chief complaint: Fever/hypotension\\n HPI:\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. RA O2 requirement prior to admission.\\n 24 Hour Events:\\n Spiked to 101\\n Weaned off Neo\\n EKG - At 04:00 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 02:33 AM\\n Cefipime - 10:17 AM\\n Levofloxacin - 10:17 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n asa 325\\n neurontin\\n advair\\n flecinide\\n levofloxacin\\n vanc 1g\\n atrovent\\n cefepime\\n hep TID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 37.1\\nC (98.7\\n HR: 109 (82 - 113) bpm\\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\\n RR: 27 (17 - 27) insp/min\\n SpO2: 100% 50%FM\\n Heart rhythm: ST (Sinus Tachycardia)\\n CVP: 7 (7 - 7)mmHg\\n Total In:\\n 7,234 mL\\n 672 mL\\n PO:\\n 400 mL\\n 200 mL\\n TF:\\n IVF:\\n 834 mL\\n 472 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 2,880 mL\\n Urine:\\n 3,060 mL\\n 2,880 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -2,208 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n GEN NAD\\n CV regular s1 s2 no m/r/g\\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\\n Prolonged exp phase apex\\n ABD Soft, NT/ND\\n EXT Trace edema\\n SKIN No rashes\\n NEURO Non-focal\\n Labs / Radiology:\\n 9.2 g/dL\\n 161 K/uL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n BNP-Pending\\n Assessment and Plan\\n 59M with severe SIRS likely as a consequence of recent gemcitabine\\n therapy. Sepsis a possibility but so far no infectious source\\n identified on evaluation. His oxygen requirement appear to be\\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\\n There may be a component of underlying pulm HTN given the pneumoectomy\\n and the prior PE. Agree with MICU team plan of care and empahsize:\\n HoTN\\n -gemcitabine vs. sepsis vs. cardiac vs. PE\\n -weaned off pressor\\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\\n abx and continue levaquin\\n -Will Check CTPA to rule out PE and eval for PNA\\n -Check BNP\\n -Continue antiarrythmic therapy\\n -not on anticoagulation due to bleeding risk.\\n -Give fluid if hypotensive\\n Hypoxemia\\n -requiring supp FiO2 via NC - wean as tolerated\\n - Atrovent q6\\n -Will start emperic solumedol 125Q6\\n Afib\\n -Continue home meds holding dilt until BP improves\\n H/o Pulmonary embolism- will check CTA, per patient had \\n problem from chest wound from anticoagulation.\\n Recurrent NSCLCA\\n -s/p gemcitabine\\n COPD\\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\\n BiPAP\\n ICU Care\\n Nutrition: regluar diet\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ heprin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : ICU\\n Total time spent: 35 mins\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374815,\n \"text\": \"Nursing Admission Note\\n Pt is a 59 yo male, comes to the ED last eve after having fever,\\n weakness and nausea at home.\\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\\n ablasion, PE\\ns , he is not on anti-ocag for this, multiple bouts\\n of pna, +ppd in past, full course of INH given.\\n In the , pt\\ns bp upon arrival was in the 70\\ns, hr in the 120\\ns. He\\n received 6L of ns, and started on neo. Hr 70\\ns bp 116\\ns now. Initially\\n sepsis catheter placed, unable to position well and was replaced with a\\n tlc. Initial lactate 2.9, now 0.6.\\n Sent to the micu for further care\\n Pt is divorced and lives at home with his two supportive daughters\\n Acute \\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 374933,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 04:00 PM\\n \\n - continued abx for emprici covergae in setting of fever, hypotension,\\n although still most likely gemcitabine related\\n - needed intermittant pressors during the day\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Cefipime - 10:20 PM\\n Vancomycin - 02:33 AM\\n Infusions:\\n Phenylephrine - 0.2 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 36.6\\nC (97.8\\n HR: 101 (78 - 110) bpm\\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\\n RR: 17 (16 - 26) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 7,234 mL\\n 386 mL\\n PO:\\n 400 mL\\n TF:\\n IVF:\\n 834 mL\\n 386 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 1,980 mL\\n Urine:\\n 3,060 mL\\n 1,980 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -1,594 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 161 K/uL\\n 9.2 g/dL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\\n - on levoquin chronically\\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 374935,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 04:00 PM\\n \\n - continued abx for emprici covergae in setting of fever, hypotension,\\n although still most likely gemcitabine related\\n - needed intermittant pressors during the day\\n - spiked temp to 101, rigors\\n resolved with Tylenol, not cultured\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Cefipime - 10:20 PM\\n Vancomycin - 02:33 AM\\n Infusions:\\n Phenylephrine - 0.2 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 36.6\\nC (97.8\\n HR: 101 (78 - 110) bpm\\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\\n RR: 17 (16 - 26) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 7,234 mL\\n 386 mL\\n PO:\\n 400 mL\\n TF:\\n IVF:\\n 834 mL\\n 386 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 1,980 mL\\n Urine:\\n 3,060 mL\\n 1,980 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -1,594 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 161 K/uL\\n 9.2 g/dL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\\n - on levoquin chronically\\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 374937,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n EKG - At 04:00 PM\\n \\n - continued abx for emprici covergae in setting of fever, hypotension,\\n although still most likely gemcitabine related\\n - needed intermittant pressors during the day\\n - spiked temp to 101, rigors\\n resolved with Tylenol, not cultured\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 10:00 AM\\n Cefipime - 10:20 PM\\n Vancomycin - 02:33 AM\\n Infusions:\\n Phenylephrine - 0.2 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.3\\nC (101\\n Tcurrent: 36.6\\nC (97.8\\n HR: 101 (78 - 110) bpm\\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\\n RR: 17 (16 - 26) insp/min\\n SpO2: 93%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 7,234 mL\\n 386 mL\\n PO:\\n 400 mL\\n TF:\\n IVF:\\n 834 mL\\n 386 mL\\n Blood products:\\n Total out:\\n 4,930 mL\\n 1,980 mL\\n Urine:\\n 3,060 mL\\n 1,980 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,304 mL\\n -1,594 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 161 K/uL\\n 9.2 g/dL\\n 103 mg/dL\\n 0.7 mg/dL\\n 24 mEq/L\\n 3.9 mEq/L\\n 7 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 27.5 %\\n 6.1 K/uL\\n [image002.jpg]\\n 04:06 PM\\n 05:09 AM\\n WBC\\n 5.6\\n 6.1\\n Hct\\n 29.2\\n 27.5\\n Plt\\n 147\\n 161\\n Cr\\n 0.6\\n 0.7\\n Glucose\\n 108\\n 103\\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n ACUTE PAIN\\n SEPSIS WITHOUT ORGAN DYSFUNCTION\\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\\n gemcitabine, last dose on who p/w fever, hypotension and\\n tachycardia.\\n .\\n # Hypotension/Fever: Presents with recent immunosupression but no\\n neutropenia. Pt has fever and hypotension refractory to fluids.\\n However, his CVP is 10, he has good urine output and lactate has\\n improved which indicates that he is likely volume rescucitated. In\\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\\n localizing source at this time with baseline CXR and neg UA. His shock\\n is most likely a distrubtive shock picture and is most likely c/w\\n reaction to gemcitabine.\\n - wean off neo as tolerated\\n - keep MAP 60 or SPB>85\\n - monitor CVP and urine output\\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\\n - on levoquin chronically\\n - f/u blood and urine Cx\\n - obtain sputum cx if possible\\n .\\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\\n diarrhea and has nl creatinine.\\n - check albumin\\n - will follow\\n .\\n # Atrial fibrillation: In sinus rhythm.\\n - Continue flecainide, aspirin.\\n - restart home diltiazem once 24 hrs off pressors\\n .\\n # COPD: continue advair, prn albuterol, spiriva\\n .\\n # Anemia: Likely from bone marrow supression from chemotherapy\\n - trend for now\\n - guiac stools\\n .\\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\\n concomitant radiation completed for squamous cell lung cancer\\n s/p left pneumonectomy on and s/p first dose of palliative\\n Taxotere on .\\n - treatment per Onc when infection resolves\\n .\\n # FEN: cardiac/heart healthy diet, replete lytes prn\\n .\\n # Prophylaxis: sc heparin, bowel regimen prn\\n .\\n # Code: presumed full\\n .\\n # Communication: Daughter (; HCP is son\\n , Phone number: \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 04:48 AM\\n 18 Gauge - 04:49 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 374998,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n Hypotension (not Shock)\\n Assessment:\\n Pt alert and oriented. No episodes of dizziness. Bp normotensive. O2\\n sat\\ns dropping occ to high 80\\ns. hr in 90\\ns to low 100\\ns with occ\\n pvc\\n Action:\\n ,contd cefipime,vanco and levoquin, solumedrol had been given Q8hr\\n and has now been inc to q 6/hrs.\\n Response:\\n No drop in blood pressure, mentaing fine with map>60, urine output\\n slowing down.\\n Plan:\\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Pt with 5lnc on all shift and will occ drop o2 sat\\ns to the high 80\\n resp rate in the 20\\ns, lung sounds witih insp/exp wheezes. Vss.\\n Action:\\n Pt receiving nebs and using inhalers. Also receiving steroids which\\n have been inc to q 6/hrs. occ will put on face tent to help with\\n desaturation.\\n Response:\\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\\n comfortable on 5L nc mostly and intermittent sob is manged with face\\n tent.(50%), final read of cta neg for pe.\\n Plan:\\n cont nebs,solumedrol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 375086,\n \"text\": \"HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\\n pneumonectomy in presented with fever and dizziness post\\n chemotherapy with gemcitabine,last dose was on .At the time of\\n presentation to ED BP was 116/76 but subsequently HR went up to 120\\n and BP dropped to 80\\ns,A central line was placed and received 6L\\n NS,,HR improved to 100\\ns post fluid but BP was 85/40.Started on low\\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\\n to MICU for further care.\\n ICU course:Neo was successfully weaned off,started on solumedrol,02\\n wened to 3L NC,ruled out PE with CTA.\\n Cancer (Malignant Neoplasm), Lung\\n Assessment:\\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\\nt uses O2 at\\n home,known copd also,received the pt this am with 5L NC,sats in\\n 91-95%,resting comfortably,diminished breath sounds on the\\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\\n past,HR 90-120,sinus,CTA neg for PE\\n Action:\\n Contd nebs,abx ,steroid,02 weaned to 3L NC\\n Response:\\n Sats mostly in 92-95%,but does desats to high 80\\ns at times,but quckly\\n reverts back,also asymptamatic with desats,does gets sob at times with\\n exertion which may require high amount of 02 for a brief period of\\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\\n Plan:\\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\\n and solumedrol.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1078223,\n \"text\": \" 10:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for interval change as remains hypoxic.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with gemcitabine related inflammatory lung disease\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for interval change as remains hypoxic.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DDBc WED 12:19 PM\\n PFI: No change from prior day. Nonspecific but progressive right-sided\\n process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest radiograph.\\n\\n INDICATION: Patient with lung cancer on gemcitabine. To further assess.\\n\\n TECHNIQUE: radiograph was obtained.\\n\\n COMPARISON: .\\n\\n REPORT:\\n\\n Patient is status post pneumonectomy on the left side. A left-sided central\\n line is identified in situ. There is evidence of widespread patchy change in\\n the right lung, which is nonspecific, but as mentioned before could reflect\\n toxic drug damage ,edema or infection. The appearances are certainly not\\n changed from prior day, but when compared to multiple prior radiographs have\\n demonstrated probable progressive change. The nodular pattern may be\\n misleading given the widespread emphysematous change present. Osseous\\n structures are grossly unremarkable.\\n\\n CONCLUSION:\\n\\n No change from previous day.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077654,\n \"text\": \" 12:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? line placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with new L IJ\\n REASON FOR THIS EXAMINATION:\\n ? line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 59-year-old male with new left IJ. Evaluate line placement.\\n\\n COMPARISON: at 10:37 p.m.\\n\\n SINGLE AP VIEW OF THE CHEST: There is a new left internal jugular central\\n line, with tip crossing midline and likely extending into the right\\n brachiocephalic vein.\\n\\n Again noted are left pneumonectomy changes, with shift of midline structures\\n to the left. Within the right lung are emphysematous changes, with patchy\\n nodular and airspace opacities within the right lower lung, as previously\\n seen, likely reflecting residual infection. Of note, the right costophrenic\\n sulcus is excluded.\\n\\n IMPRESSION: Left IJ central line tip crossing midline, and crossing over to\\n the right brachiocephalic vein.\\n\\n Dr. was paged at the time of this interpretation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1077880,\n \"text\": \" 1:30 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: eval for pneumonia, PEs.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\\n REASON FOR THIS EXAMINATION:\\n eval for pneumonia, PEs.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 9:31 PM\\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\\n Increased diffuse right lung opacities and new small right pleural effusion,\\n could be due to superimposed edema on infection and emphysema. Right middle\\n lobe nodule slightly increased, likely infectious. Persistent worrisome\\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CTPA INPATIENT\\n\\n REASON FOR EXAM: 59-year-old men with history of PE, rule out pneumonia, now\\n with hypoxia.\\n\\n TECHNIQUE: Chest MDCT was performed without and following 100 cc of\\n intravenous Optiray using 5 mm and 2.5 mm axial slice thickness. Coronal,\\n sagittal and oblique reformations were also obtained.\\n\\n COMPARISON: and priors back to .\\n\\n FINDINGS: There is no pulmonary embolism to the subsegmental level on the\\n right. Left pneumonectomy is again seen. Soft tissue in the left hilar\\n region and lateral to the hilar stump is unchanged, worrisome for local\\n recurrence, up to 12 mm in thickness lateral to the surgical sutures. Basilar\\n pleural nodules are also unchanged, corresponding to areas of FDG avidity on\\n the most recent PET/CT. Emphysema is unchanged.\\n\\n Peribronchial and diffuse opacities in the right lung have increased. Right\\n middle lobe peribronchial opacity also slightly increased (3:63). Scattered\\n coronary artery calcifications are unchanged. Tiny small right pleural\\n effusion is new. Signs of anemia persist. There is no pericardial effusion.\\n\\n This study was not tailored for subdiaphragmatic evaluation but the upper\\n abdomen is unremarkable. There is no bone lesion suspicious for malignancy.\\n Left humeral bone infarct or enchondroma is unchanged. Left thoracotomy\\n changes are stable.\\n\\n IMPRESSION:\\n 1. No evidence of pulmonary embolism.\\n\\n 2. Increased peribronchial and diffuse right lung opacities, superimposed\\n upon emphysema. The diffuse abnormalities may be due to pulmonary edema,\\n especially given a new small right pleural effusion, but diffuse infection is\\n (Over)\\n\\n 1:30 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: eval for pneumonia, PEs.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n also possible. Right middle lobe and other peribronchial opacities slightly\\n increased, likely infectious, but attention to this region should be paid on\\n subsequent followups.\\n\\n 3. Persistent soft tissue lateral to the hilar pneumonectomy stump, very\\n worrisome for local recurrence. Unchanged left basilar pleural nodules,\\n suggestive of pleural metastases.\\n\\n 4. Signs of anemia.\\n\\n 5. Stable old left humeral bone infarct or enchondroma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-24 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1077881,\n \"text\": \", MED MICU-7 1:30 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: eval for pneumonia, PEs.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\\n REASON FOR THIS EXAMINATION:\\n eval for pneumonia, PEs.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\\n Increased diffuse right lung opacities and new small right pleural effusion,\\n could be due to superimposed edema on infection and emphysema. Right middle\\n lobe nodule slightly increased, likely infectious. Persistent worrisome\\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1078224,\n \"text\": \", MED MICU-7 10:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for interval change as remains hypoxic.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with gemcitabine related inflammatory lung disease\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for interval change as remains hypoxic.\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: No change from prior day. Nonspecific but progressive right-sided\\n process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077661,\n \"text\": \" 2:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? new position of L IJ\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with repositioned L IJ\\n REASON FOR THIS EXAMINATION:\\n ? new position of L IJ\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 59-year-old male with repositioned left IJ.\\n\\n COMPARISON: .\\n\\n SINGLE AP VIEW OF THE CHEST: The left internal jugular central venous\\n catheter tip appears in same position, likely within the right brachiocephalic\\n vein. There has been no other interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077662,\n \"text\": \" 4:01 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with new L IJ\\n REASON FOR THIS EXAMINATION:\\n ? placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 59-year-old male with new left IJ. Evaluate placement.\\n\\n COMPARISON: at 2:22 a.m.\\n\\n SINGLE AP VIEW OF THE CHEST: There is a left internal jugular venous\\n catheter, which has been retracted, and tip likely lies within the left\\n brachiocephalic vein. There have been no other interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077967,\n \"text\": \" 3:47 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n eval for change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 3:13 PM\\n Interval increase in reticular nodular opacities in the right mid lung and\\n lower lobe concerning for volume overload, infection or, less likely\\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 59-year-old male with hypoxia. Evaluate for change.\\n\\n COMPARISON: Multiple studies including most recent of and CT of\\n .\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: As before, there is complete opacification\\n of the left hemithorax consistent with prior pneumonectomy. Nodular opacities\\n in the right peripheral lung base are not significantly changed from prior.\\n However, there is increased reticulonodular opacities in the right lung base\\n concerning for volume overload, infection or, less likely, post- pneumectomy\\n syndrome resulting in impaired lymphatic or venous drainage. The remainder of\\n the exam including the left IJ catheter is unchanged.\\n\\n IMPRESSION:\\n 1. Stable post- pneumectomy appearance.\\n\\n 2. Increased reticular nodular opacity in the right mid- and lower lung\\n concerning for volume overload, infection or post-pneumectomy syndrome\\n resulting in impairment of lymphatic or venous drainage.\\n\\n 3. Unchanged nodular opacities in the right peripheral lung base.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077968,\n \"text\": \", MED MICU-7 3:47 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n eval for change\\n ______________________________________________________________________________\\n PFI REPORT\\n Interval increase in reticular nodular opacities in the right mid lung and\\n lower lobe concerning for volume overload, infection or, less likely\\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077647,\n \"text\": \" 10:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with squamous cell lung CA, Hypotensive, tachycardic, febrile.\\n I s/p L lubectomy\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 59-year-old male with squamous cell carcinoma, hypotensive,\\n tachycardia, status post left pneumonectomy. Evaluate for infiltrate.\\n\\n COMPARISON: .\\n\\n SINGLE SUPINE AP VIEW OF THE CHEST: The patient is status post left\\n pneumonectomy, with fluid within the left pneumonectomy space. There is\\n unchanged leftward shift of mediastinal structures. The right lung contains\\n ill-defined patchy and nodular densities, particularly within the right lower\\n lung, which may reflect residual areas of consolidation, likely infectious, as\\n seen on prior chest CT . Emphysema is also noted. There is no\\n pleural effusion or pneumothorax within the right lung.\\n\\n IMPRESSION:\\n 1. Stable post left pneumonectomy changes.\\n 2. Patchy nodular densities within the right lower lung, likely reflect\\n residual infection, as seen on chest CT .\\n 3. Emphysema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1077729,\n \"text\": \" 1:08 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: pls eval for infiltrate, interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old man with lung ca, s/p pneumonectomy, now s/p hydration\\n REASON FOR THIS EXAMINATION:\\n pls eval for infiltrate, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Evaluation for interval change.\\n\\n COMPARISON: , 3:59 a.m.\\n\\n FINDINGS: As compared to the previous examination, there is little overall\\n change. The left-sided central venous access line is in constant position,\\n with its tip projecting over the slightly displaced trachea. The total\\n opacification of the left hemithorax is constant (status post pneumonectomy).\\n In the right lung, there is a minimal decrease of the diffuse parenchymal\\n opacities that remain, however, clearly visible, notably in the periphery of\\n the lung.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217629,\n \"text\": \"Sinus tachycardia. Lateral ST-T wave changes. Cannot rule out myocardial\\nischemia. Compared to the previous tracing of atrial fibrillation has\\nnow converted to sinus rhythm. Ventricular premature beats have resolved.\\nLateral ST-T wave changes are new. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217628,\n \"text\": \"Sinus tachycardia\\nAnterolateral ST-T changes are nonspecific\\nSince previous tracing of , the heart rate has decreased, ST-T wave\\nabnormalities are less\\n\\n\"\n }\n]"}}},{"rowIdx":292,"cells":{"subject_id":{"kind":"number","value":96643,"string":"96,643"},"hadm_id":{"kind":"number","value":152852,"string":"152,852"},"target_text":{"kind":"string","value":"60yo female with history of MS, neurogenic bladder and disorder who presents from rehab with altered mental status, found to have E. coli UTI, bacteremia and sepsis, resolved with antibiotics. 1. E. coli UTI, bacteremia, and sepsis- Patient presented with altered mental status, elevated WBC, elevated lactate and positive UA. Imaging concerning for pyelonephritis. She received ceftriaxone in the ED but developed possible anaphylaxis. Initially treated in the MICU given sepsis with temperature of 101 and tachycardic to the 130s. Meropenem and Vancomycin started in the MICU. The urology service was consulted and they determined that the only indication for drainage would be if there is an obstruction; she has chronic hydronephrosis due to neurogenic bladder and reflux. An arterial line and a central venous access line were placed and patient given fluids. Her urine and blood cultures both resulted E.coli sensitive to fluoroquinolones. Her vancomycin and meropenem were discontinued and switched to cipro to complete a 14-day treatment course (last day ). UTI appears related to sexual intercourse and neurogenic bladder. Consider post-coital prophylaxis. 2. Altered mental status- Pt was initially lethargic upon her admission to the MICU. She was extremely agitated on the night of and she was given seroquel and haldol which eventually calmed her down. Her mental status waxed and waned during her stay in the MICU and she was re-started on her home wellbutrin and divalproex. Pt had a negative head CT. After transfer to the floor, patient continues to have waxing and mental status, but slowly improved over time. AAOx3 on discharge. Trazodone held in the setting of altered mental status, consider restarting as outpatient when stable. 3. Possible Anaphylaxis- Patient became hypotensive to the high 70s while undergoing CT scan in the ED after receiving ceftriaxone. She received benadryl, steroid, famotidine and epinephrine with reponse in BP. Rash resolved by the time of her admission to the MICU. Unclear if this is secondary to contrast vs ceftriaxone the patient received in the ED as she has a known penicillin allergy. 4. Multiple sclerosis- patient takes Glatiramer for relapsing MS. She is not on any other chronic medications (interferon beta 1a, natalizumab). She is taking baclofen and detrol for history of neurogenic bladder. Copoxone was initially held in the setting of sepsis. Restarted on discharge. Her baclofen and detrol were continued at her home dose. 5. Neurogenic bladder- Patient has incontinence at baseline without urinary retention. Detrol held in the setting of UTI and sepsis. Consider restarting as outpatient. 6. Depression, disorder - Pt was periodically with altered mental status and agitation during her stay in the MICU. Her home buproprion and divalproex were continued. 7. Hyperlipidemia- continued on her home statin # Transitional issues- Pending HIV screening results, blood culture, urine culture (will communicate to Dr. Restart Detrol after UTI treatment Restart Trazodone once mental status completely back to baseline Consider starting Bactrim DS for postcoital prophylaxis"},"extractive_notes_summ":{"kind":"string","value":"There is left retrocardiac opacification, likely atelectasis. EXAMINATION: NON-CONTRAST HEAD CT. There is delayed excretion of contrast of the left as compared to the right kidney. (Over) 1:03 AM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for intraabdominal process Contrast: OPTIRAY Amt: FINAL REPORT (Cont) CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and uterus are unremarkable. This examination is motion limited with repeat axial series attempted through the region of greatest motion in the mid abdomen. There is mild left hydroureteronephrosis demonstrated to the level of the distal ureter (300B:33) where there is an apparent intraluminal filling defect involving the left distal ureter, of indeterminate significance. Mild left hydroureteronephrosis demonstrated to the level of distal ureter where there is an apparent filling defect which non-specific and may represent a stone, debris, or even possibly soft tissue. Contrast is demonstrated within the right renal collecting system. FINDINGS: CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal bibasilar atelectasis, left slightly greater than right. FINDINGS: A frontal view was performed only with a lateral deferred secondary to patient's request. Delayed excretion of contrast involving the left kidney. Also, a left-sided retrocardiac density remains and raises question of atelectasis versus infiltrate. Whit ematter hypodense foci- likely non-specific. Ectasia of the left renal pelvis is seen. There is extensive periventricular and subcortical hypodense foci which are non-specific in appearance. Non-specific ST-T wave changes in the anterior precordial leads.Compared to the previous tracing of the anterior precordial T wavechanges are slightly less prominent. The patient is noted to have a cervical fusion, incompletely assessed on this examination. During the interval, a left-sided central venous line has been placed using the subclavian approach. These findings may benon-specific although cannot exclude the possibility of myocardial ischemia.Clinical correlation is suggested. Clip # Reason: Is there evidence of outflow obstruction (renal calculi)? EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH. Mild left hydroureteronephrosis with an apparent intraluminal filling defect in the distal ureter which is non-specific and may represent debris, a non-calcified, stone, and soft tissue also remains a possibility. Lead V6 is absent. Lead V6 is absent. Loss of the normal corticomedullary differentiation of the left kidney which raises concern for possible pyelonephritis. There is suggestion of loss of the normal corticomedullary differentiation, particularly on the repeat sequences (2B:104 and 2B:110) that raises concern for infection. Evaluate for intracranial process. REASON FOR THIS EXAMINATION: Is there evidence of outflow obstruction (renal calculi)? The urinary bladder appears within normal limits. Thick-walled enhancing bladder compatible with clinically known cystitis. Thick-walled bladder compatible with clinically known cystitis. Recent abdominal CT showing left hydroureteronephrosis. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of 130 cc of Optiray intravenous contrast. There is hyperostosis frontalis. FINDINGS: AP single view of the chest has been obtained with patient in supine position. Sinus rhythm with borderline lowQRS voltage. Right ocular lens is not seen. There is grade 1 anterolisthesis of the L3 on L4 vertebral body. FINAL REPORT STUDY: Renal ultrasound. IMPRESSION: Left retrocardiac opacification, likely atelectasis, though infection remains a less likely possibility. The ureteral jets are seen bilaterally. The line terminates overlying the SVC at the level 3 cm below the carina and still above the expected entrance into the right atrium. Borderline low QRS voltage. (Over) 1:03 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for intracranial process FINAL REPORT (Cont) The liver, gallbladder, spleen, both adrenal glands, right kidney and right ureter, pancreas, and visualized loops of intra-abdominal small and large bowel are unremarkable. The bladder is relatively thick-walled with enhancement in keeping with known diagnosis of cystitis. Evaluate for acute intra-abdominal process. Sphenoid sinus septation inserts on the right carotid groove. There is normal corticomedullary echotexture. Sinus rhythm. T wave inversion in leads V1-V3 withnon-specific T wave flattening in leads I, aVL and V4-V5. EXAMINATION: CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST. General vascular appearance in the lung is that of congestion; however, this might be simulated by patient's poor inspirational effort and motion blur. 1:03 AM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for intraabdominal process Contrast: OPTIRAY Amt: MEDICAL CONDITION: 60 year old woman with altered mental status, abdominal pain and tenderness, RLQ pain REASON FOR THIS EXAMINATION: evaluate for intraabdominal process No contraindications for IV contrast WET READ: 3:19 AM Subtle loss of the corticomedullary differentiation of the left kidney with delayed excretion raises concern for pyelonephritis. The cardiomediastinal and hilar contours are normal. Motion-limited examination demonstrating no acute intracranial hemorrhage or mass effect. In addition, there is diffuse prominence of the extra-axial spaces and sulci in the parietal and occipital lobes and posterior fosssa."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2181-09-13 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":1213254,"text":" 1:31 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: EVALUATE FOR CARDIOPULMONARY PROCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with altered mental status.\n\n EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n A frontal view was performed only with a lateral deferred secondary to\n patient's request. There is left retrocardiac opacification, likely\n atelectasis. The remainder of the lungs are clear with no other focal\n opacification. There are no pleural effusions or pneumothorax. The\n cardiomediastinal and hilar contours are normal. There may be pulmonary\n vascular congestion, though the vasculature is in part enlarged by supine\n technique. Contrast is demonstrated within the right renal collecting system.\n The patient is noted to have a cervical fusion, incompletely assessed on this\n examination.\n\n IMPRESSION: Left retrocardiac opacification, likely atelectasis, though\n infection remains a less likely possibility.\n\n"},{"category":"Radiology","chartdate":"2181-09-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1213249,"text":" 1:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:28 AM\n Motion limited. Diffuse global atrophy. No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with altered mental status. Evaluate for\n intracranial process.\n\n EXAMINATION: NON-CONTRAST HEAD CT.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. Initial\n attempts were motion limited. Subsequent attempts still demonstrated\n limitations from motion.\n\n FINDINGS:\n\n Motion-limited images through the brain are grossly unremarkable with no\n evidence of hemorrhage, edema, mass effect, or obvious acute infarction. The\n -white matter differentiation is preserved. There is extensive\n periventricular and subcortical hypodense foci which are non-specific in\n appearance. The ventricles and sulci are prominent, most compatible with a\n component of involutional change. In addition, there is diffuse prominence of\n the extra-axial spaces and sulci in the parietal and occipital lobes and\n posterior fosssa. There is hyperostosis frontalis. The visualized portions\n of the paranasal sinuses and mastoid air cells are well aerated. Sphenoid\n sinus septation inserts on the right carotid groove.\n Right ocular lens is not seen.\n\n IMPRESSION:\n\n 1. Motion-limited examination demonstrating no acute intracranial hemorrhage\n or mass effect.\n 2. Whit ematter hypodense foci- likely non-specific. However, correlate\n clinically to decide on the need for further workup with MRI if not\n contra-indicated.\n (Over)\n\n 1:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2181-09-13 00:00:00.000","description":"CT ABD & PELVIS WITH CONTRAST","row_id":1213250,"text":" 1:03 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intraabdominal process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status, abdominal pain and tenderness,\n RLQ pain\n REASON FOR THIS EXAMINATION:\n evaluate for intraabdominal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:19 AM\n Subtle loss of the corticomedullary differentiation of the left kidney with\n delayed excretion raises concern for pyelonephritis. Mild left\n hydroureteronephrosis with an apparent intraluminal filling defect in the\n distal ureter which is non-specific and may represent debris, a non-calcified,\n stone, and soft tissue also remains a possibility.\n Thick-walled bladder compatible with clinically known cystitis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with altered mental status and abdominal pain\n and tenderness. Evaluate for acute intra-abdominal process.\n\n EXAMINATION: CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the uneventful administration of 130 cc of\n Optiray intravenous contrast. This examination is motion limited with repeat\n axial series attempted through the region of greatest motion in the mid\n abdomen. Coronal and sagittal reformations are provided for review.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n There is minimal bibasilar atelectasis, left slightly greater than right. The\n lung bases are otherwise clear with no focal parenchymal opacification.\n\n The liver, gallbladder, spleen, both adrenal glands, right kidney and right\n ureter, pancreas, and visualized loops of intra-abdominal small and large\n bowel are unremarkable.\n\n There is delayed excretion of contrast of the left as compared to the right\n kidney. There is suggestion of loss of the normal corticomedullary\n differentiation, particularly on the repeat sequences (2B:104 and 2B:110) that\n raises concern for infection. There is mild left hydroureteronephrosis\n demonstrated to the level of the distal ureter (300B:33) where there is an\n apparent intraluminal filling defect involving the left distal ureter, of\n indeterminate significance.\n (Over)\n\n 1:03 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intraabdominal process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n uterus are unremarkable. The bladder is relatively thick-walled with\n enhancement in keeping with known diagnosis of cystitis. There is no pelvic\n free fluid. There is no pelvic or inguinal lymphadenopathy. The appendix is\n normal in appearance. This can best be appreciated with tip at the level of\n 300B:28.\n\n BONE WINDOWS: There are multilevel degenerative changes with dextroconvex\n scoliosis of the thoracolumbar spine. There is grade 1 anterolisthesis of the\n L3 on L4 vertebral body.\n\n IMPRESSION:\n\n 1. Loss of the normal corticomedullary differentiation of the left kidney\n which raises concern for possible pyelonephritis.\n 2. Delayed excretion of contrast involving the left kidney. Mild left\n hydroureteronephrosis demonstrated to the level of distal ureter where there\n is an apparent filling defect which non-specific and may represent a stone,\n debris, or even possibly soft tissue.\n 3. Thick-walled enhancing bladder compatible with clinically known cystitis.\n\n"},{"category":"Radiology","chartdate":"2181-09-13 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1213343,"text":" 3:41 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate placement of left subclavian line\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with presumed urosepsis\n REASON FOR THIS EXAMINATION:\n Evaluate placement of left subclavian line\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 60-year-old female patient with presumed urosepsis, evaluate\n placement of left subclavian line.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. Analysis is performed in direct comparison with the next\n preceding similar study obtained 13 hours earlier during the same day. During\n the interval, a left-sided central venous line has been placed using the\n subclavian approach. The line terminates overlying the SVC at the level 3 cm\n below the carina and still above the expected entrance into the right atrium.\n No pneumothorax or any other placement-related complication is identified.\n General vascular appearance in the lung is that of congestion; however, this\n might be simulated by patient's poor inspirational effort and motion blur.\n Also, a left-sided retrocardiac density remains and raises question of\n atelectasis versus infiltrate. No pneumothorax is identified.\n\n\n"},{"category":"Radiology","chartdate":"2181-09-18 00:00:00.000","description":"RENAL U.S.","row_id":1213895,"text":" 8:49 AM\n RENAL U.S. Clip # \n Reason: Is there evidence of outflow obstruction (renal calculi)?\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with multiple sclerosis and neurogenic bladder, with\n abdominal CT findings of L hydroureteronephrosis with filling defect concerning\n for possible stone or soft tissue, as well as pyelonephritis and cystitis. Pt\n has E. coli UTI and was in the ICU for urosepsis.\n REASON FOR THIS EXAMINATION:\n Is there evidence of outflow obstruction (renal calculi)?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound.\n\n INDICATION: 60-year-old female with multiple sclerosis and neurogenic\n bladder. E. coli urinary tract infection. Recent abdominal CT showing left\n hydroureteronephrosis.\n\n TECHNIQUE: Realtime Grayscale and color Doppler imaging of the kidneys\n bilaterally and urinary bladder was performed and reviewed.\n\n Correlation is made to previous CT of the abdomen and pelvis dated .\n\n FINDINGS: The right kidney measures 12 cm in size and the left kidney\n measures 12 cm in size. There is normal corticomedullary echotexture.\n Ectasia of the left renal pelvis is seen. There is no evidence of\n hydronephrosis or nephrolithiasis.\n\n The urinary bladder appears within normal limits. The ureteral jets are seen\n bilaterally.\n\n IMPRESSION: No evidence of hydronephrosis or nephrolithiasis.\n\n\n\n"},{"category":"ECG","chartdate":"2181-09-13 00:00:00.000","description":"Report","row_id":236021,"text":"Baseline artifact. Lead V6 is absent. Sinus rhythm with borderline low\nQRS voltage. Non-specific ST-T wave changes in the anterior precordial leads.\nCompared to the previous tracing of the anterior precordial T wave\nchanges are slightly less prominent. Lead V6 is absent. Suggest repeat tracing.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2181-09-12 00:00:00.000","description":"Report","row_id":236022,"text":"Sinus rhythm. Borderline low QRS voltage. T wave inversion in leads V1-V3 with\nnon-specific T wave flattening in leads I, aVL and V4-V5. These findings may be\nnon-specific although cannot exclude the possibility of myocardial ischemia.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-09-13 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 1213254,\n \"text\": \" 1:31 AM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: EVALUATE FOR CARDIOPULMONARY PROCESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with altered mental status\\n REASON FOR THIS EXAMINATION:\\n evaluate for cardiopulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 60-year-old female with altered mental status.\\n\\n EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH.\\n\\n COMPARISONS: None available.\\n\\n FINDINGS:\\n\\n A frontal view was performed only with a lateral deferred secondary to\\n patient's request. There is left retrocardiac opacification, likely\\n atelectasis. The remainder of the lungs are clear with no other focal\\n opacification. There are no pleural effusions or pneumothorax. The\\n cardiomediastinal and hilar contours are normal. There may be pulmonary\\n vascular congestion, though the vasculature is in part enlarged by supine\\n technique. Contrast is demonstrated within the right renal collecting system.\\n The patient is noted to have a cervical fusion, incompletely assessed on this\\n examination.\\n\\n IMPRESSION: Left retrocardiac opacification, likely atelectasis, though\\n infection remains a less likely possibility.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-09-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1213249,\n \"text\": \" 1:03 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluate for intracranial process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with altered mental status\\n REASON FOR THIS EXAMINATION:\\n evaluate for intracranial process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 2:28 AM\\n Motion limited. Diffuse global atrophy. No acute intracranial process.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old female with altered mental status. Evaluate for\\n intracranial process.\\n\\n EXAMINATION: NON-CONTRAST HEAD CT.\\n\\n COMPARISONS: None available.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the brain. Initial\\n attempts were motion limited. Subsequent attempts still demonstrated\\n limitations from motion.\\n\\n FINDINGS:\\n\\n Motion-limited images through the brain are grossly unremarkable with no\\n evidence of hemorrhage, edema, mass effect, or obvious acute infarction. The\\n -white matter differentiation is preserved. There is extensive\\n periventricular and subcortical hypodense foci which are non-specific in\\n appearance. The ventricles and sulci are prominent, most compatible with a\\n component of involutional change. In addition, there is diffuse prominence of\\n the extra-axial spaces and sulci in the parietal and occipital lobes and\\n posterior fosssa. There is hyperostosis frontalis. The visualized portions\\n of the paranasal sinuses and mastoid air cells are well aerated. Sphenoid\\n sinus septation inserts on the right carotid groove.\\n Right ocular lens is not seen.\\n\\n IMPRESSION:\\n\\n 1. Motion-limited examination demonstrating no acute intracranial hemorrhage\\n or mass effect.\\n 2. Whit ematter hypodense foci- likely non-specific. However, correlate\\n clinically to decide on the need for further workup with MRI if not\\n contra-indicated.\\n (Over)\\n\\n 1:03 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluate for intracranial process\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-09-13 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS WITH CONTRAST\",\n \"row_id\": 1213250,\n \"text\": \" 1:03 AM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: evaluate for intraabdominal process\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with altered mental status, abdominal pain and tenderness,\\n RLQ pain\\n REASON FOR THIS EXAMINATION:\\n evaluate for intraabdominal process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 3:19 AM\\n Subtle loss of the corticomedullary differentiation of the left kidney with\\n delayed excretion raises concern for pyelonephritis. Mild left\\n hydroureteronephrosis with an apparent intraluminal filling defect in the\\n distal ureter which is non-specific and may represent debris, a non-calcified,\\n stone, and soft tissue also remains a possibility.\\n Thick-walled bladder compatible with clinically known cystitis.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 60-year-old female with altered mental status and abdominal pain\\n and tenderness. Evaluate for acute intra-abdominal process.\\n\\n EXAMINATION: CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST.\\n\\n COMPARISONS: None available.\\n\\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\\n to the pubic symphysis after the uneventful administration of 130 cc of\\n Optiray intravenous contrast. This examination is motion limited with repeat\\n axial series attempted through the region of greatest motion in the mid\\n abdomen. Coronal and sagittal reformations are provided for review.\\n\\n FINDINGS:\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\\n\\n There is minimal bibasilar atelectasis, left slightly greater than right. The\\n lung bases are otherwise clear with no focal parenchymal opacification.\\n\\n The liver, gallbladder, spleen, both adrenal glands, right kidney and right\\n ureter, pancreas, and visualized loops of intra-abdominal small and large\\n bowel are unremarkable.\\n\\n There is delayed excretion of contrast of the left as compared to the right\\n kidney. There is suggestion of loss of the normal corticomedullary\\n differentiation, particularly on the repeat sequences (2B:104 and 2B:110) that\\n raises concern for infection. There is mild left hydroureteronephrosis\\n demonstrated to the level of the distal ureter (300B:33) where there is an\\n apparent intraluminal filling defect involving the left distal ureter, of\\n indeterminate significance.\\n (Over)\\n\\n 1:03 AM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: evaluate for intraabdominal process\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\\n uterus are unremarkable. The bladder is relatively thick-walled with\\n enhancement in keeping with known diagnosis of cystitis. There is no pelvic\\n free fluid. There is no pelvic or inguinal lymphadenopathy. The appendix is\\n normal in appearance. This can best be appreciated with tip at the level of\\n 300B:28.\\n\\n BONE WINDOWS: There are multilevel degenerative changes with dextroconvex\\n scoliosis of the thoracolumbar spine. There is grade 1 anterolisthesis of the\\n L3 on L4 vertebral body.\\n\\n IMPRESSION:\\n\\n 1. Loss of the normal corticomedullary differentiation of the left kidney\\n which raises concern for possible pyelonephritis.\\n 2. Delayed excretion of contrast involving the left kidney. Mild left\\n hydroureteronephrosis demonstrated to the level of distal ureter where there\\n is an apparent filling defect which non-specific and may represent a stone,\\n debris, or even possibly soft tissue.\\n 3. Thick-walled enhancing bladder compatible with clinically known cystitis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-09-13 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1213343,\n \"text\": \" 3:41 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: Evaluate placement of left subclavian line\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with presumed urosepsis\\n REASON FOR THIS EXAMINATION:\\n Evaluate placement of left subclavian line\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest, AP portable single view.\\n\\n INDICATION: 60-year-old female patient with presumed urosepsis, evaluate\\n placement of left subclavian line.\\n\\n FINDINGS: AP single view of the chest has been obtained with patient in\\n supine position. Analysis is performed in direct comparison with the next\\n preceding similar study obtained 13 hours earlier during the same day. During\\n the interval, a left-sided central venous line has been placed using the\\n subclavian approach. The line terminates overlying the SVC at the level 3 cm\\n below the carina and still above the expected entrance into the right atrium.\\n No pneumothorax or any other placement-related complication is identified.\\n General vascular appearance in the lung is that of congestion; however, this\\n might be simulated by patient's poor inspirational effort and motion blur.\\n Also, a left-sided retrocardiac density remains and raises question of\\n atelectasis versus infiltrate. No pneumothorax is identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-09-18 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 1213895,\n \"text\": \" 8:49 AM\\n RENAL U.S. Clip # \\n Reason: Is there evidence of outflow obstruction (renal calculi)?\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old woman with multiple sclerosis and neurogenic bladder, with\\n abdominal CT findings of L hydroureteronephrosis with filling defect concerning\\n for possible stone or soft tissue, as well as pyelonephritis and cystitis. Pt\\n has E. coli UTI and was in the ICU for urosepsis.\\n REASON FOR THIS EXAMINATION:\\n Is there evidence of outflow obstruction (renal calculi)?\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Renal ultrasound.\\n\\n INDICATION: 60-year-old female with multiple sclerosis and neurogenic\\n bladder. E. coli urinary tract infection. Recent abdominal CT showing left\\n hydroureteronephrosis.\\n\\n TECHNIQUE: Realtime Grayscale and color Doppler imaging of the kidneys\\n bilaterally and urinary bladder was performed and reviewed.\\n\\n Correlation is made to previous CT of the abdomen and pelvis dated .\\n\\n FINDINGS: The right kidney measures 12 cm in size and the left kidney\\n measures 12 cm in size. There is normal corticomedullary echotexture.\\n Ectasia of the left renal pelvis is seen. There is no evidence of\\n hydronephrosis or nephrolithiasis.\\n\\n The urinary bladder appears within normal limits. The ureteral jets are seen\\n bilaterally.\\n\\n IMPRESSION: No evidence of hydronephrosis or nephrolithiasis.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2181-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 236021,\n \"text\": \"Baseline artifact. Lead V6 is absent. Sinus rhythm with borderline low\\nQRS voltage. Non-specific ST-T wave changes in the anterior precordial leads.\\nCompared to the previous tracing of the anterior precordial T wave\\nchanges are slightly less prominent. Lead V6 is absent. Suggest repeat tracing.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2181-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 236022,\n \"text\": \"Sinus rhythm. Borderline low QRS voltage. T wave inversion in leads V1-V3 with\\nnon-specific T wave flattening in leads I, aVL and V4-V5. These findings may be\\nnon-specific although cannot exclude the possibility of myocardial ischemia.\\nClinical correlation is suggested. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":293,"cells":{"subject_id":{"kind":"number","value":23483,"string":"23,483"},"hadm_id":{"kind":"number","value":108568,"string":"108,568"},"target_text":{"kind":"string","value":"59 year old female with dilated CM (EF 15%) s/p BiV ICD, s/p CABG ' SVG-LAD, Severe MR & TR, PAF, presenting with SOB & fevers. 1. CV: A) Pump: The patient presented with a history of CHF/CMP and hx, sx and exam consistent with failure (SOB, orthopnea, JVD, mild crackles, non-pitting edema). On admission, she was started on milrinone and her lasix was increased as her BP tolerated. She did not diurese well on this regimen and was transferred to the CCU on where a a Swan Ganz catheter was placed for tailored CHF therapy. In the CCU, she was continued on milrinone gtt and a nipride gtt was titirated up to achieve a CI of >2.2 and a decreased SVR and PAP. On this therapy she achieved good diuresis with average 24 hours fluid balance negative 1-2L. After the initial success with diuresis, the patient was started on valsartan and imdur in an attempt to wean off drips and convert to oral medication. With steadily increasing doses of valsartan and imdur, she did wean off the nipride and the milrinone but developed an episode of sustained hypotension and decreased urine output when the milrinone was stopped. From this it was presumed that the patient required the additional inotropic support of the milrinone, and after re-starting milrinone her CO and CI increased sufficiently to maintain MAP >60. On HD#10 (), the patient was on a stable dose of aldactone 25mg once daily (decreased from 50mg po daily as an outpatient), bisoprolol 5mg once daily, milrinone 0.385mcg/kg/min gtt and was loaded on digoxin. Her isordil, nipride, valsartan, and lasix were discontinued. Once on a stable heart failure regimen, the patient was transferred out of the CCU and sent to the step down unit. There her ins and outs were not well recorded and secondary to a foley that was re-inserted on the floor, she developed a UTI/pyelonephritis confirmed by CT scan which required re-admission to the CCU for further management. On her second admission to the CCU, her heart failure regimen was again altered due to her inability to tolerate milrinone secondary to development of persistent HA. She was empirically taken off milrinone with subsequent decompensation and was then started on low dose dopamine instead. She tolerated the dopamine well with good urine output and maintenance of pressures. She was able to regain forward flow and returned to compensated heart failure. At this point her regimen consisted of Dopamine 2.5mcg/kg/min, bisoprolol 5mg once daily, and digoxin 0.125mg once daily. She was taken off the aldactone for persistent hyponatremia. Initially the plan was to discharge her on home dopamine, but without right heart catheterization, approval was not granted for home dopamine infusion. The patient refused another right heart cath. Upon the patient's insistence, dopamine was discontinued. She maintained her blood pressures and remained in compensated CHF during the following day. She also decided to pursue cardiac transplantation prior to discharge. The PFT's, carotid studies and panel of serologies were sent prior to discharge."},"extractive_notes_summ":{"kind":"string","value":"felt to be r/t dc'ing of milrinone am. k- 3.6, re'd 40meq (started on nocts) kcl iv and then 40meq kcl po, repeat lytes pnd this pm.resp- on 3l sats 96-100. l/s clear with cxs/coarse sounds lower, esp. isordil, lasix, bisoprolol held in am d/t low bp. RECEIVING LASIX 80 MG IV BID.GI: ABD SL DISTENDED, + BOWEL SOUNDS. digoxin level added on and pnd. LOWER EXTREMITIES 3+ PITTING EDEMA.RESP: O2 3L VIA NC. off milrinone gtt since d/t headaches.heparin at 1000uhr. (describing headache)o: pls see carevue flowsheet for complete vs/data/eventsid: temp is low. Vanco and Imipenem dc'd. Off Milrinone CO was 3.6 from 4.7, CI 1.93 from 2.51, SVR 1044 from 851, cvp 7 from 10. abg: 7.40/31/73/20/-3. No bm.GU: UO has picked up since milrinone restarted.ID: afebrile, cont on ceftriaxone.A/P: treating pyelonephritis, BP stable on Milrinone, UO improving. Family called.A: Off Lasix gtt/restarted valsartin and coumadin/slightly decreased niprideP: Cont to keep careful I & O. bp 90-105/60 via nbp.coags sent off pic line this am. RLL crackles, RUL, LLL, LUL all clear.GI/GU: +bs, + med. (first dose 4/11)HR 80 Vpaced. BP became more stable & Milrinone restarted at 0.385mcg/kg/min at 16:00. She was replaced with 60 meq KCL, nuerta phos and Mag oxide. \"O: Please see careview for VS and additional data.CV: Pt HR 80-81 AV paced, NBP 95-107/36-72, pt continues on dopamine gtt 2.5 mcg/kg/min. Diuretics held today.ID: TM 99.4. pads 36 to 28, cvp 23 to 14, co 4.4, up to 5.3 this pm ci 2.73, svr 863. hct 35.2, ptt 78.9, inr 1.6. cont. COUMADIN RESTARTED ON . milrinone resumed at prior dose without a bolus.hr 80s vpaced w pvcs. CO/CI STABLE ON PRESENT REGIME OF MEDS; NIPRIDE 2 MCG/KG/MIN, MILRINONE 0.385 MCG/KG/MIN. Full code.CV: Upon start of shift, am meds were held r/t hypotension. D/C FLAGYL FOR R/O S DIFF. BP 94/49-102/64. on same doses nipride, heparin, milrinone, lasix. \"O: For complete VS see CCU flow sheet.ID: T-max 99.8po.CV: Some changes made in taylored therapy today. supplements.OOB QD as tol. cont on vanco(needs trough before mdnoc dose), po flagyl and imipenum.had abd ct which noted l pylonephritis.cv: hr 80-100, mostly vpaced. lasix held d/t hypotension. also cont on tid clonipin.a: afib, hypotension, poor uop.p: cont to follow hemodynamics, volume status. K 3.4, will replete w/ 60mEq sliding scale when Mg is complete. BP 97/62- 109/69.contin. WBC 15.BC/urine pnd from .HR 80's vpaced. apnea noted. abx, recent c+s pnd.cv- hr 80s vpaced with occ to freq pvc, occ. holding lasix in setting of bacterimia.k 5.0, mg 2.1.resp: labored w min exertion. lfts elevated, down for liver us.p- cont. MILRINONE DOWN TO 0.18MCG/KG/MIN. contact precautions dc'd.cv: hr 80-90s paced, occ pvc. po4 1.3, re'd neutraphos. inr 1.6, ptt 78.dig level 3.4 this am and dose was held.na 124(128). Mg 1.6 repleted.Resp: Pt conts to have dyspniec with exertion. Diuretics held today. HR 73-85 A-fib, occ. supprort to pt. refused- able to fall asleep again.A: improved u/o on dopa. She was started on milronone and diuresed, but remains profoundly anasarcic.CV: HR has been in 70s, afib, multiple PVCs and occasional paced beats. She initially had hematuria, but it has since resolved.GI: Pt conts to have excellent apetite. ccu npno- id-afebrile. a peripheral line was placed by the iv team.resp: basilar cxs. Labs (18:00) Mg 1.7, repleting w/ 4gm Mag Sulfate IV. \"O: For complete VS see CCU flow sheet.ID: Pt afebrile.CV: Nipride being weaned. rec'd dose of fiorocet w some effect. IV Heparin dc'd at 12n d/t elevated INR. f/u liver us results. ptt 92. inr 1.8.resp: rr 20s. (1 of which was drawn peripherally this am). EKG DONE, MD NOTIFIED. u/o improved on milrinone. one run of VT 8bts, rate 150. asympt. on ceftriax q24hr. SEE CAREVUE FOR VS/OBJECTIVE DATACV: HR 80 V-PACED W/PVC'S/OCCS COUPLETS, BP 99-106/50-60'S ON DOPAMINE @ 2.5MCGS; HEPARIN REMAINS AT 800U/HR W/PTT W/I RANGE 83RESP: SATS 98-99% ON 2L NC, SATS 89-92% ON ROOM AIR, LUNGS - FEW CRACKLES AT BASESALT COMFORT: PT CONTINUES C/O HA - 2MG IV MSO4 GIVEN X1 W/SOME RELIEF - SLEEPING OFF/ONGI: LIVER US REVEALED INFLAMMATION OF COMMON BILE DUCT PER TECHNO STOOLGU: FOLEY DRAINING YELLOW URINE I/O'S EVEN FOR DAYSOCIAL: - WILL CALL IN AMA: VS UNCHANGED AFTER CHANGE FROM MILRINONE TO DOPAMINE CONTINUED HA - UNKNOWN ETIOLOGYP: MONITOR VS, CONT DOPA/HEPARIN, ASSESS HEADACHE - MEDS FOR COMFORT AND ASSESS EFFECTIVENESS - CONT FOLLOW LFT'S, ASSESS MENTAL STATUS,CONT SUPPORTIVE CARE. Atrial sensed ventricular pacedSince previous tracing of , ventricular ectopy absent Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , sinus rhythm now absent Atrial sensed ventricular pacedVentricular premature complexesSince previous tracing of , atrial fibrillation now absent Atrial sensed ventricular pacedVentricular premature complexesSince previous tracing of , atrial fibrillation now absent Since the previous tracing of there is a runof ventricular paced rhythm. Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change Compared to the previous tracingof atrial fibrillation is no longer recorded and the rhythm is sinuswith atrial sensing and ventricular pacing. Ventricular couplets. There is atrial and ventricular pacing. fibrillationSince previous tracing of , sinus rhythm now absent Intermittentventricular paced rhythm. Pacemaker rhyth. CONTINUED DIURESES UNTIL MINNOC. Atrial fibrillation and demand ventricular pacingIntraventricular conduction delay - left axis deviationSince previous tracing, atrial fibrillation is new Ventricular paced rhythmAtrial mechanism appears to be flutter/? Compared to the previous tracingthe atria are now paced. Paced rhythmSince previous tracing, no significant change Atrial sensed and ventricular paced rhythm. Compared tothe previous tracing no significant change.TRACING #1 +MUR. Compared tothe previous tracing of no significant change.TRACING #2 DP PALP. Regular ventricular pacing. Regular ventricular pacing. MHR 80S SR, NO VEA. Atrial fibrillation. Marked left axis deviation.Intraventricular conduction defect. PT TO ASSIST W/ RECONDITIONING. Pacemaker rhythm. Left ventricular hypertrophy. A-V sequential pacing*** complex QRS morphology - no further analysis ***Since previous tracing, the heart rate is faster PCWP OF 24. CONTINUE DIURESIS AS TOLERATED. IMPROVED MV 72% AND CI >3. MAGNESIUM AND POTASSIUM REPLACED. C/O SORENESS AT SWAN INSERTION SITE. 10L. No further analysis. No further analysis. NEG >1L AT 2300 LAST EVENING. PT MED W/ OXYCODONE AND TYLENOL W/ GOOD EFFECTS.RESP:LUNGS W/ CRACKLES AT BASES OTHERWISE CLR. CCU NURSING NOTESS:I'M FEELING BETTER THIS EVENING.O:59YR OLD FEMALE W/ DILATED CM, CHF MANAGEMENT CCU DAY 4, REMAINS ON MILRINONE, HEPARIN, LASIX . SNP WEANED OFF AND VALSARTAN INCREASED TO 80MG."},"n_notes":{"kind":"number","value":47,"string":"47"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2166-04-08 00:00:00.000","description":"Report","row_id":1569270,"text":"ccu nursing progress note\ns: out of 10. (describing headache)\no: pls see carevue flowsheet for complete vs/data/events\nid: temp is low. 95-97 orally. wbc 15. cont on ceftriaxone for ecoli pyelonephritis/bacteremia. bld and urine recultured.\ncv: no cp. ^'d sob at rest, lethargic and poor uop. felt to be r/t dc'ing of milrinone am. milrinone resumed at prior dose without a bolus.\nhr 80s vpaced w pvcs. bp 90-105/60 via nbp.\ncoags sent off pic line this am. inr 8.1, ptt >150. repeat sent from peripheral draw, awaiting results.\nheparin off at noon for poss lp in w/u of persistent ha.\nresp: sats 94-98% on ra, 95-100% on 2l nc. has periods of sob at rest, ^'d w exertion. also noted someirreg patterns similar to cheynne . abg: 7.40/31/73/20/-3. lactate 5.6.\ngi: poor appetite. no nv. no stool. taking only juice. abd benign.\ngu: had not voided since 11pm last noc, up to void at 10am without result. foley placed at 12n. urine is drk brn to red. cr 1.4 stable from yesterday. na 126(129, 124, 121). hco3 18(25).\nms: lethargic, groggy. c/o ha, describes as severe, sl relief w fioricet. neuro consulted to eval. oob w assist x1.\nsocial: pt spoke w brother by phone, no other visits.\na: further decompensated heart failure off milrinone w evidence of hypoperfusion and metabolic acidosis. cont headache of unknown etiology.\np: reeval labs this eve w restart of milrinone. follow resp exam, volume status. med for comfort. check results of repeat coags. med for comfort. support to pt.\n"},{"category":"Nursing/other","chartdate":"2166-04-08 00:00:00.000","description":"Report","row_id":1569271,"text":"CCU NPN 3-11pm\nCV: cont on milrinone .38mcg/kg/min, restarted at 12N, HR 80 v-paced, BP high90's-low100/60's, UO picked up to 50-100cc/hr. States she is SOB, does not appear is distress. Sat 93-94% on RA. PTT >150 earlier today, repeat at 2130 was 63.4. Restarting Hep at 100U/hr without a bolus at 2300. Follow PTT in 6hrs.\n\nResp: crackles at bases bilaterally, with scattered rhonchi, intermittently coughing, nonproductive.\n\nNeuro: cont to c/o HA, given oxycontin at 1630 and Clonazepam. Has been sleepy but states that she does not sleep. Neruo evaluated. No focal findings, recommended MSO4 for pain, dc'ed Oxycontin and Fioricet(can get rebound HA's), recommended good night sleep.\nPt has been sleeping since ~ after nieces left.\n\nGI: ate custard at dinner, drinking sips of juice. No bm.\n\nGU: UO has picked up since milrinone restarted.\n\nID: afebrile, cont on ceftriaxone.\n\nA/P: treating pyelonephritis, BP stable on Milrinone, UO improving. Lethargic, now sleeping. Reevaluate HA after she awakens, MSO4 for pain prn(has not gotten yet).\n\n\n\n"},{"category":"Nursing/other","chartdate":"2166-03-29 00:00:00.000","description":"Report","row_id":1569251,"text":"CCU NSG NOTE: ALT IN CV/HEART FAILURE\nS: \"I always have chest pain, this is just worse.\"\nO: For complete VS see CCU flow sheet.\nID: T-max 99.8po.\nCV: Some changes made in taylored therapy today. Her lasix gtt was d/c and she is now receiving lasix 80mg iv bid. She has received her second dose. Her nipride was decreased from 2.2 mic/kilo to 2mic/kilo with increase in SVR to 1191 and with an increase in filling pressures. She was put back on her valsartin 40mg and last c.o 2 hours after that were 5.7/ 3.05/ 758. Nipride remains a 2.0. Heparin remains at 1000 with a theraputic PTT, and coumadin 5mg po was started. She was replaced with 60 meq KCL, nuerta phos and Mag oxide. Afternoon lyted contd low and she will receive 4 amp of mag and KPhos. Hr has been in 80s to mid 80, going between v-paced and NSR. BP has been 89-101/60-70s. PAP has been 45-50/22-28 with wedge of 20 and RA .\nRESP: Pt has faint rales at bases. Early she had exp wheezes, but is clear now.\nRENAL: With lasix off at 9a and IV lasix given at 9:30 pt was 3700cc neg for the day and 8 liters neg LOS.\nGI: Pt OOB to comode and had Lg G- stool. She is eating very well with no c/o of nausea. She needs dietary consult to help with her diet when she returns home.\nSKIN: Despite excellent diuresis she conts to have 3+ pitting edema in extremities. No areas of breakdown.\nMS: Pt oriented X 3. She conts to become very fatigued with minmal exertion. She declined getting OOB this afternoon. Spirits seem good. Family called.\nA: Off Lasix gtt/restarted valsartin and coumadin/slightly decreased nipride\nP: Cont to keep careful I & O. Monitor for change in hemodynamics. REcheck lytes later tonight.\n"},{"category":"Nursing/other","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":1569257,"text":"CCU Nurse Progress Note 3p-11p\n59 yo female patient w/ decompensated heart failure admitted to CCU for diuresis and tailored therapy. Full code.\n\nCV: Upon start of shift, am meds were held r/t hypotension. Milrinone was dc'ed at 10:00a also r/t hypotension. Off Milrinone CO was 3.6 from 4.7, CI 1.93 from 2.51, SVR 1044 from 851, cvp 7 from 10. BP became more stable & Milrinone restarted at 0.385mcg/kg/min at 16:00. Numbers got better, CO 4.5, CI 2.41, SVR 996, cvp 14, maps 60's. HR 80-82 Vpaced, occ. PVC's. BP 85-93/46-77. Dig, Nipride(off yesterday), Valsartan & Coumadin all dc'ed today. Hep gtt cont at 1000 units/hr, PTT remains therapeutic at 82.3. Mixed venous sat (18:00) = 60. Will not resume coumadin until swan dc'd.\n\nNeuro: A&Ox3, calm & cooperative. C/O swan site pain given Oxycodone 5mg PO.\n\nResp: becomes SOB, tired w/ activity, such as getting up to commode. Will rest a few secs, then is ok. RR 14-20. Sats 90-97 room air. RLL crackles, RUL, LLL, LUL all clear.\n\nGI/GU: +bs, + med. formed bm. Foley draining amber, cloudy urine. Given 80mg IV Lasix 20:30, responding well. Output 390cc so far since Lasix dose. 24h balance +181. Bun/Crea 17/0.7.\n\nID: afebrile, no abx.\n\nSkin: Intact. Multiple ecchymoses right arm r/t bp cuff, which was switched from left arm r/t pain.\n\nSocial: No family members visited this shift, however patient did speak to someone (not sure of who) on the phone. Pt spoke w/ us about her decision not to have the heart transplant. She said she does not know what, but something does not make her feel comfortable about it. She is also concerned about the rehab period post-op. Pt verbalized that she made & is comfortable w/ her decision, and is ready to deal with any consequences of it.\n\nA/P: 59 yo w/ CHF, volume overloaded, admitted to CCU for Milrinone, diuresis, and tailored therapy. Monitor hemodynamics, & fluid balance. Monitor PTT. Electrolytes needed at 01:00 due to Lasix dose. Support patient and family.\n\nNote entered by: , Student Nurse \n"},{"category":"Nursing/other","chartdate":"2166-04-01 00:00:00.000","description":"Report","row_id":1569258,"text":"CCU NPN 11p-7a\nS: \"I feel okay...I have ankles.\"\n\nO: Please see careview for VS and additional data.\n\nCV: PT V paced with underlying rhythm afib, HR 80-83, NBP 84-94/46-53, MAPs 56-67, Intern , MD aware and will tol MAPs> 55 while pt sleeping. PAP 42-50/20-25, CVP 9-11. This am CO 5.3 (was 4.5) CI 2.83 (was 2.41) SVR 740 (was 996), pt continues on milrinone 0.385 mcg/kg/min, Heparin gtt 1000 units/hr. Pt given 400 mg PO amiodarone for rhythm control. AM labs pending. Pt palp pulses + edema in lower extremities.\n\nResp: Pt LS CTA to crackles RLL, O2 sats 92-95 on room air, RR 16-19, pt + dry sounding, nonproductive cough. Pt denies SOB, resting comfortably/sleeping in bed.\n\nGI/GU: pt abd soft, + BS x 4, no stool this shift. Pt with foley cath draining dark yellow urine, approx 15-210 cc/hr, HO aware. Pt +99.5 cc at midnoc, pt -10 L LOS. Midnoc lasix dose held d/t pt still diuresing with dose given late at ( was due 1600), pt MAPs<60 this am-dose held, HO aware.\n\nNeuro: Pt sleeping throughout most of night, cooperative with care, A & O x 3, MAE.\n\nA/P: 59 y/o female continues on milrinone gtt, BP dropping slightly with MAPS >55, midnoc lasix dose held. CO/CI improved from last set. Continue to monitor rhythm, BP and given meds as ordered/ pt tol. Continue to monitor I&O's, u/o. Follow up wiht am labs and replete as necessary. Continue to assist pt in advancing activity as tol. Continue to provide emotional support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2166-04-01 00:00:00.000","description":"Report","row_id":1569259,"text":"ccu npn\no- afebrile. cv- hr 80s vpaced, no vea. cont. on same milrinone and heparin iv, amiodarone po. isordil, lasix, bisoprolol held in am d/t low bp. bp 80s-90s/. after discussion w/ho, bisoprolol given 2pm with map low 60s. digoxin level added on and pnd. dig load ordered pnd level. 2nd iv in this pm w/plans to d/c pa line. heparin to be held this pm for pa line d/c. pt eval for picc for ?home milrinone. iv to try picc in am. case manager looking into picc/insurance for home milrinone, ?goes through infusion clinic.\nresp- on r/a sats high 90s. l/s clear w/faint exp. wheeze. no sob. u/o adeq to low and concentrated.\ngi- app. fair, no bm.\nms-a+x3, states needs to think about whether or not wants to go home on milrinone, and she was told would need a home health visit qd.\nactivity- oob to chair most day, tol well.\na- bp somewhat higher while awake, tol bisoprolol.\np- ?give lasix depending on bp, check w/ho. start digoxin depending on level. hold heparin for pa line/cordis d/c. oob/PT as tolerated. ?picc . cont. emotional support. f/u insurance, infusion clinic teaching w/picc.\n"},{"category":"Nursing/other","chartdate":"2166-04-02 00:00:00.000","description":"Report","row_id":1569260,"text":"ccu npn 11p-7a\nCarevue System down most of shift. Vital signs kept onto flow sheet, then entered into carevue at 0400 when system available. Written note entered into Pt's green chart. See chart for details.\n"},{"category":"Nursing/other","chartdate":"2166-03-30 00:00:00.000","description":"Report","row_id":1569252,"text":"NURSING PROGRESS NOTE 7P-7A\nS: IT HURTS WHEN I TAKE A DEEP BREATH IN:\n\nO: NEURO: PT. AWAKE AND ALERT, ORIENTED X3. PLEASANT AND COOPERATIVE. MOVING ALL EXTREMITIES. TURNS SELF IN BED. C/O PAIN UNDER LEFT BREAST WORSENING WITH DEEP INSPIRATION. GIVEN OXYCODONE 5 MG PO X1 AND TYLENOL 650 MG PO X1 WITH FAIR RELIEF FROM PAIN. SLEPT IN SHORT NAPS DURING NOC.\n\nCV: SEE FLOW SHEET FOR HEMODYNAMIC #'S. CO/CI STABLE ON PRESENT REGIME OF MEDS; NIPRIDE 2 MCG/KG/MIN, MILRINONE 0.385 MCG/KG/MIN. HR 80 SR NO VEA NOTED. LYTES REPLETED IN EVENING AND REPEAT LABS WNL.\n\nRESP: LUNGS CRACKLES IN BASES WITH EXP WHEEZE NOTED IN UPPER AIRWAYS. O2 SAT ON ROOM DOWN TO 88-89%. PUT ON 2L NC WITH IMPROVING O2 SAT TO 94-96%. DENIES C/O SOB.\n\nGU: URINE OUTPUT TRENDING DOWN AFTER LASIX GTT WEANED TO OFF. I/O (+) 350 OVER 24HRS. (STILL (-) 8L FOR LOS). URINE BLOOD TINGED, CLOUDY. HCT STABLE @ 34. COUMADIN RESTARTED ON . RECEIVING LASIX 80 MG IV BID.\n\nGI: ABD SL DISTENDED, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM . APPETITE FAIR.\n\nSKIN: INTACT, NO BREAKDOWN NOTED. RIGHT ARM HAS SEVERAL ECCHYMOTIC AREAS FROM NIBP CUFF. LOWER EXTREMITY EDEMA LESSENING. NOW 2+ TO KNEES.\n\nA/P: CO/CI STABLE, URINE OUTPUT LESS OFF LASIX GTT. STILL NEG. PAIN UNDER LEFT BREAST ? PLEURITIC. FAIR RELIEF FROM PAIN WITH OXYCODONE.\n? WEAN NIPRIDE AS CI TOL (KEEP CI > 2.2). MONITOR LYTES AND REPLETE AS NEEDED, UPDATE PT. ON PLAN OF CARE PER TEAM.\n"},{"category":"Nursing/other","chartdate":"2166-04-07 00:00:00.000","description":"Report","row_id":1569267,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\n\n\nS- \"I STILL HAVE A BIT OF HEADACHE BUT THOSE MEDICINES HELP \"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\nCV- VS REMAINS STABLE- HR- 90'S VPACED WITH OCCASIONAL PVC'S.\nBP- 95/63- NO HYPOTENSION THIS SHIFT AT ALL.\nREMAINS ON HEPARIN GTT 1000U AND MILRINONE 0.375.\nRECEIVED 20 KCL FOR K-3.7\n\nRESP- 02 SATS >95% ON 2L NP, SOME CX AT BASE AND REMAINS TACHYPNIC WITH EXERTION. NONPRODUCTIVE COUGH.\nRECEIVED 1 L NS FOR (+) BUMP CREATININE AFTER LASIX AND (+) DEHYDRATION PRESUMED. I/O (+) 1700CC AS OF 12AM. NO DISTRESS FROM RESP STANDPOINT.\n\nID- AFEBRILE ALL DAY YESTERDAY AND TONITE- NO VANCO SATURDAY NITE OR SUNDAY MORNING D/T HIGH LEVELS- CHANGED TO Q 24/RENAL DOSE- TO RECHECK TROUGH WITH AM LABS. D/C FLAGYL FOR R/O S DIFF. REMAINS ON IMIPENEM Q 6 HOUR TO TREAT GM (-) RODS BACTEREMIA WITH PYLONEPHRITIS AS SOURCE.\n\nGU- OOB X 2 TO COMMODE FOR UO- REMAINS AMBER IN COLOR AND MINIMAL AMOUNTS. NO FURTHER IV FLUID THIS SHIFT.\nSENT URINE LYTES FOR ASSESSMENT OF HYPONATREMIA /BUMP IN CREATININE AND BETTER ASSESS FLUID STATUS.\n\nGI- LIX STOOL X 1 WITH URINE- UNABLE TO TEST FOR GUAIC.\nTAKING IN MEDS AND LIX, NO FOOD ON EVES/NITES CURRENTLY.\nNO NAUSEA.\n\n PT IN GOOD SPIRITS THIS EVENING- C/O HEADACHE BUT BETTER CONTROL OF PAIN WITH FIORICET. CURRENTLY SLEEPING AFTER CLONAZEPAM AND ZOLOFT.\nSPEAKING A LOT ABOUT CONCERNS WITH RETURN TO HOME ON IV MILRINONE ETC, SUPPORT SERVICES TO BE PROVIDED. APPEARS ENCOURAGED FEVERS GONE AND INFECTION CONTROLLED BY CURRENT ANTIBX.\n\nA/ PT CURRENTLY HEMODYNAMICALLY STABLE S/P CHF EXACERBATION C/B UROSEPSIS.\n\nCONTINUE ANTIBX AS ORDERED TO TREAT GM (-) RODS.\nWATCH FOR FURTHER FEVERS OR ANY HEMODYNAMIC COMPROMISE.\nRECHECK AM TROUGH LEVEL VANCO DOSE- GIVE IF LEVEL WNL.\nASSESS URINE LYTES FOR ? MORE FLUID BOLUSES TODAY.\n? RELOAD COUMADIN TODAY, CONTINUE HEPARIN GTT AT 1000U PENDING AM PTT LEVELS.\nPT IS DNR,\nKEEP PT AWARE OF PLAN OF CARE, CONTINUE D/C PLANNING\n\n"},{"category":"Nursing/other","chartdate":"2166-04-07 00:00:00.000","description":"Report","row_id":1569268,"text":"Nursing Progress Note\nS: \" I still have this awful headache.\"\n\nO: Please see flow sheet for objective data. Milrinone d/c'd after rounds secondary to severe headaches. Tele AF with periods of V pacing. SBP > 90. IV heparin dc'd at 1 pm for ? aspiration of neck. Ultrasound done of neck and L arm. IV Heparin restarted at 1000u/hr at 5pm.\n\nResp: Lungs with crackles throughout the bases. Pt is dyspneic with minimal exertion although sats unchanged 96-99% on 2 l nasal prongs.\n\nNeuro: Pt is alert and oriented. Able to MAE. OOB to comode several times with minimal assistance. Conts to c/o headache more severe this pm after ultrasound. Given fioricet 2 tabs with some effect.\n\nGU/GI: Appetite remains poor. Denies any nausea. Taking in mostly liquids. Abd is soft with bowel sounds present. 1 liquid stool today.\nVoiding in sm amts of amber to red urine. No further IV fluids today. Diuretics held today.\n\nID: TM 99.4. Vanco and Imipenem dc'd. Started on Ceftriaxone 1 gm Q 24hr. ( Urine sensitivity).\n\nA&P: Milrinone dc'd secondary to severe headaches. Monitor BP and urine output. ? dopamine Bp drops. Fioricet prn headaches. Cont POC.\n"},{"category":"Nursing/other","chartdate":"2166-04-08 00:00:00.000","description":"Report","row_id":1569269,"text":"CCU NPN 1900-0700\nS: \" My head still hurts \"\nO: TM 99.8po. on ceftriax q24hr. (first dose 4/11)\nHR 80 Vpaced. BP 90-117/60's. off milrinone gtt since d/t headaches.\nheparin at 1000uhr. AM labs pnd at 0600.\n\nvoided x1 for 300cc amber urine. neg. 300cc for and total 12L neg. LOS.\npt. c/o SOB x1 in middle of night but also with increase in headache and due for pain meds. lung exam unchanged. sats good. discussed with intern and did not give lasix. intern stated that prelim. plan for AM is to restart milrinone gtt since headache has not abated off gtt.\nsats 98% on 2lnc. RA sat same. LS crackles right base to 1/3 up.\nRR 30-40.\n\nvery dyspneic with any activity. does not sleep well. oxycontin 2tabs in eve and then flouricet repeated at 0330. pt. reports this morning that headache feels the same- has not abated. sleeping in short periods. short periods of apnea. sats stable.\n\n assist OOB to commode.\n\nA/P: AM labs pnd. poor u/o. no lasix. ? plan to restart milrinone gtt. monitor and assess headache. pain meds.\n\n\n"},{"category":"Nursing/other","chartdate":"2166-04-10 00:00:00.000","description":"Report","row_id":1569277,"text":"7p-11p CCU Nursing Progress Notes\nC/V: on Dopamine 2.5mcg/kg/min. HR 80-81 V-paced, no ectopy noted. BP 101/65 - 105/67.\n\nNeuro: A&Ox3, cooperative. no c/o pain or headache.\n\nResp: On room air maintaining sats high 90's-100. RR 19-22.\n\nGI/GU: foley draining clear dk yellow urine, hourly urine output decreasing since :00 (140 -> 120 -> 26cc/hr). +bs, -bm. Patient ate 90cc Jello, drank 220cc cranberry juice.\n\nID: afebrile, cont. on Ceftriaxone q24h.\n\nSocial: and sister called.\n\nAccess: 22 r forearm, flushed and clamped. PICC infusing Dopamine 2.5mcg/kg/min.\n\nA: Monitor headache, nutrition & fluid status.\nP: ? plan to move to floor tomorrow.\n\nNote entered by: , Student Nurse \n"},{"category":"Nursing/other","chartdate":"2166-04-11 00:00:00.000","description":"Report","row_id":1569278,"text":"CCU NPN 11p-7a\nS: \"I still have the headache.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 80-81 AV paced, NBP 95-107/36-72, pt continues on dopamine gtt 2.5 mcg/kg/min. AM labs pending.\n\nResp: Pt RR regualar and even 19-22 at rest, RR up to 30 with ambulation to commode, O2 sats 94-100 on room air.\n\nGI/GU: Pt abd soft, +BS x4. Pt with lg amt loose brown stool x 1. Pt with foley cath draining clr dark yellow to yellow urine 20-225 cc/hr. Pt -355cc at midnoc, - cc LOS.\n\nNeuro: Pt alert and oriented, cooperative with care. Pt ambulated OOB to commode x 1 overnoc, pt steady on feet. Tylenol given x 1 for headache, pt refused morphine. Pt did not c/o pain until asked if in pain.\n\n\nID: Pt afebrile, cont on abx.\n\nA/P: Pt continues on dopamine with adequate MAPS and u/o. Continue to monitor hemodynamics, continue to monitor u/o and resp status. Continue to follow lytes and LFTs, continue to assist pt in activity and enc nutrition. Monitor HA and provide pain meds and emotional support. Continue with plan per CCU Team.\n\n\n"},{"category":"Nursing/other","chartdate":"2166-03-28 00:00:00.000","description":"Report","row_id":1569249,"text":"ccu npn\no-id- afebrile.\ncv- hr 70s afib in am, pacer rate increased to 80 by ep and then converted to sr with pacing w/occ to freq pvcs, more in am vs occ. pacing in am. pads 36 to 28, cvp 23 to 14, co 4.4, up to 5.3 this pm ci 2.73, svr 863. hct 35.2, ptt 78.9, inr 1.6. cont. on same doses nipride, heparin, milrinone, lasix. diuresing well in am, then u/o up to 300-575cc/hr this pm. i+o neg about 1500cc currently. k- 3.6, re'd 40meq (started on nocts) kcl iv and then 40meq kcl po, repeat lytes pnd this pm.\nresp- on 3l sats 96-100. l/s clear with cxs/coarse sounds lower, esp. r. sob on exertion more in am. u/o as above.\ngi-abd soft w/bowel sounds. app fair to good, limiting po fluids well.\nms- a+o x3, slept in naps off/on in am.\nskin- has ecchymosis r arm bp cuff changed to l arm, small r hip. has no breakdown. repos. side to back per pt. comfort, moves self around bed also.\nsocial- fx called, updated on pt's condition and plan. teaching done w/pt also regarding progress, pa line, meds, etc. understands.\na- diuresing well. ci improved with increased hr, more pacing.\np- cont. same iv meds. follow rhythm, bp, co/ci/svr, diuresis. check lytes sent, replace as needed.\n\n"},{"category":"Nursing/other","chartdate":"2166-03-29 00:00:00.000","description":"Report","row_id":1569250,"text":"NURSING PROGRESS NOTE 7P-7A\nS: \"I CAN'T BELIEVE HOW SWOLLEN MY LEGS ARE\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3. PLEASANT, COOPERATIVE. MOVING ALL EXTREMITIES.\n\nCV: HR 82-86 SR WITH OCC PVC. BP 94/49-102/64. PA 60/21-55/20 CVP 6-11. DENIES C/O CP. REMAINS ON NIPRIDE 2.2 MCG/KG/MIN, LASIX DECREASED TO 5 MG/HR, HEPARIN 1000 UNITS/HR, MILRINONE 0.385 MCG/KG. LOWER EXTREMITIES 3+ PITTING EDEMA.\n\nRESP: O2 3L VIA NC. CRACKLES NOTED IN BASES. OCC CONGESTED COUGH, NON PRODUCTIVE.\n\nGU: URINE CLEAR YELLOW. I/O (-) 2.5 L OVER 24 HRS. (-) 6.6 L FOR LOS.\n\nGI: ABD SOFT, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM .\n\nSKIN: INTACT, NO BROKENS AREAS.\n\nC/O PAIN AT SG CATH (RIGHT IJ). GIVEN TYLENOL WITH RELIEF FROM PAIN. SLEPT IN SHORT NAPS OVERNIGHT.\n\nA/P: STABLE ON PRESENT MEDS, DIURESING WELL. MONITOR LYTES, REPLETE AS NEEDED. MAINTAIN CI 2.2. UPDATE PT. AND FAMILY ON PLAN OF CARE.\n"},{"category":"Nursing/other","chartdate":"2166-04-06 00:00:00.000","description":"Report","row_id":1569265,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\n\nS- \" I NEED TO GET UP SO QUICK TO MAKE THE BATHROOM..I DON'T HAVE TIME TO CALL YOU..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE WITH HR- 90'S V PACED, OCC VEA ON MILRINONE 0.375, HEPARIN GTT 1000U/HOUR. BP- 95/55- 100/60.\nNO HYPOTENSION OR ARRYTHMIAS THIS SHIFT.\nAM LABS PENDING CURRENTLY\n\nRESP- O2 SATS ALL > 95% ON 2L NP- TACHYNPNIC WITH ANY EXERTION- CX AT BASE- LEFT > RT.\nGIVEN 80 LASIX IVP D/T I/O (+)500CC\nOF NOTE, NO FOLEY CURRENTLY TO PROVIDE HOURLY ACCURATE U.O.\nCOMFORTABLE AT REST, NONPRODUCTIVE COUGH\n\nID- SPIKED AGAIN TO 102 9P- GIVEN TYLENOL 650- REMAINS ON IMIPENUM TO COVER GM (-) RODS. HELD 12AM VANCO DOSE D/T HIGH TROUGH LEVEL 33.\nHO AWARE.\nNO CHANGES TO ANTIBX REGIMEN CURRENTLY- STOOL SPECIMENS FROM MICRO PENDING- REMAINS ON FLAGYL TID PO.\n\nGU- FOLEY CATH D/C ON DAYS.\nPT FOUND TO BE GETTING OOB ON OWN IN SPITE OF INSTRUCTION TO CALL FOR ASSIST.\nAMBER DARK URINE X 2 AFTER LASIX- TOTAL ABOUT 500CC IN ALL WITH LIX STOOL AS WELL.\n\nGI- LIX STOOL X 2- UNABLE TO TEST/GUAIC- UP TO COMMODE ON OWN .\nC DIFF R/O PENDING\nCONTINUES ON FLAGYL\nPOOR APPETITE, TAKING MEDS AND LIX WITHOUT PROBLEM\nNO NAUSEA\n\nMS- SLEPT WELL TONITE\nC/O HEADACHE- GIVEN TYLENOL\nUNDERSTANDS CURRENT PLAN OF CARE AND SOURCE OF INFECTION\nUNDERSTANDS NEED FOR ASSIST TO GET UP TO COMMODE.\n\nA/ PT S/P LONG COURSE FOR CHF EXACERBATION/CM CURRENTLY ADMITTED TO CCU FOR SEPSIS/PYLONEPHRITIS.\n\nCONTINUE CURRENT ANTIBX TX\nWATCH FOR FURTHER RESULTS OF SPECIMENS TO MICRO\n? D/C FLAGYL IF (-) STOOL.\n? RECHECK VANCO LEVEL PRE-12NOON VANCO DOSE.\nCONTINUE CV MEDS AS ORDERED- WATCH HEMODYNAMICS CLOSELY.\nCONSIDER RE-LOAD COUMADIN IF CONTINUES TO BE HEMODYNAMICALLY STABLE AND IN NO NEED OF INVASIVE LINE PLACEMENT\nPT IS DNR.\nKEEP PT AWARE OF PLAN OF CARE, SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2166-04-06 00:00:00.000","description":"Report","row_id":1569266,"text":"ccu nursing progress note\ns: the headache is somewhat better after that medicine(fiorocet)\no: pls see carevue flowsheet for complete vs/data/events\nid: t max 100.3. wbc 15. cont on imipenum. vanco to cont but level 21.9 for trough before scheduled q 24hr dose. level will be checked in am and dosed as indicated. po flagyl dc'd as cdiff specs have been neg to date and no stool since last night. contact precautions dc'd.\ncv: hr 80-90s paced, occ pvc. k 3.4, repleted w 40 po and k 3.7 this eve. will replete additional 20meq. bp 90-100/50-60. not orthostatic this am. cont on milrinone, dose unchanged.\nheparin at 1000units/hr. ptt 92. inr 1.8.\nresp: rr 20s. labored w activity. basilar cxs. sats 95-100% on 2l nc.\ngi: ate toast this eve. good po intake of fluids. no n/v. no stool this am.\ngu: cr bumped to 1.9(1.4). na 121(124, 128, 132). felt pt dry. rec'd 1l ns at 150cc/hr over course of day. will resend unrine lytes and chemistries this eve. voiding drk brn cloudy urine at bedside commode.\nms: alert. c/o mod-severe ha . underwent head ct, no acute process noted. med w oxycodone ^to 10mg without relief. rec'd dose of fiorocet w some effect. sister visited.\na: ha. hyponatremia, cr bumped. fever abated.\np: follow response to hydration, assess for resp compromise. med for comfort. supprort to pt.\n"},{"category":"Nursing/other","chartdate":"2166-04-09 00:00:00.000","description":"Report","row_id":1569274,"text":"CCU NURSING 1500-1900\nS. \"I'VE NEVER HAD A HEADACHE LIKE THIS BEFORE - ITS THROBBING!\"\n\nO. SEE CAREVUE FOR VS/OBJECTIVE DATA\n\nCV: HR 80 V-PACED W/PVC'S/OCCS COUPLETS, BP 99-106/50-60'S ON DOPAMINE @ 2.5MCGS; HEPARIN REMAINS AT 800U/HR W/PTT W/I RANGE 83\n\nRESP: SATS 98-99% ON 2L NC, SATS 89-92% ON ROOM AIR, LUNGS - FEW CRACKLES AT BASES\n\nALT COMFORT: PT CONTINUES C/O HA - 2MG IV MSO4 GIVEN X1 W/SOME RELIEF - SLEEPING OFF/ON\n\nGI: LIVER US REVEALED INFLAMMATION OF COMMON BILE DUCT PER TECH\nNO STOOL\n\nGU: FOLEY DRAINING YELLOW URINE I/O'S EVEN FOR DAY\n\nSOCIAL: - WILL CALL IN AM\n\nA: VS UNCHANGED AFTER CHANGE FROM MILRINONE TO DOPAMINE\n CONTINUED HA - UNKNOWN ETIOLOGY\n\nP: MONITOR VS, CONT DOPA/HEPARIN, ASSESS HEADACHE - MEDS FOR COMFORT AND ASSESS EFFECTIVENESS - CONT FOLLOW LFT'S, ASSESS MENTAL STATUS,\nCONT SUPPORTIVE CARE.\n\n"},{"category":"Nursing/other","chartdate":"2166-04-10 00:00:00.000","description":"Report","row_id":1569275,"text":"CCU NPN 1900-0700\nS: \" I still have a headache \"\nO: afeb. contin. on ceftriax.\nHR 80's V paced with occas. PVC's. one run of VT 8bts, rate 150. asympt. K+ 4.4. BP 97/62- 109/69.\ncontin. on dopamine at 2.5mcq/k/min. and heparin 800u/hr. AM PTT 69.\ndig. contin. on hold. contin. on aldactone, bisoprolol. amio QD.\n\nGU: u/o 60-75cc/hr. neg. 200cc for , currently ~ even since MN.\nGI: only asking for cranberry juice. not hungry for boost. discussed need for more nutrition. pt. states she will try to drink nutritional supplements.\nResp: LS crackles bases which is baseline. sats 99% on 2lnc. DOE noted even with sitting up, etc. RR 30-40\n\npt. slept well tonight, wakes easily to name and appears less lethargic when awake. contin. to c/o headache but only when asked about it. offered morphine but pt. refused- able to fall asleep again.\n\nA: improved u/o on dopa. headache unchanged but tolerable to pt. no morphine since . poor nutrition status- enc. supplements.\nOOB QD as tol. follow plan per interdis. team.\nP:\n"},{"category":"Nursing/other","chartdate":"2166-04-10 00:00:00.000","description":"Report","row_id":1569276,"text":"Nursing Progress Note\n\nS: \" My headache feels a little better.\"\n\nO: Please see flow sheet for objective data. Dopamine remains at 2.5mcgs/kg/min. IV Heparin dc'd at 12n d/t elevated INR. Tele paced rhythm with occ AF. Mg 1.6 repleted.\n\nResp: Pt conts to have dyspniec with exertion. Lungs scattered rales at bases. O2 sats 95-98% on RA.\n\nNeuro: Pt is alert and oriented. Less sleepy today. Conts to c/o headache although much less than over past couple of days. Denies need for any meds. OOB to chair with minimal assistance. Slightly unsteady on her feet. OOB ambulating x's1 short distance with PT.\n\nGU/GI: Appetite remains poor. Pt taking in good amts of liquids very little solid food. Denies N/V. Abd is soft with bowel sounds present. Sm amt of brown liquid stool this am. LFT's trending down. Foley draining yellow urine with some sediment. Creat .8. Diuretics held today. Aldactone dc'd d/t sodium 129.\n\nA&P: Tolerating dopa after dc of Milrinone. I&O even today. Encourage po intake. Encourage ambulation. Cont with POC.\n"},{"category":"Nursing/other","chartdate":"2166-03-27 00:00:00.000","description":"Report","row_id":1569246,"text":"CCU NSG NOTE: ALT IN CV\nS: \"I've had this before and it was an ordeal\"\nO: For complete VS see CCU flow sheet.\nThis 59y old woman was transfered to CCU for swan placement and taylored therapy. THis pt with known heart failure with EF <15% was admitted to 6 with increasing sob. She was started on milronone and diuresed, but remains profoundly anasarcic.\nCV: HR has been in 70s, afib, multiple PVCs and occasional paced beats. BP stable in 1-teens/ 60-70s. She conts on milrinone .385 mic/kilo. She was consented for swan placement, which is occuring now. SHe has been K+ replaced and is receiving IV mag now.She is usually on coumadin, but has been off it since yesterday.\nRESP: She has bbr, but sats 97-99% on RA\nRENAL: Foley was inserted. I & O from Fa 6 added up and pt is ~2 liters neg LOS. SHe received lasix 40IV at 0830 this am.\nGI: Pt has been NPO\nMS: Pt A & O X 3. She is divorced. SHe has 1 son who is her proxy, but with whom she does not communicate. SHe has 2 neices who are very close with her and who will be in tonight.\nA: End stage heart failure pt admitted for swan\nP: Get numbers once swan in. Confirm with pt if she still wants son to be proxy. Monitor for change. Careful I & O\n\n"},{"category":"Nursing/other","chartdate":"2166-03-27 00:00:00.000","description":"Report","row_id":1569247,"text":"CCU Nurse Progress Notes 7a-7p\n59 yo patient transferred today from 6 for swan placement and diuresis. Full code.\n\nCV: Swan placed, numbers at placement were (16:00): pap 79/36, pcwp 36, cvp 24, co 3.8, ci 1.87, svr 1221, MV sat 55%. Started on Nipride gtt (titrate to MAP >= 60), at 1mcg/kg/min numbers were: pap 73/36, pap mean 49, cvp 22, co 3.6, ci 1.77, svr 1267, MV sat 50%. Increased Nipride to 3mcg/kg/min and will recheck numbers. Lasix gtt started at 5mg/hr, increased to 10mg/hr. Labs (18:00) Mg 1.7, repleting w/ 4gm Mag Sulfate IV. K 3.4, will replete w/ 60mEq sliding scale when Mg is complete. Heparin gtt at 1000units/hr, started without a bolus. HR 73-85 A-fib, occ. PVC's., BP 96-116/54-74. Pt denies CP/SOB. Dig level 0.7, was held on floor for elevated level, not yet reordered here.\n\nNeuro: Pt was given 2mg IV Ativan, total 75mcg fent and 1.5mg versed during swan insertion. Pt remains A&Ox3, calm & cooperative. C/O HA, given tylenol.\n\nResp: RR low-mid 20's. O2 sat high 90's-100, room air. LS RUL, LUL expiratory wheezes, RLL, LLL crackles. 21:00 placed on 3L nc d/t sats dropping to 89% when asleep.\n\nGI/GU: +bs, -bm. Foley draining clear dark, yellow urine. Given 5mg/hr Lasix IV drip at 19:00, increased to 10mg/hr. UO up to 90-140cc/hr last couple hours. BUN/Cr 23/0.7\n\nSocial: This shift, pt changed proxy to her two nieces, form completed and in front of chart, copies given to pt/neices. Contact info on board in room for spokesperson. The two nieces were in to visit, and the patient's son called.\n\nID: afebrile, no abx. c-diff neg.\n\nSkin: intact.\n\nA/P: 59 yr old with CHF, volume overloaded, transferred to CCU for tailored therapy, swan, IV milrinone, Nipride, lasix, Monitor hemodynamics, fluid balance, lytes, and PTT needed at 01:00. increase Milrinone if #'s not improved on higher Nipride dose. Support pt and family.\n\nNote entered by: , Student Nurse \n"},{"category":"Nursing/other","chartdate":"2166-03-28 00:00:00.000","description":"Report","row_id":1569248,"text":"Neuro a/ox3 slept comfortably most of the night\ncvs HR 60-70's afib with pvc K+ 3.4 tx 60 meq kcl IV repeat K+ pnding, bp 96/64-110/66. On nipride 2.0 mcg/kg/min, lasix 10 mg IV q hr, milronone .385 mcg/kg/min and heparin 1000u IV C.O. 3.4, CI 1.82 SVR 1412, CVP 20, P/D 70/31 nipride increased to 2.5 mcg/kg/min CO 5.0, CI 2.67, SVR 896, CVP 16 P/D 60/30. PTT within parameters am pnding skin w+d pitting edema to LE pp+\nResp 3lnp lungs faint exp wheeze b/l am faint crackles b/l throughout o2 sats 96-99%, mixed venous 55-68%\ngu lasix 10 mg IV gtt neg 1194 from mn to 0500 cr.7 bun 11\nGI abd snt bs+ no stool alt 61, ast 86, ld 327, total bili 2.3 alk phos 124\nID wbc 8 afebrile\na. cmp ef < 15%, severe MR \nafib\nLFT elevated\np. monitor CO, CI, titrates gtt accordingly, replete lytes per scale, IV heparin, monitor LFT abd exam\n"},{"category":"Nursing/other","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":1569255,"text":"ADDENDUM\nO:BP TRENDING LOWER. MILRINONE DOWN TO 0.18MCG/KG/MIN. REPORTED TO DR. . PT , SBP SLT IMPROVED WHILE AWAKE. MHR INTERMITTANTLY V-PACING W/ UNDERLYING AFIB. EKG DONE, MD NOTIFIED.\n"},{"category":"Nursing/other","chartdate":"2166-04-04 00:00:00.000","description":"Report","row_id":1569261,"text":"Nursing Progress Note\n\n59yo women with known CAD s/p Mi , s/p CABG x's1 severe MR & TR,pul HTN, PAF EF 15% with h/o VT with placement of BIV pacer. Several admits for CHF excacerbation. Recent admit to CCU for tailored therapy with transfer to 6 on . Plan was for home infusion of Milrinone. PICC was placed with much difficulty. Today pt spiked at temp to 102.4 with elevated WBC. Urine and bld cultures sent. Started on Vanco and Zosyn pending cultures. Hemodynamcially stable so far. Concern for sepsis with little reserve.To be transfered to CCU for close observation. Pt has been made a DNR/DNI and she has refused a heart transplant.\n"},{"category":"Nursing/other","chartdate":"2166-04-05 00:00:00.000","description":"Report","row_id":1569262,"text":"CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\n S- \" I AM SO TIRED I JUST WANT TO SLEEP\"\n\nO- SEE FLOWSHEET FOR ALL OBJECTIVE DATA\nPLEASE REFER TO EXCELLENT / MEDICAL NOTES FOR DETAILS R/T EXTENSIVE AND COMPLICATED HPI/PMH.\n\nIN BRIEF, THIS IS A 59 YR OLD PT WITH EXTENSIVE CV HX SIGNIFICANT FOR\nMI, CAD, S/P CABG AND ISCHEMIC/DILATED CM (EF- 15%) AS WELL AS SEVERE TR/MR. SHE IS S/P BIVENT PACER/ICD INSERTION, PULM HTN, RESTRICTIVE LUNG DX, PAF, LAD DISSECTION AND ANEURISM. PT ALSO HAS DX- ON SYTHROID AND S/P THYROTOXICOSIS D/T AMIO.\n\nTHIS PT WAS ADMITTED TO CV STEPDOWN FOR CHF EXACERBATION WITH C/O SOB AND FEVERS FOR SEVERAL DAYS PTA. SHE WAS STARTED ON INOTROPY AND DIURESIS WITHOUT MUCH IMPROVEMENT AND TRANSFERED TO CCU ON FOR PA LINE AND FINE TUNING OF HER MEDICAL REGIMEN. PT WAS STARTED ON NIPRIDE IN ADDITION TO HER MILRINONE WITH 12 L DIURESIS AS A RESULT AND WEANED OFF THE NIPRIDE, STARTED ON DIGOXIN WITH HOPES OF A MILRINONE WEAN. SHE DEVELOPED PAF AND WAS STARTED ON AMIODORONE LOAD WHICH IS FINISHED AS OF AND HER BIVENT PACER/ICD WAS INTERROGATED AND ADJUSTED TO ALLOW FOR BETTER SYNCHRONY.A PICC LINE WAS INSERTED IN RT AC FOR PLAN FOR D/C TO HOME ON MILRINONE AND ON , PT DEVELOPED FEVERS TO 102.9 WITH WC AND BANDEMIA. SHE WAS PAN CULTURED AND STARTED ON VANCO/ZOSYN/PO FLAGYL FOR R/O CDIFF( S/P SOME GI COMPLAINTS/ABD PAIN, EMESIS/NAUSEA, LOOSE STOOL), AND SENT TO CCU 7P .\nPT WAS TX WITH TYLENOL, CONTINUED ON MILRINONE/HEP/DIG/AMIO AND DID NOT EXHIBIT ANY CV INSTABILITY. NO FURTHER FEVERS,BUT ID RECOMMENDED CHANGING OVER FROM ZOSYN TO IMIPENUM.LATER THIS SHIFT, B/C WERE CALLED BACK FOR (+) GM (-) RODS AND HO CALLED. NO CHANGE TO THERAPY AT THIS TIME, PT REMAINS CV STABLE AND AFEBRILE, HERE FOR CLOSER MONITORING.\n\nREVIEW OF SYSTEMS:\nPLEASE REFER TO CAREVUE/FLOWSHEET.\n\nCV- VSS- BP-90-108/50-60 WITH HR- 90'S V PACED. RECEIVED 3 GM MG/40 KCL ON EVES FOR LOW LEVELS.\n\nRESP- CLEAR- NO TROUBLE WITH SOB, BREATHING AT MID 20'S, O2 SATS- 97%.\nOFF ALL DIURESIS. REMAINS ON 2L NP.\n\nID- AFEBRILE- SEE ABOVE-\nIMIPENUM, VANCO, PO FLAGYL.\nGM (-) RODS BC.\nCONTACT PRECAUTIONS FOR R/O CDIFF.\n\nGU- FAIR UO- 20-30CC/HOUR, DARK AMBER CLEAR VIA FOLEY.\n\nGI- TOOK PM MEDS WITHOUT PROBLEM, NO NAUSEA THIS SHIFT, NO STOOL- RECEIVED ANZIMET UPON TRANFER FROM 6, (+) BOWEL SOUNDS.\nDECLINING ANY FOOD/CRACKERS/TOAST AT THIS TIME,,JUST WANTS TO SLEEP.\n\"FEELS LOUSY\"\n\n PT LETHARGIC FROM ANZIMET AND OVERALL FEELING \"LOUSY\"\nA AND O X 3- SISTER CALLED AS WELL AS FRIEND- SPOKE TO FRIEND ON THE PHONE. SLEPT REST OF SHIFT,\nDENIES PAIN, SOB.\n\nA/ PT WITH EXTENSIVE CV HX/CM CURRENTLY ADMITTED WITH R/O SEPSIS\n\nCONTINUE TO CLOSELY MONITOR CV STATUS AS WELL AS ? FEVER/RESULTS OF URINE AND STOOL SPECIMENS. CONTINUE MILRINONE/DIG/HEPARIN AS ORDERED.\nREPEAT BLOOD CULTURE THIS AM WITH AM LABS.\nREPLETE LYTES AS NEEDED.\nWATCH RENAL FX/BUN/CREAT/UO- ? NEED FOR GENTLE HYDRATION IF WORSENS IN SETTING OF S/P FEVERS ETC.\nCONTINUE ANTIBX AS ORDERED.\nCOMFORT/SUPPORT\nPT IS DNR/DNI AS OF .\nC/O TO FLOOR\n"},{"category":"Nursing/other","chartdate":"2166-04-05 00:00:00.000","description":"Report","row_id":1569263,"text":"CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\n(Continued)\n ONCE MEDICALLY APPROPRIATE.\nCONTACT PRECAUTIONS UNTIL CDIFF R/O.\nKEEP PT AWARE OF PLAN OF CARE.\n\n"},{"category":"Nursing/other","chartdate":"2166-04-05 00:00:00.000","description":"Report","row_id":1569264,"text":"ccu nursing progress note\ns: i just feel chills, like when you have the flu\no: pls see carevue flowsheet for complete vs/data/events\nid: t spike to 102.0 po. wbc to 20(18). gr neg rods id'd in bld cultures from . 2 sets of cultures pend from .(1 of which was drawn peripherally this am). urine poss source w ua +wbc and bacteria. need further speciation. cont on vanco(needs trough before mdnoc dose), po flagyl and imipenum.\nhad abd ct which noted l pylonephritis.\ncv: hr 80-100, mostly vpaced. occ intrinsic rhythm when>90. bp 90-105/50-60. cont on milrinone at .38mcg/kg/min. heparin at 1000units/hr. inr 1.6, ptt 78.\ndig level 3.4 this am and dose was held.\nna 124(128). holding lasix in setting of bacterimia.\nk 5.0, mg 2.1.\nresp: labored w min exertion. sats >95% on 2l nc. faint cxs at bases.\ngi: anorexia, declining any food. had 2 lrg liquid stools. sample sent for cdiff. taking ice chips, encouraged po's as tol.\ngu: concentrated urine w o/p 10-20cc/hr. foley dc'd per ccu team's order at 2pm. pt dtv 8-10pm. cr 1.4(1.1).\nskin: intact. access: l single lumen picc, 1peripheral.\nms: lethargic most of day. cooperative. oob w assist to use bedside commode. c/o headache most of day w little relief from oxycodone +/- tylenol. c/o photophobia as well. c/o l flank pain mostly w palpation.\nsocial: friend visited. called.\na: pyleonephritis and bactermia. bp stable. hyponatremia and ^cr...likely dry intravasc.\np: follow fever. await further id of organism. monitor hemodynamics and volume status. med for comfort. support to pt.\n"},{"category":"Nursing/other","chartdate":"2166-04-09 00:00:00.000","description":"Report","row_id":1569272,"text":"CCU NPN 2300-0700\nO:\nTM 99po. contin. on ceftriax q24hr. WBC 15.\nBC/urine pnd from .\n\nHR 80's vpaced. occas. PVC. underlying rhythm NSR. contin. on amio 400mgpo. BP 99/57-110/58. milrinone .38mcq/k/min and heparin at 1000u/hr. PTT 133.6- hep. off x1hr and will restart at 800u/hr at 0630. K+ 3.7- 40KCL IV.\nu/o 50-100cc/hr, concentrated. even for and currently neg. ~ 200cc since MN.\n\nsats 88-90% on RA , occas. apnea noted. 2lnc placed with sats improving to 98%. crackles at bases. shallow breathing pattern. RR 30-40.\n\npt. contin. to c/o headache, states that she did get some relief from morphine. 2mg x2 during night. slept better tonight.\n\nno stool. thirsty. asking for juice.\n\nA/P: slept better- better paincontrol with morphine. VSS. u/o improved on milrinone. K+ repletion.\ncheck PTT at 1230. OOB today. assess effectiveness of morphine.\n"},{"category":"Nursing/other","chartdate":"2166-04-09 00:00:00.000","description":"Report","row_id":1569273,"text":"ccu npn\no- id-afebrile. cont. abx, recent c+s pnd.\ncv- hr 80s vpaced with occ to freq pvc, occ. couplet. bp 100-114/50s. k-re'd total 40meq iv/po for 3.7, mg 1.7 re'd 1 amp iv. po4 1.3, re'd neutraphos. hct 32.1. milrinone d/c'd and started on dopamine about 1hr later at 2.5mic/kg/min without change in bp/hr/vea. u/o slightly less, still adequate, ho aware, prefered not to increase dopamine. ptt 83.8 on decreased heparin 800units/hr.\nresp- on r/a sats high 90s most day, down to 90-92 this pm while asleep. l/s cxs/coarse sounds lower bilat. sob with any exertion in am, even talking, less sob this pm. u/o about 50cc/hr. i+o goal even day, about even 2pm.\ngi-abd soft w/bowel sounds. poor appetite, ate banana in am, taking juice. ordered choc. boost and boost pudding, none arrived, called this pm for boost. inc.small smear liquid stool in am, yellow/brn.\nlfts up, down to ultrasound for liver us 3pm.\nms/pain-a+o x3, sleepy all day, somewhat more awake this pm. c/o still h/a, re'd morphine 2mg iv x1 11:30am w/some relief.\nskin- intact. lots ecchymosis, esp arms.\nactivity- oob to chair most day, tol well, needs assist of 2 to stand/pivot,unsteady on her feet. back to bed this pm for liver us.\naccess- picc patent, dsg/cap changed. peripheral iv for routine change, unable to restart, iv coming to try to restart.\na- changed to dopamine. lfts elevated, down for liver us.\np- cont. dopamine, increase if u/o or bp falls, sats drop. monitor also for increased hr/bp, vea. o2 prn. f/u liver us results. goal i+o even. enc. try boost/boost pudding. enc. oob as tolerated. f/u new iv per iv team.\n\n"},{"category":"Nursing/other","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":1569256,"text":"ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\n\ns: \"it's hard to believe i can get this tired just sitting up\"\no: cv: vpaced in the 80s. underlying rhythm afib. no vea. maps cont low 54-62 on low dose milrinone. holding am meds d/t hypotension. discussed on rounds team concerned that new recurrent afib (poss brought on by milrinone) was contributing to hypotension and felt bp may improve off milrinone and then add back oral agents. milrinone dc'd at 10am. no change in bp appreciated. ci 1.9(2.5 on milrinone), svr 1000(850 on milrinone). bp starting to trend up in afternoon w maps to 65 and systolic 85/ . will resume valsartan at lower dose if map >60. then eval other oral agents.\n\npt oob all morning, transfered w min assist. had trans c/o dizzyness while sitting up and bp <80/ . but did not appear to be postural.\npap 40-50/22-27, cvp 7-12.\nheparin at 1000units/hr. ptt 82. inr 1.4. cont coumadin dosing daily. plan to possibly remove pa line this eve(discussed w team concern of starting longacting anticoagulants with vague plans to remove invasive lines). a peripheral line was placed by the iv team.\n\nresp: basilar cxs. labored w activity but maintains sats >93% on ra. no sob at rest. had minor nose bleed but also had clot about the size of an egg pass from her nose.\n\ngi: good intake. no bm this shift.\ngu: poor uop. lasix held d/t hypotension. cr 0.7.\nms: alert, oriented, cooperative. c/o pain at insertion site, med w oxycodone w good effect. also cont on tid clonipin.\n\na: afib, hypotension, poor uop.\np: cont to follow hemodynamics, volume status. resume oral meds and monitor closely. med for comfort. support to pt.\n"},{"category":"Nursing/other","chartdate":"2166-03-30 00:00:00.000","description":"Report","row_id":1569253,"text":"CCU NSG NOTE: ALT IN CV/HEART FAILURE\nS: \"I can see my ankles!\"\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nCV: Nipride being weaned. She started the day on 2 mic/kilo and is now down to .5mic/kilo since 1630. Last numbers on 1 mic/kilo were index of 2.9 and SVR 771. She received 40mg valsartin this am and pm dose will be increased to 80mg and nipride will be shut off. She conts on milrinone .385 and heparin at 1000u hr. She conts on po dig and coumadin. HR is in 80 and today she is primarily in NSR, though occasional paced beats are seen. BP has been in mid 90s/60s. PAPs are slowly decreasing to 40-50s/19-25 with RA . K+ was at 1600 and mag 1.5, she will be replaced.\nRESP: Lungs sounded clear this afternoon. When lying in bed sat will drop to 94%, but with deep breathing she quickly comes up to high 90s. She denies any SOB\nRENAL: She received lasix 80mg iv at 8am with fair response. Lasix had been changed to Q d. BUt a second dose of 80mg was given at 1630 and pt is now 430cc neg since midnight with todays goal neg 1 liter, and neg >9liters LOS. She initially had hematuria, but it has since resolved.\nGI: Pt conts to have excellent apetite. She had G- bm this evening.\nACTIVITY: Pt OOB with minimal assist this afternoon. SHe becomes dypnic with minor activity, but it resolves quickly. She needs encouragement to maintain independence. She will need PT once the swan is out.\nMS/COMFORT: Pt A & O X 3, cooperative. She c/o of discomfort in left axilla area with nearly resolves with tylenol and oxycodone 5mg, last given at 3pm. She has had continuous low level chest pain for many years.\nA: Weaning nipride/conts on milrinone\nP: ?Increase valsartin for 8pm. Keep careful I & O. REpleat lytes. Assist pt with postion changes. DIetary consult is needed as pt is unclear on low salt/heart failure diet as well as daily weights and how to deal with weight gain. She will also need PT consult.\n"},{"category":"Nursing/other","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":1569254,"text":"CCU NURSING NOTES\nS:I'M FEELING BETTER THIS EVENING.\nO:59YR OLD FEMALE W/ DILATED CM, CHF MANAGEMENT CCU DAY 4, REMAINS ON MILRINONE, HEPARIN, LASIX . SNP WEANED OFF AND VALSARTAN INCREASED TO 80MG. IMPROVED MV 72% AND CI >3. PCWP OF 24. CONTINUED DIURESES UNTIL MINNOC. NEG >1L AT 2300 LAST EVENING. 10L. MHR 80S SR, NO VEA. MAGNESIUM AND POTASSIUM REPLACED. +MUR. DP PALP. C/O SORENESS AT SWAN INSERTION SITE. PT MED W/ OXYCODONE AND TYLENOL W/ GOOD EFFECTS.\nRESP:LUNGS W/ CRACKLES AT BASES OTHERWISE CLR. SATS 97% ON 3L. SOME DOE BUT PT ABLE TO REPOSITION HERSELF IN BED W/O ASSIST.\nGI:ABD SOFT, +BS.\nGU:+HEMATURIA, PINK COLORED URINE.\nA/P:SLOW IMPROVEMENT OF CHF, CONTINUE TO MONITOR HEMODYNAMICS AS PT IS WEANED OF MILRINONE. CONTINUE DIURESIS AS TOLERATED. PT TEACHING FOR CHF MANAGEMENT, NUTRITION. PT TO ASSIST W/ RECONDITIONING.\n"},{"category":"ECG","chartdate":"2166-04-11 00:00:00.000","description":"Report","row_id":284072,"text":"There is atrial and ventricular pacing. Compared to the previous tracing\nthe atria are now paced.\n\n"},{"category":"ECG","chartdate":"2166-04-09 00:00:00.000","description":"Report","row_id":284073,"text":"Atrial sensed ventricular paced\nVentricular premature complexes\nSince previous tracing of , atrial fibrillation now absent\n\n"},{"category":"ECG","chartdate":"2166-04-07 00:00:00.000","description":"Report","row_id":284074,"text":"Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2166-04-14 00:00:00.000","description":"Report","row_id":283843,"text":"A-V sequential pacing\n*** complex QRS morphology - no further analysis ***\nSince previous tracing, the heart rate is faster\n\n"},{"category":"ECG","chartdate":"2166-04-06 00:00:00.000","description":"Report","row_id":284075,"text":"Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , sinus rhythm now absent\n\n"},{"category":"ECG","chartdate":"2166-04-03 00:00:00.000","description":"Report","row_id":284076,"text":"Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\nof atrial fibrillation is no longer recorded and the rhythm is sinus\nwith atrial sensing and ventricular pacing.\n\n"},{"category":"ECG","chartdate":"2166-04-01 00:00:00.000","description":"Report","row_id":284077,"text":"Regular ventricular pacing. Pacemaker rhythm. No further analysis. Compared to\nthe previous tracing of no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":284078,"text":"Regular ventricular pacing. Pacemaker rhyth. No further analysis. Compared to\nthe previous tracing no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2166-03-31 00:00:00.000","description":"Report","row_id":284079,"text":"Ventricular paced rhythm\nAtrial mechanism appears to be flutter/? fibrillation\nSince previous tracing of , sinus rhythm now absent\n\n"},{"category":"ECG","chartdate":"2166-03-29 00:00:00.000","description":"Report","row_id":284080,"text":"Atrial sensed ventricular paced\nSince previous tracing of , ventricular ectopy absent\n\n"},{"category":"ECG","chartdate":"2166-03-28 00:00:00.000","description":"Report","row_id":284081,"text":"Atrial sensed ventricular paced\nVentricular premature complexes\nSince previous tracing of , atrial fibrillation now absent\n\n"},{"category":"ECG","chartdate":"2166-03-28 00:00:00.000","description":"Report","row_id":284082,"text":"Atrial fibrillation. Ventricular couplets. Marked left axis deviation.\nIntraventricular conduction defect. Left ventricular hypertrophy. Intermittent\nventricular paced rhythm. Since the previous tracing of there is a run\nof ventricular paced rhythm.\n\n"},{"category":"ECG","chartdate":"2166-03-25 00:00:00.000","description":"Report","row_id":284083,"text":"Atrial fibrillation and demand ventricular pacing\nIntraventricular conduction delay - left axis deviation\nSince previous tracing, atrial fibrillation is new\n\n"},{"category":"ECG","chartdate":"2166-03-24 00:00:00.000","description":"Report","row_id":284084,"text":"Paced rhythm\nSince previous tracing, no significant change\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569270,\n \"text\": \"ccu nursing progress note\\ns: out of 10. (describing headache)\\no: pls see carevue flowsheet for complete vs/data/events\\nid: temp is low. 95-97 orally. wbc 15. cont on ceftriaxone for ecoli pyelonephritis/bacteremia. bld and urine recultured.\\ncv: no cp. ^'d sob at rest, lethargic and poor uop. felt to be r/t dc'ing of milrinone am. milrinone resumed at prior dose without a bolus.\\nhr 80s vpaced w pvcs. bp 90-105/60 via nbp.\\ncoags sent off pic line this am. inr 8.1, ptt >150. repeat sent from peripheral draw, awaiting results.\\nheparin off at noon for poss lp in w/u of persistent ha.\\nresp: sats 94-98% on ra, 95-100% on 2l nc. has periods of sob at rest, ^'d w exertion. also noted someirreg patterns similar to cheynne . abg: 7.40/31/73/20/-3. lactate 5.6.\\ngi: poor appetite. no nv. no stool. taking only juice. abd benign.\\ngu: had not voided since 11pm last noc, up to void at 10am without result. foley placed at 12n. urine is drk brn to red. cr 1.4 stable from yesterday. na 126(129, 124, 121). hco3 18(25).\\nms: lethargic, groggy. c/o ha, describes as severe, sl relief w fioricet. neuro consulted to eval. oob w assist x1.\\nsocial: pt spoke w brother by phone, no other visits.\\na: further decompensated heart failure off milrinone w evidence of hypoperfusion and metabolic acidosis. cont headache of unknown etiology.\\np: reeval labs this eve w restart of milrinone. follow resp exam, volume status. med for comfort. check results of repeat coags. med for comfort. support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569271,\n \"text\": \"CCU NPN 3-11pm\\nCV: cont on milrinone .38mcg/kg/min, restarted at 12N, HR 80 v-paced, BP high90's-low100/60's, UO picked up to 50-100cc/hr. States she is SOB, does not appear is distress. Sat 93-94% on RA. PTT >150 earlier today, repeat at 2130 was 63.4. Restarting Hep at 100U/hr without a bolus at 2300. Follow PTT in 6hrs.\\n\\nResp: crackles at bases bilaterally, with scattered rhonchi, intermittently coughing, nonproductive.\\n\\nNeuro: cont to c/o HA, given oxycontin at 1630 and Clonazepam. Has been sleepy but states that she does not sleep. Neruo evaluated. No focal findings, recommended MSO4 for pain, dc'ed Oxycontin and Fioricet(can get rebound HA's), recommended good night sleep.\\nPt has been sleeping since ~ after nieces left.\\n\\nGI: ate custard at dinner, drinking sips of juice. No bm.\\n\\nGU: UO has picked up since milrinone restarted.\\n\\nID: afebrile, cont on ceftriaxone.\\n\\nA/P: treating pyelonephritis, BP stable on Milrinone, UO improving. Lethargic, now sleeping. Reevaluate HA after she awakens, MSO4 for pain prn(has not gotten yet).\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569251,\n \"text\": \"CCU NSG NOTE: ALT IN CV/HEART FAILURE\\nS: \\\"I always have chest pain, this is just worse.\\\"\\nO: For complete VS see CCU flow sheet.\\nID: T-max 99.8po.\\nCV: Some changes made in taylored therapy today. Her lasix gtt was d/c and she is now receiving lasix 80mg iv bid. She has received her second dose. Her nipride was decreased from 2.2 mic/kilo to 2mic/kilo with increase in SVR to 1191 and with an increase in filling pressures. She was put back on her valsartin 40mg and last c.o 2 hours after that were 5.7/ 3.05/ 758. Nipride remains a 2.0. Heparin remains at 1000 with a theraputic PTT, and coumadin 5mg po was started. She was replaced with 60 meq KCL, nuerta phos and Mag oxide. Afternoon lyted contd low and she will receive 4 amp of mag and KPhos. Hr has been in 80s to mid 80, going between v-paced and NSR. BP has been 89-101/60-70s. PAP has been 45-50/22-28 with wedge of 20 and RA .\\nRESP: Pt has faint rales at bases. Early she had exp wheezes, but is clear now.\\nRENAL: With lasix off at 9a and IV lasix given at 9:30 pt was 3700cc neg for the day and 8 liters neg LOS.\\nGI: Pt OOB to comode and had Lg G- stool. She is eating very well with no c/o of nausea. She needs dietary consult to help with her diet when she returns home.\\nSKIN: Despite excellent diuresis she conts to have 3+ pitting edema in extremities. No areas of breakdown.\\nMS: Pt oriented X 3. She conts to become very fatigued with minmal exertion. She declined getting OOB this afternoon. Spirits seem good. Family called.\\nA: Off Lasix gtt/restarted valsartin and coumadin/slightly decreased nipride\\nP: Cont to keep careful I & O. Monitor for change in hemodynamics. REcheck lytes later tonight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569257,\n \"text\": \"CCU Nurse Progress Note 3p-11p\\n59 yo female patient w/ decompensated heart failure admitted to CCU for diuresis and tailored therapy. Full code.\\n\\nCV: Upon start of shift, am meds were held r/t hypotension. Milrinone was dc'ed at 10:00a also r/t hypotension. Off Milrinone CO was 3.6 from 4.7, CI 1.93 from 2.51, SVR 1044 from 851, cvp 7 from 10. BP became more stable & Milrinone restarted at 0.385mcg/kg/min at 16:00. Numbers got better, CO 4.5, CI 2.41, SVR 996, cvp 14, maps 60's. HR 80-82 Vpaced, occ. PVC's. BP 85-93/46-77. Dig, Nipride(off yesterday), Valsartan & Coumadin all dc'ed today. Hep gtt cont at 1000 units/hr, PTT remains therapeutic at 82.3. Mixed venous sat (18:00) = 60. Will not resume coumadin until swan dc'd.\\n\\nNeuro: A&Ox3, calm & cooperative. C/O swan site pain given Oxycodone 5mg PO.\\n\\nResp: becomes SOB, tired w/ activity, such as getting up to commode. Will rest a few secs, then is ok. RR 14-20. Sats 90-97 room air. RLL crackles, RUL, LLL, LUL all clear.\\n\\nGI/GU: +bs, + med. formed bm. Foley draining amber, cloudy urine. Given 80mg IV Lasix 20:30, responding well. Output 390cc so far since Lasix dose. 24h balance +181. Bun/Crea 17/0.7.\\n\\nID: afebrile, no abx.\\n\\nSkin: Intact. Multiple ecchymoses right arm r/t bp cuff, which was switched from left arm r/t pain.\\n\\nSocial: No family members visited this shift, however patient did speak to someone (not sure of who) on the phone. Pt spoke w/ us about her decision not to have the heart transplant. She said she does not know what, but something does not make her feel comfortable about it. She is also concerned about the rehab period post-op. Pt verbalized that she made & is comfortable w/ her decision, and is ready to deal with any consequences of it.\\n\\nA/P: 59 yo w/ CHF, volume overloaded, admitted to CCU for Milrinone, diuresis, and tailored therapy. Monitor hemodynamics, & fluid balance. Monitor PTT. Electrolytes needed at 01:00 due to Lasix dose. Support patient and family.\\n\\nNote entered by: , Student Nurse \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569258,\n \"text\": \"CCU NPN 11p-7a\\nS: \\\"I feel okay...I have ankles.\\\"\\n\\nO: Please see careview for VS and additional data.\\n\\nCV: PT V paced with underlying rhythm afib, HR 80-83, NBP 84-94/46-53, MAPs 56-67, Intern , MD aware and will tol MAPs> 55 while pt sleeping. PAP 42-50/20-25, CVP 9-11. This am CO 5.3 (was 4.5) CI 2.83 (was 2.41) SVR 740 (was 996), pt continues on milrinone 0.385 mcg/kg/min, Heparin gtt 1000 units/hr. Pt given 400 mg PO amiodarone for rhythm control. AM labs pending. Pt palp pulses + edema in lower extremities.\\n\\nResp: Pt LS CTA to crackles RLL, O2 sats 92-95 on room air, RR 16-19, pt + dry sounding, nonproductive cough. Pt denies SOB, resting comfortably/sleeping in bed.\\n\\nGI/GU: pt abd soft, + BS x 4, no stool this shift. Pt with foley cath draining dark yellow urine, approx 15-210 cc/hr, HO aware. Pt +99.5 cc at midnoc, pt -10 L LOS. Midnoc lasix dose held d/t pt still diuresing with dose given late at ( was due 1600), pt MAPs<60 this am-dose held, HO aware.\\n\\nNeuro: Pt sleeping throughout most of night, cooperative with care, A & O x 3, MAE.\\n\\nA/P: 59 y/o female continues on milrinone gtt, BP dropping slightly with MAPS >55, midnoc lasix dose held. CO/CI improved from last set. Continue to monitor rhythm, BP and given meds as ordered/ pt tol. Continue to monitor I&O's, u/o. Follow up wiht am labs and replete as necessary. Continue to assist pt in advancing activity as tol. Continue to provide emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569259,\n \"text\": \"ccu npn\\no- afebrile. cv- hr 80s vpaced, no vea. cont. on same milrinone and heparin iv, amiodarone po. isordil, lasix, bisoprolol held in am d/t low bp. bp 80s-90s/. after discussion w/ho, bisoprolol given 2pm with map low 60s. digoxin level added on and pnd. dig load ordered pnd level. 2nd iv in this pm w/plans to d/c pa line. heparin to be held this pm for pa line d/c. pt eval for picc for ?home milrinone. iv to try picc in am. case manager looking into picc/insurance for home milrinone, ?goes through infusion clinic.\\nresp- on r/a sats high 90s. l/s clear w/faint exp. wheeze. no sob. u/o adeq to low and concentrated.\\ngi- app. fair, no bm.\\nms-a+x3, states needs to think about whether or not wants to go home on milrinone, and she was told would need a home health visit qd.\\nactivity- oob to chair most day, tol well.\\na- bp somewhat higher while awake, tol bisoprolol.\\np- ?give lasix depending on bp, check w/ho. start digoxin depending on level. hold heparin for pa line/cordis d/c. oob/PT as tolerated. ?picc . cont. emotional support. f/u insurance, infusion clinic teaching w/picc.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569260,\n \"text\": \"ccu npn 11p-7a\\nCarevue System down most of shift. Vital signs kept onto flow sheet, then entered into carevue at 0400 when system available. Written note entered into Pt's green chart. See chart for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569252,\n \"text\": \"NURSING PROGRESS NOTE 7P-7A\\nS: IT HURTS WHEN I TAKE A DEEP BREATH IN:\\n\\nO: NEURO: PT. AWAKE AND ALERT, ORIENTED X3. PLEASANT AND COOPERATIVE. MOVING ALL EXTREMITIES. TURNS SELF IN BED. C/O PAIN UNDER LEFT BREAST WORSENING WITH DEEP INSPIRATION. GIVEN OXYCODONE 5 MG PO X1 AND TYLENOL 650 MG PO X1 WITH FAIR RELIEF FROM PAIN. SLEPT IN SHORT NAPS DURING NOC.\\n\\nCV: SEE FLOW SHEET FOR HEMODYNAMIC #'S. CO/CI STABLE ON PRESENT REGIME OF MEDS; NIPRIDE 2 MCG/KG/MIN, MILRINONE 0.385 MCG/KG/MIN. HR 80 SR NO VEA NOTED. LYTES REPLETED IN EVENING AND REPEAT LABS WNL.\\n\\nRESP: LUNGS CRACKLES IN BASES WITH EXP WHEEZE NOTED IN UPPER AIRWAYS. O2 SAT ON ROOM DOWN TO 88-89%. PUT ON 2L NC WITH IMPROVING O2 SAT TO 94-96%. DENIES C/O SOB.\\n\\nGU: URINE OUTPUT TRENDING DOWN AFTER LASIX GTT WEANED TO OFF. I/O (+) 350 OVER 24HRS. (STILL (-) 8L FOR LOS). URINE BLOOD TINGED, CLOUDY. HCT STABLE @ 34. COUMADIN RESTARTED ON . RECEIVING LASIX 80 MG IV BID.\\n\\nGI: ABD SL DISTENDED, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM . APPETITE FAIR.\\n\\nSKIN: INTACT, NO BREAKDOWN NOTED. RIGHT ARM HAS SEVERAL ECCHYMOTIC AREAS FROM NIBP CUFF. LOWER EXTREMITY EDEMA LESSENING. NOW 2+ TO KNEES.\\n\\nA/P: CO/CI STABLE, URINE OUTPUT LESS OFF LASIX GTT. STILL NEG. PAIN UNDER LEFT BREAST ? PLEURITIC. FAIR RELIEF FROM PAIN WITH OXYCODONE.\\n? WEAN NIPRIDE AS CI TOL (KEEP CI > 2.2). MONITOR LYTES AND REPLETE AS NEEDED, UPDATE PT. ON PLAN OF CARE PER TEAM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569267,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\\n\\n\\nS- \\\"I STILL HAVE A BIT OF HEADACHE BUT THOSE MEDICINES HELP \\\"\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\nCV- VS REMAINS STABLE- HR- 90'S VPACED WITH OCCASIONAL PVC'S.\\nBP- 95/63- NO HYPOTENSION THIS SHIFT AT ALL.\\nREMAINS ON HEPARIN GTT 1000U AND MILRINONE 0.375.\\nRECEIVED 20 KCL FOR K-3.7\\n\\nRESP- 02 SATS >95% ON 2L NP, SOME CX AT BASE AND REMAINS TACHYPNIC WITH EXERTION. NONPRODUCTIVE COUGH.\\nRECEIVED 1 L NS FOR (+) BUMP CREATININE AFTER LASIX AND (+) DEHYDRATION PRESUMED. I/O (+) 1700CC AS OF 12AM. NO DISTRESS FROM RESP STANDPOINT.\\n\\nID- AFEBRILE ALL DAY YESTERDAY AND TONITE- NO VANCO SATURDAY NITE OR SUNDAY MORNING D/T HIGH LEVELS- CHANGED TO Q 24/RENAL DOSE- TO RECHECK TROUGH WITH AM LABS. D/C FLAGYL FOR R/O S DIFF. REMAINS ON IMIPENEM Q 6 HOUR TO TREAT GM (-) RODS BACTEREMIA WITH PYLONEPHRITIS AS SOURCE.\\n\\nGU- OOB X 2 TO COMMODE FOR UO- REMAINS AMBER IN COLOR AND MINIMAL AMOUNTS. NO FURTHER IV FLUID THIS SHIFT.\\nSENT URINE LYTES FOR ASSESSMENT OF HYPONATREMIA /BUMP IN CREATININE AND BETTER ASSESS FLUID STATUS.\\n\\nGI- LIX STOOL X 1 WITH URINE- UNABLE TO TEST FOR GUAIC.\\nTAKING IN MEDS AND LIX, NO FOOD ON EVES/NITES CURRENTLY.\\nNO NAUSEA.\\n\\n PT IN GOOD SPIRITS THIS EVENING- C/O HEADACHE BUT BETTER CONTROL OF PAIN WITH FIORICET. CURRENTLY SLEEPING AFTER CLONAZEPAM AND ZOLOFT.\\nSPEAKING A LOT ABOUT CONCERNS WITH RETURN TO HOME ON IV MILRINONE ETC, SUPPORT SERVICES TO BE PROVIDED. APPEARS ENCOURAGED FEVERS GONE AND INFECTION CONTROLLED BY CURRENT ANTIBX.\\n\\nA/ PT CURRENTLY HEMODYNAMICALLY STABLE S/P CHF EXACERBATION C/B UROSEPSIS.\\n\\nCONTINUE ANTIBX AS ORDERED TO TREAT GM (-) RODS.\\nWATCH FOR FURTHER FEVERS OR ANY HEMODYNAMIC COMPROMISE.\\nRECHECK AM TROUGH LEVEL VANCO DOSE- GIVE IF LEVEL WNL.\\nASSESS URINE LYTES FOR ? MORE FLUID BOLUSES TODAY.\\n? RELOAD COUMADIN TODAY, CONTINUE HEPARIN GTT AT 1000U PENDING AM PTT LEVELS.\\nPT IS DNR,\\nKEEP PT AWARE OF PLAN OF CARE, CONTINUE D/C PLANNING\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569268,\n \"text\": \"Nursing Progress Note\\nS: \\\" I still have this awful headache.\\\"\\n\\nO: Please see flow sheet for objective data. Milrinone d/c'd after rounds secondary to severe headaches. Tele AF with periods of V pacing. SBP > 90. IV heparin dc'd at 1 pm for ? aspiration of neck. Ultrasound done of neck and L arm. IV Heparin restarted at 1000u/hr at 5pm.\\n\\nResp: Lungs with crackles throughout the bases. Pt is dyspneic with minimal exertion although sats unchanged 96-99% on 2 l nasal prongs.\\n\\nNeuro: Pt is alert and oriented. Able to MAE. OOB to comode several times with minimal assistance. Conts to c/o headache more severe this pm after ultrasound. Given fioricet 2 tabs with some effect.\\n\\nGU/GI: Appetite remains poor. Denies any nausea. Taking in mostly liquids. Abd is soft with bowel sounds present. 1 liquid stool today.\\nVoiding in sm amts of amber to red urine. No further IV fluids today. Diuretics held today.\\n\\nID: TM 99.4. Vanco and Imipenem dc'd. Started on Ceftriaxone 1 gm Q 24hr. ( Urine sensitivity).\\n\\nA&P: Milrinone dc'd secondary to severe headaches. Monitor BP and urine output. ? dopamine Bp drops. Fioricet prn headaches. Cont POC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569269,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" My head still hurts \\\"\\nO: TM 99.8po. on ceftriax q24hr. (first dose 4/11)\\nHR 80 Vpaced. BP 90-117/60's. off milrinone gtt since d/t headaches.\\nheparin at 1000uhr. AM labs pnd at 0600.\\n\\nvoided x1 for 300cc amber urine. neg. 300cc for and total 12L neg. LOS.\\npt. c/o SOB x1 in middle of night but also with increase in headache and due for pain meds. lung exam unchanged. sats good. discussed with intern and did not give lasix. intern stated that prelim. plan for AM is to restart milrinone gtt since headache has not abated off gtt.\\nsats 98% on 2lnc. RA sat same. LS crackles right base to 1/3 up.\\nRR 30-40.\\n\\nvery dyspneic with any activity. does not sleep well. oxycontin 2tabs in eve and then flouricet repeated at 0330. pt. reports this morning that headache feels the same- has not abated. sleeping in short periods. short periods of apnea. sats stable.\\n\\n assist OOB to commode.\\n\\nA/P: AM labs pnd. poor u/o. no lasix. ? plan to restart milrinone gtt. monitor and assess headache. pain meds.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569277,\n \"text\": \"7p-11p CCU Nursing Progress Notes\\nC/V: on Dopamine 2.5mcg/kg/min. HR 80-81 V-paced, no ectopy noted. BP 101/65 - 105/67.\\n\\nNeuro: A&Ox3, cooperative. no c/o pain or headache.\\n\\nResp: On room air maintaining sats high 90's-100. RR 19-22.\\n\\nGI/GU: foley draining clear dk yellow urine, hourly urine output decreasing since :00 (140 -> 120 -> 26cc/hr). +bs, -bm. Patient ate 90cc Jello, drank 220cc cranberry juice.\\n\\nID: afebrile, cont. on Ceftriaxone q24h.\\n\\nSocial: and sister called.\\n\\nAccess: 22 r forearm, flushed and clamped. PICC infusing Dopamine 2.5mcg/kg/min.\\n\\nA: Monitor headache, nutrition & fluid status.\\nP: ? plan to move to floor tomorrow.\\n\\nNote entered by: , Student Nurse \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569278,\n \"text\": \"CCU NPN 11p-7a\\nS: \\\"I still have the headache.\\\"\\n\\nO: Please see careview for VS and additional data.\\n\\nCV: Pt HR 80-81 AV paced, NBP 95-107/36-72, pt continues on dopamine gtt 2.5 mcg/kg/min. AM labs pending.\\n\\nResp: Pt RR regualar and even 19-22 at rest, RR up to 30 with ambulation to commode, O2 sats 94-100 on room air.\\n\\nGI/GU: Pt abd soft, +BS x4. Pt with lg amt loose brown stool x 1. Pt with foley cath draining clr dark yellow to yellow urine 20-225 cc/hr. Pt -355cc at midnoc, - cc LOS.\\n\\nNeuro: Pt alert and oriented, cooperative with care. Pt ambulated OOB to commode x 1 overnoc, pt steady on feet. Tylenol given x 1 for headache, pt refused morphine. Pt did not c/o pain until asked if in pain.\\n\\n\\nID: Pt afebrile, cont on abx.\\n\\nA/P: Pt continues on dopamine with adequate MAPS and u/o. Continue to monitor hemodynamics, continue to monitor u/o and resp status. Continue to follow lytes and LFTs, continue to assist pt in activity and enc nutrition. Monitor HA and provide pain meds and emotional support. Continue with plan per CCU Team.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569249,\n \"text\": \"ccu npn\\no-id- afebrile.\\ncv- hr 70s afib in am, pacer rate increased to 80 by ep and then converted to sr with pacing w/occ to freq pvcs, more in am vs occ. pacing in am. pads 36 to 28, cvp 23 to 14, co 4.4, up to 5.3 this pm ci 2.73, svr 863. hct 35.2, ptt 78.9, inr 1.6. cont. on same doses nipride, heparin, milrinone, lasix. diuresing well in am, then u/o up to 300-575cc/hr this pm. i+o neg about 1500cc currently. k- 3.6, re'd 40meq (started on nocts) kcl iv and then 40meq kcl po, repeat lytes pnd this pm.\\nresp- on 3l sats 96-100. l/s clear with cxs/coarse sounds lower, esp. r. sob on exertion more in am. u/o as above.\\ngi-abd soft w/bowel sounds. app fair to good, limiting po fluids well.\\nms- a+o x3, slept in naps off/on in am.\\nskin- has ecchymosis r arm bp cuff changed to l arm, small r hip. has no breakdown. repos. side to back per pt. comfort, moves self around bed also.\\nsocial- fx called, updated on pt's condition and plan. teaching done w/pt also regarding progress, pa line, meds, etc. understands.\\na- diuresing well. ci improved with increased hr, more pacing.\\np- cont. same iv meds. follow rhythm, bp, co/ci/svr, diuresis. check lytes sent, replace as needed.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569250,\n \"text\": \"NURSING PROGRESS NOTE 7P-7A\\nS: \\\"I CAN'T BELIEVE HOW SWOLLEN MY LEGS ARE\\\"\\n\\nO: NEURO: PT. ALERT AND ORIENTED X3. PLEASANT, COOPERATIVE. MOVING ALL EXTREMITIES.\\n\\nCV: HR 82-86 SR WITH OCC PVC. BP 94/49-102/64. PA 60/21-55/20 CVP 6-11. DENIES C/O CP. REMAINS ON NIPRIDE 2.2 MCG/KG/MIN, LASIX DECREASED TO 5 MG/HR, HEPARIN 1000 UNITS/HR, MILRINONE 0.385 MCG/KG. LOWER EXTREMITIES 3+ PITTING EDEMA.\\n\\nRESP: O2 3L VIA NC. CRACKLES NOTED IN BASES. OCC CONGESTED COUGH, NON PRODUCTIVE.\\n\\nGU: URINE CLEAR YELLOW. I/O (-) 2.5 L OVER 24 HRS. (-) 6.6 L FOR LOS.\\n\\nGI: ABD SOFT, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM .\\n\\nSKIN: INTACT, NO BROKENS AREAS.\\n\\nC/O PAIN AT SG CATH (RIGHT IJ). GIVEN TYLENOL WITH RELIEF FROM PAIN. SLEPT IN SHORT NAPS OVERNIGHT.\\n\\nA/P: STABLE ON PRESENT MEDS, DIURESING WELL. MONITOR LYTES, REPLETE AS NEEDED. MAINTAIN CI 2.2. UPDATE PT. AND FAMILY ON PLAN OF CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569265,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\\n\\nS- \\\" I NEED TO GET UP SO QUICK TO MAKE THE BATHROOM..I DON'T HAVE TIME TO CALL YOU..\\\"\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT REMAINS HEMODYNAMICALLY STABLE WITH HR- 90'S V PACED, OCC VEA ON MILRINONE 0.375, HEPARIN GTT 1000U/HOUR. BP- 95/55- 100/60.\\nNO HYPOTENSION OR ARRYTHMIAS THIS SHIFT.\\nAM LABS PENDING CURRENTLY\\n\\nRESP- O2 SATS ALL > 95% ON 2L NP- TACHYNPNIC WITH ANY EXERTION- CX AT BASE- LEFT > RT.\\nGIVEN 80 LASIX IVP D/T I/O (+)500CC\\nOF NOTE, NO FOLEY CURRENTLY TO PROVIDE HOURLY ACCURATE U.O.\\nCOMFORTABLE AT REST, NONPRODUCTIVE COUGH\\n\\nID- SPIKED AGAIN TO 102 9P- GIVEN TYLENOL 650- REMAINS ON IMIPENUM TO COVER GM (-) RODS. HELD 12AM VANCO DOSE D/T HIGH TROUGH LEVEL 33.\\nHO AWARE.\\nNO CHANGES TO ANTIBX REGIMEN CURRENTLY- STOOL SPECIMENS FROM MICRO PENDING- REMAINS ON FLAGYL TID PO.\\n\\nGU- FOLEY CATH D/C ON DAYS.\\nPT FOUND TO BE GETTING OOB ON OWN IN SPITE OF INSTRUCTION TO CALL FOR ASSIST.\\nAMBER DARK URINE X 2 AFTER LASIX- TOTAL ABOUT 500CC IN ALL WITH LIX STOOL AS WELL.\\n\\nGI- LIX STOOL X 2- UNABLE TO TEST/GUAIC- UP TO COMMODE ON OWN .\\nC DIFF R/O PENDING\\nCONTINUES ON FLAGYL\\nPOOR APPETITE, TAKING MEDS AND LIX WITHOUT PROBLEM\\nNO NAUSEA\\n\\nMS- SLEPT WELL TONITE\\nC/O HEADACHE- GIVEN TYLENOL\\nUNDERSTANDS CURRENT PLAN OF CARE AND SOURCE OF INFECTION\\nUNDERSTANDS NEED FOR ASSIST TO GET UP TO COMMODE.\\n\\nA/ PT S/P LONG COURSE FOR CHF EXACERBATION/CM CURRENTLY ADMITTED TO CCU FOR SEPSIS/PYLONEPHRITIS.\\n\\nCONTINUE CURRENT ANTIBX TX\\nWATCH FOR FURTHER RESULTS OF SPECIMENS TO MICRO\\n? D/C FLAGYL IF (-) STOOL.\\n? RECHECK VANCO LEVEL PRE-12NOON VANCO DOSE.\\nCONTINUE CV MEDS AS ORDERED- WATCH HEMODYNAMICS CLOSELY.\\nCONSIDER RE-LOAD COUMADIN IF CONTINUES TO BE HEMODYNAMICALLY STABLE AND IN NO NEED OF INVASIVE LINE PLACEMENT\\nPT IS DNR.\\nKEEP PT AWARE OF PLAN OF CARE, SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569266,\n \"text\": \"ccu nursing progress note\\ns: the headache is somewhat better after that medicine(fiorocet)\\no: pls see carevue flowsheet for complete vs/data/events\\nid: t max 100.3. wbc 15. cont on imipenum. vanco to cont but level 21.9 for trough before scheduled q 24hr dose. level will be checked in am and dosed as indicated. po flagyl dc'd as cdiff specs have been neg to date and no stool since last night. contact precautions dc'd.\\ncv: hr 80-90s paced, occ pvc. k 3.4, repleted w 40 po and k 3.7 this eve. will replete additional 20meq. bp 90-100/50-60. not orthostatic this am. cont on milrinone, dose unchanged.\\nheparin at 1000units/hr. ptt 92. inr 1.8.\\nresp: rr 20s. labored w activity. basilar cxs. sats 95-100% on 2l nc.\\ngi: ate toast this eve. good po intake of fluids. no n/v. no stool this am.\\ngu: cr bumped to 1.9(1.4). na 121(124, 128, 132). felt pt dry. rec'd 1l ns at 150cc/hr over course of day. will resend unrine lytes and chemistries this eve. voiding drk brn cloudy urine at bedside commode.\\nms: alert. c/o mod-severe ha . underwent head ct, no acute process noted. med w oxycodone ^to 10mg without relief. rec'd dose of fiorocet w some effect. sister visited.\\na: ha. hyponatremia, cr bumped. fever abated.\\np: follow response to hydration, assess for resp compromise. med for comfort. supprort to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569274,\n \"text\": \"CCU NURSING 1500-1900\\nS. \\\"I'VE NEVER HAD A HEADACHE LIKE THIS BEFORE - ITS THROBBING!\\\"\\n\\nO. SEE CAREVUE FOR VS/OBJECTIVE DATA\\n\\nCV: HR 80 V-PACED W/PVC'S/OCCS COUPLETS, BP 99-106/50-60'S ON DOPAMINE @ 2.5MCGS; HEPARIN REMAINS AT 800U/HR W/PTT W/I RANGE 83\\n\\nRESP: SATS 98-99% ON 2L NC, SATS 89-92% ON ROOM AIR, LUNGS - FEW CRACKLES AT BASES\\n\\nALT COMFORT: PT CONTINUES C/O HA - 2MG IV MSO4 GIVEN X1 W/SOME RELIEF - SLEEPING OFF/ON\\n\\nGI: LIVER US REVEALED INFLAMMATION OF COMMON BILE DUCT PER TECH\\nNO STOOL\\n\\nGU: FOLEY DRAINING YELLOW URINE I/O'S EVEN FOR DAY\\n\\nSOCIAL: - WILL CALL IN AM\\n\\nA: VS UNCHANGED AFTER CHANGE FROM MILRINONE TO DOPAMINE\\n CONTINUED HA - UNKNOWN ETIOLOGY\\n\\nP: MONITOR VS, CONT DOPA/HEPARIN, ASSESS HEADACHE - MEDS FOR COMFORT AND ASSESS EFFECTIVENESS - CONT FOLLOW LFT'S, ASSESS MENTAL STATUS,\\nCONT SUPPORTIVE CARE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569275,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" I still have a headache \\\"\\nO: afeb. contin. on ceftriax.\\nHR 80's V paced with occas. PVC's. one run of VT 8bts, rate 150. asympt. K+ 4.4. BP 97/62- 109/69.\\ncontin. on dopamine at 2.5mcq/k/min. and heparin 800u/hr. AM PTT 69.\\ndig. contin. on hold. contin. on aldactone, bisoprolol. amio QD.\\n\\nGU: u/o 60-75cc/hr. neg. 200cc for , currently ~ even since MN.\\nGI: only asking for cranberry juice. not hungry for boost. discussed need for more nutrition. pt. states she will try to drink nutritional supplements.\\nResp: LS crackles bases which is baseline. sats 99% on 2lnc. DOE noted even with sitting up, etc. RR 30-40\\n\\npt. slept well tonight, wakes easily to name and appears less lethargic when awake. contin. to c/o headache but only when asked about it. offered morphine but pt. refused- able to fall asleep again.\\n\\nA: improved u/o on dopa. headache unchanged but tolerable to pt. no morphine since . poor nutrition status- enc. supplements.\\nOOB QD as tol. follow plan per interdis. team.\\nP:\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569276,\n \"text\": \"Nursing Progress Note\\n\\nS: \\\" My headache feels a little better.\\\"\\n\\nO: Please see flow sheet for objective data. Dopamine remains at 2.5mcgs/kg/min. IV Heparin dc'd at 12n d/t elevated INR. Tele paced rhythm with occ AF. Mg 1.6 repleted.\\n\\nResp: Pt conts to have dyspniec with exertion. Lungs scattered rales at bases. O2 sats 95-98% on RA.\\n\\nNeuro: Pt is alert and oriented. Less sleepy today. Conts to c/o headache although much less than over past couple of days. Denies need for any meds. OOB to chair with minimal assistance. Slightly unsteady on her feet. OOB ambulating x's1 short distance with PT.\\n\\nGU/GI: Appetite remains poor. Pt taking in good amts of liquids very little solid food. Denies N/V. Abd is soft with bowel sounds present. Sm amt of brown liquid stool this am. LFT's trending down. Foley draining yellow urine with some sediment. Creat .8. Diuretics held today. Aldactone dc'd d/t sodium 129.\\n\\nA&P: Tolerating dopa after dc of Milrinone. I&O even today. Encourage po intake. Encourage ambulation. Cont with POC.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569246,\n \"text\": \"CCU NSG NOTE: ALT IN CV\\nS: \\\"I've had this before and it was an ordeal\\\"\\nO: For complete VS see CCU flow sheet.\\nThis 59y old woman was transfered to CCU for swan placement and taylored therapy. THis pt with known heart failure with EF <15% was admitted to 6 with increasing sob. She was started on milronone and diuresed, but remains profoundly anasarcic.\\nCV: HR has been in 70s, afib, multiple PVCs and occasional paced beats. BP stable in 1-teens/ 60-70s. She conts on milrinone .385 mic/kilo. She was consented for swan placement, which is occuring now. SHe has been K+ replaced and is receiving IV mag now.She is usually on coumadin, but has been off it since yesterday.\\nRESP: She has bbr, but sats 97-99% on RA\\nRENAL: Foley was inserted. I & O from Fa 6 added up and pt is ~2 liters neg LOS. SHe received lasix 40IV at 0830 this am.\\nGI: Pt has been NPO\\nMS: Pt A & O X 3. She is divorced. SHe has 1 son who is her proxy, but with whom she does not communicate. SHe has 2 neices who are very close with her and who will be in tonight.\\nA: End stage heart failure pt admitted for swan\\nP: Get numbers once swan in. Confirm with pt if she still wants son to be proxy. Monitor for change. Careful I & O\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569247,\n \"text\": \"CCU Nurse Progress Notes 7a-7p\\n59 yo patient transferred today from 6 for swan placement and diuresis. Full code.\\n\\nCV: Swan placed, numbers at placement were (16:00): pap 79/36, pcwp 36, cvp 24, co 3.8, ci 1.87, svr 1221, MV sat 55%. Started on Nipride gtt (titrate to MAP >= 60), at 1mcg/kg/min numbers were: pap 73/36, pap mean 49, cvp 22, co 3.6, ci 1.77, svr 1267, MV sat 50%. Increased Nipride to 3mcg/kg/min and will recheck numbers. Lasix gtt started at 5mg/hr, increased to 10mg/hr. Labs (18:00) Mg 1.7, repleting w/ 4gm Mag Sulfate IV. K 3.4, will replete w/ 60mEq sliding scale when Mg is complete. Heparin gtt at 1000units/hr, started without a bolus. HR 73-85 A-fib, occ. PVC's., BP 96-116/54-74. Pt denies CP/SOB. Dig level 0.7, was held on floor for elevated level, not yet reordered here.\\n\\nNeuro: Pt was given 2mg IV Ativan, total 75mcg fent and 1.5mg versed during swan insertion. Pt remains A&Ox3, calm & cooperative. C/O HA, given tylenol.\\n\\nResp: RR low-mid 20's. O2 sat high 90's-100, room air. LS RUL, LUL expiratory wheezes, RLL, LLL crackles. 21:00 placed on 3L nc d/t sats dropping to 89% when asleep.\\n\\nGI/GU: +bs, -bm. Foley draining clear dark, yellow urine. Given 5mg/hr Lasix IV drip at 19:00, increased to 10mg/hr. UO up to 90-140cc/hr last couple hours. BUN/Cr 23/0.7\\n\\nSocial: This shift, pt changed proxy to her two nieces, form completed and in front of chart, copies given to pt/neices. Contact info on board in room for spokesperson. The two nieces were in to visit, and the patient's son called.\\n\\nID: afebrile, no abx. c-diff neg.\\n\\nSkin: intact.\\n\\nA/P: 59 yr old with CHF, volume overloaded, transferred to CCU for tailored therapy, swan, IV milrinone, Nipride, lasix, Monitor hemodynamics, fluid balance, lytes, and PTT needed at 01:00. increase Milrinone if #'s not improved on higher Nipride dose. Support pt and family.\\n\\nNote entered by: , Student Nurse \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569248,\n \"text\": \"Neuro a/ox3 slept comfortably most of the night\\ncvs HR 60-70's afib with pvc K+ 3.4 tx 60 meq kcl IV repeat K+ pnding, bp 96/64-110/66. On nipride 2.0 mcg/kg/min, lasix 10 mg IV q hr, milronone .385 mcg/kg/min and heparin 1000u IV C.O. 3.4, CI 1.82 SVR 1412, CVP 20, P/D 70/31 nipride increased to 2.5 mcg/kg/min CO 5.0, CI 2.67, SVR 896, CVP 16 P/D 60/30. PTT within parameters am pnding skin w+d pitting edema to LE pp+\\nResp 3lnp lungs faint exp wheeze b/l am faint crackles b/l throughout o2 sats 96-99%, mixed venous 55-68%\\ngu lasix 10 mg IV gtt neg 1194 from mn to 0500 cr.7 bun 11\\nGI abd snt bs+ no stool alt 61, ast 86, ld 327, total bili 2.3 alk phos 124\\nID wbc 8 afebrile\\na. cmp ef < 15%, severe MR \\nafib\\nLFT elevated\\np. monitor CO, CI, titrates gtt accordingly, replete lytes per scale, IV heparin, monitor LFT abd exam\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569255,\n \"text\": \"ADDENDUM\\nO:BP TRENDING LOWER. MILRINONE DOWN TO 0.18MCG/KG/MIN. REPORTED TO DR. . PT , SBP SLT IMPROVED WHILE AWAKE. MHR INTERMITTANTLY V-PACING W/ UNDERLYING AFIB. EKG DONE, MD NOTIFIED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569261,\n \"text\": \"Nursing Progress Note\\n\\n59yo women with known CAD s/p Mi , s/p CABG x's1 severe MR & TR,pul HTN, PAF EF 15% with h/o VT with placement of BIV pacer. Several admits for CHF excacerbation. Recent admit to CCU for tailored therapy with transfer to 6 on . Plan was for home infusion of Milrinone. PICC was placed with much difficulty. Today pt spiked at temp to 102.4 with elevated WBC. Urine and bld cultures sent. Started on Vanco and Zosyn pending cultures. Hemodynamcially stable so far. Concern for sepsis with little reserve.To be transfered to CCU for close observation. Pt has been made a DNR/DNI and she has refused a heart transplant.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569262,\n \"text\": \"CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\\n S- \\\" I AM SO TIRED I JUST WANT TO SLEEP\\\"\\n\\nO- SEE FLOWSHEET FOR ALL OBJECTIVE DATA\\nPLEASE REFER TO EXCELLENT / MEDICAL NOTES FOR DETAILS R/T EXTENSIVE AND COMPLICATED HPI/PMH.\\n\\nIN BRIEF, THIS IS A 59 YR OLD PT WITH EXTENSIVE CV HX SIGNIFICANT FOR\\nMI, CAD, S/P CABG AND ISCHEMIC/DILATED CM (EF- 15%) AS WELL AS SEVERE TR/MR. SHE IS S/P BIVENT PACER/ICD INSERTION, PULM HTN, RESTRICTIVE LUNG DX, PAF, LAD DISSECTION AND ANEURISM. PT ALSO HAS DX- ON SYTHROID AND S/P THYROTOXICOSIS D/T AMIO.\\n\\nTHIS PT WAS ADMITTED TO CV STEPDOWN FOR CHF EXACERBATION WITH C/O SOB AND FEVERS FOR SEVERAL DAYS PTA. SHE WAS STARTED ON INOTROPY AND DIURESIS WITHOUT MUCH IMPROVEMENT AND TRANSFERED TO CCU ON FOR PA LINE AND FINE TUNING OF HER MEDICAL REGIMEN. PT WAS STARTED ON NIPRIDE IN ADDITION TO HER MILRINONE WITH 12 L DIURESIS AS A RESULT AND WEANED OFF THE NIPRIDE, STARTED ON DIGOXIN WITH HOPES OF A MILRINONE WEAN. SHE DEVELOPED PAF AND WAS STARTED ON AMIODORONE LOAD WHICH IS FINISHED AS OF AND HER BIVENT PACER/ICD WAS INTERROGATED AND ADJUSTED TO ALLOW FOR BETTER SYNCHRONY.A PICC LINE WAS INSERTED IN RT AC FOR PLAN FOR D/C TO HOME ON MILRINONE AND ON , PT DEVELOPED FEVERS TO 102.9 WITH WC AND BANDEMIA. SHE WAS PAN CULTURED AND STARTED ON VANCO/ZOSYN/PO FLAGYL FOR R/O CDIFF( S/P SOME GI COMPLAINTS/ABD PAIN, EMESIS/NAUSEA, LOOSE STOOL), AND SENT TO CCU 7P .\\nPT WAS TX WITH TYLENOL, CONTINUED ON MILRINONE/HEP/DIG/AMIO AND DID NOT EXHIBIT ANY CV INSTABILITY. NO FURTHER FEVERS,BUT ID RECOMMENDED CHANGING OVER FROM ZOSYN TO IMIPENUM.LATER THIS SHIFT, B/C WERE CALLED BACK FOR (+) GM (-) RODS AND HO CALLED. NO CHANGE TO THERAPY AT THIS TIME, PT REMAINS CV STABLE AND AFEBRILE, HERE FOR CLOSER MONITORING.\\n\\nREVIEW OF SYSTEMS:\\nPLEASE REFER TO CAREVUE/FLOWSHEET.\\n\\nCV- VSS- BP-90-108/50-60 WITH HR- 90'S V PACED. RECEIVED 3 GM MG/40 KCL ON EVES FOR LOW LEVELS.\\n\\nRESP- CLEAR- NO TROUBLE WITH SOB, BREATHING AT MID 20'S, O2 SATS- 97%.\\nOFF ALL DIURESIS. REMAINS ON 2L NP.\\n\\nID- AFEBRILE- SEE ABOVE-\\nIMIPENUM, VANCO, PO FLAGYL.\\nGM (-) RODS BC.\\nCONTACT PRECAUTIONS FOR R/O CDIFF.\\n\\nGU- FAIR UO- 20-30CC/HOUR, DARK AMBER CLEAR VIA FOLEY.\\n\\nGI- TOOK PM MEDS WITHOUT PROBLEM, NO NAUSEA THIS SHIFT, NO STOOL- RECEIVED ANZIMET UPON TRANFER FROM 6, (+) BOWEL SOUNDS.\\nDECLINING ANY FOOD/CRACKERS/TOAST AT THIS TIME,,JUST WANTS TO SLEEP.\\n\\\"FEELS LOUSY\\\"\\n\\n PT LETHARGIC FROM ANZIMET AND OVERALL FEELING \\\"LOUSY\\\"\\nA AND O X 3- SISTER CALLED AS WELL AS FRIEND- SPOKE TO FRIEND ON THE PHONE. SLEPT REST OF SHIFT,\\nDENIES PAIN, SOB.\\n\\nA/ PT WITH EXTENSIVE CV HX/CM CURRENTLY ADMITTED WITH R/O SEPSIS\\n\\nCONTINUE TO CLOSELY MONITOR CV STATUS AS WELL AS ? FEVER/RESULTS OF URINE AND STOOL SPECIMENS. CONTINUE MILRINONE/DIG/HEPARIN AS ORDERED.\\nREPEAT BLOOD CULTURE THIS AM WITH AM LABS.\\nREPLETE LYTES AS NEEDED.\\nWATCH RENAL FX/BUN/CREAT/UO- ? NEED FOR GENTLE HYDRATION IF WORSENS IN SETTING OF S/P FEVERS ETC.\\nCONTINUE ANTIBX AS ORDERED.\\nCOMFORT/SUPPORT\\nPT IS DNR/DNI AS OF .\\nC/O TO FLOOR\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569263,\n \"text\": \"CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\\n(Continued)\\n ONCE MEDICALLY APPROPRIATE.\\nCONTACT PRECAUTIONS UNTIL CDIFF R/O.\\nKEEP PT AWARE OF PLAN OF CARE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569264,\n \"text\": \"ccu nursing progress note\\ns: i just feel chills, like when you have the flu\\no: pls see carevue flowsheet for complete vs/data/events\\nid: t spike to 102.0 po. wbc to 20(18). gr neg rods id'd in bld cultures from . 2 sets of cultures pend from .(1 of which was drawn peripherally this am). urine poss source w ua +wbc and bacteria. need further speciation. cont on vanco(needs trough before mdnoc dose), po flagyl and imipenum.\\nhad abd ct which noted l pylonephritis.\\ncv: hr 80-100, mostly vpaced. occ intrinsic rhythm when>90. bp 90-105/50-60. cont on milrinone at .38mcg/kg/min. heparin at 1000units/hr. inr 1.6, ptt 78.\\ndig level 3.4 this am and dose was held.\\nna 124(128). holding lasix in setting of bacterimia.\\nk 5.0, mg 2.1.\\nresp: labored w min exertion. sats >95% on 2l nc. faint cxs at bases.\\ngi: anorexia, declining any food. had 2 lrg liquid stools. sample sent for cdiff. taking ice chips, encouraged po's as tol.\\ngu: concentrated urine w o/p 10-20cc/hr. foley dc'd per ccu team's order at 2pm. pt dtv 8-10pm. cr 1.4(1.1).\\nskin: intact. access: l single lumen picc, 1peripheral.\\nms: lethargic most of day. cooperative. oob w assist to use bedside commode. c/o headache most of day w little relief from oxycodone +/- tylenol. c/o photophobia as well. c/o l flank pain mostly w palpation.\\nsocial: friend visited. called.\\na: pyleonephritis and bactermia. bp stable. hyponatremia and ^cr...likely dry intravasc.\\np: follow fever. await further id of organism. monitor hemodynamics and volume status. med for comfort. support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569272,\n \"text\": \"CCU NPN 2300-0700\\nO:\\nTM 99po. contin. on ceftriax q24hr. WBC 15.\\nBC/urine pnd from .\\n\\nHR 80's vpaced. occas. PVC. underlying rhythm NSR. contin. on amio 400mgpo. BP 99/57-110/58. milrinone .38mcq/k/min and heparin at 1000u/hr. PTT 133.6- hep. off x1hr and will restart at 800u/hr at 0630. K+ 3.7- 40KCL IV.\\nu/o 50-100cc/hr, concentrated. even for and currently neg. ~ 200cc since MN.\\n\\nsats 88-90% on RA , occas. apnea noted. 2lnc placed with sats improving to 98%. crackles at bases. shallow breathing pattern. RR 30-40.\\n\\npt. contin. to c/o headache, states that she did get some relief from morphine. 2mg x2 during night. slept better tonight.\\n\\nno stool. thirsty. asking for juice.\\n\\nA/P: slept better- better paincontrol with morphine. VSS. u/o improved on milrinone. K+ repletion.\\ncheck PTT at 1230. OOB today. assess effectiveness of morphine.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569273,\n \"text\": \"ccu npn\\no- id-afebrile. cont. abx, recent c+s pnd.\\ncv- hr 80s vpaced with occ to freq pvc, occ. couplet. bp 100-114/50s. k-re'd total 40meq iv/po for 3.7, mg 1.7 re'd 1 amp iv. po4 1.3, re'd neutraphos. hct 32.1. milrinone d/c'd and started on dopamine about 1hr later at 2.5mic/kg/min without change in bp/hr/vea. u/o slightly less, still adequate, ho aware, prefered not to increase dopamine. ptt 83.8 on decreased heparin 800units/hr.\\nresp- on r/a sats high 90s most day, down to 90-92 this pm while asleep. l/s cxs/coarse sounds lower bilat. sob with any exertion in am, even talking, less sob this pm. u/o about 50cc/hr. i+o goal even day, about even 2pm.\\ngi-abd soft w/bowel sounds. poor appetite, ate banana in am, taking juice. ordered choc. boost and boost pudding, none arrived, called this pm for boost. inc.small smear liquid stool in am, yellow/brn.\\nlfts up, down to ultrasound for liver us 3pm.\\nms/pain-a+o x3, sleepy all day, somewhat more awake this pm. c/o still h/a, re'd morphine 2mg iv x1 11:30am w/some relief.\\nskin- intact. lots ecchymosis, esp arms.\\nactivity- oob to chair most day, tol well, needs assist of 2 to stand/pivot,unsteady on her feet. back to bed this pm for liver us.\\naccess- picc patent, dsg/cap changed. peripheral iv for routine change, unable to restart, iv coming to try to restart.\\na- changed to dopamine. lfts elevated, down for liver us.\\np- cont. dopamine, increase if u/o or bp falls, sats drop. monitor also for increased hr/bp, vea. o2 prn. f/u liver us results. goal i+o even. enc. try boost/boost pudding. enc. oob as tolerated. f/u new iv per iv team.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569256,\n \"text\": \"ccu nursing progress note\\npls see carevue flowsheet for complete vs/data/events\\n\\ns: \\\"it's hard to believe i can get this tired just sitting up\\\"\\no: cv: vpaced in the 80s. underlying rhythm afib. no vea. maps cont low 54-62 on low dose milrinone. holding am meds d/t hypotension. discussed on rounds team concerned that new recurrent afib (poss brought on by milrinone) was contributing to hypotension and felt bp may improve off milrinone and then add back oral agents. milrinone dc'd at 10am. no change in bp appreciated. ci 1.9(2.5 on milrinone), svr 1000(850 on milrinone). bp starting to trend up in afternoon w maps to 65 and systolic 85/ . will resume valsartan at lower dose if map >60. then eval other oral agents.\\n\\npt oob all morning, transfered w min assist. had trans c/o dizzyness while sitting up and bp <80/ . but did not appear to be postural.\\npap 40-50/22-27, cvp 7-12.\\nheparin at 1000units/hr. ptt 82. inr 1.4. cont coumadin dosing daily. plan to possibly remove pa line this eve(discussed w team concern of starting longacting anticoagulants with vague plans to remove invasive lines). a peripheral line was placed by the iv team.\\n\\nresp: basilar cxs. labored w activity but maintains sats >93% on ra. no sob at rest. had minor nose bleed but also had clot about the size of an egg pass from her nose.\\n\\ngi: good intake. no bm this shift.\\ngu: poor uop. lasix held d/t hypotension. cr 0.7.\\nms: alert, oriented, cooperative. c/o pain at insertion site, med w oxycodone w good effect. also cont on tid clonipin.\\n\\na: afib, hypotension, poor uop.\\np: cont to follow hemodynamics, volume status. resume oral meds and monitor closely. med for comfort. support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569253,\n \"text\": \"CCU NSG NOTE: ALT IN CV/HEART FAILURE\\nS: \\\"I can see my ankles!\\\"\\nO: For complete VS see CCU flow sheet.\\nID: Pt afebrile.\\nCV: Nipride being weaned. She started the day on 2 mic/kilo and is now down to .5mic/kilo since 1630. Last numbers on 1 mic/kilo were index of 2.9 and SVR 771. She received 40mg valsartin this am and pm dose will be increased to 80mg and nipride will be shut off. She conts on milrinone .385 and heparin at 1000u hr. She conts on po dig and coumadin. HR is in 80 and today she is primarily in NSR, though occasional paced beats are seen. BP has been in mid 90s/60s. PAPs are slowly decreasing to 40-50s/19-25 with RA . K+ was at 1600 and mag 1.5, she will be replaced.\\nRESP: Lungs sounded clear this afternoon. When lying in bed sat will drop to 94%, but with deep breathing she quickly comes up to high 90s. She denies any SOB\\nRENAL: She received lasix 80mg iv at 8am with fair response. Lasix had been changed to Q d. BUt a second dose of 80mg was given at 1630 and pt is now 430cc neg since midnight with todays goal neg 1 liter, and neg >9liters LOS. She initially had hematuria, but it has since resolved.\\nGI: Pt conts to have excellent apetite. She had G- bm this evening.\\nACTIVITY: Pt OOB with minimal assist this afternoon. SHe becomes dypnic with minor activity, but it resolves quickly. She needs encouragement to maintain independence. She will need PT once the swan is out.\\nMS/COMFORT: Pt A & O X 3, cooperative. She c/o of discomfort in left axilla area with nearly resolves with tylenol and oxycodone 5mg, last given at 3pm. She has had continuous low level chest pain for many years.\\nA: Weaning nipride/conts on milrinone\\nP: ?Increase valsartin for 8pm. Keep careful I & O. REpleat lytes. Assist pt with postion changes. DIetary consult is needed as pt is unclear on low salt/heart failure diet as well as daily weights and how to deal with weight gain. She will also need PT consult.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569254,\n \"text\": \"CCU NURSING NOTES\\nS:I'M FEELING BETTER THIS EVENING.\\nO:59YR OLD FEMALE W/ DILATED CM, CHF MANAGEMENT CCU DAY 4, REMAINS ON MILRINONE, HEPARIN, LASIX . SNP WEANED OFF AND VALSARTAN INCREASED TO 80MG. IMPROVED MV 72% AND CI >3. PCWP OF 24. CONTINUED DIURESES UNTIL MINNOC. NEG >1L AT 2300 LAST EVENING. 10L. MHR 80S SR, NO VEA. MAGNESIUM AND POTASSIUM REPLACED. +MUR. DP PALP. C/O SORENESS AT SWAN INSERTION SITE. PT MED W/ OXYCODONE AND TYLENOL W/ GOOD EFFECTS.\\nRESP:LUNGS W/ CRACKLES AT BASES OTHERWISE CLR. SATS 97% ON 3L. SOME DOE BUT PT ABLE TO REPOSITION HERSELF IN BED W/O ASSIST.\\nGI:ABD SOFT, +BS.\\nGU:+HEMATURIA, PINK COLORED URINE.\\nA/P:SLOW IMPROVEMENT OF CHF, CONTINUE TO MONITOR HEMODYNAMICS AS PT IS WEANED OF MILRINONE. CONTINUE DIURESIS AS TOLERATED. PT TEACHING FOR CHF MANAGEMENT, NUTRITION. PT TO ASSIST W/ RECONDITIONING.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284072,\n \"text\": \"There is atrial and ventricular pacing. Compared to the previous tracing\\nthe atria are now paced.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284073,\n \"text\": \"Atrial sensed ventricular paced\\nVentricular premature complexes\\nSince previous tracing of , atrial fibrillation now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284074,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism is probably atrial fibrillation\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283843,\n \"text\": \"A-V sequential pacing\\n*** complex QRS morphology - no further analysis ***\\nSince previous tracing, the heart rate is faster\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284075,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism is probably atrial fibrillation\\nSince previous tracing of , sinus rhythm now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284076,\n \"text\": \"Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\\nof atrial fibrillation is no longer recorded and the rhythm is sinus\\nwith atrial sensing and ventricular pacing.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-04-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284077,\n \"text\": \"Regular ventricular pacing. Pacemaker rhythm. No further analysis. Compared to\\nthe previous tracing of no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284078,\n \"text\": \"Regular ventricular pacing. Pacemaker rhyth. No further analysis. Compared to\\nthe previous tracing no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284079,\n \"text\": \"Ventricular paced rhythm\\nAtrial mechanism appears to be flutter/? fibrillation\\nSince previous tracing of , sinus rhythm now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284080,\n \"text\": \"Atrial sensed ventricular paced\\nSince previous tracing of , ventricular ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284081,\n \"text\": \"Atrial sensed ventricular paced\\nVentricular premature complexes\\nSince previous tracing of , atrial fibrillation now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284082,\n \"text\": \"Atrial fibrillation. Ventricular couplets. Marked left axis deviation.\\nIntraventricular conduction defect. Left ventricular hypertrophy. Intermittent\\nventricular paced rhythm. Since the previous tracing of there is a run\\nof ventricular paced rhythm.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284083,\n \"text\": \"Atrial fibrillation and demand ventricular pacing\\nIntraventricular conduction delay - left axis deviation\\nSince previous tracing, atrial fibrillation is new\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-03-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 284084,\n \"text\": \"Paced rhythm\\nSince previous tracing, no significant change\\n\\n\"\n }\n]"}}},{"rowIdx":294,"cells":{"subject_id":{"kind":"number","value":22071,"string":"22,071"},"hadm_id":{"kind":"number","value":125295,"string":"125,295"},"target_text":{"kind":"string","value":"During his cardiac catheterization on the day of admission, there was a complication involving the PTCA/stent of OM causing jailing of his AV groove, left circumflex with loss of dissection of his lower OM. Post procedure the patient experienced persistent chest pain, hypotension to the 60's/30's and was noted to have hematocrit drop from 44 to 34.9. Also with increasing right groin pain. The patient had CT of abdomen and pelvis showing mild to moderate hematoma and no retroperitoneal bleed. Patient also had several episodes of bradycardia requiring Atropine. He was transferred to the CCU on for further management of his chest pain, hypotension and decreased hematocrit. The patient ruled in for an MI by enzymes, likely secondary to include OM/jailed AV groove, left circumflex with positive CKs which peaked at 763/45 on . The patient was maintained on Aspirin, Lipitor and Plavix. Once he became hemodynamically stable on he was started on Metoprolol and Captopril which were titrated upwards as blood pressure tolerated. He continued to have mild to moderate pain intermittently on and without EKG changes in response to sublingual Nitroglycerin. The patient's episodes of hypotension responded well to 4-6 liters of IV fluids on to , as well as two units of packed red blood cells. This was thought to be secondary to difference in blood pressure cuff measurements between the floor and CCU as his blood pressure was not as low when measured in the CCU after. The patient had a bedside echo on which was notable for a limited view of left ventricular ejection fraction of 50%, no obvious effusion but could not rule out possible effusion, no tamponade was noted. An official TTE on showed post echo density consistent with pericardial effusion hematoma, etc. The patient will most likely get an outpatient stress test with EF evaluation as an outpatient. The patient's initial hematocrit drop of 10 points may have reflected blood loss from two catheterizations and dilution after 4-6 liters of fluid resuscitation, however, he received two units of packed red blood cells on the morning of and his hematocrit was checked , remaining fairly stable. He was guaiac negative throughout. On he was noted to have non palpable right foot pulses found on the evening of . The patient complained of increasing right groin pain and was found to have a right groin bruit on exam. Ultrasound was done on revealing a 5 by 3 bilobed pseudoaneurysm with a narrow neck associated with the right common femoral artery. The patient's hematocrit remained stable. The patient underwent an interventional radiology procedure with thrombin injection on . A repeat ultrasound was done on the day of discharge which revealed a successful thrombosing of the right groin pseudoaneurysm. The patient did not require any additional intervention with regard to the right groin pseudoaneurysm. The patient did well throughout the remainder of his hospital stay, remained hemodynamically stable with stable hematocrit. He was noted to have several bradycardic episodes overnight with heart rate as low as mid 40's, but these only occurred overnight while the patient was sleeping. Since these episodes were not symptomatic and did not occur during the day, the patient was continued on his Atenolol. The patient was discharged stable."},"extractive_notes_summ":{"kind":"string","value":"VOIDING WELL .,IF HCT STABLE BE TRANS . Mild tricuspid [1+]regurgitation is seen. FINDINGS: Duplex evaluation was performed of the right lower extremity. FINAL REPORT INDICATION: Right groin hematoma/pseudoaneurysm. FINAL REPORT HISTORY: Right inguinal pseudoaneurysm. R GROIN ECCYMOTIC ,SOFT HEMATOMA UNCHANGED.ULTRASOUND SHOWS PSEUDOANEURYSM. sp stent om,complicated by hypotension,hematomaAM CK RISING . There is an echo-dense space seen posteriorly at the level ofthe AV groove c/w pericardial effusion, hematoma, etc. The basal inferoposterior wall ishypokinetic. This is in comparison to the above studies which showed a right common femoral artery pseudoaneurysm which underwent initially felt to be failed thrombin injection IMPRESSION: Thrombosed right femoral artery pseudoaneurysm. Pericardial effusion.Height: (in) 69Weight (lb): 260BSA (m2): 2.31 m2BP (mm Hg): 118/65Status: InpatientDate/Time: at 15:39Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of theinteratrial septum.LEFT VENTRICLE: The left ventricular cavity size is normal.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter. pericardial fat).Compared with the prior study of , images are still suboptimal. There is a moderate echo-dense space seen posteriorly c/wpericardial effusion, blood, pericardial fat, etc.Follow-up study is recommended. with R groin pseudoaneurysm. with R groin pseudoaneurysm. There is at least mildmitral regurgitation. scale and Doppler son of the right common femoral artery and vein were performed. BP STABLE ,TOL LOPRESSER AND ACE . Left atrial abnormality. RIGHT; GUID FOR COMPRESS/REPAIR OF AVF/PSEUDO RIGHT Reason: arterial duplex with thrombin injection of pseudoaneurysm. The remaining basal segments are contracting well (the apex isnot seen). Pt has significant caridac hx.Neuro: Pt intact. First degree A-V block. First degree A-V block. First degree A-V block. First degree A-V block. Sinus bradycardia. CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse calcification of the abdominal aorta. There is moderate pulmonary artery systolichypertension. R. GROIN WITH SMALL OOZE & MOD. U/O 45-180CC/HR.ID: T(MAX)98.3(PO).LABS: HCT 36.2, PT 12.7, PTT 26.4, INR 1.0, K 4.0, BUN/CREAT 13/0.7, BS 112, CA 7.0, MG 1.6, PO4 4.4, ALB 3.3, & CK 217 WITH MB16%.PLAN: CONT. FINDINGS: The patient has a right inguinal pseudoaneurysm arising off the common femoral artery. Suboptimalimage quality due to body habitus.Conclusions:The left atrium is moderately dilated. Mitralregurgitation is present but cannot be quantified.TRICUSPID VALVE: The tricuspid valve leaflets are normal. TRANSFUSED 1U PRBC FOR HCT 34.9. The inferior wallis akinetic. There is an echo-denseseen anteriorly (? pseudoaneurysm r groin sp stent,miSR TO SB NO ECTOPY . REASON FOR THIS EXAMINATION: follow right groin pseudoaneurysm. a complication from cath developed a hematoma in R groin. The left ventricle is borderline tomildly hypertrophied. Minimal stranding is seen about the right lower psoas and iliacus muscles. T waveinversions in leads I and aVL suggest possible anterolateral ischemia. Evaluate for pseudoaneurysm. Compared to tracing #1 nodiagnostic interim change.TRACING #2 Now with decreased hematocrit and increasing mass in right groin. This appears to be a small hematoma. IMPRESSION: Findings most consistent with a 5.0 x 3.0 bilobed pseudoaneurysm with a narrow neck associated with the right common femoral artery. DISTAL PULSES BY DOPPLER . Status post attempted thrombin injection. REASON FOR THIS EXAMINATION: arterial duplex with thrombin injection of pseudoaneurysm. SIZE HEMATOMA. PATIENT/TEST INFORMATION:Indication: Hypotension, S/P intervention.? On limited views, rightventricular systolic function is good. +BPPP. Hct, and extreme TN in right groin. E/D WELL. TECHNIQUE: Multiple axial images were obtained from the mid abdomen to the upper thigh without IV contrast. VOIDING LG AMTS BLD TINGED URINE .ALERT/ORIENTED/ COOPERATIVERI BY CK, BE DEVELOPING PSEUDO ANUERYSMFOLLOW HCT, MONITOR SIZE HEMATOMA For Thrombin injection. There is moderate pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal. Compared to tracing #3 nodiagnostic interim change.TRACING #4 ULTRASOUND ORDERED . Pt to cath lab on stented OM. The common femoral vein were both somewhat compressed under this large pulsatile lesion. Sinus bradycardia - first degree A-V blockLateral ST-T changes may be due to myocardial ischemia Effusion.BP (mm Hg): 78/45Status: InpatientDate/Time: at 22:11Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:TRICUSPID VALVE: The tricuspid valve is not well visualized.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Conclusions:Views are limited. C/O PERSISTENT CP # ON SCALE 1-10, UNRELIEVED BY IV MSO4. MED C PERCOCETTE FOR PAIN C RELIEF . BS CLEAR BUT SLIGHTLY DIMINISHED AT BASES. 9:20 AM FEMORAL VASCULAR US RIGHT Clip # Reason: follow right groin pseudoaneurysm. There is a small high attenuation fluid collection medial and inferior to this soft tissue stranding measuring approximately 3cm in largest diameter. IMPRESSION: 1) Right upper thigh and groin soft tissue stranding with adjacent small high attenuation fluid collection. The left ventricle may be hypertrophied. Pt especially needs to keep R leg .Cardiac: Pt in SR/SB do ectopy. This did not yield complete occlusion of the pseudoaneurysm, slight decrease in size after injection. Monitor dopplers and hematoma carefully! BS+. REPEAT HCT PENDING . BP 88-119/39-58. The right ventricle is not seen. The aortic and mitral valves aregrossly normal. The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. DID WELL ON PRONGS FOR REMAINDER OF NOC. Pt had an episode of CP at 0250 pt claims it was non radiationg CP, pt received 1 SL NTG, relief with NTG, EKG done no significant changes.Resp: Pt has hx of sleep apenia."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2138-08-14 00:00:00.000","description":"Report","row_id":1551775,"text":"pseudoaneurysm r groin sp stent,mi\nSR TO SB NO ECTOPY . BP STABLE ,TOL LOPRESSER AND ACE . R GROIN ECCYMOTIC ,SOFT HEMATOMA UNCHANGED.ULTRASOUND SHOWS PSEUDOANEURYSM. MED C PERCOCETTE FOR PAIN C RELIEF . HCT STABLE AT 32. DISTAL PULSES BY DOPPLER . BS CL, SAT 98 RM AIR . WILL USE BIBAP TONITE . E/D WELL. VOIDING WELL .,IF HCT STABLE BE TRANS .\n"},{"category":"Nursing/other","chartdate":"2138-08-13 00:00:00.000","description":"Report","row_id":1551772,"text":"SEE ADMISSION HISTORY/ICU EVENTS FORM FOR DETAILS OF PMH.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE.\nRESP: O2->2L NP. O2 SATS 97-100%. RR 11-16. BS CLEAR BUT SLIGHTLY\n DIMINISHED AT BASES. ATTEMPTED BIPAP BRIEFLY WHEN GOING TO SLEEP\n (D/T SLEEP APNEA), BUT HOSPITAL BIPAP MACHINE DIFFERENT THAN\n HIS OWN & HE FELT LIKE HE WAS NOT GETTING ENOUGH AIR. RPT AWARE\n & ATTEMPTED TO ASSIST PT TO NO AVAIL. DID WELL ON PRONGS FOR\n REMAINDER OF NOC. NO APNEA ALARMS.\nCARDIAC: HR52->73 SR WITH NO ECTOPY. BP 88-119/39-58. C/O PERSISTENT\n CP # ON SCALE 1-10, UNRELIEVED BY IV MSO4. R. GROIN WITH\n SMALL OOZE & MOD. SIZE HEMATOMA. +BPPP. TRANSFUSED 1U PRBC\n FOR HCT 34.9. IV 1/2NS 150CC/HR.\nGI: ABD. SL. DISTENDED. BS+. NO STOOL. NPO X MEDS & FEW ICE CHIPS.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 45-180CC/HR.\nID: T(MAX)98.3(PO).\nLABS: HCT 36.2, PT 12.7, PTT 26.4, INR 1.0, K 4.0, BUN/CREAT 13/0.7,\n BS 112, CA 7.0, MG 1.6, PO4 4.4, ALB 3.3, & CK 217 WITH MB16%.\nPLAN: CONT. TO CYCLE CK'S(NEXT DRAW 0800). CONT. TO FOLLOW HCTS &\n ASSESS R. GROIN HEMATOMA.\n"},{"category":"Nursing/other","chartdate":"2138-08-13 00:00:00.000","description":"Report","row_id":1551773,"text":"sp stent om,complicated by hypotension,hematoma\nAM CK RISING . C/P 4 AT IPM . NO EKG CHANGES . PAIN RELIEVED BY 3 SL NITROS . 4 PM CK PENDING . ALSO C/O HOT FLASHES .\n\nPT C/O POPPING,INCREASED PAIN IN GROIN , BRUIT NOW PRESENT . ULTRASOUND ORDERED . REPEAT HCT PENDING . PULSES BY DOPPLER DISTAL.\n\nSAT 100 RM AIR. NO EPISODES SLEEP APNEA\n\nE/D WELL .NO STOOL\n\nFOLEY DC . VOIDING LG AMTS BLD TINGED URINE .\n\nALERT/ORIENTED/ COOPERATIVE\n\nRI BY CK, BE DEVELOPING PSEUDO ANUERYSM\n\nFOLLOW HCT, MONITOR SIZE HEMATOMA\n\n\n"},{"category":"Nursing/other","chartdate":"2138-08-14 00:00:00.000","description":"Report","row_id":1551774,"text":"CCU Nursing Progress Note\nPt is a 54 y.o male RI for MI. Pt to cath lab on stented OM. S/P stent placement, pt had complications of a hematoma in R groin, Episodes of CP, and hypotension. Pt has significant caridac hx.\n\nNeuro: Pt intact. A&O x3. Pt moves all extremeties well. Pt instructed to remain flat until told otherwise. Pt frustrated but very cooperative. Pt especially needs to keep R leg .\n\nCardiac: Pt in SR/SB do ectopy. BP in 100's to 130's systolic. a complication from cath developed a hematoma in R groin. Area is ecchymotic and very painful upon palpation, and pain without manipulation. Hematoma expanding and is marked. HCT remaining stable at 34. Dopplerable pulses fluxuating with amplitude of doppler. Pt also has pseudo anneurysm, and bruiet. Pt receiving percocet q 6/hr for pain. Pt had an episode of CP at 0250 pt claims it was non radiationg CP, pt received 1 SL NTG, relief with NTG, EKG done no significant changes.\n\nResp: Pt has hx of sleep apenia. Pt is on bi-pap at night, and 4L NC when off bipap. BS clear.\n\nGI: Pt on infrequent liquids, with meds, pt had coffee brought in by family and did not tolerate well. Guiac all stools x3, none have been done. BS present pt obese\n\nGU: Pt on sips for meds. Pt voids good urine output, No IVF at this time. Urine creatinine and microalbumin sent at 2100.\n\nMisc: Ultrasound in AM for hematoma. Family supportive. Monitor dopplers and hematoma carefully!\n"},{"category":"Echo","chartdate":"2138-08-12 00:00:00.000","description":"Report","row_id":65879,"text":"PATIENT/TEST INFORMATION:\nIndication: Hypotension, S/P intervention.\n? Effusion.\nBP (mm Hg): 78/45\nStatus: Inpatient\nDate/Time: at 22:11\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nViews are limited. The left ventricle may be hypertrophied. The inferior wall\nis akinetic. The remaining basal segments are contracting well (the apex is\nnot seen). The right ventricle is not seen. The aortic and mitral valves are\ngrossly normal. There is a moderate echo-dense space seen posteriorly c/w\npericardial effusion, blood, pericardial fat, etc.\n\nFollow-up study is recommended.\n\n\n"},{"category":"Echo","chartdate":"2138-08-13 00:00:00.000","description":"Report","row_id":65773,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nS/P intervention (circumflex stent).\n? Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 260\nBSA (m2): 2.31 m2\nBP (mm Hg): 118/65\nStatus: Inpatient\nDate/Time: at 15:39\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mitral\nregurgitation is present but cannot be quantified.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. There is no pulmonic valve stenosis.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality due to body habitus.\n\nConclusions:\nThe left atrium is moderately dilated. The left ventricle is borderline to\nmildly hypertrophied. Views are limited. The basal inferoposterior wall is\nhypokinetic. The remaining basal segments are contracting well. The apex is\nnot seen. The LVEF cannot be accurately estimated. On limited views, right\nventricular systolic function is good. The aortic leaflets (3) appear\nstructurally normal with good leaflet excursion. Aortic regurgitation cannot\nbe excluded. The mitral leaflets are mildly thickened. There is at least mild\nmitral regurgitation. There is moderate pulmonary artery systolic\nhypertension. There is an echo-dense space seen posteriorly at the level of\nthe AV groove c/w pericardial effusion, hematoma, etc. There is an echo-dense\nseen anteriorly (? pericardial fat).\nCompared with the prior study of , images are still suboptimal. There\nhas probably been no significant change (views not entirely comparable).\n\n\n"},{"category":"ECG","chartdate":"2138-08-14 00:00:00.000","description":"Report","row_id":142248,"text":"Sinus bradycardia\n - first degree A-V block\nLateral ST-T changes may be due to myocardial ischemia\n\n"},{"category":"ECG","chartdate":"2138-08-13 00:00:00.000","description":"Report","row_id":142249,"text":"Normal sinus rhythm. First degree A-V block. Compared to tracing #3 no\ndiagnostic interim change.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2138-08-12 00:00:00.000","description":"Report","row_id":142250,"text":"Sinus bradycardia. First degree A-V block. Compared to tracing #2 no diagnostic\ninterim change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2138-08-12 00:00:00.000","description":"Report","row_id":142251,"text":"Normal sinus rhythm. First degree A-V block. Compared to tracing #1 no\ndiagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2138-08-12 00:00:00.000","description":"Report","row_id":142252,"text":"Normal sinus rhythm. First degree A-V block. Left atrial abnormality. T wave\ninversions in leads I and aVL suggest possible anterolateral ischemia. T wave\nflattening in leads V5-V6. No previous tracing available for comparison.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2138-08-18 00:00:00.000","description":"R FEMORAL VASCULAR US RIGHT","row_id":743691,"text":" 9:20 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: follow right groin pseudoaneurysm.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p M.I. with R groin pseudoaneurysm. Failed thrombin injection\n on Friday.\n REASON FOR THIS EXAMINATION:\n follow right groin pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right groin hematoma/pseudoaneurysm. Status post attempted\n thrombin injection.\n\n FINDINGS: Duplex evaluation was performed of the right lower extremity. The\n study compared to and . On the current study there is no evidence\n of right groin pseudoaneurysm or AV fistula. The common femoral artery and\n common femoral vein are patent without evidence of obstruction. This is in\n comparison to the above studies which showed a right common femoral artery\n pseudoaneurysm which underwent initially felt to be failed thrombin injection\n\n IMPRESSION: Thrombosed right femoral artery pseudoaneurysm.\n\n"},{"category":"Radiology","chartdate":"2138-08-15 00:00:00.000","description":"ART DUP EXT LO UNI;F/U","row_id":743568,"text":" 2:52 PM\n ART DUP EXT LO UNI;F/U; TRANS THERAPY, EMBO S&I RIGHT Clip # \n TRANS-CATH OCC./EMBO . RIGHT; GUID FOR COMPRESS/REPAIR OF AVF/PSEUDO RIGHT\n Reason: arterial duplex with thrombin injection of pseudoaneurysm.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p M.I. with R groin pseudoaneurysm.\n REASON FOR THIS EXAMINATION:\n arterial duplex with thrombin injection of pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right inguinal pseudoaneurysm. For Thrombin injection.\n\n FINDINGS: The patient has a right inguinal pseudoaneurysm arising off the\n common femoral artery. Under real-time ultrasound evaluation, after\n discussion with the patient, a 20 g. needle was placed within the\n pseudoaneurysm. Approximately 1000 units of Thrombin was injected. This did\n not yield complete occlusion of the pseudoaneurysm, slight decrease in size\n after injection. No change in peripheral exam.\n\n IMPRESSION: Persistent right common femoral artery pseudoaneurysm after 1000\n units of Thrombin (currently measuring 1.2 X 2.3 cm). Size is such that would\n recommend follow up in 2 or 3 days as this may spontaneously thrombose. If\n persistence is documented at that time, would consider open repair.\n\n"},{"category":"Radiology","chartdate":"2138-08-14 00:00:00.000","description":"R FEMORAL VASCULAR US RIGHT","row_id":743503,"text":" 1:05 PM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: 54 yo man question pseudoaneurysm post cardiac catheterizati\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with . Hct, and extreme TN in right groin.\n REASON FOR THIS EXAMINATION:\n 54 yo man question pseudoaneurysm post cardiac catheterization. Please\n evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n LOWER EXTREMITY ULTRASOUND\n\n CLINICAL INDICATION: 54 year old man status post cardiac catheterization. Now\n with decreased hematocrit and increasing mass in right groin. Evaluate for\n pseudoaneurysm.\n\n scale and Doppler son of the right common femoral artery and vein\n were performed. There is a bilobed hypoechoic structure measuring\n approximately 5.0 x 3.0 cm anterior to the common femoral artery with a small\n neck communicating with the artery. The common femoral vein were both\n somewhat compressed under this large pulsatile lesion. This lesion contains\n arterial waveforms. No definite evidence of AV fistula was demonstrated,\n although the proximal common femoral vein waveform appeared somewhat mixed,\n likely secondary to reverberations from the adjacent pulsatile mass.\n\n IMPRESSION: Findings most consistent with a 5.0 x 3.0 bilobed pseudoaneurysm\n with a narrow neck associated with the right common femoral artery.\n\n"},{"category":"Radiology","chartdate":"2138-08-12 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":743411,"text":" 9:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal hematoma\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p cardiac cath today now with hypotension, right groin and\n back pain, and 10 point Hct drop.\n REASON FOR THIS EXAMINATION:\n evaluate for retroperitoneal hematoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P cardiac catheterization with hypotension, groin and back pain\n at 10 point HCT drop.\n\n TECHNIQUE: Multiple axial images were obtained from the mid abdomen to the\n upper thigh without IV contrast.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse calcification of the\n abdominal aorta. There is residual contrast within the collecting systems\n bilaterally. Minimal stranding is seen about the right lower psoas and iliacus\n muscles. More prominent soft tissue stranding is seen within the right groin\n above the common femoral vessels. There is a small high attenuation fluid\n collection medial and inferior to this soft tissue stranding measuring\n approximately 3cm in largest diameter. There is no free fluid within the\n pelvis. The rectum and prostate are normal in appearance. There is a Foley\n catheter within the bladder.\n\n Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: 1) Right upper thigh and groin soft tissue stranding with adjacent\n small high attenuation fluid collection. This appears to be a small hematoma.\n There is mild stranding along the psoas and iliacus which may relate to this\n same process. No retroperitoneal hematoma is identified.\n\n These findings were communicated to the team caring for the patient.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2138-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1551775,\n \"text\": \"pseudoaneurysm r groin sp stent,mi\\nSR TO SB NO ECTOPY . BP STABLE ,TOL LOPRESSER AND ACE . R GROIN ECCYMOTIC ,SOFT HEMATOMA UNCHANGED.ULTRASOUND SHOWS PSEUDOANEURYSM. MED C PERCOCETTE FOR PAIN C RELIEF . HCT STABLE AT 32. DISTAL PULSES BY DOPPLER . BS CL, SAT 98 RM AIR . WILL USE BIBAP TONITE . E/D WELL. VOIDING WELL .,IF HCT STABLE BE TRANS .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2138-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1551772,\n \"text\": \"SEE ADMISSION HISTORY/ICU EVENTS FORM FOR DETAILS OF PMH.\\n\\nNEURO: A&O X3. PLEASANT & COOPERATIVE.\\nRESP: O2->2L NP. O2 SATS 97-100%. RR 11-16. BS CLEAR BUT SLIGHTLY\\n DIMINISHED AT BASES. ATTEMPTED BIPAP BRIEFLY WHEN GOING TO SLEEP\\n (D/T SLEEP APNEA), BUT HOSPITAL BIPAP MACHINE DIFFERENT THAN\\n HIS OWN & HE FELT LIKE HE WAS NOT GETTING ENOUGH AIR. RPT AWARE\\n & ATTEMPTED TO ASSIST PT TO NO AVAIL. DID WELL ON PRONGS FOR\\n REMAINDER OF NOC. NO APNEA ALARMS.\\nCARDIAC: HR52->73 SR WITH NO ECTOPY. BP 88-119/39-58. C/O PERSISTENT\\n CP # ON SCALE 1-10, UNRELIEVED BY IV MSO4. R. GROIN WITH\\n SMALL OOZE & MOD. SIZE HEMATOMA. +BPPP. TRANSFUSED 1U PRBC\\n FOR HCT 34.9. IV 1/2NS 150CC/HR.\\nGI: ABD. SL. DISTENDED. BS+. NO STOOL. NPO X MEDS & FEW ICE CHIPS.\\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 45-180CC/HR.\\nID: T(MAX)98.3(PO).\\nLABS: HCT 36.2, PT 12.7, PTT 26.4, INR 1.0, K 4.0, BUN/CREAT 13/0.7,\\n BS 112, CA 7.0, MG 1.6, PO4 4.4, ALB 3.3, & CK 217 WITH MB16%.\\nPLAN: CONT. TO CYCLE CK'S(NEXT DRAW 0800). CONT. TO FOLLOW HCTS &\\n ASSESS R. GROIN HEMATOMA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2138-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1551773,\n \"text\": \"sp stent om,complicated by hypotension,hematoma\\nAM CK RISING . C/P 4 AT IPM . NO EKG CHANGES . PAIN RELIEVED BY 3 SL NITROS . 4 PM CK PENDING . ALSO C/O HOT FLASHES .\\n\\nPT C/O POPPING,INCREASED PAIN IN GROIN , BRUIT NOW PRESENT . ULTRASOUND ORDERED . REPEAT HCT PENDING . PULSES BY DOPPLER DISTAL.\\n\\nSAT 100 RM AIR. NO EPISODES SLEEP APNEA\\n\\nE/D WELL .NO STOOL\\n\\nFOLEY DC . VOIDING LG AMTS BLD TINGED URINE .\\n\\nALERT/ORIENTED/ COOPERATIVE\\n\\nRI BY CK, BE DEVELOPING PSEUDO ANUERYSM\\n\\nFOLLOW HCT, MONITOR SIZE HEMATOMA\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2138-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1551774,\n \"text\": \"CCU Nursing Progress Note\\nPt is a 54 y.o male RI for MI. Pt to cath lab on stented OM. S/P stent placement, pt had complications of a hematoma in R groin, Episodes of CP, and hypotension. Pt has significant caridac hx.\\n\\nNeuro: Pt intact. A&O x3. Pt moves all extremeties well. Pt instructed to remain flat until told otherwise. Pt frustrated but very cooperative. Pt especially needs to keep R leg .\\n\\nCardiac: Pt in SR/SB do ectopy. BP in 100's to 130's systolic. a complication from cath developed a hematoma in R groin. Area is ecchymotic and very painful upon palpation, and pain without manipulation. Hematoma expanding and is marked. HCT remaining stable at 34. Dopplerable pulses fluxuating with amplitude of doppler. Pt also has pseudo anneurysm, and bruiet. Pt receiving percocet q 6/hr for pain. Pt had an episode of CP at 0250 pt claims it was non radiationg CP, pt received 1 SL NTG, relief with NTG, EKG done no significant changes.\\n\\nResp: Pt has hx of sleep apenia. Pt is on bi-pap at night, and 4L NC when off bipap. BS clear.\\n\\nGI: Pt on infrequent liquids, with meds, pt had coffee brought in by family and did not tolerate well. Guiac all stools x3, none have been done. BS present pt obese\\n\\nGU: Pt on sips for meds. Pt voids good urine output, No IVF at this time. Urine creatinine and microalbumin sent at 2100.\\n\\nMisc: Ultrasound in AM for hematoma. Family supportive. Monitor dopplers and hematoma carefully!\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2138-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65879,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Hypotension, S/P intervention.\\n? Effusion.\\nBP (mm Hg): 78/45\\nStatus: Inpatient\\nDate/Time: at 22:11\\nTest: Portable TTE(Focused views)\\nDoppler: No Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\\n\\nConclusions:\\nViews are limited. The left ventricle may be hypertrophied. The inferior wall\\nis akinetic. The remaining basal segments are contracting well (the apex is\\nnot seen). The right ventricle is not seen. The aortic and mitral valves are\\ngrossly normal. There is a moderate echo-dense space seen posteriorly c/w\\npericardial effusion, blood, pericardial fat, etc.\\n\\nFollow-up study is recommended.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2138-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65773,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease.\\nS/P intervention (circumflex stent).\\n? Pericardial effusion.\\nHeight: (in) 69\\nWeight (lb): 260\\nBSA (m2): 2.31 m2\\nBP (mm Hg): 118/65\\nStatus: Inpatient\\nDate/Time: at 15:39\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is moderately dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of the\\ninteratrial septum.\\n\\nLEFT VENTRICLE: The left ventricular cavity size is normal.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\\ndiameter.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion. There is no significant aortic valve stenosis.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mitral\\nregurgitation is present but cannot be quantified.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\\nregurgitation is seen. There is moderate pulmonary artery systolic\\nhypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal. There is no pulmonic valve stenosis.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\\nimage quality due to body habitus.\\n\\nConclusions:\\nThe left atrium is moderately dilated. The left ventricle is borderline to\\nmildly hypertrophied. Views are limited. The basal inferoposterior wall is\\nhypokinetic. The remaining basal segments are contracting well. The apex is\\nnot seen. The LVEF cannot be accurately estimated. On limited views, right\\nventricular systolic function is good. The aortic leaflets (3) appear\\nstructurally normal with good leaflet excursion. Aortic regurgitation cannot\\nbe excluded. The mitral leaflets are mildly thickened. There is at least mild\\nmitral regurgitation. There is moderate pulmonary artery systolic\\nhypertension. There is an echo-dense space seen posteriorly at the level of\\nthe AV groove c/w pericardial effusion, hematoma, etc. There is an echo-dense\\nseen anteriorly (? pericardial fat).\\nCompared with the prior study of , images are still suboptimal. There\\nhas probably been no significant change (views not entirely comparable).\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142248,\n \"text\": \"Sinus bradycardia\\n - first degree A-V block\\nLateral ST-T changes may be due to myocardial ischemia\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142249,\n \"text\": \"Normal sinus rhythm. First degree A-V block. Compared to tracing #3 no\\ndiagnostic interim change.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142250,\n \"text\": \"Sinus bradycardia. First degree A-V block. Compared to tracing #2 no diagnostic\\ninterim change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142251,\n \"text\": \"Normal sinus rhythm. First degree A-V block. Compared to tracing #1 no\\ndiagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-08-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142252,\n \"text\": \"Normal sinus rhythm. First degree A-V block. Left atrial abnormality. T wave\\ninversions in leads I and aVL suggest possible anterolateral ischemia. T wave\\nflattening in leads V5-V6. No previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-08-18 00:00:00.000\",\n \"description\": \"R FEMORAL VASCULAR US RIGHT\",\n \"row_id\": 743691,\n \"text\": \" 9:20 AM\\n FEMORAL VASCULAR US RIGHT Clip # \\n Reason: follow right groin pseudoaneurysm.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man s/p M.I. with R groin pseudoaneurysm. Failed thrombin injection\\n on Friday.\\n REASON FOR THIS EXAMINATION:\\n follow right groin pseudoaneurysm.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right groin hematoma/pseudoaneurysm. Status post attempted\\n thrombin injection.\\n\\n FINDINGS: Duplex evaluation was performed of the right lower extremity. The\\n study compared to and . On the current study there is no evidence\\n of right groin pseudoaneurysm or AV fistula. The common femoral artery and\\n common femoral vein are patent without evidence of obstruction. This is in\\n comparison to the above studies which showed a right common femoral artery\\n pseudoaneurysm which underwent initially felt to be failed thrombin injection\\n\\n IMPRESSION: Thrombosed right femoral artery pseudoaneurysm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-08-15 00:00:00.000\",\n \"description\": \"ART DUP EXT LO UNI;F/U\",\n \"row_id\": 743568,\n \"text\": \" 2:52 PM\\n ART DUP EXT LO UNI;F/U; TRANS THERAPY, EMBO S&I RIGHT Clip # \\n TRANS-CATH OCC./EMBO . RIGHT; GUID FOR COMPRESS/REPAIR OF AVF/PSEUDO RIGHT\\n Reason: arterial duplex with thrombin injection of pseudoaneurysm.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man s/p M.I. with R groin pseudoaneurysm.\\n REASON FOR THIS EXAMINATION:\\n arterial duplex with thrombin injection of pseudoaneurysm.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Right inguinal pseudoaneurysm. For Thrombin injection.\\n\\n FINDINGS: The patient has a right inguinal pseudoaneurysm arising off the\\n common femoral artery. Under real-time ultrasound evaluation, after\\n discussion with the patient, a 20 g. needle was placed within the\\n pseudoaneurysm. Approximately 1000 units of Thrombin was injected. This did\\n not yield complete occlusion of the pseudoaneurysm, slight decrease in size\\n after injection. No change in peripheral exam.\\n\\n IMPRESSION: Persistent right common femoral artery pseudoaneurysm after 1000\\n units of Thrombin (currently measuring 1.2 X 2.3 cm). Size is such that would\\n recommend follow up in 2 or 3 days as this may spontaneously thrombose. If\\n persistence is documented at that time, would consider open repair.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-08-14 00:00:00.000\",\n \"description\": \"R FEMORAL VASCULAR US RIGHT\",\n \"row_id\": 743503,\n \"text\": \" 1:05 PM\\n FEMORAL VASCULAR US RIGHT Clip # \\n Reason: 54 yo man question pseudoaneurysm post cardiac catheterizati\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with . Hct, and extreme TN in right groin.\\n REASON FOR THIS EXAMINATION:\\n 54 yo man question pseudoaneurysm post cardiac catheterization. Please\\n evaluate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n LOWER EXTREMITY ULTRASOUND\\n\\n CLINICAL INDICATION: 54 year old man status post cardiac catheterization. Now\\n with decreased hematocrit and increasing mass in right groin. Evaluate for\\n pseudoaneurysm.\\n\\n scale and Doppler son of the right common femoral artery and vein\\n were performed. There is a bilobed hypoechoic structure measuring\\n approximately 5.0 x 3.0 cm anterior to the common femoral artery with a small\\n neck communicating with the artery. The common femoral vein were both\\n somewhat compressed under this large pulsatile lesion. This lesion contains\\n arterial waveforms. No definite evidence of AV fistula was demonstrated,\\n although the proximal common femoral vein waveform appeared somewhat mixed,\\n likely secondary to reverberations from the adjacent pulsatile mass.\\n\\n IMPRESSION: Findings most consistent with a 5.0 x 3.0 bilobed pseudoaneurysm\\n with a narrow neck associated with the right common femoral artery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-08-12 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 743411,\n \"text\": \" 9:57 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: evaluate for retroperitoneal hematoma\\n Field of view: 40\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man s/p cardiac cath today now with hypotension, right groin and\\n back pain, and 10 point Hct drop.\\n REASON FOR THIS EXAMINATION:\\n evaluate for retroperitoneal hematoma\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P cardiac catheterization with hypotension, groin and back pain\\n at 10 point HCT drop.\\n\\n TECHNIQUE: Multiple axial images were obtained from the mid abdomen to the\\n upper thigh without IV contrast.\\n\\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse calcification of the\\n abdominal aorta. There is residual contrast within the collecting systems\\n bilaterally. Minimal stranding is seen about the right lower psoas and iliacus\\n muscles. More prominent soft tissue stranding is seen within the right groin\\n above the common femoral vessels. There is a small high attenuation fluid\\n collection medial and inferior to this soft tissue stranding measuring\\n approximately 3cm in largest diameter. There is no free fluid within the\\n pelvis. The rectum and prostate are normal in appearance. There is a Foley\\n catheter within the bladder.\\n\\n Soft tissue and osseous structures are unremarkable.\\n\\n IMPRESSION: 1) Right upper thigh and groin soft tissue stranding with adjacent\\n small high attenuation fluid collection. This appears to be a small hematoma.\\n There is mild stranding along the psoas and iliacus which may relate to this\\n same process. No retroperitoneal hematoma is identified.\\n\\n These findings were communicated to the team caring for the patient.\\n\\n\"\n }\n]"}}},{"rowIdx":295,"cells":{"subject_id":{"kind":"number","value":62594,"string":"62,594"},"hadm_id":{"kind":"number","value":185555,"string":"185,555"},"target_text":{"kind":"string","value":"65 year old female with a history of ESLD NASH c/b portal hypertension, esophageal varices, portal gastropathy, and recurrent GI bleeds who presents with altered mental status. . # Shock: The patient presented wth altered mentas status and given known cirrhosis and h/o encephalopathy was high on differential. The patient had been intubated at an OSH for airway protection. Ammonia elevated at OSH. Infection was considered although the patient was afebrile, without leukocytosis. Recent paracentesis 2 days ago without e/o SBP. No current peritoneal signs. No pna on CXR althouth + effusion on R. No UTI on U/A. The patient had TCAs on tox but on amitriptyline. Also has benzos on tox and not on home med list. Could be contributing. CT head negative. Given roving eyes on exam, must also consider seizure activity. The patient was treated for hepatic encephalopathy with lactulos and rifaximin, however her mental status did not improve. . The patient was cultured, however over her two day hospital course the patients blood pressure continued to fall. A central line was attempted but complicated line placement in the patients carotid artery. Vascular surgery was consulted, the patient was given FFP and the line was removed. A femoral line was placed and the patient started on pressers. However the patients BP remained low, her LFTs rose, and the patient went into ARF requiring placement of a dialysis line. However, not long after line placement the patients pressures continued to drop requiring three pressers. A decision was made by the family to withdraw care. The patient was made CMO, extubated, and the patient expired after a brief period. Post-Mortem examination was declined by the family."},"extractive_notes_summ":{"kind":"string","value":"Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Left retrocardiac atelectasis is again noted. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Response: CRRT on hold given worsening hemodynamic picture Plan: Dialysis on hold Hypotension (not Shock) Assessment: Worsening hypotension Action: Pt on max dose levophed and neosynephrine gtt, and map <60, vasopressin gtt added with map 57-60. Albuterol/atrovent MDI given. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. Called vascular who later removed after FFP. Called vascular who later removed after FFP. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. Started peripheral neo and dopamine. Started peripheral neo and dopamine. CXR w/R opacity ?pleural effusion. Hold diuretics. Endotracheal tube tip is again seen to be low, about 1 cm above the carina, again advised repositioning. Plan per MICU attending to take pt to OR for removal d/t coagulopathy and high risk of thrombus. - repeat ABG here - treat as above - repeat lytes in am . Agree with plan to treat altered mental status and acute respiratory failure as presumed hepatic encephalopathy. Check Abd US w/Doppler. A diagnostic paracentesis r/out sbp at that time as well. Likely hypovolemic/circulatory from sepsis. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. Action: Tx w/ lactulose q 2 h for goal stool x/day for likely hepatic encephalopathy. - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . CT head negative for acute process. CT head negative for acute process. CT head negative for acute process. CT head negative for acute process. HPI: Discharged from after admit for pain, melena and anemia. Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Called vascular who later removed after FFP. Called vascular who later removed after FFP. Called vascular who later removed after FFP. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Albuterol/atrovent MDI given. Albuterol/atrovent MDI given. Started peripheral neo and dopamine. Started peripheral neo and dopamine. Started peripheral neo and dopamine. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. Will treat with albumin for ascites. A diagnostic paracentesis r/out sbp at that time as well. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. # Hypotension: Pt had relative hypotension on arrival to ICU with associated tachycardia. Agree with holding off on antibiotics (will continue prophylactic cipro) 2) Acute respiratory failure - intubated for airway protection 3) Hypotension - likely volume depleted, in setting of diuretics, slightly elevated Hct, tachycardia. - repeat ABG here - treat as above - repeat lytes in am . - repeat ABG here - treat as above - repeat lytes in am . # respiratory failure: intubated for airway protection in the setting of altered mental status. # respiratory failure: intubated for airway protection in the setting of altered mental status. # respiratory failure: intubated for airway protection in the setting of altered mental status. # DISP: ICU RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ALTERED MENTAL STATUS (NOT DELIRIUM) HYPOTENSION (NOT SHOCK) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) ICU Care Nutrition: Glycemic Control: Lines: Arterial Line - 08:30 AM 20 Gauge - 06:00 PM Multi Lumen - 08:03 PM 22 Gauge - 11:59 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided."},"n_notes":{"kind":"number","value":38,"string":"38"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2145-01-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1053327,"text":" 10:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia, pulm edema vs other pulmonary process as etiology\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with ESLD, cirrhosis found unresponsive, intubated.\n REASON FOR THIS EXAMINATION:\n pneumonia, pulm edema vs other pulmonary process as etiology of presentation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH, , AT 2236 HOURS.\n\n HISTORY: End-stage liver disease, cirrhosis, found unresponsive and\n intubated. Assess for pneumonia, edema.\n\n COMMENT: AP view of chest provided. Comparison is made with at 1434\n hours.\n\n FINDINGS: There is a new small right pleural effusion. There is also\n increased opacity of the right hemithorax which could be due to layering\n fluid; however, the patient was imaged in the upright position. Previously,\n the patient had interstitial lung disease primarily in the apices. This is no\n longer seen; however, there now appears to be some pulmonary vascular\n congestion and probable mild edema.\n\n The endotracheal tube tip is 1 cm above the carina. Recommend repositioning.\n Nasogastric tube is coiled in the region of the stomach.\n\n Findings regarding endotracheal tube were discussed with the patient's nurse,\n , on at 1600 hours.\n\n IMPRESSION:\n 1. New right pleural effusion and mild pulmonary edema.\n\n 2. Low position of endotracheal tube. Advise repositioning.\n\n\n"},{"category":"Radiology","chartdate":"2145-01-16 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1053409,"text":" 3:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval line placement\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with recent line placement\n REASON FOR THIS EXAMINATION:\n please eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n Single portable radiograph of the chest demonstrates interval placement of a\n right-sided central venous catheter. The catheter position is unusual as the\n catheter seen to cross to the patient's left of midline. The catheter\n projects over the aortic root. There is an endotracheal tube present with its\n tip located 2 cm above the carina. Bibasilar atelectasis and right-sided\n effusion are again seen. No pneumothorax is identified. The nasogastric tube\n is again seen to be present within the stomach.\n\n IMPRESSION:\n\n Persistent bibasilar atelectasis and right-sided pleural effusion.\n\n Interval placement of right neck central venous catheter. The catheter\n position is unusual as it crosses to the patient's left of midline and\n projects over the aortic root. The catheter is likely located within the\n right common carotid artery with the tip in the aortic root.\n\n The remaining support lines are in place.\n\n Findings were discussed with the MICU nurse caring for the patient, \n at at 7:45 p.m.\n\n"},{"category":"Radiology","chartdate":"2145-01-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1053451,"text":" 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with ESLD cirrhosis, r pleural effusion\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion.\n\n Single portable radiograph of the chest demonstrates a persistent right-sided\n pleural effusion. Increased opacities involving both lungs are worse when\n compared to . There is a small left-sided effusion. The\n cardiomediastinal contours are unchanged. The endotracheal tube and\n nasogastric tube are unchanged. The right neck central venous catheter has\n been removed. No pneumothorax.\n\n IMPRESSION:\n\n Worsening airspace opacities involving both lungs. Finding represents\n pulmonary edema and/or pneumonia.\n\n Right-sided effusion, similar to that seen previously.\n\n Support lines in place.\n\n\n"},{"category":"Radiology","chartdate":"2145-01-16 00:00:00.000","description":"DUPLEX DOP ABD/PEL LIMITED","row_id":1053359,"text":", A. MED MICU 7:37 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n PFI REPORT\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\n thrombosis.\n\n"},{"category":"Radiology","chartdate":"2145-01-16 00:00:00.000","description":"DUPLEX DOP ABD/PEL LIMITED","row_id":1053358,"text":" 7:37 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 11:34 AM\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\n thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n portal hypertension, type 2 diabetes, altered mental status for evaluation of\n liver abnormalities.\n\n LIVER ULTRASOUND: -scale and color Doppler son images were\n obtained that demonstrate the liver is of heterogeneous echogenicity with no\n focal liver lesions demonstrated. There is a persistent large right pleural\n effusion. The study is limited and only the main hepatic artery is\n demonstrated with a normal-appearing waveform. Wall-to-wall flow is\n demonstrated in the portal vein with no evidence of thrombus. There is a\n patent umbilical vein. Minor ascites is seen. The gallbladder appears normal\n and is not distended and the common bile duct measures to 4.4 mm. The left\n kidney measures 10.1 cm, the right kidney is not fully visualized but there is\n no evidence for hydronephrosis or nephrolithiasis. The spleen measures 11.9\n cm.\n\n IMPRESSION: Limited son study; no evidence for portal vein thrombosis\n or major ascites or hydronephrosis.\n\n"},{"category":"Radiology","chartdate":"2145-01-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1053334,"text":" 12:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: UPRIGHT\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with cirrhosis, DM, layering effusion on supine CXR. Please\n perform semi-upright to better characterize effusion\n REASON FOR THIS EXAMINATION:\n UPRIGHT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM AT 0040 HOURS\n\n HISTORY: Cirrhosis and layering effusion on chest radiograph. Better\n characterize.\n\n COMMENT: AP view of chest provided. Comparison is made with at 2236\n hours.\n\n FINDINGS: Again seen is a moderate right pleural effusion, which appears\n mildly increased than the previous study. This could be due to differences in\n patient position. Pulmonary vascular congestion and mild edema is again\n noted. The nasogastric tube is coiled in the stomach. Endotracheal tube tip\n is again seen to be low, about 1 cm above the carina, again advised\n repositioning. Left retrocardiac atelectasis is again noted. It is mild in\n amount.\n\n IMPRESSION:\n 1. Moderate right pleural effusion more conspicuous than on the previous\n study, which may be due to change in position of the patient.\n\n\n"},{"category":"General","chartdate":"2145-01-17 00:00:00.000","description":"ICU Event Note","row_id":651543,"text":"Clinician: Resident\n Spoke with Ms. HCP, her son Chip about her turn for the worse\n today. She appear to have overwhelming sepsis with acute renal failure\n and hypotension that is not responding to 3 pressors. Her son called\n her family in and wishes to withdraw care as this is consistent with\n her prior stated wishes for no agressive measures if she gets to a\n point where she is not likely to get better. Her family is now at the\n bedside and we will proceed with withdrawal of ETT and pressors. They\n are aware that she will likely pass away very quickly.\n Total time spent: 60 minutes\n"},{"category":"General","chartdate":"2145-01-17 00:00:00.000","description":"ICU Event Note","row_id":651544,"text":"Clinician: Resident\n Called at 20:35 to see patient for pronouncement of death. Patient\n does not respond to tactile stimuli or verbal stimuli, Pupils are fixed\n and dilated, carotid pulses absent, no heart sounds, no spontaneous\n respirations, extremities warm.\n TIME OF DEATH: 8:37PM\n Family present and declined post-mortem examination. Attending and\n admitting notified.\n"},{"category":"Nursing","chartdate":"2145-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":651529,"text":"65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Increased peep and fio2 for desatting\n Action:\n Pt presently on ac 12 450 peep 10 100%, vent support slowly increased\n over shift due to intolerance with movement, laying flat. Pt being sx\n via ett for sm-copious amount thin frothy yellow secretions.\n Family meeting held and pt made DNR, with plans to make pt when\n other children come in to visit.\n Response:\n Poor tolerance to activity and increased vent support\n Plan:\n Plan to make pt \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Worsening creat, anuria, acidosis\n Action:\n Left Femoral Hd line placed by Renal team without incident, line\n transduced and cvp type waveform noted. Plans for CRRT, due to volume\n overload, and worsening acidosis, but unable to start due to\n hypotension despite 3^rd pressor being added, MICU team aware.\n Response:\n CRRT on hold given worsening hemodynamic picture\n Plan:\n Dialysis on hold\n Hypotension (not Shock)\n Assessment:\n Worsening hypotension\n Action:\n Pt on max dose levophed and neosynephrine gtt, and map <60, vasopressin\n gtt added with map 57-60. Pt received albumen 75gm iv with no change in\n bp. EKG done with no new changes, trop sent 1.54, team aware. Cvo2 72%.\n Pt with coffee grounds noted in GI aspirates this am, hct slowly\n trending down.\n Worsening anasarka noted, arms and legs tense with edema.\n Pt received vi gent 100mg iv, and started on IV cipro.\n Response:\n Pt remains hypotensive now on 3 pressors\n Plan:\n Awaiting other family members visit.\n Altered mental status (not Delirium)\n Assessment:\n Pt min responsive n fent gtt\n Action:\n Pt intermittently opens eyes to stimulation, spont moves all\n extremites, but does not follow commands, conts on fent gtt at 25mcg/hr\n Pupils remains unequal\n GI aspirates high, unable to receive q2 lactulose doses, moving bowels,\n x2 this shift.\n Response:\n No change in mental status\n Plan:\n Cont fent gtt.\n"},{"category":"Physician ","chartdate":"2145-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":651452,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed. Now on Levophed and neo.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Had BM x 2 with lactulose\n Coffee grounds emesis from OGT this am\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated, not responsive\n to voice or sternal rub\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\n bilateral exp wheezes, palpable on exam\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\n paracentesis CDI\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\n Skin: Warm, diaphoretic\n Neurologic: Not responsive to stimuli, sedated\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\n congestion\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n .\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection given septic physiology although not febrile but\n does have new leukocytosis, likely from stress response. Recent\n paracentesis rules out SBP although could have developed secondary\n peritonitis from tap. No current peritoneal signs on exam. No focal\n infiltrate on CXR although + effusion on R and may have aspitated. No\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\n amitriptyline, will d/c. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u sputum culture and (GPC)\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs\n - would not tolerate tap R pleural effusion\n - f/u culture data\n - continue broad abx with vanc/cefepime\n .\n # Hypoxemic respiratory failure: intubated for airway protection in the\n setting of altered mental status and has had persistent hypoxia, most\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\n ventilation and oxygenation at OSH. Has large right pleural effusion,\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\n aspiration and was 9 L positive yesterday, likely complicating picture.\n - VAP ppx\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\n - Increase PEEP as BP tolerates to increase recruitment\n - Serial ABGs\n - treat altered MS as below\n - try to improve fluid status by improving renal function, fluid\n mobilization, may need CVVH vs HD\n .\n # Hypotension: Pt had relative hypotension on arrival to ICU with\n associated tachycardia. Likely has low baseline from liver disease.\n Given altered mental status, concern for infection/sepsis especially\n given persistent pressor requirement, elevated WBC although ahs not had\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\n signs of bleeding until coffee grounds this am. Likely\n hypovolemic/circulatory from sepsis. Could also have component of\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \n also be related to sedation.\n - Serial HCT\n - hold diuretics\n - Abx for possible sepsis (source pulmonary vs abdominal)\n - Aline placed for monitoring\n - continue pressors, wean as tolerated, goal MAP>65\n - albumin for volume resuscitation\n - check random cortisol\n - defer para for now since minimal ascites, on broad coverage for abx\n and would be risk given coagulopathy, unsafe for transport\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\n perfusion with hypotension and may have component of ATN from prolonged\n hypotension yesterday. Fena 0.1. have component of HRS.\n - albumin 1g/kg\n - hold diuretics for now\n - maintain MAP>65\n - may need CVVH since UOP poor despite total body volume overloaded\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\n .\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\n hypotension.\n - appreciate liver recs- hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers without PV thrombosis\n - add albumin to regimen\n .\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\n transfusion in setting of UGIB. Has known iron deficiency anemia and\n has had multiple episodes of UGI bleeding from portal gastropathy and\n varices.\n - 2 large bore IVs\n - type and screen\n - CBC\n - cont iron\n - PPI \n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\n starting, had been holding Po meds for residuals concern for\n aspiration. Slowly introduce meds. Give reglan if high residuals\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\n .\n # CODE: FULL. Will have family discussion today regarding goals of\n care, may need dialysis\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":651288,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n Cx: pending\n CXR: upright image shows R pleural effusion\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":651308,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n Cx: pending\n CXR: upright image shows R pleural effusion\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 65 year old female with a history of ESLD \n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\n gastropathy, and recurrent GI bleeds who presents with altered mental\n status. Last admitted for GAVE/UGIB in and similar admission other\n hospital admit in . Recent GAVE treatment with thermal\n therapy. Recent d/c after tap for ?SBP\n neg. 2 days later was\n found on floor next to bed by son, last seen night before, brought to\n where intubated for a/w protection. CT head -\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\n Urine tox pos for TCA, benzo.\n Here at , intubated/sedated. Unclear if not taking lactulose, but\n dietary indiscretion was a possibility over holidays. Treated for\n encephalopathy, initially held off on antibiotics other than FQ\n prophylaxis. Awaiting pan-cultures. Also rehydrated overnight. Other\n history notable for encephalopathy and SBP in past. Meds at home, FQ,\n fluoxetine, rifaximin, iron, lactulose, PPI, lasix, spironolactone,\n albuterol, advair, metformin. ?all to bactrim, but has taken in past.\n Lives in by herself, no etoh/tob currently.\n Exam notable for Tm BP HR RR with sat on 450 x 12, PEEP 5, FiO2 .4 w/\n 7.48/25/132 Post surgical pupils, roving eye movements, hard collar,\n reg RR, soft Syst murmur, nontender +BS, 2+ LE edema, w/draw to painful\n stimuli. Labs notable for WBC 8.3K, HCT 31, K+ 5.1, Cr 1.0. CXR with ,\n ABG 7.5/24/97 on Fio2 .4.\n Agree with plan to treat altered mental status and acute respiratory\n failure as presumed hepatic encephalopathy. Aggressively continue\n lactulose. Check Abd US w/Doppler. No evidence for acute infection,\n but will begin broad spectrum antibiotics pending full culture data.\n Respiratory failure likely due to mental status, wean ventilator as\n tolerated. Hypotension responding to IVF, but may require pressors.\n Hold diuretics. Continue rifaximin. Holding metformin and monitoring\n BS. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:24 ------\n"},{"category":"Nursing","chartdate":"2145-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":651367,"text":"65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presented from an osh intubated after being found down at\n home. She was recently discharged home following a week long stay for a\n gib. At that time, an egd revealed grade II esophageal varices and she\n was transfused w/2 units prbc\ns. A diagnostic paracentesis r/out sbp at\n that time as well. She was sent home on .\n She was admitted to the micu from on \n after being found unresponsive by her son. decreased responsiveness\n is felt to be d/t encephalopathy likely r/t her underlying liver\n disease, ?dietary indiscretion over the holiday, and noncompliance with\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\n benzos although benzo use is not part of her medical regimen. Also of\n note, her left pupil was found to be dilated and nonreactive, but a\n head ct was reportedly negative. Additonally, her micu stay has been\n c/b hypotension requiring pressor support despite aggressive fluid\n resuscitation w/o evidence of any active gi bleeding. There is no clear\n source of infection.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2145-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":651441,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH. Has large right pleural effusion, volume\n overloaded. ETT approx. 2cm above carina. also have VAP vs\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n - consider\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure.\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Respiratory ","chartdate":"2145-01-16 00:00:00.000","description":"Respiratory Care Shift Note","row_id":651186,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/.4/+6 peep\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: underlying illness\n not resolved\n Respiratory Care Shift Procedures: RSBI\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":651281,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651253,"text":". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given. Fentanyl iv push\n given\n Response:\n O2 sats 96-98%, blood gas 7.50/24/97\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics. For abd ultrasounds today.and liver consult\n in Am\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 80-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat 27/1.1, UO 5ml/hr even after fluid bolus\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651343,"text":"PMH: Pt is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive. According to report, she was discharged from on\n and had been in her usual state of health. She was last seen well\n the evening of at ~ 8 pm when her son dropped her off at home.\n Son tried to contact her today but she did not pick up the phone. She\n was then found this am, unresponsive, slumped out of bed onto the\n floor. EMS was called and she was brought to hospital. EMS\n reported she was unable to respond verbally. ? blown pupil on left per\n EMS report. There she was intubated for airway protection. At\n hospital, CT head was negative. CXR showed opacity in R\n hemithorax c/w layering R pleural effusion and pulmonary vascular\n congestion. Urine tox screen positive for benzos and TCAs. She was\n recently admitted with abdominal pain, melena, and low Hct\n (33->23 in 1 wk). She underwent EGD which showed grade II varices,\n portal gastropathy, and angioectasias in the antrum which were treated\n with thermal therapy. She received 2 units PRBCs with Hct 23->29. She\n also received an ultrasound guided paracentesis without evidence of\n SBP. She was also admitted for slow Hct drop (24->20\n over 1 wk) and guiaic positive stools. She received 2 units PRBCs with\n Hct 20->26. She was treated with octreotide, PPI gtts. EGD showed\n gastric antral ectasia with varices but without an active source of\n bleed. Hct remained stable throughout admission. During the last\n admission she was found to have an area of cellulitis at the area of an\n outpt Derm biopsy and she received Augmentin and Bactrim for 7 day\n course. Her U/A at that time was negative but grew out E coli sensitive\n to Bactrim. She was due to follow up at for repeat endoscopy.\n However, in the interim she was admitted to hospital for GI\n bleeding. She was transfused 4 units PRBCs and had EGD which showed\n small esophageal varices and portal hypertension. She was then seen in\n liver f/u on and was complaining of abdominal and ankle swelling\n in the setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black\n stools. Upon arrival to ICU, patient is intubated and sedated.\n Events : A line placed in AM. Attempt at RIJ triple lumen\n placement failed: line placed in carotid artery as evidenced by chest\n film and pulsatile waveform. Plan per MICU attending to take pt to OR\n for removal d/t coagulopathy and high risk of thrombus.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS course w/ crackles and insp/exp wheeze throughout day. Pt intubated\n on AC 40%/450/12/5. Sp02 variable 89-100%. Mod amts thick tan\n secretions sux\ned throughout day. ABG in afternoon 7.25/32/72.\n Action:\n Fi02 increased to 60%. Nebs prn via ET tube.\n Response:\n Sp02 100%. Pt appears dusky. UOP minimal at 10-20 ml/hr.\n Plan:\n Maintain ABPs w/ pressors, attempt diuresis when appropriate.\n Altered mental status (not Delirium)\n Assessment:\n PT does not follow commands, L pupil non reactive, R pupil reactive.\n Pt withdraws to painful stim, non-purposeful movt all extremities.\n Action:\n Tx w/ lactulose q 2 h for goal stool x/day for likely hepatic\n encephalopathy.\n Response:\n Pt had 1 med BM today.\n Plan:\n Cont bowel regimen.\n Hypotension (not Shock)\n Assessment:\n A line placement confirms hypotension, SBP drops to 60s- 70s,\n particularly w/ sedation (fentanyl bolus). MAPs dropping to 40-50.\n Action:\n Total of 6 L NS fluid bolus since admission. Phenylephrine and\n dopamine gtts started at 1800 via PIV (only access at this time). MICU\n attending and team placing fem line now for central access.\n Response:\n Pt remains hypotensive during line placement.\n Plan:\n Maintain pressors via CVL.\n"},{"category":"Respiratory ","chartdate":"2145-01-16 00:00:00.000","description":"Respiratory Care Shift Note","row_id":651345,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n Pt remained on AC 40% most of shift until PaO2 dropped to 72 late\n afternoon. FiO2 to 60%. BS worsening combination of coarse crackles,\n rhonchi, wheeze not responding to inhaled dilators. Presents as fluid\n overload but is hypotensive and agitated. Unable to adequately sedate\n hypotension. Placing central line at present to get more accurate\n picture of fluid status. Wean FiO2 when possible.\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":651167,"text":"Chief Complaint: altered MS\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Discharged from after admit for pain, melena and\n anemia. Was in usual health, dropped off at home by son last night at\n 8pm after party, this AM did not answer phone, son found pt slumped\n against bed on floor, not following commands. Pt brought to by EMS - afebrile, stable BP>100 syst, tachycardic, intubated\n for airway protection, CT head was negative, CXR c/w layering R pleural\n effusion and pulmonary vascular congestion. Labs were remarkable for\n WBC 6.5, Hct 35 (28.9 ), Na 132(stable), K 5.5 (5.1 on ),\n Bicarb 18 (25 ), Cr 1.1 (stable). ALT/AST similar to recent admit,\n Tbili down to 3.4 from 6.6. Ammonia 182 (last checked in our system 112\n on ). Urine tox screen positive for benzos and TCAs.\n Patient was admitted in for pain and melena, on endoscopy\n had angioectasia treated with thermal therapy.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she\n Transfer from other hospital\n History obtained from Family / Friend\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Other medications:\n Amitriptyline 10 mg PO HS\n Ciprofloxacin 250 mg Q24H\n Fluoxetine 10 mg PO DAILY\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \n Rifaximin 600 mg \n Triamcinolone Acetonide 0.1 % Topical TID\n Ferrous Sulfate 325 mg TID\n Lactulose Thirty ML PO QHS\n Lactulose (45) ML PO BID\n Omeprazole 20 mg \n Lasix 40 mg once a day\n Spironolactone 50 mg once a day\n Albuterol Sulfate Two q4h prn\n Calcitrate-Vitamin D 315-200 mg-unit\n Metformin 500 mg twice a day\n Past medical history:\n Family history:\n Social History:\n # ESLD NASH with cirrhosis and portal hypertension\n - followed by Dr. \n - on transplant list\n - history of Grade II esophageal varices\n # GAVE (gastral antral vascular ectasia)\n # h/o SBP\n # h/o gastritis\n # anemia\n - iron deficiency by labs\n - elevated MCV, B12/folate nl\n # Hypertension\n # diabetes mellitus type II\n # Psoriasis\n # depression\n # s/p C-section\n # s/p appy\n # s/p knee surgery for meniscal tear\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives in alone, 3 children, nonsmoker and has not had\n any alcohol in 2 years, but no hx of heavy drinking, no illicit drug\n use. She is not married. She has not worked for 4-5 months and was\n released from her job as a cashier due to confusion.\n Review of systems:\n Flowsheet Data as of 12:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 111 (111 - 114) bpm\n BP: 88/40(53) {88/39(53) - 130/92(102)} mmHg\n RR: 21 (21 - 23) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -224 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (601 - 601) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 42.9 cmH2O/mL\n SpO2: 99%\n ABG: ////\n Ve: 15.4 L/min\n Physical Examination\n Eyes / Conjunctiva: roving eyes, post- pupil\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed, withdraws all 4 extrem to\n painful stimuli, equivocal plantars\n Labs / Radiology\n 225 K/uL\n 31.0 %\n 10.9 g/dL\n 8.3 K/uL\n [image002.jpg]\n 10:42 PM\n WBC\n 8.3\n Hct\n 31.0\n Plt\n 225\n Other labs: Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\n Eos:0.5 %\n Imaging: CXR reviewed - probable layering right effusion\n EGD : Grade 2 esophageal varices\n Portal hypertensive gastropathy, angioectasias in antrum\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n Issues being addressed include:\n 1) altered MS - likely hepatic encephalopathy, possibly due to dietary\n indiscretion, unclear if compliant with meds/lactulose. No evidence for\n acute GI bleed or infection. Doubt meningitis. CT head reported to be\n without bleed or acute process. Roving eyes likely due to metabolic\n coma. Will treat with lactulose and rifaximin. u/s to look for\n ascites, unlikely SBP. need repeat CT or MRI, consider LP, EEG if\n no improvement by AM. Agree with holding off on antibiotics (will\n continue prophylactic cipro)\n 2) Acute respiratory failure - intubated for airway protection\n 3) Hypotension - likely volume depleted, in setting of diuretics,\n slightly elevated Hct, tachycardia. Possibly sepsis but less likely -\n no obvious source. Agree with volume resuscitation, hold diuretics\n 4) ESLD due to NASH with cirrhosis and portal hypertension - Alb 2.8,\n INR 1.7, liver consult in am, treatment of hepatic encephalopathy as\n above\n Rest of plan as detailed in Dr. note. Son \n has been updated.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 10:05 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU, Total time spent: 39 minutes, Patient is critically\n ill\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident Admission Note","row_id":651168,"text":"Chief Complaint: unresponsive\n PCP: ,\n GI: \n HPI:\n Ms. is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Labs\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\n positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. The remainder of her hospital course in unclear as there is not\n currently a discharge summary available. She also received an\n ultrasound guided paracentesis without evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amitriptyline 10 mg PO HS\n Ciprofloxacin 250 mg Q24H\n Fluoxetine 10 mg PO DAILY\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \n Rifaximin 600 mg \n Triamcinolone Acetonide 0.1 % Topical TID as needed for psoriasis.\n Ferrous Sulfate 325 mg TID\n Lactulose Thirty ML PO QHS\n Lactulose (45) ML PO BID\n Omeprazole 20 mg \n Lasix 40 mg once a day\n Spironolactone 50 mg once a day\n Albuterol Sulfate Two puffs every four hours as needed\n Calcitrate-Vitamin D 315-200 mg-unit once a day\n Metformin 500 mg twice a day\n Past medical history:\n Family history:\n Social History:\n # ESLD NASH with cirrhosis and portal hypertension\n - followed by Dr. \n - on transplant list\n - history of Grade II esophageal varices\n # GAVE (gastral antral vascular ectasia)\n # h/o SBP\n # h/o gastritis\n # anemia\n - iron deficiency by labs\n - elevated MCV, B12/folate nl\n # Hypertension\n # diabetes mellitus type II\n # Psoriasis\n # depression\n # s/p C-section\n # s/p appy\n # s/p knee surgery for meniscal tear\n mother with lung CA, 3 brothers with DM\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She lives in alone. She has 3 children who live in\n , , and . Their ages are 37, 40, and 45. She is a\n nonsmoker and has not had any alcohol in 2 years. Apparently, she was\n not a heavy drinker. She has no illicit drug use. She is not married\n and does not have a current partner. She has not worked for 4-5 months\n and was released from her job as a cashier due to confusion. She has\n applied for disability.\n Review of systems:\n Flowsheet Data as of 12:27 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.4\n HR: 113 (111 - 114) bpm\n BP: 107/38(57) {88/38(53) - 130/92(102)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 155 mL\n 186 mL\n PO:\n TF:\n IVF:\n 155 mL\n 186 mL\n Blood products:\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 166 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 601) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n PIP: 12 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 99%\n ABG: ///19/\n Ve: 14.8 L/min\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\n exp wheezes\n Abdominal: Soft, Non-tender, No(t) Distended, No(t) Tender: , site of\n prior LLQ paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, Movement: Purposeful,\n Sedated, Tone: Normal, withdraws all extremities to painful stimuli.\n Roving eye movements. CN 2-12 grossly intact. Plantar responses mute B\n Labs / Radiology\n 225 K/uL\n 10.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 19 mEq/L\n 109 mEq/L\n 5.1 mEq/L\n 138 mEq/L\n 31.0 %\n 8.3 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 10:42 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.3\n Hct\n 31.0\n Plt\n 225\n Cr\n 1.0\n Glucose\n 102\n Other labs: PT / PTT / INR:18.6/37.4/1.7, ALT / AST:36/87, Alk Phos / T\n Bili:91/4.0, Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\n Eos:0.5 %, Albumin:2.6 g/dL, LDH:403 IU/L, Ca++:8.3 mg/dL, Mg++:1.7\n mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: from :\n ABG 7.48/25/132 on PSV 15/10 with FiO2 50%.\n .\n PT 19.3, PTT 37.9, INR 1.7\n .\n WBC 6.5, Hct 35.9, plts 208\n .\n Na 132, K 5.5, Cl 101, CO2 18, BUN 27, Cr 1.1, Glu 114, Ca 9.3, Tbili\n 3.4, AST 84, ALT 37, Ammonia 182, alb 2.8, AP 108, CK 337, MB 11, TnT\n 0.04\n .\n Tox screen: positive for TCAs, positive for benzos, negative for\n opiates, barbs, amph, cocaine, THC\n .\n U/A: negative\n Imaging: EGD :\n Grade 2 esophageal varices\n Portal hypertensive gastropathy\n Angioectasias in the antrum (thermal therapy)\n .\n colonoscopy :\n Diverticulosis of the sigmoid colon\n Otherwise normal colonoscopy to cecum\n ECG: ECG : abnormal p wave axis. ? sinus tach vs Atach. Low limb\n lead voltage. Tall TWs, not hyperacute. Compared to prior ECG ,\n inferior QWs have resolved, p wave axis is different, and TWs are more\n prominent.\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651178,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651179,"text":". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Labs\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\n positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. The remainder of her hospital course in unclear as there is not\n currently a discharge summary available. She also received an\n ultrasound guided paracentesis without evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651180,"text":". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2145-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":651391,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2145-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":651392,"text":"65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presented from an osh intubated after being found down at\n home. She was recently discharged home following a week long stay for a\n gib. At that time, an egd revealed grade II esophageal varices and she\n was transfused w/2 units prbc\ns. A diagnostic paracentesis r/out sbp at\n that time as well. She was sent home on .\n She was admitted to the micu from on \n after being found unresponsive by her son. decreased responsiveness\n is felt to be d/t encephalopathy likely r/t her underlying liver\n disease, ?dietary indiscretion over the holiday, and noncompliance with\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\n benzos although benzo use is not part of her medical regimen. Also of\n note, her left pupil was found to be dilated and nonreactive, but a\n head ct was reportedly negative. Additionally, her micu stay has been\n c/b hypotension requiring pressor support despite aggressive fluid\n resuscitation. There is no overt evidence of any active gi bleeding.\n There is no clear source of infection.\n Events overnight included removal of the right ij that was placed\n arterially. The line was removed w/o incident by surgery. There is no\n hematoma/edema at the insertion site.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on ac 12x450 w/peep5 and o2 60%.\n SRR 12-14/min. MV 15-19 liters. Diffuse rhonchi and expiratory wheezing\n noted on lung exam. Repeat abg this am showing a worsening acidosis\n although oxygenation has improved: 25/94/7.26/12/-13.\n She has been suctioned for small to moderate amts of thick, pink-tinged\n sputum w/?aspiration.\n Action:\n Sputim culture repeated for ?aspiration. Metabolic acidosis worsening\n this morning with a rise in creat level.\n Response:\n Although ogt initially placed to suction for ?aspiration, ogt is now\n clamped and being used for po meds.\n Plan:\n Follow lung exam, serial abg results closely. Suction as needed and\n monitor for possible aspiration.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains unresponsive but transiently agitated. She was placed on a\n low dose fentanyl drip after receiving several boluses. She has\n received lactulose q4hrs overnight and has had one moderate sized bowel\n movement. Left pupil remains dilated and unresponsive. +corneals.\n Action:\n Placed on a low dose fentanyl drip for comfort. No change in mental\n status/neuro exam noted overnight despite rtc lactulose.\n Response:\n More comfortable on a fentanyl drip.\n Plan:\n Follow neuro exam closely. Con\nt rtc lactulose and fentanyl drip for\n now.\n Hypotension (not Shock)\n Assessment:\n Received pt on maximum doses of both levophed and neo. Both drip rates\n were weaned slowly although the levophed drip rate has since been\n increased d/t persistent hypotension in the setting of a worsening\n acidosis. Of note, wbc elevated from 10 to 15 this morning. Pt has\n been afebrile. Awaiting culture results from yesterday.\n Action:\n Slowly weaning pressor support. Hypotension may be r/t sepsis given new\n leukocytosis.\n Response:\n Although requiring an increase in levophed this morning, the pt has\n tolerated an overall reduction in pressor support.\n Plan:\n Follow hemodynamic status closely. Wean pressors as pt tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rise in creat level from 1.1 to 1.5 this morning. As noted above,\n metabolic acidosis is worsening. Uop 0-10cc/hr at the present time. +3\n pitting edema now present.\n Action:\n None.\n Response:\n Unchanged.\n Plan:\n Follow serial lab results, monitor uop, edema closely.\n"},{"category":"Nursing","chartdate":"2145-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":651503,"text":"65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2145-01-17 00:00:00.000","description":"Physician Resident Progress Note","row_id":651388,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2145-01-17 00:00:00.000","description":"Nursing Progress Note","row_id":651546,"text":"Following another family meeting this evening, the pt\ns children\n made the decision to withdraw from aggressive care measures and\n redirect care to cmo status. The family expressed a desire to extubate\n as well as discontinue all vasopressors. The pt was extubated with\n discontinuation of triple pressors ~ and expired @2037.\n The micu team did offer an autopsy to the family which was declined.\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651229,"text":". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given.\n Response:\n O2 sats 96-98%,\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 90-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":651230,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":651231,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2145-01-16 00:00:00.000","description":"Nursing Progress Note","row_id":651233,"text":". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given.\n Response:\n O2 sats 96-98%,\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics. For abd ultrasounds today.and liver consult\n in Am\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 90-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"},{"category":"Respiratory ","chartdate":"2145-01-16 00:00:00.000","description":"Respiratory Care Shift Note","row_id":651225,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/.4/+6 peep\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: underlying illness\n not resolved\n Respiratory Care Shift Procedures: RSBI 48\n"},{"category":"Physician ","chartdate":"2145-01-16 00:00:00.000","description":"ICU Attending Event Note","row_id":651322,"text":"Clinician: Attending\n MICU ATTENDING CRITICAL CARE NOTE:\n Notified by housestaff that CXR on patient following central line\n placement suggests line is arterial rather than in internal jugular.\n We have transduced the line and indeed the waveform is arterial. Given\n underlying coagulopathy from liver disease, will consult Vascular\n Surgery and have them assist in removing the line. Will likely need\n additional FFP to try to correct coagulopathy. MICU housestaff will\n also notify patient\ns son by telephone.\n Patient remains critically ill\n Total time 20 minutes\n"},{"category":"Respiratory ","chartdate":"2145-01-17 00:00:00.000","description":"Respiratory Care Shift Note","row_id":651384,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:diffuse i/e wheeze/rhonchi needing freq repeated sxn.\n Secretions\n Sputum color / consistency: Rusty/bright yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/+5 peep/.6\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping, Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway\n Continues profoundly acidotic (metabolic) despite Ve 17-19 L.\n"},{"category":"Respiratory ","chartdate":"2145-01-17 00:00:00.000","description":"Respiratory Care Shift Note","row_id":651534,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Frothy\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues with refractory hyoxemia and metabolic acidosis. Awaiting\n arrival of family member before withdrawing support.\n"},{"category":"Physician ","chartdate":"2145-01-17 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":651465,"text":"Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed. Now on Levophed and neo.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Had BM x 2 with lactulose\n Coffee grounds emesis from OGT this am\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated, not responsive\n to voice or sternal rub\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\n bilateral exp wheezes, palpable on exam\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\n paracentesis CDI\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\n Skin: Warm, diaphoretic\n Neurologic: Not responsive to stimuli, sedated\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\n congestion\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n .\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection given septic physiology although not febrile but\n does have new leukocytosis, likely from stress response. Recent\n paracentesis rules out SBP although could have developed secondary\n peritonitis from tap. No current peritoneal signs on exam. No focal\n infiltrate on CXR although + effusion on R and may have aspitated. No\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\n amitriptyline, will d/c. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u sputum culture and (GPC)\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs\n - would not tolerate tap R pleural effusion\n - f/u culture data\n - continue broad abx with vanc/cefepime\n .\n # Hypoxemic respiratory failure: intubated for airway protection in the\n setting of altered mental status and has had persistent hypoxia, most\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\n ventilation and oxygenation at OSH. Has large right pleural effusion,\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\n aspiration and was 9 L positive yesterday, likely complicating picture.\n - VAP ppx\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\n - Increase PEEP as BP tolerates to increase recruitment\n - Serial ABGs\n - treat altered MS as below\n - try to improve fluid status by improving renal function, fluid\n mobilization, may need CVVH vs HD\n .\n # Hypotension: Pt had relative hypotension on arrival to ICU with\n associated tachycardia. Likely has low baseline from liver disease.\n Given altered mental status, concern for infection/sepsis especially\n given persistent pressor requirement, elevated WBC although ahs not had\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\n signs of bleeding until coffee grounds this am. Likely\n hypovolemic/circulatory from sepsis. Could also have component of\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \n also be related to sedation.\n - Serial HCT\n - hold diuretics\n - Abx for possible sepsis (source pulmonary vs abdominal)\n - Aline placed for monitoring\n - continue pressors, wean as tolerated, goal MAP>65\n - albumin for volume resuscitation\n - check random cortisol\n - defer para for now since minimal ascites, on broad coverage for abx\n and would be risk given coagulopathy, unsafe for transport\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\n perfusion with hypotension and may have component of ATN from prolonged\n hypotension yesterday. Fena 0.1. have component of HRS.\n - albumin 1g/kg\n - hold diuretics for now\n - maintain MAP>65\n - may need CVVH since UOP poor despite total body volume overloaded\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\n .\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\n hypotension.\n - appreciate liver recs- hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers without PV thrombosis\n - add albumin to regimen\n .\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\n transfusion in setting of UGIB. Has known iron deficiency anemia and\n has had multiple episodes of UGI bleeding from portal gastropathy and\n varices.\n - 2 large bore IVs\n - type and screen\n - CBC\n - cont iron\n - PPI \n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\n starting, had been holding Po meds for residuals concern for\n aspiration. Slowly introduce meds. Give reglan if high residuals\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\n .\n # CODE: FULL. Will have family discussion today regarding goals of\n care, may need dialysis\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 65 year old female with a history of ESLD \n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\n gastropathy, and recurrent GI bleeds who presents with altered mental\n status. Last admitted for GAVE/UGIB in and similar admission other\n hospital admit in . Recent GAVE treatment with thermal\n therapy. Recent d/c after tap for ?SBP\n neg. 2 days later was\n found on floor next to bed by son, last seen night before, brought to\n where intubated for a/w protection. CT head -\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\n Urine tox pos for TCA, benzo.\n Here at , intubated/sedated. Unclear if not taking lactulose, but\n dietary indiscretion was a possibility over holidays vs mild sepsis\n following GI procedure for GAVE. Treated for encephalopathy, treated\n with broad spectrum antibiotics and FQ prophylaxis. Awaiting\n pan-cultures. Over last 24 hr, initially responded to fluids, then\n required CVL\n line placed in R carotid, line removed by vascular and\n new line placed in femoral vein. Requiring neo and levophed to\n maintain pressure. Abd US showing no portal vein thrombosis,\n continuing on antibiotics, lactulose and rifaximin.\n Intubated/sedated, unresponsive, Exam notable for Tm 99.1 BP 96/52 HR\n 88 RR 28 with sat 98 on AC 450 x 12, PEEP 5, FiO2 .6 w/ 7.26/25/94.\n Bladder pressure 18. 9L+ yesterday. Post surgical pupils, coarse BS,\n reg RR, soft Syst murmur, nontender +BS, 3+ LE edema, minimal w/draw to\n painful stimuli. Labs notable for WBC 15.1K, HCT 28, K+ 4.7, Cr 1.5\n HCO3 11, Lactate 6.4. UNa 10 FeNa .1, INR 1.9. TBili 5.2, CK 1024.\n CXR worsening R base effusion.\n Agree with plan to treat altered mental status and acute respiratory\n failure as presumed hepatic encephalopathy vs sepsis now with\n progressive respiratory and renal failure. Her status is declining with\n anasarca and increasing oxygen and pressor requirement. Attempt\n increase in PEEP and continue aggressive therapy including possible\n CVVH. We will also continue to update the family. No evidence for\n acute infection, but will remains on broad spectrum antibiotics pending\n full culture data. Will treat with albumin for ascites. Continue\n rifaximin and lactulose. Holding metformin and monitoring BS.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:15 ------\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1053327,\n \"text\": \" 10:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pneumonia, pulm edema vs other pulmonary process as etiology\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 65 year old woman with ESLD, cirrhosis found unresponsive, intubated.\\n REASON FOR THIS EXAMINATION:\\n pneumonia, pulm edema vs other pulmonary process as etiology of presentation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH, , AT 2236 HOURS.\\n\\n HISTORY: End-stage liver disease, cirrhosis, found unresponsive and\\n intubated. Assess for pneumonia, edema.\\n\\n COMMENT: AP view of chest provided. Comparison is made with at 1434\\n hours.\\n\\n FINDINGS: There is a new small right pleural effusion. There is also\\n increased opacity of the right hemithorax which could be due to layering\\n fluid; however, the patient was imaged in the upright position. Previously,\\n the patient had interstitial lung disease primarily in the apices. This is no\\n longer seen; however, there now appears to be some pulmonary vascular\\n congestion and probable mild edema.\\n\\n The endotracheal tube tip is 1 cm above the carina. Recommend repositioning.\\n Nasogastric tube is coiled in the region of the stomach.\\n\\n Findings regarding endotracheal tube were discussed with the patient's nurse,\\n , on at 1600 hours.\\n\\n IMPRESSION:\\n 1. New right pleural effusion and mild pulmonary edema.\\n\\n 2. Low position of endotracheal tube. Advise repositioning.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1053409,\n \"text\": \" 3:37 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: please eval line placement\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 65 year old woman with recent line placement\\n REASON FOR THIS EXAMINATION:\\n please eval line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Central line placement.\\n\\n Single portable radiograph of the chest demonstrates interval placement of a\\n right-sided central venous catheter. The catheter position is unusual as the\\n catheter seen to cross to the patient's left of midline. The catheter\\n projects over the aortic root. There is an endotracheal tube present with its\\n tip located 2 cm above the carina. Bibasilar atelectasis and right-sided\\n effusion are again seen. No pneumothorax is identified. The nasogastric tube\\n is again seen to be present within the stomach.\\n\\n IMPRESSION:\\n\\n Persistent bibasilar atelectasis and right-sided pleural effusion.\\n\\n Interval placement of right neck central venous catheter. The catheter\\n position is unusual as it crosses to the patient's left of midline and\\n projects over the aortic root. The catheter is likely located within the\\n right common carotid artery with the tip in the aortic root.\\n\\n The remaining support lines are in place.\\n\\n Findings were discussed with the MICU nurse caring for the patient, \\n at at 7:45 p.m.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1053451,\n \"text\": \" 3:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for interval change\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 65 year old woman with ESLD cirrhosis, r pleural effusion\\n REASON FOR THIS EXAMINATION:\\n please assess for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Pleural effusion.\\n\\n Single portable radiograph of the chest demonstrates a persistent right-sided\\n pleural effusion. Increased opacities involving both lungs are worse when\\n compared to . There is a small left-sided effusion. The\\n cardiomediastinal contours are unchanged. The endotracheal tube and\\n nasogastric tube are unchanged. The right neck central venous catheter has\\n been removed. No pneumothorax.\\n\\n IMPRESSION:\\n\\n Worsening airspace opacities involving both lungs. Finding represents\\n pulmonary edema and/or pneumonia.\\n\\n Right-sided effusion, similar to that seen previously.\\n\\n Support lines in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"DUPLEX DOP ABD/PEL LIMITED\",\n \"row_id\": 1053359,\n \"text\": \", A. MED MICU 7:37 AM\\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \\n -59 DISTINCT PROCEDURAL SERVICE\\n Reason: EVAL FOR PV THROMBOSIS\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n PFI REPORT\\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\\n thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"DUPLEX DOP ABD/PEL LIMITED\",\n \"row_id\": 1053358,\n \"text\": \" 7:37 AM\\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \\n -59 DISTINCT PROCEDURAL SERVICE\\n Reason: EVAL FOR PV THROMBOSIS\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 11:34 AM\\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\\n thrombosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n portal hypertension, type 2 diabetes, altered mental status for evaluation of\\n liver abnormalities.\\n\\n LIVER ULTRASOUND: -scale and color Doppler son images were\\n obtained that demonstrate the liver is of heterogeneous echogenicity with no\\n focal liver lesions demonstrated. There is a persistent large right pleural\\n effusion. The study is limited and only the main hepatic artery is\\n demonstrated with a normal-appearing waveform. Wall-to-wall flow is\\n demonstrated in the portal vein with no evidence of thrombus. There is a\\n patent umbilical vein. Minor ascites is seen. The gallbladder appears normal\\n and is not distended and the common bile duct measures to 4.4 mm. The left\\n kidney measures 10.1 cm, the right kidney is not fully visualized but there is\\n no evidence for hydronephrosis or nephrolithiasis. The spleen measures 11.9\\n cm.\\n\\n IMPRESSION: Limited son study; no evidence for portal vein thrombosis\\n or major ascites or hydronephrosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1053334,\n \"text\": \" 12:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: UPRIGHT\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 65 year old woman with cirrhosis, DM, layering effusion on supine CXR. Please\\n perform semi-upright to better characterize effusion\\n REASON FOR THIS EXAMINATION:\\n UPRIGHT\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH FROM AT 0040 HOURS\\n\\n HISTORY: Cirrhosis and layering effusion on chest radiograph. Better\\n characterize.\\n\\n COMMENT: AP view of chest provided. Comparison is made with at 2236\\n hours.\\n\\n FINDINGS: Again seen is a moderate right pleural effusion, which appears\\n mildly increased than the previous study. This could be due to differences in\\n patient position. Pulmonary vascular congestion and mild edema is again\\n noted. The nasogastric tube is coiled in the stomach. Endotracheal tube tip\\n is again seen to be low, about 1 cm above the carina, again advised\\n repositioning. Left retrocardiac atelectasis is again noted. It is mild in\\n amount.\\n\\n IMPRESSION:\\n 1. Moderate right pleural effusion more conspicuous than on the previous\\n study, which may be due to change in position of the patient.\\n\\n\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 651543,\n \"text\": \"Clinician: Resident\\n Spoke with Ms. HCP, her son Chip about her turn for the worse\\n today. She appear to have overwhelming sepsis with acute renal failure\\n and hypotension that is not responding to 3 pressors. Her son called\\n her family in and wishes to withdraw care as this is consistent with\\n her prior stated wishes for no agressive measures if she gets to a\\n point where she is not likely to get better. Her family is now at the\\n bedside and we will proceed with withdrawal of ETT and pressors. They\\n are aware that she will likely pass away very quickly.\\n Total time spent: 60 minutes\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 651544,\n \"text\": \"Clinician: Resident\\n Called at 20:35 to see patient for pronouncement of death. Patient\\n does not respond to tactile stimuli or verbal stimuli, Pupils are fixed\\n and dilated, carotid pulses absent, no heart sounds, no spontaneous\\n respirations, extremities warm.\\n TIME OF DEATH: 8:37PM\\n Family present and declined post-mortem examination. Attending and\\n admitting notified.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651529,\n \"text\": \"65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status now with hypotension,\\n persistent respiratory failure, acute renal failure.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Increased peep and fio2 for desatting\\n Action:\\n Pt presently on ac 12 450 peep 10 100%, vent support slowly increased\\n over shift due to intolerance with movement, laying flat. Pt being sx\\n via ett for sm-copious amount thin frothy yellow secretions.\\n Family meeting held and pt made DNR, with plans to make pt when\\n other children come in to visit.\\n Response:\\n Poor tolerance to activity and increased vent support\\n Plan:\\n Plan to make pt \\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Worsening creat, anuria, acidosis\\n Action:\\n Left Femoral Hd line placed by Renal team without incident, line\\n transduced and cvp type waveform noted. Plans for CRRT, due to volume\\n overload, and worsening acidosis, but unable to start due to\\n hypotension despite 3^rd pressor being added, MICU team aware.\\n Response:\\n CRRT on hold given worsening hemodynamic picture\\n Plan:\\n Dialysis on hold\\n Hypotension (not Shock)\\n Assessment:\\n Worsening hypotension\\n Action:\\n Pt on max dose levophed and neosynephrine gtt, and map <60, vasopressin\\n gtt added with map 57-60. Pt received albumen 75gm iv with no change in\\n bp. EKG done with no new changes, trop sent 1.54, team aware. Cvo2 72%.\\n Pt with coffee grounds noted in GI aspirates this am, hct slowly\\n trending down.\\n Worsening anasarka noted, arms and legs tense with edema.\\n Pt received vi gent 100mg iv, and started on IV cipro.\\n Response:\\n Pt remains hypotensive now on 3 pressors\\n Plan:\\n Awaiting other family members visit.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt min responsive n fent gtt\\n Action:\\n Pt intermittently opens eyes to stimulation, spont moves all\\n extremites, but does not follow commands, conts on fent gtt at 25mcg/hr\\n Pupils remains unequal\\n GI aspirates high, unable to receive q2 lactulose doses, moving bowels,\\n x2 this shift.\\n Response:\\n No change in mental status\\n Plan:\\n Cont fent gtt.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651452,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 08:30 AM\\n ULTRASOUND - At 08:47 AM\\n MULTI LUMEN - START 03:45 PM\\n MULTI LUMEN - STOP 05:34 PM\\n MULTI LUMEN - START 08:03 PM\\n SPUTUM CULTURE - At 10:03 PM\\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\\n Attempted RIJ placement but was in R carotid. Called vascular who later\\n removed after FFP.\\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\\n CVL placed. Now on Levophed and neo.\\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\\n and rifaximin\\n Concern for aspiration\\n Abdominal U/S without PV thrombosis. Suboptimal study\\n Had BM x 2 with lactulose\\n Coffee grounds emesis from OGT this am\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 03:39 PM\\n Cefipime - 09:00 PM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Phenylephrine - 2.8 mcg/Kg/min\\n Norepinephrine - 0.25 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 10:00 AM\\n Fentanyl - 09:22 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 100 (99 - 108) bpm\\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\\n RR: 28 (21 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 9,369 mL\\n 635 mL\\n PO:\\n TF:\\n IVF:\\n 7,755 mL\\n 475 mL\\n Blood products:\\n 1,389 mL\\n Total out:\\n 239 mL\\n 90 mL\\n Urine:\\n 239 mL\\n 40 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 9,130 mL\\n 545 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 451) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 13 cmH2O\\n SpO2: 94%\\n ABG: 7.33/23/70/11/-11\\n Ve: 19.8 L/min\\n PaO2 / FiO2: 117\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated, not responsive\\n to voice or sternal rub\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\\n bilateral exp wheezes, palpable on exam\\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\\n paracentesis CDI\\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\\n Skin: Warm, diaphoretic\\n Neurologic: Not responsive to stimuli, sedated\\n Labs / Radiology\\n 216 K/uL\\n 9.3 g/dL\\n 115 mg/dL\\n 1.5 mg/dL\\n 11 mEq/L\\n 4.7 mEq/L\\n 31 mg/dL\\n 111 mEq/L\\n 138 mEq/L\\n 28.0 %\\n 15.1 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n 09:58 AM\\n 05:28 PM\\n 07:01 PM\\n 07:18 PM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n 15.1\\n 15.1\\n Hct\\n 31.0\\n 30.7\\n 28.4\\n 28.0\\n Plt\\n 16\\n Cr\\n 1.0\\n 1.1\\n 1.5\\n TCO2\\n 19\\n 15\\n 15\\n 13\\n Glucose\\n 102\\n 73\\n 115\\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\\n congestion\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status now with hypotension,\\n persistent respiratory failure, acute renal failure.\\n .\\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection given septic physiology although not febrile but\\n does have new leukocytosis, likely from stress response. Recent\\n paracentesis rules out SBP although could have developed secondary\\n peritonitis from tap. No current peritoneal signs on exam. No focal\\n infiltrate on CXR although + effusion on R and may have aspitated. No\\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\\n amitriptyline, will d/c. Also has benzos on tox and not on home med\\n list. Could be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u sputum culture and (GPC)\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs\\n - would not tolerate tap R pleural effusion\\n - f/u culture data\\n - continue broad abx with vanc/cefepime\\n .\\n # Hypoxemic respiratory failure: intubated for airway protection in the\\n setting of altered mental status and has had persistent hypoxia, most\\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\\n ventilation and oxygenation at OSH. Has large right pleural effusion,\\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\\n aspiration and was 9 L positive yesterday, likely complicating picture.\\n - VAP ppx\\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\\n - Increase PEEP as BP tolerates to increase recruitment\\n - Serial ABGs\\n - treat altered MS as below\\n - try to improve fluid status by improving renal function, fluid\\n mobilization, may need CVVH vs HD\\n .\\n # Hypotension: Pt had relative hypotension on arrival to ICU with\\n associated tachycardia. Likely has low baseline from liver disease.\\n Given altered mental status, concern for infection/sepsis especially\\n given persistent pressor requirement, elevated WBC although ahs not had\\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\\n signs of bleeding until coffee grounds this am. Likely\\n hypovolemic/circulatory from sepsis. Could also have component of\\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \\n also be related to sedation.\\n - Serial HCT\\n - hold diuretics\\n - Abx for possible sepsis (source pulmonary vs abdominal)\\n - Aline placed for monitoring\\n - continue pressors, wean as tolerated, goal MAP>65\\n - albumin for volume resuscitation\\n - check random cortisol\\n - defer para for now since minimal ascites, on broad coverage for abx\\n and would be risk given coagulopathy, unsafe for transport\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\\n perfusion with hypotension and may have component of ATN from prolonged\\n hypotension yesterday. Fena 0.1. have component of HRS.\\n - albumin 1g/kg\\n - hold diuretics for now\\n - maintain MAP>65\\n - may need CVVH since UOP poor despite total body volume overloaded\\n .\\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\\n .\\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\\n hypotension.\\n - appreciate liver recs- hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers without PV thrombosis\\n - add albumin to regimen\\n .\\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\\n transfusion in setting of UGIB. Has known iron deficiency anemia and\\n has had multiple episodes of UGI bleeding from portal gastropathy and\\n varices.\\n - 2 large bore IVs\\n - type and screen\\n - CBC\\n - cont iron\\n - PPI \\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\\n starting, had been holding Po meds for residuals concern for\\n aspiration. Slowly introduce meds. Give reglan if high residuals\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\\n .\\n # CODE: FULL. Will have family discussion today regarding goals of\\n care, may need dialysis\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 08:30 AM\\n 20 Gauge - 06:00 PM\\n Multi Lumen - 08:03 PM\\n 22 Gauge - 11:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651288,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:36 PM\\n EKG - At 12:10 AM\\n URINE CULTURE - At 12:36 AM\\n SPUTUM CULTURE - At 01:37 AM\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 112 (108 - 114) bpm\\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\\n RR: 30 (21 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 1,030 mL\\n 1,683 mL\\n PO:\\n TF:\\n IVF:\\n 1,030 mL\\n 1,683 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 70 mL\\n Urine:\\n 240 mL\\n 70 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 790 mL\\n 1,613 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 451 (450 - 601) mL\\n Vt (Spontaneous): 677 (677 - 677) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n RSBI: 48\\n PIP: 15 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.2 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.50/24/96./19/-2\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\\n Cardiovascular: S1S2 RRR no mrg\\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\\n wheezes\\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\\n paracentesis, CDI\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\\n not responsive and does not follow commands\\n Labs / Radiology\\n 226 K/uL\\n 10.6 g/dL\\n 73 mg/dL\\n 1.1 mg/dL\\n 19 mEq/L\\n 5.0 mEq/L\\n 27 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 10.0 K/uL\\n [image002.jpg]\\n Cx: pending\\n CXR: upright image shows R pleural effusion\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n Hct\\n 31.0\\n 30.7\\n Plt\\n 225\\n 226\\n Cr\\n 1.0\\n 1.1\\n TCO2\\n 19\\n Glucose\\n 102\\n 73\\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection not febrile, with no leukocytosis. Recent\\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\\n amitriptyline. Also has benzos on tox and not on home med list. Could\\n be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u abdominal US\\n - send blood cultures\\n - sputum culture\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs (? Antibiotics)\\n - ? tap R pleural effusion\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\\n BPs however UOP was still poor this morning.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - Aline placed for CVL\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n -consider adding albumin to regimen\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 651308,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:36 PM\\n EKG - At 12:10 AM\\n URINE CULTURE - At 12:36 AM\\n SPUTUM CULTURE - At 01:37 AM\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 112 (108 - 114) bpm\\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\\n RR: 30 (21 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 1,030 mL\\n 1,683 mL\\n PO:\\n TF:\\n IVF:\\n 1,030 mL\\n 1,683 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 70 mL\\n Urine:\\n 240 mL\\n 70 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 790 mL\\n 1,613 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 451 (450 - 601) mL\\n Vt (Spontaneous): 677 (677 - 677) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n RSBI: 48\\n PIP: 15 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.2 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.50/24/96./19/-2\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\\n Cardiovascular: S1S2 RRR no mrg\\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\\n wheezes\\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\\n paracentesis, CDI\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\\n not responsive and does not follow commands\\n Labs / Radiology\\n 226 K/uL\\n 10.6 g/dL\\n 73 mg/dL\\n 1.1 mg/dL\\n 19 mEq/L\\n 5.0 mEq/L\\n 27 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 10.0 K/uL\\n [image002.jpg]\\n Cx: pending\\n CXR: upright image shows R pleural effusion\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n Hct\\n 31.0\\n 30.7\\n Plt\\n 225\\n 226\\n Cr\\n 1.0\\n 1.1\\n TCO2\\n 19\\n Glucose\\n 102\\n 73\\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection not febrile, with no leukocytosis. Recent\\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\\n amitriptyline. Also has benzos on tox and not on home med list. Could\\n be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u abdominal US\\n - send blood cultures\\n - sputum culture\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs (? Antibiotics)\\n - ? tap R pleural effusion\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\\n BPs however UOP was still poor this morning.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - Aline placed for CVL\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n -consider adding albumin to regimen\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 65 year old female with a history of ESLD \\n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\\n gastropathy, and recurrent GI bleeds who presents with altered mental\\n status. Last admitted for GAVE/UGIB in and similar admission other\\n hospital admit in . Recent GAVE treatment with thermal\\n therapy. Recent d/c after tap for ?SBP\\n neg. 2 days later was\\n found on floor next to bed by son, last seen night before, brought to\\n where intubated for a/w protection. CT head -\\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\\n Urine tox pos for TCA, benzo.\\n Here at , intubated/sedated. Unclear if not taking lactulose, but\\n dietary indiscretion was a possibility over holidays. Treated for\\n encephalopathy, initially held off on antibiotics other than FQ\\n prophylaxis. Awaiting pan-cultures. Also rehydrated overnight. Other\\n history notable for encephalopathy and SBP in past. Meds at home, FQ,\\n fluoxetine, rifaximin, iron, lactulose, PPI, lasix, spironolactone,\\n albuterol, advair, metformin. ?all to bactrim, but has taken in past.\\n Lives in by herself, no etoh/tob currently.\\n Exam notable for Tm BP HR RR with sat on 450 x 12, PEEP 5, FiO2 .4 w/\\n 7.48/25/132 Post surgical pupils, roving eye movements, hard collar,\\n reg RR, soft Syst murmur, nontender +BS, 2+ LE edema, w/draw to painful\\n stimuli. Labs notable for WBC 8.3K, HCT 31, K+ 5.1, Cr 1.0. CXR with ,\\n ABG 7.5/24/97 on Fio2 .4.\\n Agree with plan to treat altered mental status and acute respiratory\\n failure as presumed hepatic encephalopathy. Aggressively continue\\n lactulose. Check Abd US w/Doppler. No evidence for acute infection,\\n but will begin broad spectrum antibiotics pending full culture data.\\n Respiratory failure likely due to mental status, wean ventilator as\\n tolerated. Hypotension responding to IVF, but may require pressors.\\n Hold diuretics. Continue rifaximin. Holding metformin and monitoring\\n BS. Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 45 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:24 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651367,\n \"text\": \"65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presented from an osh intubated after being found down at\\n home. She was recently discharged home following a week long stay for a\\n gib. At that time, an egd revealed grade II esophageal varices and she\\n was transfused w/2 units prbc\\ns. A diagnostic paracentesis r/out sbp at\\n that time as well. She was sent home on .\\n She was admitted to the micu from on \\n after being found unresponsive by her son. decreased responsiveness\\n is felt to be d/t encephalopathy likely r/t her underlying liver\\n disease, ?dietary indiscretion over the holiday, and noncompliance with\\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\\n benzos although benzo use is not part of her medical regimen. Also of\\n note, her left pupil was found to be dilated and nonreactive, but a\\n head ct was reportedly negative. Additonally, her micu stay has been\\n c/b hypotension requiring pressor support despite aggressive fluid\\n resuscitation w/o evidence of any active gi bleeding. There is no clear\\n source of infection.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651441,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 08:30 AM\\n ULTRASOUND - At 08:47 AM\\n MULTI LUMEN - START 03:45 PM\\n MULTI LUMEN - STOP 05:34 PM\\n MULTI LUMEN - START 08:03 PM\\n SPUTUM CULTURE - At 10:03 PM\\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\\n Attempted RIJ placement but was in R carotid. Called vascular who later\\n removed after FFP.\\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\\n CVL placed.\\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\\n and rifaximin\\n Concern for aspiration\\n Abdominal U/S without PV thrombosis. Suboptimal study\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 03:39 PM\\n Cefipime - 09:00 PM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Phenylephrine - 2.8 mcg/Kg/min\\n Norepinephrine - 0.25 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 10:00 AM\\n Fentanyl - 09:22 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 100 (99 - 108) bpm\\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\\n RR: 28 (21 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 9,369 mL\\n 635 mL\\n PO:\\n TF:\\n IVF:\\n 7,755 mL\\n 475 mL\\n Blood products:\\n 1,389 mL\\n Total out:\\n 239 mL\\n 90 mL\\n Urine:\\n 239 mL\\n 40 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 9,130 mL\\n 545 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 451) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 13 cmH2O\\n SpO2: 94%\\n ABG: 7.33/23/70/11/-11\\n Ve: 19.8 L/min\\n PaO2 / FiO2: 117\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\\n Cardiovascular: S1S2 RRR no mrg\\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\\n wheezes\\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\\n paracentesis, CDI\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\\n not responsive and does not follow commands\\n Labs / Radiology\\n 216 K/uL\\n 9.3 g/dL\\n 115 mg/dL\\n 1.5 mg/dL\\n 11 mEq/L\\n 4.7 mEq/L\\n 31 mg/dL\\n 111 mEq/L\\n 138 mEq/L\\n 28.0 %\\n 15.1 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n 09:58 AM\\n 05:28 PM\\n 07:01 PM\\n 07:18 PM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n 15.1\\n 15.1\\n Hct\\n 31.0\\n 30.7\\n 28.4\\n 28.0\\n Plt\\n 16\\n Cr\\n 1.0\\n 1.1\\n 1.5\\n TCO2\\n 19\\n 15\\n 15\\n 13\\n Glucose\\n 102\\n 73\\n 115\\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection not febrile, with no leukocytosis. Recent\\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\\n amitriptyline. Also has benzos on tox and not on home med list. Could\\n be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u abdominal US\\n - send blood cultures\\n - sputum culture\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs (? Antibiotics)\\n - ? tap R pleural effusion\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH. Has large right pleural effusion, volume\\n overloaded. ETT approx. 2cm above carina. also have VAP vs\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n - consider\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\\n BPs however UOP was still poor this morning.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - Aline placed for CVL\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.5. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\\n failure.\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n -consider adding albumin to regimen\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 08:30 AM\\n 20 Gauge - 06:00 PM\\n Multi Lumen - 08:03 PM\\n 22 Gauge - 11:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651186,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 1\\n Ideal body weight: 52.2 None\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location: Outside hospital\\n Reason: airway protection\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: A/C 450x12/.4/+6 peep\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment: none noted\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: underlying illness\\n not resolved\\n Respiratory Care Shift Procedures: RSBI\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651281,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:36 PM\\n EKG - At 12:10 AM\\n URINE CULTURE - At 12:36 AM\\n SPUTUM CULTURE - At 01:37 AM\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 112 (108 - 114) bpm\\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\\n RR: 30 (21 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 1,030 mL\\n 1,683 mL\\n PO:\\n TF:\\n IVF:\\n 1,030 mL\\n 1,683 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 70 mL\\n Urine:\\n 240 mL\\n 70 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 790 mL\\n 1,613 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 451 (450 - 601) mL\\n Vt (Spontaneous): 677 (677 - 677) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n RSBI: 48\\n PIP: 15 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.2 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.50/24/96./19/-2\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 226 K/uL\\n 10.6 g/dL\\n 73 mg/dL\\n 1.1 mg/dL\\n 19 mEq/L\\n 5.0 mEq/L\\n 27 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 10.0 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n Hct\\n 31.0\\n 30.7\\n Plt\\n 225\\n 226\\n Cr\\n 1.0\\n 1.1\\n TCO2\\n 19\\n Glucose\\n 102\\n 73\\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: multiple possible etiologies. Given known\\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\\n consider infection although although afebrile, with no leukocytosis.\\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\\n on tox but on amitriptyline. Also has benzos on tox and not on home med\\n list. Could be contributing. CT head negative. Given roving eyes on\\n exam, must also consider seizure activity.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - abdominal u/s to eval for ascites for dx para\\n - send blood cultures\\n - sputum culture\\n - repeat U/A here\\n - repeat CXR\\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\\n Neuro consult for EEG\\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\\n infection\\n - consider tap of R sided pleural effusion if further evidence of\\n infection and no improvement with above measures\\n - no flumazenil given concern possibility of seizures\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - CVL prn for vasopressors\\n .\\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\\n Hyperchloremic currently. Most likely due to GI losses. Slightly\\n improved from OSH.\\n - repeat ABG here\\n - treat as above\\n - repeat lytes in am\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651253,\n \"text\": \". is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Urine\\n tox screen positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. She also received an ultrasound guided paracentesis without\\n evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received patient intubated for airway protection and on A?C mode,\\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\\n sats 98-100%.\\n Action:\\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\\n overbreathing with vent. Albuterol/atrovent MDI given. Fentanyl iv push\\n given\\n Response:\\n O2 sats 96-98%, blood gas 7.50/24/97\\n Plan:\\n Continue monitor resp status and wean vent accordingly\\n Altered mental status (not Delirium)\\n Assessment:\\n Unresponsive, not opening eyes or following commands, nonpurposeful\\n movements noted, patient with ESLD on transplant list\\n Action:\\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\\n Response:\\n Continue to be unresponsive, patient has non purposeful movements on\\n her neck and UE,\\n Plan:\\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\\n and continue antibiotics. For abd ultrasounds today.and liver consult\\n in Am\\n Hypotension (not Shock)\\n Assessment:\\n Sbp 80-100 monitored via NIBP\\n Action:\\n Fluid bolus to 3L NS\\n Response:\\n SBP 80-110\\n Plan:\\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\\n challenge fluid and A line to monitor blood pressure.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Low urine output 5-10ml/hr\\n Action:\\n Fluid bolus given, U/A sent with urine lytes\\n Response:\\n Bun/creat 27/1.1, UO 5ml/hr even after fluid bolus\\n Plan:\\n Monitor UO and bun/creat, continue fluid bolus.\\n ,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651343,\n \"text\": \"PMH: Pt is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive. According to report, she was discharged from on\\n and had been in her usual state of health. She was last seen well\\n the evening of at ~ 8 pm when her son dropped her off at home.\\n Son tried to contact her today but she did not pick up the phone. She\\n was then found this am, unresponsive, slumped out of bed onto the\\n floor. EMS was called and she was brought to hospital. EMS\\n reported she was unable to respond verbally. ? blown pupil on left per\\n EMS report. There she was intubated for airway protection. At\\n hospital, CT head was negative. CXR showed opacity in R\\n hemithorax c/w layering R pleural effusion and pulmonary vascular\\n congestion. Urine tox screen positive for benzos and TCAs. She was\\n recently admitted with abdominal pain, melena, and low Hct\\n (33->23 in 1 wk). She underwent EGD which showed grade II varices,\\n portal gastropathy, and angioectasias in the antrum which were treated\\n with thermal therapy. She received 2 units PRBCs with Hct 23->29. She\\n also received an ultrasound guided paracentesis without evidence of\\n SBP. She was also admitted for slow Hct drop (24->20\\n over 1 wk) and guiaic positive stools. She received 2 units PRBCs with\\n Hct 20->26. She was treated with octreotide, PPI gtts. EGD showed\\n gastric antral ectasia with varices but without an active source of\\n bleed. Hct remained stable throughout admission. During the last\\n admission she was found to have an area of cellulitis at the area of an\\n outpt Derm biopsy and she received Augmentin and Bactrim for 7 day\\n course. Her U/A at that time was negative but grew out E coli sensitive\\n to Bactrim. She was due to follow up at for repeat endoscopy.\\n However, in the interim she was admitted to hospital for GI\\n bleeding. She was transfused 4 units PRBCs and had EGD which showed\\n small esophageal varices and portal hypertension. She was then seen in\\n liver f/u on and was complaining of abdominal and ankle swelling\\n in the setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black\\n stools. Upon arrival to ICU, patient is intubated and sedated.\\n Events : A line placed in AM. Attempt at RIJ triple lumen\\n placement failed: line placed in carotid artery as evidenced by chest\\n film and pulsatile waveform. Plan per MICU attending to take pt to OR\\n for removal d/t coagulopathy and high risk of thrombus.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS course w/ crackles and insp/exp wheeze throughout day. Pt intubated\\n on AC 40%/450/12/5. Sp02 variable 89-100%. Mod amts thick tan\\n secretions sux\\ned throughout day. ABG in afternoon 7.25/32/72.\\n Action:\\n Fi02 increased to 60%. Nebs prn via ET tube.\\n Response:\\n Sp02 100%. Pt appears dusky. UOP minimal at 10-20 ml/hr.\\n Plan:\\n Maintain ABPs w/ pressors, attempt diuresis when appropriate.\\n Altered mental status (not Delirium)\\n Assessment:\\n PT does not follow commands, L pupil non reactive, R pupil reactive.\\n Pt withdraws to painful stim, non-purposeful movt all extremities.\\n Action:\\n Tx w/ lactulose q 2 h for goal stool x/day for likely hepatic\\n encephalopathy.\\n Response:\\n Pt had 1 med BM today.\\n Plan:\\n Cont bowel regimen.\\n Hypotension (not Shock)\\n Assessment:\\n A line placement confirms hypotension, SBP drops to 60s- 70s,\\n particularly w/ sedation (fentanyl bolus). MAPs dropping to 40-50.\\n Action:\\n Total of 6 L NS fluid bolus since admission. Phenylephrine and\\n dopamine gtts started at 1800 via PIV (only access at this time). MICU\\n attending and team placing fem line now for central access.\\n Response:\\n Pt remains hypotensive during line placement.\\n Plan:\\n Maintain pressors via CVL.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651345,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation:\\n Ideal body weight:\\n Ideal tidal volume:\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position:\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure:\\n Cuff volume:\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds:\\n RUL Lung Sounds:\\n LUL Lung Sounds:\\n LLL Lung Sounds:\\n Comments:\\n Secretions\\n Sputum color / consistency:\\n Sputum source/amount:\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Specialized Gas Therapy\\n Nitric Oxide\\n PPM used: ppm\\n Indication:\\n Effect of therapy: []\\n Nitric Oxide trial:\\n Comments:\\n HeliOx:\\n Additional O[2] by cannula: L/min\\n Continuous nebulized bronchodilator:\\n Comments:\\n Recruitment Maneuvers Done\\n CPAP pressure used: cm H2O\\n Duration: sec\\n Times per shift:\\n Comments:\\n Pt remained on AC 40% most of shift until PaO2 dropped to 72 late\\n afternoon. FiO2 to 60%. BS worsening combination of coarse crackles,\\n rhonchi, wheeze not responding to inhaled dilators. Presents as fluid\\n overload but is hypotensive and agitated. Unable to adequately sedate\\n hypotension. Placing central line at present to get more accurate\\n picture of fluid status. Wean FiO2 when possible.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 651167,\n \"text\": \"Chief Complaint: altered MS\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n Discharged from after admit for pain, melena and\\n anemia. Was in usual health, dropped off at home by son last night at\\n 8pm after party, this AM did not answer phone, son found pt slumped\\n against bed on floor, not following commands. Pt brought to by EMS - afebrile, stable BP>100 syst, tachycardic, intubated\\n for airway protection, CT head was negative, CXR c/w layering R pleural\\n effusion and pulmonary vascular congestion. Labs were remarkable for\\n WBC 6.5, Hct 35 (28.9 ), Na 132(stable), K 5.5 (5.1 on ),\\n Bicarb 18 (25 ), Cr 1.1 (stable). ALT/AST similar to recent admit,\\n Tbili down to 3.4 from 6.6. Ammonia 182 (last checked in our system 112\\n on ). Urine tox screen positive for benzos and TCAs.\\n Patient was admitted in for pain and melena, on endoscopy\\n had angioectasia treated with thermal therapy.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she\\n Transfer from other hospital\\n History obtained from Family / Friend\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Other medications:\\n Amitriptyline 10 mg PO HS\\n Ciprofloxacin 250 mg Q24H\\n Fluoxetine 10 mg PO DAILY\\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \\n Rifaximin 600 mg \\n Triamcinolone Acetonide 0.1 % Topical TID\\n Ferrous Sulfate 325 mg TID\\n Lactulose Thirty ML PO QHS\\n Lactulose (45) ML PO BID\\n Omeprazole 20 mg \\n Lasix 40 mg once a day\\n Spironolactone 50 mg once a day\\n Albuterol Sulfate Two q4h prn\\n Calcitrate-Vitamin D 315-200 mg-unit\\n Metformin 500 mg twice a day\\n Past medical history:\\n Family history:\\n Social History:\\n # ESLD NASH with cirrhosis and portal hypertension\\n - followed by Dr. \\n - on transplant list\\n - history of Grade II esophageal varices\\n # GAVE (gastral antral vascular ectasia)\\n # h/o SBP\\n # h/o gastritis\\n # anemia\\n - iron deficiency by labs\\n - elevated MCV, B12/folate nl\\n # Hypertension\\n # diabetes mellitus type II\\n # Psoriasis\\n # depression\\n # s/p C-section\\n # s/p appy\\n # s/p knee surgery for meniscal tear\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: lives in alone, 3 children, nonsmoker and has not had\\n any alcohol in 2 years, but no hx of heavy drinking, no illicit drug\\n use. She is not married. She has not worked for 4-5 months and was\\n released from her job as a cashier due to confusion.\\n Review of systems:\\n Flowsheet Data as of 12:20 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 111 (111 - 114) bpm\\n BP: 88/40(53) {88/39(53) - 130/92(102)} mmHg\\n RR: 21 (21 - 23) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 16 mL\\n PO:\\n TF:\\n IVF:\\n 16 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 240 mL\\n Urine:\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -224 mL\\n Respiratory\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 601 (601 - 601) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n PIP: 23 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 42.9 cmH2O/mL\\n SpO2: 99%\\n ABG: ////\\n Ve: 15.4 L/min\\n Physical Examination\\n Eyes / Conjunctiva: roving eyes, post- pupil\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\\n ant/lat)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: No(t) Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Tone: Not assessed, withdraws all 4 extrem to\\n painful stimuli, equivocal plantars\\n Labs / Radiology\\n 225 K/uL\\n 31.0 %\\n 10.9 g/dL\\n 8.3 K/uL\\n [image002.jpg]\\n 10:42 PM\\n WBC\\n 8.3\\n Hct\\n 31.0\\n Plt\\n 225\\n Other labs: Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\\n Eos:0.5 %\\n Imaging: CXR reviewed - probable layering right effusion\\n EGD : Grade 2 esophageal varices\\n Portal hypertensive gastropathy, angioectasias in antrum\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n Issues being addressed include:\\n 1) altered MS - likely hepatic encephalopathy, possibly due to dietary\\n indiscretion, unclear if compliant with meds/lactulose. No evidence for\\n acute GI bleed or infection. Doubt meningitis. CT head reported to be\\n without bleed or acute process. Roving eyes likely due to metabolic\\n coma. Will treat with lactulose and rifaximin. u/s to look for\\n ascites, unlikely SBP. need repeat CT or MRI, consider LP, EEG if\\n no improvement by AM. Agree with holding off on antibiotics (will\\n continue prophylactic cipro)\\n 2) Acute respiratory failure - intubated for airway protection\\n 3) Hypotension - likely volume depleted, in setting of diuretics,\\n slightly elevated Hct, tachycardia. Possibly sepsis but less likely -\\n no obvious source. Agree with volume resuscitation, hold diuretics\\n 4) ESLD due to NASH with cirrhosis and portal hypertension - Alb 2.8,\\n INR 1.7, liver consult in am, treatment of hepatic encephalopathy as\\n above\\n Rest of plan as detailed in Dr. note. Son \\n has been updated.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines / Intubation:\\n 20 Gauge - 10:05 PM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU, Total time spent: 39 minutes, Patient is critically\\n ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 651168,\n \"text\": \"Chief Complaint: unresponsive\\n PCP: ,\\n GI: \\n HPI:\\n Ms. is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Labs\\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\\n positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. The remainder of her hospital course in unclear as there is not\\n currently a discharge summary available. She also received an\\n ultrasound guided paracentesis without evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Patient admitted from: Transfer from other hospital\\n History obtained from Family / Medical records\\n Patient unable to provide history: Sedated, Encephalopathy,\\n Unresponsive\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Amitriptyline 10 mg PO HS\\n Ciprofloxacin 250 mg Q24H\\n Fluoxetine 10 mg PO DAILY\\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \\n Rifaximin 600 mg \\n Triamcinolone Acetonide 0.1 % Topical TID as needed for psoriasis.\\n Ferrous Sulfate 325 mg TID\\n Lactulose Thirty ML PO QHS\\n Lactulose (45) ML PO BID\\n Omeprazole 20 mg \\n Lasix 40 mg once a day\\n Spironolactone 50 mg once a day\\n Albuterol Sulfate Two puffs every four hours as needed\\n Calcitrate-Vitamin D 315-200 mg-unit once a day\\n Metformin 500 mg twice a day\\n Past medical history:\\n Family history:\\n Social History:\\n # ESLD NASH with cirrhosis and portal hypertension\\n - followed by Dr. \\n - on transplant list\\n - history of Grade II esophageal varices\\n # GAVE (gastral antral vascular ectasia)\\n # h/o SBP\\n # h/o gastritis\\n # anemia\\n - iron deficiency by labs\\n - elevated MCV, B12/folate nl\\n # Hypertension\\n # diabetes mellitus type II\\n # Psoriasis\\n # depression\\n # s/p C-section\\n # s/p appy\\n # s/p knee surgery for meniscal tear\\n mother with lung CA, 3 brothers with DM\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: She lives in alone. She has 3 children who live in\\n , , and . Their ages are 37, 40, and 45. She is a\\n nonsmoker and has not had any alcohol in 2 years. Apparently, she was\\n not a heavy drinker. She has no illicit drug use. She is not married\\n and does not have a current partner. She has not worked for 4-5 months\\n and was released from her job as a cashier due to confusion. She has\\n applied for disability.\\n Review of systems:\\n Flowsheet Data as of 12:27 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.9\\nC (98.4\\n HR: 113 (111 - 114) bpm\\n BP: 107/38(57) {88/38(53) - 130/92(102)} mmHg\\n RR: 24 (21 - 24) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 155 mL\\n 186 mL\\n PO:\\n TF:\\n IVF:\\n 155 mL\\n 186 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 20 mL\\n Urine:\\n 240 mL\\n 20 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -85 mL\\n 166 mL\\n Respiratory\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 601) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n PIP: 12 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.1 cmH2O/mL\\n SpO2: 99%\\n ABG: ///19/\\n Ve: 14.8 L/min\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\\n tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\\n exp wheezes\\n Abdominal: Soft, Non-tender, No(t) Distended, No(t) Tender: , site of\\n prior LLQ paracentesis, CDI\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: Responds to: Noxious stimuli, Movement: Purposeful,\\n Sedated, Tone: Normal, withdraws all extremities to painful stimuli.\\n Roving eye movements. CN 2-12 grossly intact. Plantar responses mute B\\n Labs / Radiology\\n 225 K/uL\\n 10.9 g/dL\\n 102 mg/dL\\n 1.0 mg/dL\\n 28 mg/dL\\n 19 mEq/L\\n 109 mEq/L\\n 5.1 mEq/L\\n 138 mEq/L\\n 31.0 %\\n 8.3 K/uL\\n [image002.jpg]\\n \\n 2:33 A12/26/ 10:42 PM\\n \\n 10:20 P\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 8.3\\n Hct\\n 31.0\\n Plt\\n 225\\n Cr\\n 1.0\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:18.6/37.4/1.7, ALT / AST:36/87, Alk Phos / T\\n Bili:91/4.0, Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\\n Eos:0.5 %, Albumin:2.6 g/dL, LDH:403 IU/L, Ca++:8.3 mg/dL, Mg++:1.7\\n mg/dL, PO4:2.3 mg/dL\\n Fluid analysis / Other labs: from :\\n ABG 7.48/25/132 on PSV 15/10 with FiO2 50%.\\n .\\n PT 19.3, PTT 37.9, INR 1.7\\n .\\n WBC 6.5, Hct 35.9, plts 208\\n .\\n Na 132, K 5.5, Cl 101, CO2 18, BUN 27, Cr 1.1, Glu 114, Ca 9.3, Tbili\\n 3.4, AST 84, ALT 37, Ammonia 182, alb 2.8, AP 108, CK 337, MB 11, TnT\\n 0.04\\n .\\n Tox screen: positive for TCAs, positive for benzos, negative for\\n opiates, barbs, amph, cocaine, THC\\n .\\n U/A: negative\\n Imaging: EGD :\\n Grade 2 esophageal varices\\n Portal hypertensive gastropathy\\n Angioectasias in the antrum (thermal therapy)\\n .\\n colonoscopy :\\n Diverticulosis of the sigmoid colon\\n Otherwise normal colonoscopy to cecum\\n ECG: ECG : abnormal p wave axis. ? sinus tach vs Atach. Low limb\\n lead voltage. Tall TWs, not hyperacute. Compared to prior ECG ,\\n inferior QWs have resolved, p wave axis is different, and TWs are more\\n prominent.\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: multiple possible etiologies. Given known\\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\\n consider infection although although afebrile, with no leukocytosis.\\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\\n on tox but on amitriptyline. Also has benzos on tox and not on home med\\n list. Could be contributing. CT head negative. Given roving eyes on\\n exam, must also consider seizure activity.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - abdominal u/s to eval for ascites for dx para\\n - send blood cultures\\n - sputum culture\\n - repeat U/A here\\n - repeat CXR\\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\\n Neuro consult for EEG\\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\\n infection\\n - consider tap of R sided pleural effusion if further evidence of\\n infection and no improvement with above measures\\n - no flumazenil given concern possibility of seizures\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - CVL prn for vasopressors\\n .\\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\\n Hyperchloremic currently. Most likely due to GI losses. Slightly\\n improved from OSH.\\n - repeat ABG here\\n - treat as above\\n - repeat lytes in am\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n ICU Care\\n Nutrition:\\n Comments: NPO\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651178,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651179,\n \"text\": \". is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Labs\\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\\n positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. The remainder of her hospital course in unclear as there is not\\n currently a discharge summary available. She also received an\\n ultrasound guided paracentesis without evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651180,\n \"text\": \". is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Urine\\n tox screen positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. She also received an ultrasound guided paracentesis without\\n evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651391,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 08:30 AM\\n ULTRASOUND - At 08:47 AM\\n MULTI LUMEN - START 03:45 PM\\n MULTI LUMEN - STOP 05:34 PM\\n MULTI LUMEN - START 08:03 PM\\n SPUTUM CULTURE - At 10:03 PM\\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\\n Attempted RIJ placement but was in R carotid. Called vascular who later\\n removed after FFP.\\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\\n CVL placed.\\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\\n and rifaximin\\n Concern for aspiration\\n Abdominal U/S without PV thrombosis. Suboptimal study\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 03:39 PM\\n Cefipime - 09:00 PM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Phenylephrine - 2.8 mcg/Kg/min\\n Norepinephrine - 0.25 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 10:00 AM\\n Fentanyl - 09:22 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 100 (99 - 108) bpm\\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\\n RR: 28 (21 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 9,369 mL\\n 635 mL\\n PO:\\n TF:\\n IVF:\\n 7,755 mL\\n 475 mL\\n Blood products:\\n 1,389 mL\\n Total out:\\n 239 mL\\n 90 mL\\n Urine:\\n 239 mL\\n 40 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 9,130 mL\\n 545 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 451) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 13 cmH2O\\n SpO2: 94%\\n ABG: 7.33/23/70/11/-11\\n Ve: 19.8 L/min\\n PaO2 / FiO2: 117\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\\n Cardiovascular: S1S2 RRR no mrg\\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\\n wheezes\\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\\n paracentesis, CDI\\n Extremities: Right: 2+, Left: 2+\\n Skin: Warm\\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\\n not responsive and does not follow commands\\n Labs / Radiology\\n 216 K/uL\\n 9.3 g/dL\\n 115 mg/dL\\n 1.5 mg/dL\\n 11 mEq/L\\n 4.7 mEq/L\\n 31 mg/dL\\n 111 mEq/L\\n 138 mEq/L\\n 28.0 %\\n 15.1 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n 09:58 AM\\n 05:28 PM\\n 07:01 PM\\n 07:18 PM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n 15.1\\n 15.1\\n Hct\\n 31.0\\n 30.7\\n 28.4\\n 28.0\\n Plt\\n 16\\n Cr\\n 1.0\\n 1.1\\n 1.5\\n TCO2\\n 19\\n 15\\n 15\\n 13\\n Glucose\\n 102\\n 73\\n 115\\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection not febrile, with no leukocytosis. Recent\\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\\n amitriptyline. Also has benzos on tox and not on home med list. Could\\n be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u abdominal US\\n - send blood cultures\\n - sputum culture\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs (? Antibiotics)\\n - ? tap R pleural effusion\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\\n BPs however UOP was still poor this morning.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - Aline placed for CVL\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n -consider adding albumin to regimen\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 08:30 AM\\n 20 Gauge - 06:00 PM\\n Multi Lumen - 08:03 PM\\n 22 Gauge - 11:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651392,\n \"text\": \"65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presented from an osh intubated after being found down at\\n home. She was recently discharged home following a week long stay for a\\n gib. At that time, an egd revealed grade II esophageal varices and she\\n was transfused w/2 units prbc\\ns. A diagnostic paracentesis r/out sbp at\\n that time as well. She was sent home on .\\n She was admitted to the micu from on \\n after being found unresponsive by her son. decreased responsiveness\\n is felt to be d/t encephalopathy likely r/t her underlying liver\\n disease, ?dietary indiscretion over the holiday, and noncompliance with\\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\\n benzos although benzo use is not part of her medical regimen. Also of\\n note, her left pupil was found to be dilated and nonreactive, but a\\n head ct was reportedly negative. Additionally, her micu stay has been\\n c/b hypotension requiring pressor support despite aggressive fluid\\n resuscitation. There is no overt evidence of any active gi bleeding.\\n There is no clear source of infection.\\n Events overnight included removal of the right ij that was placed\\n arterially. The line was removed w/o incident by surgery. There is no\\n hematoma/edema at the insertion site.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains orally intubated and vented on ac 12x450 w/peep5 and o2 60%.\\n SRR 12-14/min. MV 15-19 liters. Diffuse rhonchi and expiratory wheezing\\n noted on lung exam. Repeat abg this am showing a worsening acidosis\\n although oxygenation has improved: 25/94/7.26/12/-13.\\n She has been suctioned for small to moderate amts of thick, pink-tinged\\n sputum w/?aspiration.\\n Action:\\n Sputim culture repeated for ?aspiration. Metabolic acidosis worsening\\n this morning with a rise in creat level.\\n Response:\\n Although ogt initially placed to suction for ?aspiration, ogt is now\\n clamped and being used for po meds.\\n Plan:\\n Follow lung exam, serial abg results closely. Suction as needed and\\n monitor for possible aspiration.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt remains unresponsive but transiently agitated. She was placed on a\\n low dose fentanyl drip after receiving several boluses. She has\\n received lactulose q4hrs overnight and has had one moderate sized bowel\\n movement. Left pupil remains dilated and unresponsive. +corneals.\\n Action:\\n Placed on a low dose fentanyl drip for comfort. No change in mental\\n status/neuro exam noted overnight despite rtc lactulose.\\n Response:\\n More comfortable on a fentanyl drip.\\n Plan:\\n Follow neuro exam closely. Con\\nt rtc lactulose and fentanyl drip for\\n now.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on maximum doses of both levophed and neo. Both drip rates\\n were weaned slowly although the levophed drip rate has since been\\n increased d/t persistent hypotension in the setting of a worsening\\n acidosis. Of note, wbc elevated from 10 to 15 this morning. Pt has\\n been afebrile. Awaiting culture results from yesterday.\\n Action:\\n Slowly weaning pressor support. Hypotension may be r/t sepsis given new\\n leukocytosis.\\n Response:\\n Although requiring an increase in levophed this morning, the pt has\\n tolerated an overall reduction in pressor support.\\n Plan:\\n Follow hemodynamic status closely. Wean pressors as pt tolerates.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Rise in creat level from 1.1 to 1.5 this morning. As noted above,\\n metabolic acidosis is worsening. Uop 0-10cc/hr at the present time. +3\\n pitting edema now present.\\n Action:\\n None.\\n Response:\\n Unchanged.\\n Plan:\\n Follow serial lab results, monitor uop, edema closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651503,\n \"text\": \"65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status now with hypotension,\\n persistent respiratory failure, acute renal failure.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651388,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 08:30 AM\\n ULTRASOUND - At 08:47 AM\\n MULTI LUMEN - START 03:45 PM\\n MULTI LUMEN - STOP 05:34 PM\\n MULTI LUMEN - START 08:03 PM\\n SPUTUM CULTURE - At 10:03 PM\\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\\n Attempted RIJ placement but was in R carotid. Called vascular who later\\n removed after FFP.\\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\\n CVL placed.\\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\\n and rifaximin\\n Concern for aspiration\\n Abdominal U/S without PV thrombosis. Suboptimal study\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 03:39 PM\\n Cefipime - 09:00 PM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Phenylephrine - 2.8 mcg/Kg/min\\n Norepinephrine - 0.25 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 10:00 AM\\n Fentanyl - 09:22 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 100 (99 - 108) bpm\\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\\n RR: 28 (21 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 9,369 mL\\n 635 mL\\n PO:\\n TF:\\n IVF:\\n 7,755 mL\\n 475 mL\\n Blood products:\\n 1,389 mL\\n Total out:\\n 239 mL\\n 90 mL\\n Urine:\\n 239 mL\\n 40 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 9,130 mL\\n 545 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 451) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 13 cmH2O\\n SpO2: 94%\\n ABG: 7.33/23/70/11/-11\\n Ve: 19.8 L/min\\n PaO2 / FiO2: 117\\n Physical Examination\\n Labs / Radiology\\n 216 K/uL\\n 9.3 g/dL\\n 115 mg/dL\\n 1.5 mg/dL\\n 11 mEq/L\\n 4.7 mEq/L\\n 31 mg/dL\\n 111 mEq/L\\n 138 mEq/L\\n 28.0 %\\n 15.1 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n 09:58 AM\\n 05:28 PM\\n 07:01 PM\\n 07:18 PM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n 15.1\\n 15.1\\n Hct\\n 31.0\\n 30.7\\n 28.4\\n 28.0\\n Plt\\n 16\\n Cr\\n 1.0\\n 1.1\\n 1.5\\n TCO2\\n 19\\n 15\\n 15\\n 13\\n Glucose\\n 102\\n 73\\n 115\\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 08:30 AM\\n 20 Gauge - 06:00 PM\\n Multi Lumen - 08:03 PM\\n 22 Gauge - 11:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651546,\n \"text\": \"Following another family meeting this evening, the pt\\ns children\\n made the decision to withdraw from aggressive care measures and\\n redirect care to cmo status. The family expressed a desire to extubate\\n as well as discontinue all vasopressors. The pt was extubated with\\n discontinuation of triple pressors ~ and expired @2037.\\n The micu team did offer an autopsy to the family which was declined.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651229,\n \"text\": \". is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Urine\\n tox screen positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. She also received an ultrasound guided paracentesis without\\n evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received patient intubated for airway protection and on A?C mode,\\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\\n sats 98-100%.\\n Action:\\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\\n overbreathing with vent. Albuterol/atrovent MDI given.\\n Response:\\n O2 sats 96-98%,\\n Plan:\\n Continue monitor resp status and wean vent accordingly\\n Altered mental status (not Delirium)\\n Assessment:\\n Unresponsive, not opening eyes or following commands, nonpurposeful\\n movements noted, patient with ESLD on transplant list\\n Action:\\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\\n Response:\\n Continue to be unresponsive, patient has non purposeful movements on\\n her neck and UE,\\n Plan:\\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\\n and continue antibiotics\\n Hypotension (not Shock)\\n Assessment:\\n Sbp 80-100 monitored via NIBP\\n Action:\\n Fluid bolus to 3L NS\\n Response:\\n SBP 90-110\\n Plan:\\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\\n challenge fluid and A line to monitor blood pressure.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Low urine output 5-10ml/hr\\n Action:\\n Fluid bolus given, U/A sent with urine lytes\\n Response:\\n Bun/creat\\n Plan:\\n Monitor UO and bun/creat, continue fluid bolus.\\n ,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651230,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:36 PM\\n EKG - At 12:10 AM\\n URINE CULTURE - At 12:36 AM\\n SPUTUM CULTURE - At 01:37 AM\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 112 (108 - 114) bpm\\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\\n RR: 30 (21 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 1,030 mL\\n 1,683 mL\\n PO:\\n TF:\\n IVF:\\n 1,030 mL\\n 1,683 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 70 mL\\n Urine:\\n 240 mL\\n 70 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 790 mL\\n 1,613 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 451 (450 - 601) mL\\n Vt (Spontaneous): 677 (677 - 677) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n RSBI: 48\\n PIP: 15 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.2 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.50/24/96./19/-2\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 226 K/uL\\n 10.6 g/dL\\n 73 mg/dL\\n 1.1 mg/dL\\n 19 mEq/L\\n 5.0 mEq/L\\n 27 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 10.0 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n Hct\\n 31.0\\n 30.7\\n Plt\\n 225\\n 226\\n Cr\\n 1.0\\n 1.1\\n TCO2\\n 19\\n Glucose\\n 102\\n 73\\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 651231,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:36 PM\\n EKG - At 12:10 AM\\n URINE CULTURE - At 12:36 AM\\n SPUTUM CULTURE - At 01:37 AM\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 112 (108 - 114) bpm\\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\\n RR: 30 (21 - 30) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 1,030 mL\\n 1,683 mL\\n PO:\\n TF:\\n IVF:\\n 1,030 mL\\n 1,683 mL\\n Blood products:\\n Total out:\\n 240 mL\\n 70 mL\\n Urine:\\n 240 mL\\n 70 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 790 mL\\n 1,613 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 451 (450 - 601) mL\\n Vt (Spontaneous): 677 (677 - 677) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 6 cmH2O\\n FiO2: 40%\\n RSBI: 48\\n PIP: 15 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 32.2 cmH2O/mL\\n SpO2: 95%\\n ABG: 7.50/24/96./19/-2\\n Ve: 13.5 L/min\\n PaO2 / FiO2: 242\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 226 K/uL\\n 10.6 g/dL\\n 73 mg/dL\\n 1.1 mg/dL\\n 19 mEq/L\\n 5.0 mEq/L\\n 27 mg/dL\\n 110 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 10.0 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n Hct\\n 31.0\\n 30.7\\n Plt\\n 225\\n 226\\n Cr\\n 1.0\\n 1.1\\n TCO2\\n 19\\n Glucose\\n 102\\n 73\\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status.\\n .\\n # altered mental status: multiple possible etiologies. Given known\\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\\n consider infection although although afebrile, with no leukocytosis.\\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\\n on tox but on amitriptyline. Also has benzos on tox and not on home med\\n list. Could be contributing. CT head negative. Given roving eyes on\\n exam, must also consider seizure activity.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - abdominal u/s to eval for ascites for dx para\\n - send blood cultures\\n - sputum culture\\n - repeat U/A here\\n - repeat CXR\\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\\n Neuro consult for EEG\\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\\n infection\\n - consider tap of R sided pleural effusion if further evidence of\\n infection and no improvement with above measures\\n - no flumazenil given concern possibility of seizures\\n .\\n # respiratory failure: intubated for airway protection in the setting\\n of altered mental status. ABG showed adequate ventilation and\\n oxygenation at OSH.\\n - VAP ppx\\n - daily wake and RSBIs with SBT\\n - treat altered MS as above\\n .\\n # hypotension: relative hypotension on arrival to ICU with associated\\n tachycardia. Given altered mental status, raises concern for infection\\n although no obvious evidence to suggest this. Unlikely GIB given normal\\n Hct. Likely hypovolemic.\\n - volume resuscitate with NS\\n - hold diuretics\\n - eval for evidence of infection as above\\n - CVL prn for vasopressors\\n .\\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\\n Hyperchloremic currently. Most likely due to GI losses. Slightly\\n improved from OSH.\\n - repeat ABG here\\n - treat as above\\n - repeat lytes in am\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\\n possibility.\\n - IVF resuscitation\\n - hold diuretics for now\\n - U/A with urine lytes\\n .\\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\\n 1.7.\\n - liver consult in am\\n - hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers\\n .\\n # anemia: Hct at OSH above most recent dc value after transfusion in\\n setting of UGIB. Has known iron deficiency anemia and has had multiple\\n episodes of UGI bleeding from portal gastropathy and varices.\\n - 2 large bore IVs\\n - type and screen\\n - Qday CBC unless evidence of active bleeding\\n - cont iron\\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\\n as well as increased Cr.\\n - repeat K now\\n - check ECG. Treat for acute ECG changes\\n - consider kayexalate\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2\\n .\\n # CODE: FULL\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 10:05 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651233,\n \"text\": \". is a 65 year old female with a history of ESLD NASH c/b\\n portal hypertension, esophageal varices, portal gastropathy, and\\n recurrent GI bleeds who is transferred from OSh after being found\\n unresponsive.\\n .\\n According to report, she was discharged from on (see below)\\n and had been in her usual state of health. She was last seen well the\\n evening of at ~ 8 pm when her son dropped her off at home. Son\\n tried to contact her today but she did not pick up the phone. She was\\n then found this am, unresponsive, slumped out of bed onto the floor.\\n EMS was called and she was brought to hospital. EMS reported\\n she was unable to respond verbally. ? blown pupil on left per EMS\\n report. There she was intubated for airway protection. At \\n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\\n layering R pleural effusion and pulmonary vascular congestion. Urine\\n tox screen positive for benzos and TCAs.\\n .\\n She was recently admitted with abdominal pain, melena, and\\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\\n varices, portal gastropathy, and angioectasias in the antrum which were\\n treated with thermal therapy. She received 2 units PRBCs with Hct\\n 23->29. She also received an ultrasound guided paracentesis without\\n evidence of SBP.\\n .\\n She was also admitted for slow Hct drop (24->20 over 1\\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\\n antral ectasia with varices but without an active source of bleed. Hct\\n remained stable throughout admission. During the last admission she\\n was found to have an area of cellulitis at the area of an outpt Derm\\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\\n at that time was negative but grew out E coli sensitive to Bactrim.\\n .\\n She was due to follow up at for repeat endoscopy. However, in the\\n interim she was admitted to hospital for GI bleeding. She\\n was transfused 4 units PRBCs and had EGD which showed small esophageal\\n varices and portal hypertension. She was then seen in liver f/u on\\n and was complaining of abdominal and ankle swelling in the\\n setting of a change in her diuretic doses during her Southshore\\n hospitalization. She also complained of intermittend dark black stools.\\n .\\n Upon arrival to ICU, patient is intubated and sedated. Further\\n ROS cannot be obtained.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received patient intubated for airway protection and on A?C mode,\\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\\n sats 98-100%.\\n Action:\\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\\n overbreathing with vent. Albuterol/atrovent MDI given.\\n Response:\\n O2 sats 96-98%,\\n Plan:\\n Continue monitor resp status and wean vent accordingly\\n Altered mental status (not Delirium)\\n Assessment:\\n Unresponsive, not opening eyes or following commands, nonpurposeful\\n movements noted, patient with ESLD on transplant list\\n Action:\\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\\n Response:\\n Continue to be unresponsive, patient has non purposeful movements on\\n her neck and UE,\\n Plan:\\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\\n and continue antibiotics. For abd ultrasounds today.and liver consult\\n in Am\\n Hypotension (not Shock)\\n Assessment:\\n Sbp 80-100 monitored via NIBP\\n Action:\\n Fluid bolus to 3L NS\\n Response:\\n SBP 90-110\\n Plan:\\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\\n challenge fluid and A line to monitor blood pressure.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Low urine output 5-10ml/hr\\n Action:\\n Fluid bolus given, U/A sent with urine lytes\\n Response:\\n Bun/creat\\n Plan:\\n Monitor UO and bun/creat, continue fluid bolus.\\n ,\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651225,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 1\\n Ideal body weight: 52.2\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location: Outside hospital\\n Reason: airway protection\\n Tube Type\\n ETT:\\n Position: 24 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: A/C 450x12/.4/+6 peep\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment: none noted\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: underlying illness\\n not resolved\\n Respiratory Care Shift Procedures: RSBI 48\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-16 00:00:00.000\",\n \"description\": \"ICU Attending Event Note\",\n \"row_id\": 651322,\n \"text\": \"Clinician: Attending\\n MICU ATTENDING CRITICAL CARE NOTE:\\n Notified by housestaff that CXR on patient following central line\\n placement suggests line is arterial rather than in internal jugular.\\n We have transduced the line and indeed the waveform is arterial. Given\\n underlying coagulopathy from liver disease, will consult Vascular\\n Surgery and have them assist in removing the line. Will likely need\\n additional FFP to try to correct coagulopathy. MICU housestaff will\\n also notify patient\\ns son by telephone.\\n Patient remains critically ill\\n Total time 20 minutes\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651384,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 3\\n Ideal body weight: 52.2\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: Unknown\\n Procedure location: Outside hospital\\n Reason: airway protection\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 8mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 26 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Exp Wheeze\\n RUL Lung Sounds: Exp Wheeze\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Exp Wheeze\\n Comments:diffuse i/e wheeze/rhonchi needing freq repeated sxn.\\n Secretions\\n Sputum color / consistency: Rusty/bright yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: A/C 450x12/+5 peep/.6\\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\\n exhalation\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Abnormal trigger efforts (efforts during\\n inspiratory)\\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\\n trapping, Erratic exhaled Tidal Volumes\\n Plan\\n Next 24-48 hours: Adjust Min. ventilation to control pH\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway\\n Continues profoundly acidotic (metabolic) despite Ve 17-19 L.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651534,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 52.2 None\\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type:\\n Size:\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Frothy\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Pt continues with refractory hyoxemia and metabolic acidosis. Awaiting\\n arrival of family member before withdrawing support.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2145-01-17 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 651465,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n ARTERIAL LINE - START 08:30 AM\\n ULTRASOUND - At 08:47 AM\\n MULTI LUMEN - START 03:45 PM\\n MULTI LUMEN - STOP 05:34 PM\\n MULTI LUMEN - START 08:03 PM\\n SPUTUM CULTURE - At 10:03 PM\\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\\n Attempted RIJ placement but was in R carotid. Called vascular who later\\n removed after FFP.\\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\\n CVL placed. Now on Levophed and neo.\\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\\n and rifaximin\\n Concern for aspiration\\n Abdominal U/S without PV thrombosis. Suboptimal study\\n Had BM x 2 with lactulose\\n Coffee grounds emesis from OGT this am\\n Allergies:\\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 03:39 PM\\n Cefipime - 09:00 PM\\n Infusions:\\n Fentanyl - 25 mcg/hour\\n Phenylephrine - 2.8 mcg/Kg/min\\n Norepinephrine - 0.25 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 10:00 AM\\n Fentanyl - 09:22 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.1\\n Tcurrent: 36.7\\nC (98.1\\n HR: 100 (99 - 108) bpm\\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\\n RR: 28 (21 - 29) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 9,369 mL\\n 635 mL\\n PO:\\n TF:\\n IVF:\\n 7,755 mL\\n 475 mL\\n Blood products:\\n 1,389 mL\\n Total out:\\n 239 mL\\n 90 mL\\n Urine:\\n 239 mL\\n 40 mL\\n NG:\\n 50 mL\\n Stool:\\n Drains:\\n Balance:\\n 9,130 mL\\n 545 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 451) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 60%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 13 cmH2O\\n SpO2: 94%\\n ABG: 7.33/23/70/11/-11\\n Ve: 19.8 L/min\\n PaO2 / FiO2: 117\\n Physical Examination\\n General Appearance: Well nourished, intubated, sedated, not responsive\\n to voice or sternal rub\\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\\n bilateral exp wheezes, palpable on exam\\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\\n paracentesis CDI\\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\\n Skin: Warm, diaphoretic\\n Neurologic: Not responsive to stimuli, sedated\\n Labs / Radiology\\n 216 K/uL\\n 9.3 g/dL\\n 115 mg/dL\\n 1.5 mg/dL\\n 11 mEq/L\\n 4.7 mEq/L\\n 31 mg/dL\\n 111 mEq/L\\n 138 mEq/L\\n 28.0 %\\n 15.1 K/uL\\n [image002.jpg]\\n 10:42 PM\\n 01:30 AM\\n 03:45 AM\\n 09:58 AM\\n 05:28 PM\\n 07:01 PM\\n 07:18 PM\\n 03:45 AM\\n WBC\\n 8.3\\n 10.0\\n 15.1\\n 15.1\\n Hct\\n 31.0\\n 30.7\\n 28.4\\n 28.0\\n Plt\\n 16\\n Cr\\n 1.0\\n 1.1\\n 1.5\\n TCO2\\n 19\\n 15\\n 15\\n 13\\n Glucose\\n 102\\n 73\\n 115\\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\\n congestion\\n Assessment and Plan\\n 65 year old female with a history of ESLD NASH c/b portal\\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\\n bleeds who presents with altered mental status now with hypotension,\\n persistent respiratory failure, acute renal failure.\\n .\\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\\n high on differential especially with ammonia elevated at OSH. Also of\\n concern is infection given septic physiology although not febrile but\\n does have new leukocytosis, likely from stress response. Recent\\n paracentesis rules out SBP although could have developed secondary\\n peritonitis from tap. No current peritoneal signs on exam. No focal\\n infiltrate on CXR although + effusion on R and may have aspitated. No\\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\\n amitriptyline, will d/c. Also has benzos on tox and not on home med\\n list. Could be contributing. CT head negative for acute process.\\n - treat for hepatic encephalopathy with lactulose, rifaximin\\n - f/u sputum culture and (GPC)\\n - consider neuro consult for possible CNS involvement, ? LP\\n - f/u liver recs\\n - would not tolerate tap R pleural effusion\\n - f/u culture data\\n - continue broad abx with vanc/cefepime\\n .\\n # Hypoxemic respiratory failure: intubated for airway protection in the\\n setting of altered mental status and has had persistent hypoxia, most\\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\\n ventilation and oxygenation at OSH. Has large right pleural effusion,\\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\\n aspiration and was 9 L positive yesterday, likely complicating picture.\\n - VAP ppx\\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\\n - Increase PEEP as BP tolerates to increase recruitment\\n - Serial ABGs\\n - treat altered MS as below\\n - try to improve fluid status by improving renal function, fluid\\n mobilization, may need CVVH vs HD\\n .\\n # Hypotension: Pt had relative hypotension on arrival to ICU with\\n associated tachycardia. Likely has low baseline from liver disease.\\n Given altered mental status, concern for infection/sepsis especially\\n given persistent pressor requirement, elevated WBC although ahs not had\\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\\n signs of bleeding until coffee grounds this am. Likely\\n hypovolemic/circulatory from sepsis. Could also have component of\\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \\n also be related to sedation.\\n - Serial HCT\\n - hold diuretics\\n - Abx for possible sepsis (source pulmonary vs abdominal)\\n - Aline placed for monitoring\\n - continue pressors, wean as tolerated, goal MAP>65\\n - albumin for volume resuscitation\\n - check random cortisol\\n - defer para for now since minimal ascites, on broad coverage for abx\\n and would be risk given coagulopathy, unsafe for transport\\n .\\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\\n perfusion with hypotension and may have component of ATN from prolonged\\n hypotension yesterday. Fena 0.1. have component of HRS.\\n - albumin 1g/kg\\n - hold diuretics for now\\n - maintain MAP>65\\n - may need CVVH since UOP poor despite total body volume overloaded\\n .\\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\\n .\\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\\n hypotension.\\n - appreciate liver recs- hepatic encephalopathy treatment as above\\n - abdominal u/s with dopplers without PV thrombosis\\n - add albumin to regimen\\n .\\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\\n transfusion in setting of UGIB. Has known iron deficiency anemia and\\n has had multiple episodes of UGI bleeding from portal gastropathy and\\n varices.\\n - 2 large bore IVs\\n - type and screen\\n - CBC\\n - cont iron\\n - PPI \\n .\\n # diabetes mellitus type II: hold metformin\\n - insulin SS\\n .\\n # depression: hold amytriptyline and fluoxetine\\n .\\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\\n starting, had been holding Po meds for residuals concern for\\n aspiration. Slowly introduce meds. Give reglan if high residuals\\n .\\n # PPx: heparin sc. PPI. lactulose\\n .\\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\\n .\\n # CODE: FULL. Will have family discussion today regarding goals of\\n care, may need dialysis\\n .\\n # COMM: (son) \\n .\\n # DISP: ICU\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ALTERED MENTAL STATUS (NOT DELIRIUM)\\n HYPOTENSION (NOT SHOCK)\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 08:30 AM\\n 20 Gauge - 06:00 PM\\n Multi Lumen - 08:03 PM\\n 22 Gauge - 11:59 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 65 year old female with a history of ESLD \\n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\\n gastropathy, and recurrent GI bleeds who presents with altered mental\\n status. Last admitted for GAVE/UGIB in and similar admission other\\n hospital admit in . Recent GAVE treatment with thermal\\n therapy. Recent d/c after tap for ?SBP\\n neg. 2 days later was\\n found on floor next to bed by son, last seen night before, brought to\\n where intubated for a/w protection. CT head -\\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\\n Urine tox pos for TCA, benzo.\\n Here at , intubated/sedated. Unclear if not taking lactulose, but\\n dietary indiscretion was a possibility over holidays vs mild sepsis\\n following GI procedure for GAVE. Treated for encephalopathy, treated\\n with broad spectrum antibiotics and FQ prophylaxis. Awaiting\\n pan-cultures. Over last 24 hr, initially responded to fluids, then\\n required CVL\\n line placed in R carotid, line removed by vascular and\\n new line placed in femoral vein. Requiring neo and levophed to\\n maintain pressure. Abd US showing no portal vein thrombosis,\\n continuing on antibiotics, lactulose and rifaximin.\\n Intubated/sedated, unresponsive, Exam notable for Tm 99.1 BP 96/52 HR\\n 88 RR 28 with sat 98 on AC 450 x 12, PEEP 5, FiO2 .6 w/ 7.26/25/94.\\n Bladder pressure 18. 9L+ yesterday. Post surgical pupils, coarse BS,\\n reg RR, soft Syst murmur, nontender +BS, 3+ LE edema, minimal w/draw to\\n painful stimuli. Labs notable for WBC 15.1K, HCT 28, K+ 4.7, Cr 1.5\\n HCO3 11, Lactate 6.4. UNa 10 FeNa .1, INR 1.9. TBili 5.2, CK 1024.\\n CXR worsening R base effusion.\\n Agree with plan to treat altered mental status and acute respiratory\\n failure as presumed hepatic encephalopathy vs sepsis now with\\n progressive respiratory and renal failure. Her status is declining with\\n anasarca and increasing oxygen and pressor requirement. Attempt\\n increase in PEEP and continue aggressive therapy including possible\\n CVVH. We will also continue to update the family. No evidence for\\n acute infection, but will remains on broad spectrum antibiotics pending\\n full culture data. Will treat with albumin for ascites. Continue\\n rifaximin and lactulose. Holding metformin and monitoring BS.\\n Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 50 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 12:15 ------\\n\"\n }\n]"}}},{"rowIdx":296,"cells":{"subject_id":{"kind":"number","value":17449,"string":"17,449"},"hadm_id":{"kind":"number","value":179268,"string":"179,268"},"target_text":{"kind":"string","value":"Hospital Course/Assessment and Plan: Patient is an 84 year old female with a history of atrial fibrillation, normocytic anemia, diabetes and hypertension who presented with weakness and a hematocrit drop from the mid 30's to 17. Patient's INR elevated, guaiac postive, but EGD negative. Received two units of packed red cells and FFP and guaiac positive. . . 1) GI bleed: Patient initially found to be guaiac positive. INR 2.7 NG lavage negative. Patient received one unit of FFP and 2 units of packed red blood cells and hematocrit demonstrated appropriate increase. Initially monitored in the MICU. EGD on did not demonstrate any active bleeds. Biopsy performed of gastric ulcers. Pathology results pending. Colonoscopy did not reveal any active bleeding lesions. Biopsy results pending. -Hematocrit stable at 28.3. On admission, hematocrit 17. -H. pylori positive. Placed on omeprazole 20 , amoxicillin 500mg , clarithromycin 500bid for ten days. After ten days, will switch to omeprazole 20mg qd. -Restarted coumadin upon discharge, with goal INR between 2 and 3. Will instruct patient to have INR and hematocrit levels to be measured by VNA. -GI recommends capsule endoscopy as outpatient in the week after discharge. Provided phone number for patient's family to arrange. Follow up EGD and potential colonoscopy in eight weeks. To be arranged by PCP. . 2) Anemia: Patient has history of normocytic anemia. Believed to be component of iron deficiency as well as B12 deficiency and is followed by Dr. . Haptoglobin 144, ferritin 24, TRF 307, TIBC 399. Folate 5.9 and B12 971. Continued on iron replacement and B12 replacement. -Scheduled for aranesp injection with Dr. on . Follow up appointments with Dr. on . . 3) Diabetes Type II: Patient's hemoglobin A1c 9.1. Blood sugar levels have been slightly elevated lately, with some glucosuria on UA. - Continued on insulin sliding scale. Restart home oral hypoglycemics. Consider increasing dose as outpatient if blood glucose levels elevated. . 4) Atrial fibrillation: Initially, well rate controlled in the 80s. Held diltiazem as concern that patient couldn't mount an adequate compensatory response if decreased volume from GI bleed. Held coumadin dose, initially, due to concern for GI bleed. Patient's rate on transfer in the low 100's. Received 10 mg IV and 60mg PO diltiazem. transfer to floor, elevated heart rate to 140's. Discharged home on home diltiazem dose of 360qd. . 5) Crackles on examination: No evidence of consolidation. Slight pulmonary edema. Will cautiously try to diurese fluid, now that perceived to be hemodynamically stable. Restarted lasix on home dose of 20qAM. . 6) Questionable Hyperparathyroidism: Patient with elevated PTH (155), in setting of elevated calcium. UPep, SPep, and vitD 1,25 levels sent. Pending. Consider outpatient follow-up. 7) Hypertension: Initially, blood pressure medications held, in setting of GI bleed. Restarted and tolerated well. . 8) Prophylaxis: Placed on PPI, . On discharge, omeprazole, amoxicillin, and clarithromycin for ten days. -Will hold fosamax until appointment with PCP . Discontinued Foley on . . 9) CODE: FULL. Confirmed with patient and daughter."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: PA and lateral chest compared to : Borderline cardiomegaly unchanged. Stable interstitial abnormality, perhaps edema. IMPRESSION: 1. BS. LBM was but pt. neg. neg. per report.Neuro: pt. Grossly unchanged appearance of the interstitial edema and left basal atelectasis. There is right basilar atelectasis and a probable effusion, probably unchanged, allowing for differences in technique. ABD soft, NT. foley placed. Question free air. pt. pt. Compared to the previous tracing of nomajor change.TRACING #1 BP 139/75-167/63. Small right pleural effusion stable. Cardiac and mediastinal contours are unchanged. rectal exam was guiac pos. NPO except small amt. plan for endoscopy for .GU: foley. denies pain. Cardiomediastinal silhouette is grossly unchanged with unchanged appearance to mild bilateral hilar fullness and interstitial edema. monitor VSS - Hx HTN. INR 2.6- Vit K+ sc. Non-diagnosticrepolarization abnormalities. no VEA. did not observe.VSS in EW. Otherwise, no major change.TRACING #2 no c/o pain, N/V. trop and urine neg per report.Arrived to CCU ~ 2100 accomp. WBC 9.2. urine neg. GI to consult. 0600 HCT is pnd with AM labs.protonix IV q12hours. IMPRESSION: Findings consistent with mild volume overload/pulmonary edema. pos. Compared to the previoustracing the ventricular rate is somewhat reduced. Lungs clear. 1.8L LOS.ID: TM 99.6 -99.4po. lytes WNL.denies CP/SOB.GI: no stool. The mediastinal contours are within normal limits allowing for patient position. There are probably small bilateral pleural effusions. u/o ~ 100cc/hr. SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH There is grossly unchanged appearance to elevation of the left hemidiaphragm, likely indicating underlying atelectasis with no definite parenchymal consolidation identified bilaterally. COMPARISON: None. plan for endoscopy today. HCT 20. recv'd 2UPRBC, 1.5L NS. lavage was negative. Atrial fibrillation, average ventricular rate 105. Comparison is made to prior radiograph dated . Granulomatous lymph node calcifications noted in the mediastinum. daughter states baseline BP ~ 140's/. Diffuse interstitial abnormality is not significantly changed. IMPRESSION: No evidence of free air. able to make needs known. is able to understand limited english. AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is upper limits of normal. CHEST, AP VIEW: Comparison is made to earlier on the same day. 25.6 at 0200. The lungs are otherwise clear without consolidations or effusions. lives alone with senior housing, has VNA ~ 1x/month.CV: HR 80-100 Afib. ice. There is bilateral hilar fullness, with pulmonary vascular redistribution. Atrial fibrillation, average ventricular rate 89. HCT 25.5 on admit to CCU. is A/O x3 per daughter who is translating. There are degenerative changes along the thoracic spine. No definite evidence of pneumonia. There is no evidence of free air. by daughter who assisted with translation. No pulmonary edema or focal pulmonary abnormality of concern. daughter Gen went home but is expected back early this AM to help with translation throughout the day.endo: FS 180- covered with SSRI.A/P: HCTs q4hr. all cardiac meds are being held for now. discomfort, s/p endoscopy, nontender exam REASON FOR THIS EXAMINATION: evaluate for free air under diaphragm FINAL REPORT INDICATIONS: 84-year-old woman with abdominal pain status post endoscopy. 6:08 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for free air under diaphragm Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with abdominal pain. CCU NPN 1900-0700S/O: 84yo Russian speaking woman with hx DM, HTN and anemia who presented to ED from PMD's office with report of generalized weakness and HCT 17. 4:58 PM CHEST (PA & LAT) Clip # Reason: r/o infiltrate, pna Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with recent Hct drop, with crackles at L base, question of PNA REASON FOR THIS EXAMINATION: r/o infiltrate, pna FINAL REPORT PA AND LATERAL CHEST FROM HISTORY: Recent hematocrit drop, crackles at the lung bases. 11:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: pls eval for PNA, particularly at L base Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with recent Hct drop, with crackles at L base, question of PNA REASON FOR THIS EXAMINATION: pls eval for PNA, particularly at L base FINAL REPORT HISTORY: Left base crackles."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2131-02-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":946717,"text":" 11:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for PNA, particularly at L base\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent Hct drop, with crackles at L base, question of\n PNA\n REASON FOR THIS EXAMINATION:\n pls eval for PNA, particularly at L base\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left base crackles.\n\n Comparison is made to prior radiograph dated .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH\n\n There is grossly unchanged appearance to elevation of the left hemidiaphragm,\n likely indicating underlying atelectasis with no definite parenchymal\n consolidation identified bilaterally. There are probably small bilateral\n pleural effusions. Cardiomediastinal silhouette is grossly unchanged with\n unchanged appearance to mild bilateral hilar fullness and interstitial edema.\n\n IMPRESSION:\n\n 1. Grossly unchanged appearance of the interstitial edema and left basal\n atelectasis. No definite evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2131-02-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":946659,"text":" 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: nausea gi bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n nausea gi bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with nausea and gastrointestinal bleed.\n\n COMPARISON: None.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is upper limits of\n normal. The mediastinal contours are within normal limits allowing for\n patient position. There is bilateral hilar fullness, with pulmonary vascular\n redistribution. The lungs are otherwise clear without consolidations or\n effusions. There are degenerative changes along the thoracic spine.\n\n IMPRESSION: Findings consistent with mild volume overload/pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2131-02-11 00:00:00.000","description":"CHEST (PA & LAT)","row_id":947125,"text":" 4:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate, pna\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent Hct drop, with crackles at L base, question of\n PNA\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, pna\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Recent hematocrit drop, crackles at the lung bases.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Borderline cardiomegaly unchanged. Lungs clear. Small right pleural effusion\n stable. Granulomatous lymph node calcifications noted in the mediastinum. No\n pulmonary edema or focal pulmonary abnormality of concern.\n\n\n"},{"category":"Radiology","chartdate":"2131-02-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":946855,"text":" 6:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for free air under diaphragm\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with abdominal pain. discomfort, s/p endoscopy,\n nontender exam\n REASON FOR THIS EXAMINATION:\n evaluate for free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 84-year-old woman with abdominal pain status post endoscopy.\n Question free air.\n\n CHEST, AP VIEW: Comparison is made to earlier on the same day. Cardiac and\n mediastinal contours are unchanged. Diffuse interstitial abnormality is not\n significantly changed. There is right basilar atelectasis and a probable\n effusion, probably unchanged, allowing for differences in technique. There is\n no evidence of free air.\n\n IMPRESSION: No evidence of free air. Stable interstitial abnormality,\n perhaps edema.\n\n\n"},{"category":"ECG","chartdate":"2131-02-08 00:00:00.000","description":"Report","row_id":272162,"text":"Atrial fibrillation, average ventricular rate 89. Compared to the previous\ntracing the ventricular rate is somewhat reduced. Otherwise, no major change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2131-02-08 00:00:00.000","description":"Report","row_id":272163,"text":"Atrial fibrillation, average ventricular rate 105. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of no\nmajor change.\nTRACING #1\n\n"},{"category":"Nursing/other","chartdate":"2131-02-09 00:00:00.000","description":"Report","row_id":1490977,"text":"CCU NPN 1900-0700\nS/O: 84yo Russian speaking woman with hx DM, HTN and anemia who presented to ED from PMD's office with report of generalized weakness and HCT 17. LBM was but pt. did not observe.\nVSS in EW. HCT 20. recv'd 2UPRBC, 1.5L NS. foley placed. no c/o pain, N/V. lavage was negative. rectal exam was guiac pos. INR 2.6- Vit K+ sc. neg. trop and urine neg per report.\n\nArrived to CCU ~ 2100 accomp. by daughter who assisted with translation. pt. lives alone with senior housing, has VNA ~ 1x/month.\n\nCV: HR 80-100 Afib. no VEA. BP 139/75-167/63. all cardiac meds are being held for now. lytes WNL.\ndenies CP/SOB.\nGI: no stool. ABD soft, NT. pos. BS. HCT 25.5 on admit to CCU. 25.6 at 0200. 0600 HCT is pnd with AM labs.\nprotonix IV q12hours. NPO except small amt. ice. plan for endoscopy for .\n\nGU: foley. u/o ~ 100cc/hr. neg. 1.8L LOS.\nID: TM 99.6 -99.4po. WBC 9.2. urine neg. per report.\nNeuro: pt. is A/O x3 per daughter who is translating. pt. is able to understand limited english. denies pain. able to make needs known. daughter Gen went home but is expected back early this AM to help with translation throughout the day.\n\nendo: FS 180- covered with SSRI.\n\nA/P: HCTs q4hr. plan for endoscopy today. GI to consult. monitor VSS - Hx HTN. daughter states baseline BP ~ 140's/.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-02-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 946717,\n \"text\": \" 11:36 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: pls eval for PNA, particularly at L base\\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with recent Hct drop, with crackles at L base, question of\\n PNA\\n REASON FOR THIS EXAMINATION:\\n pls eval for PNA, particularly at L base\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left base crackles.\\n\\n Comparison is made to prior radiograph dated .\\n\\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH\\n\\n There is grossly unchanged appearance to elevation of the left hemidiaphragm,\\n likely indicating underlying atelectasis with no definite parenchymal\\n consolidation identified bilaterally. There are probably small bilateral\\n pleural effusions. Cardiomediastinal silhouette is grossly unchanged with\\n unchanged appearance to mild bilateral hilar fullness and interstitial edema.\\n\\n IMPRESSION:\\n\\n 1. Grossly unchanged appearance of the interstitial edema and left basal\\n atelectasis. No definite evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-02-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 946659,\n \"text\": \" 3:51 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: nausea gi bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with\\n REASON FOR THIS EXAMINATION:\\n nausea gi bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old female with nausea and gastrointestinal bleed.\\n\\n COMPARISON: None.\\n\\n AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is upper limits of\\n normal. The mediastinal contours are within normal limits allowing for\\n patient position. There is bilateral hilar fullness, with pulmonary vascular\\n redistribution. The lungs are otherwise clear without consolidations or\\n effusions. There are degenerative changes along the thoracic spine.\\n\\n IMPRESSION: Findings consistent with mild volume overload/pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-02-11 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 947125,\n \"text\": \" 4:58 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o infiltrate, pna\\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with recent Hct drop, with crackles at L base, question of\\n PNA\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST FROM \\n\\n HISTORY: Recent hematocrit drop, crackles at the lung bases.\\n\\n IMPRESSION: PA and lateral chest compared to :\\n\\n Borderline cardiomegaly unchanged. Lungs clear. Small right pleural effusion\\n stable. Granulomatous lymph node calcifications noted in the mediastinum. No\\n pulmonary edema or focal pulmonary abnormality of concern.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-02-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 946855,\n \"text\": \" 6:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for free air under diaphragm\\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with abdominal pain. discomfort, s/p endoscopy,\\n nontender exam\\n REASON FOR THIS EXAMINATION:\\n evaluate for free air under diaphragm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 84-year-old woman with abdominal pain status post endoscopy.\\n Question free air.\\n\\n CHEST, AP VIEW: Comparison is made to earlier on the same day. Cardiac and\\n mediastinal contours are unchanged. Diffuse interstitial abnormality is not\\n significantly changed. There is right basilar atelectasis and a probable\\n effusion, probably unchanged, allowing for differences in technique. There is\\n no evidence of free air.\\n\\n IMPRESSION: No evidence of free air. Stable interstitial abnormality,\\n perhaps edema.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272162,\n \"text\": \"Atrial fibrillation, average ventricular rate 89. Compared to the previous\\ntracing the ventricular rate is somewhat reduced. Otherwise, no major change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272163,\n \"text\": \"Atrial fibrillation, average ventricular rate 105. Non-diagnostic\\nrepolarization abnormalities. Compared to the previous tracing of no\\nmajor change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490977,\n \"text\": \"CCU NPN 1900-0700\\nS/O: 84yo Russian speaking woman with hx DM, HTN and anemia who presented to ED from PMD's office with report of generalized weakness and HCT 17. LBM was but pt. did not observe.\\nVSS in EW. HCT 20. recv'd 2UPRBC, 1.5L NS. foley placed. no c/o pain, N/V. lavage was negative. rectal exam was guiac pos. INR 2.6- Vit K+ sc. neg. trop and urine neg per report.\\n\\nArrived to CCU ~ 2100 accomp. by daughter who assisted with translation. pt. lives alone with senior housing, has VNA ~ 1x/month.\\n\\nCV: HR 80-100 Afib. no VEA. BP 139/75-167/63. all cardiac meds are being held for now. lytes WNL.\\ndenies CP/SOB.\\nGI: no stool. ABD soft, NT. pos. BS. HCT 25.5 on admit to CCU. 25.6 at 0200. 0600 HCT is pnd with AM labs.\\nprotonix IV q12hours. NPO except small amt. ice. plan for endoscopy for .\\n\\nGU: foley. u/o ~ 100cc/hr. neg. 1.8L LOS.\\nID: TM 99.6 -99.4po. WBC 9.2. urine neg. per report.\\nNeuro: pt. is A/O x3 per daughter who is translating. pt. is able to understand limited english. denies pain. able to make needs known. daughter Gen went home but is expected back early this AM to help with translation throughout the day.\\n\\nendo: FS 180- covered with SSRI.\\n\\nA/P: HCTs q4hr. plan for endoscopy today. GI to consult. monitor VSS - Hx HTN. daughter states baseline BP ~ 140's/.\\n\"\n }\n]"}}},{"rowIdx":297,"cells":{"subject_id":{"kind":"number","value":99268,"string":"99,268"},"hadm_id":{"kind":"number","value":197102,"string":"197,102"},"target_text":{"kind":"string","value":"59 year old female with a history of metastatic breast CA presenting with complaints of HA and confusion, found to have a frontal mass with vasogeneic edema and mass effect on MRI. . # Brain mass: Initial neurosurgery assessment in the ED was that the patient's condition was not a surgical emergency but needed oncological staging work up first. She was started on dexamethasone and keppra. MRI revealed a solitary peripheral right frontal lobe mass with extensive vasogenic edema and mass effect. After further discussion between the oncology, neuro-oncology, and neurosurgery services, the patient was felt to be a surgical candidate, and was transferred to the neurosurgery service. She went to the operating room on . . # Breast Cancer: Per the patient's primary oncologist, the patient's capecitabine was held, as the acute surgical issues were being addressed. On she underwent MRI wand study for intraop image guidance and was taken to the OR where under general anesthesia she underwent right frontal craniotomy with excision of mass. She tolerated this well, was extubated and transferred to ICU for close monitoring. She woke up slowly and head CT was done which showed good post op appearance with no hemorrhage but slight edema. She was neurologically intact. On POD#1 she was transferred to the floor, diet and activity were advanced. Incision was clean and dry. A slow steroid taper was begun. She was transferred to the floor. Her wound was clean and dry. She remained neurologically intact.:physical therapy evaluated the patient and felt that she needed one more day of acute physical therapy. : The patient was seen by physical therapy and was given a walker for ambulation to assist in balance and energy conservation. The patient will be sent home with physical therapy and directions to ambulate with the walker at all times. On , the patient is looking forward to discharge. The patient husband is at the bedside. The patient is neurologically stable, ambulating with a walker, oriented to person place and time."},"extractive_notes_summ":{"kind":"string","value":"HEAD CT WITHOUT IV CONTRAST: There has been right frontal craniectomy, with resection of a mass in the right frontal lobe. UA negative .Cefzol preop Lines / Tubes / Drains:RIJ/left a line/PIV Wounds: Imaging:CT Fluids:NS Consults:neurosurg Billing Diagnosis: Prophylaxis: DVT:SCD Stress ulcer:PPI VAP bundle: + Comments: Communication:Comments: Code status:FULL Disposition:SICU Time spent: 35 ICU Care Lines: Multi Lumen - 12:21 AM Arterial Line - 12:30 AM 20 Gauge - 02:08 AM 18 Gauge - 02:15 AM Total time spent: UA negative .Cefzol preop Lines / Tubes / Drains:RIJ/left a line/PIV Wounds: Imaging:CT Fluids:NS Consults:neurosurg Billing Diagnosis: Prophylaxis: DVT:SCD Stress ulcer:PPI VAP bundle: + Comments: Communication:Comments: Code status:FULL Disposition:SICU Time spent: 35 ICU Care Lines: Multi Lumen - 12:21 AM Arterial Line - 12:30 AM 20 Gauge - 02:08 AM 18 Gauge - 02:15 AM Total time spent: FINAL REPORT INDICATION: Right frontal lesion, status post resection, to evaluate for postop/residual tumor. Cancer (Malignant Neoplasm), Brain Assessment: Pt s/p right frontal crani for Brain Mass Pt with PMH of systemic Breat CA metastatis Arrived to sicu with anesthesia Goal SBP <140 Pt arrived only following commands on right None verbal but appearing like she may be trying to talk Concern for possible SZ activity Pt was loaded with Dilantin prior to SICU arrival Q1hr neuro Action: STAT head CT done CT scan okay MD but noted much swelling Response: MD pt given 10mg decadron Pt was going to get additional Dilantin but Neurology resident that has been following pt came into MD request and felt that pt was jittery and with Nystagmus related to Dilantin and MD he did not feel like she was SZing just a reaction to too much Dilantin. Subsequent work up revealed esophageal metastasis for which she received radiation Surgery / Procedure and date: Right frontal Craniotomy for Brain Mass Latest Vital Signs and I/O Non-invasive BP: S:113 D:57 Temperature: 98 Arterial BP: S:119 D:62 Respiratory rate: 15 insp/min Heart Rate: 80 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 97% % O2 flow: 3 L/min FiO2 set: 24h total in: 2,844 mL 24h total out: 4,460 mL Pertinent Lab Results: Sodium: 133 mEq/L 02:17 AM Potassium: 3.8 mEq/L 02:17 AM Chloride: 101 mEq/L 02:17 AM CO2: 20 mEq/L 02:17 AM BUN: 19 mg/dL 02:17 AM Creatinine: 1.1 mg/dL 02:17 AM Glucose: 303 mg/dL 02:17 AM Hematocrit: 34.8 % 02:17 AM Finger Stick Glucose: 220 08:00 AM Valuables / Signature Patient valuables: Other valuables: OR holding. Post-surgical changes along with hemorrhage in the surgical resection cavity and significant mass effect on the right lateral ventricle and leftward shift of the midline structures, the latter not significantly changed compared (Over) 9:35 PM MR HEAD W & W/O CONTRAST Clip # Reason: 59 year old woman with s/p right fronatl resection, please c Admitting Diagnosis: BRAIN MASS Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) to the prior study."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2117-12-24 00:00:00.000","description":"Nursing Progress Note","row_id":610486,"text":"Cancer (Malignant Neoplasm), Brain\n Assessment:\n Pt s/p right frontal crani for Brain Mass\n Pt with PMH of systemic Breat CA metastatis\n Arrived to sicu with anesthesia\n Goal SBP <140\n Pt arrived only following commands on right\n None verbal but appearing like she may be trying to talk\n Concern for possible SZ activity\n Pt was loaded with Dilantin prior to SICU arrival\n Q1hr neuro\n Action:\n STAT head CT done\n CT scan okay MD but noted much swelling\n Response:\n MD pt given 10mg decadron\n Pt was going to get additional Dilantin but Neurology\n resident that has been following pt came into MD request\n and felt that pt was jittery and with Nystagmus related to Dilantin and\n MD he did not feel like she was SZing just a reaction to too much\n Dilantin. Keppra dose increased\n Starting in CT scan pt moving left side more\n Between am pt was MAE R>L alert and oriented X3\n Pt with soft voice chemo for esophageal CA which was\n diagnosed in 07\n Plan:\n Repeat CT scan possibly today\n Q1 hr neuro until 24hr post op\n Cont to monitor pain and MS \n Cont with current plan of care\n"},{"category":"Physician ","chartdate":"2117-12-24 00:00:00.000","description":"Intensivist Note","row_id":610516,"text":"SICU\n HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\n chemotherapy, now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is\n currently on Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass.\n Oncologist is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 02:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.6\nC (96.1\n T current: 35.6\nC (96.1\n HR: 65 (64 - 87) bpm\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\n RR: 14 (13 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 121 mL\n PO:\n Tube feeding:\n IV Fluid:\n 121 mL\n Blood products:\n Total out:\n 0 mL\n 3,210 mL\n Urine:\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,089 mL\n Respiratory support\n SPO2: 100%\n ABG: 7.40/36/120//-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\n stimuli), moves R>L\n Labs / Radiology\n [image002.jpg]\n 02:25 AM\n TCO2\n 23\n Assessment and Plan\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\n ,metastatic breast ca\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\n ,. Decrease dex\n Cardiovascular:goal SBP 140-160\n Pulmonary:FM\n Gastrointestinal / Abdomen:NPO ,PPI\n Nutrition:NPO\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\n Hematology:EBL 200 ,F/UP HCT\n Endocrine:\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\n Lines / Tubes / Drains:RIJ/left a line/PIV\n Wounds:\n Imaging:CT\n Fluids:NS\n Consults:neurosurg\n Billing Diagnosis:\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Lines:\n Multi Lumen - 12:21 AM\n Arterial Line - 12:30 AM\n 20 Gauge - 02:08 AM\n 18 Gauge - 02:15 AM\n Total time spent:\n"},{"category":"Nursing","chartdate":"2117-12-24 00:00:00.000","description":"Nursing Transfer Note","row_id":610530,"text":"HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\n now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\n Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass. Oncologist\n is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Cancer (Malignant Neoplasm), Brain\n Assessment:\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\n Original OR dsg dry and intact,\n Action:\n q 1 hour neuro checks changed to q 2,\n given morphine 2 mg IV prn pain,\n turned and repositioned for comfort.\n started on regular diet,\n Response:\n neuro status unchanged.\n Plan:\n transfer to 11.\n"},{"category":"Nursing","chartdate":"2117-12-24 00:00:00.000","description":"Nursing Transfer Note","row_id":610536,"text":"HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\n now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\n Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass. Oncologist\n is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Cancer (Malignant Neoplasm), Brain\n Assessment:\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\n Original OR dsg dry and intact,\n Action:\n q 1 hour neuro checks changed to q 2,\n given morphine 2 mg IV prn pain,\n turned and repositioned for comfort.\n started on regular diet,\n Response:\n neuro status unchanged.\n Plan:\n transfer to 11.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n BRAIN MASS\n Code status:\n Height:\n Admission weight:\n 90 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Migraines, systemic metastatic Breast CA initially\n presented in she had a left mastectomy and Chemo with 5yrs of\n Tamoxifen. She was well untill when she developed a cough and a\n chest Xray showed a shadow. Biopsy showed adenocarcinoma treated with\n Faslodex. Subsequent work up revealed esophageal metastasis for which\n she received radiation\n Surgery / Procedure and date: Right frontal Craniotomy for Brain\n Mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:57\n Temperature:\n 98\n Arterial BP:\n S:119\n D:62\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,844 mL\n 24h total out:\n 4,460 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 02:17 AM\n Potassium:\n 3.8 mEq/L\n 02:17 AM\n Chloride:\n 101 mEq/L\n 02:17 AM\n CO2:\n 20 mEq/L\n 02:17 AM\n BUN:\n 19 mg/dL\n 02:17 AM\n Creatinine:\n 1.1 mg/dL\n 02:17 AM\n Glucose:\n 303 mg/dL\n 02:17 AM\n Hematocrit:\n 34.8 %\n 02:17 AM\n Finger Stick Glucose:\n 220\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: OR holding.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 11\n Date & time of Transfer: 12:00 AM\n"},{"category":"Physician ","chartdate":"2117-12-24 00:00:00.000","description":"Intensivist Note","row_id":610475,"text":"SICU\n HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\n chemotherapy, now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is\n currently on Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass.\n Oncologist is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read pending.edema +\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 02:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.6\nC (96.1\n T current: 35.6\nC (96.1\n HR: 65 (64 - 87) bpm\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\n RR: 14 (13 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 121 mL\n PO:\n Tube feeding:\n IV Fluid:\n 121 mL\n Blood products:\n Total out:\n 0 mL\n 3,210 mL\n Urine:\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,089 mL\n Respiratory support\n SPO2: 100%\n ABG: 7.40/36/120//-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\n stimuli), moves R>L\n Labs / Radiology\n [image002.jpg]\n 02:25 AM\n TCO2\n 23\n Assessment and Plan\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\n ,metastatic breast ca\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\n Cardiovascular:goal SBP 140-160\n Pulmonary:FM\n Gastrointestinal / Abdomen:NPO ,PPI\n Nutrition:NPO\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\n Hematology:EBL 200 ,F/UP HCT\n Endocrine:\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\n Lines / Tubes / Drains:RIJ/left a line/PIV\n Wounds:\n Imaging:CT\n Fluids:NS\n Consults:neurosurg\n Billing Diagnosis:\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Lines:\n Multi Lumen - 12:21 AM\n Arterial Line - 12:30 AM\n 20 Gauge - 02:08 AM\n 18 Gauge - 02:15 AM\n Total time spent:\n"},{"category":"Radiology","chartdate":"2117-12-21 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1112367,"text":" 3:45 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o mets\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with met breast cancer with new onset of headaches, nausea,\n dizziness and confusion\n REASON FOR THIS EXAMINATION:\n r/o mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Brain MRI.\n\n HISTORY: 59-year-old female with metastatic breast cancer presents with new\n onset of headaches and confusion.\n\n COMPARISON: No prior brain imaging.\n\n TECHNIQUE: Sagittal T1, axial pre- and post-gadolinium T1, T2 FSE, T2 FLAIR,\n T2 GRE, diffusion, sagittal post-gadolinium MP-RAGE with axial and coronal\n reformatted sequences of the brain were obtained.\n\n FINDINGS: There is a heterogeneously enhancing 2.6 x 3.0 mass within the\n right frontal lobe. There is extensive vasogenic edema extending into the\n corpus callosum. There is approximately 15 mm of leftward shift of midline\n structures. There is no significant associated restricted diffusion. No\n additional enhancing lesions are identified. There are scattered subcortical\n T2 hyperintensities, which may reflect microvascular disease. Bone marrow\n signal is lower than expected on T1-weighted sequences, without focal\n abnormality. There is no hydrocephalus.\n\n IMPRESSION: Solitary peripheral right frontal lobe mass with extensive\n vasogenic edema and mass effect. Given the patient's history, this is\n concerning for a metastatic tumor, though a primary brain tumor cannot be\n excluded.\n\n The findings were discussed with Dr. immediately upon termination\n of the examination, at 17:00 hours on . Plans were made to\n transfer the patient to the emergency department.\n\n"},{"category":"Radiology","chartdate":"2117-12-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1112714,"text":" 1:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P RESECTION\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with R frontal crani, tumor resection from breast primary.\n REASON FOR THIS EXAMINATION:\n please eval for post op hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 3:24 AM\n No post-operative hemorrhage, continued left 8mm subfalcine herniation. Post-\n operative pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 59-year-old female with right frontal craniectomy, tumor resection\n for breast primary. Evaluate for postoperative hemorrhage.\n\n COMPARISON: MRI performed one day prior.\n\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\n vertex without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There has been right frontal craniectomy, with\n resection of a mass in the right frontal lobe. There is expected\n pneumocephalus, as well as edema in the postoperative site. There has been no\n significant degree of hemorrhage. However, the right lateral ventricle\n remains compressed, and there is again shift of midline structures to the\n right of approximately 9 mm, which is similar to the preoperative study\n . No other site of hemorrhage is identified. There is no evidence of\n transtentorial herniation. Osseous structures and soft tissues elsewhere\n appear unremarkable.\n\n IMPRESSION:\n 1. Status post right frontal craniectomy with expected edema in the\n postoperative site and continued subfalcine herniation of approximately 8 mm.\n 2. No unexpected postoperative hemorrhage.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2117-12-24 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1112715,"text":" 1:38 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: RIJ position\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right frontal craniotomy\n REASON FOR THIS EXAMINATION:\n RIJ position\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Right frontal craniotomy, assess for right IJ position.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax or pleural\n effusion. Cardiomediastinal contours are unchanged. Patient has known\n mediastinal lymphadenopathy including a large calcified lymph node in the AP\n window. The lungs are clear.\n\n\n"},{"category":"Radiology","chartdate":"2117-12-23 00:00:00.000","description":"MR HEAD W/ CONTRAST","row_id":1112663,"text":" 3:10 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: Surgical planning for \n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right frontal lesion, please do on at 3pm\n for or 5PM\n REASON FOR THIS EXAMINATION:\n Surgical planning for \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right frontal lesion. Presurgical planning.\n\n COMPARISON: MRI of the brain from .\n\n TECHNIQUE: Post-contrast axial MP-RAGE with coronal and sagittal reformats;\n and axial, coronal, and sagittal T1 post-contrast images of the brain were\n obtained.\n\n LIMITED POST-CONTRAST MRI OF THE BRAIN: There has been no significant change\n compared to two days prior. Again seen is a heterogeneously enhancing mass in\n the right frontal lobe measuring 1.9 cm AP x 2.6 cm TRV x 2.4 cm SI. There is\n again extensive vasogenic edema extending into the corpus callosum and\n approximately 12 mm of leftward midline shift. The right lateral ventricle is\n effaced. No additional enhancing lesions are identified. No hydrocephalus.\n\n IMPRESSION: Redemonstration of solitary right frontal mass with extensive\n vasogenic edema and mass effect with leftward midline shift. No change from 2\n days prior. Please refer to detailed report of the complete MRI from\n .\n\n"},{"category":"Radiology","chartdate":"2117-12-25 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1112956,"text":" 9:35 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 59 year old woman with s/p right fronatl resection, please c\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with s/p right fronatl resection, please check post op for\n residual\n REASON FOR THIS EXAMINATION:\n 59 year old woman with s/p right fronatl resection, please check post op for\n residual\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SUN 9:57 AM\n Post-surgical changes and hemorrhage in the surgical resection bed;\n significant surroudning edema, mass effect on the lateral ventricles and\n leftward subfalcine herniation by 9mm- not significantly changed; at risk for\n ACA involvement- continued close f/u with CT Head as clinically indicated.\n Residual tumor not adequately assessed given the hemorrhage in the resection\n bed. F/u.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right frontal lesion, status post resection, to evaluate for\n postop/residual tumor.\n\n COMPARISON: MR of the head done on and 17/09.\n\n TECHNIQUE: MR of the head without and with contrast.\n\n FINDINGS:\n\n There is evidence of craniotomy on the right side, in the frontal and the\n parietal regions, with post-surgical changes. Areas of blood\n products/hemorrhage are noted in the surgical resection cavity with a fluid\n level. There is significant vasogenic edema and mass effect on the frontal\n of the right lateral ventricle and mass effect on the right lateral\n ventricle, and mild shift of the midline structures to the left side by 9 mm,\n representing subfalcine herniation. There is no significant change in the\n mass effect compared to the prior study. A few small scattered FLAIR\n hyperintense foci are noted in the cerebral white matter, elsewhere, likely\n related to small vessel ischemic changes.\n\n On the post-contrast images, there is mild enhancement in the periphery of the\n hemahorrhagic focus as well as in the adjacent dura, at the surgical resection\n site. However, evaluation for residual tumor is limited due to the presence\n of pre-contrast T1 hyperintense appearance of the areas of hemorrhage.\n\n IMPRESSION:\n 1. Post-surgical changes along with hemorrhage in the surgical resection\n cavity and significant mass effect on the right lateral ventricle and leftward\n shift of the midline structures, the latter not significantly changed compared\n (Over)\n\n 9:35 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 59 year old woman with s/p right fronatl resection, please c\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to the prior study.\n\n Evaluation for residual tumor is limited on the present study. Consider\n followup, after resolution of the post-surgical changes, to assess for\n residual tumor.\n\n Close followup with CT head to assess for interval change in the mass effect,\n as clinically indicated.\n\n"},{"category":"Radiology","chartdate":"2117-12-22 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1112531,"text":" 9:21 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BRAIN MASS\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with metastatic breast ca and new brain met. needs pre-op\n chest xray.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old female with metastatic breast cancer and new brain\n metastasis. Preoperative radiograph.\n\n COMPARISON: Head CT .\n\n TWO VIEWS OF THE CHEST: The cardiomediastinal contour is normal. The heart\n is not enlarged. The lungs are clear. A calcified aorticopulmonary window\n node is seen projecting over the left mediastinum. Osseous structures and\n soft tissues appear unremarkable.\n\n IMPRESSION: No evidence of acute process.\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 610486,\n \"text\": \"Cancer (Malignant Neoplasm), Brain\\n Assessment:\\n Pt s/p right frontal crani for Brain Mass\\n Pt with PMH of systemic Breat CA metastatis\\n Arrived to sicu with anesthesia\\n Goal SBP <140\\n Pt arrived only following commands on right\\n None verbal but appearing like she may be trying to talk\\n Concern for possible SZ activity\\n Pt was loaded with Dilantin prior to SICU arrival\\n Q1hr neuro\\n Action:\\n STAT head CT done\\n CT scan okay MD but noted much swelling\\n Response:\\n MD pt given 10mg decadron\\n Pt was going to get additional Dilantin but Neurology\\n resident that has been following pt came into MD request\\n and felt that pt was jittery and with Nystagmus related to Dilantin and\\n MD he did not feel like she was SZing just a reaction to too much\\n Dilantin. Keppra dose increased\\n Starting in CT scan pt moving left side more\\n Between am pt was MAE R>L alert and oriented X3\\n Pt with soft voice chemo for esophageal CA which was\\n diagnosed in 07\\n Plan:\\n Repeat CT scan possibly today\\n Q1 hr neuro until 24hr post op\\n Cont to monitor pain and MS \\n Cont with current plan of care\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 610516,\n \"text\": \"SICU\\n HPI:\\n Ms. is a 59yo right handed woman with metastatic breast cancer\\n on xeloda now presenting with headache, found to have right frontal\\n brain mass on MRI\\n Chief complaint:\\n presenting with headache\\n PMHx:\\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\\n chemotherapy, now complicated by esophageal mets and right\\n mainstem bronchus mets, s/p mediastinal radiation. She is\\n currently on Xeloda (capecitabine) oral therapy that she takes\\n . PET from with new FDG avid adrenal mass.\\n Oncologist is Dr. at .\\n 2) ? Aura without migraine-\\n 3) UTI\\n Past Surgical History: None other than her left lumpectomy,\\n esophageal biopsy, and transbronchial biopsy\\n Current medications:\\n :\\n Xeloda PO BID\\n Bactrim (started a few days ago by her PCP)\\n Omeprazole 20mg daily\\n 24 Hour Events:\\n s/p right frontal craniotomy for tumor resection .\\n CT post op final read -.edema +\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 02:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 35.6\\nC (96.1\\n T current: 35.6\\nC (96.1\\n HR: 65 (64 - 87) bpm\\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\\n RR: 14 (13 - 20) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 121 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 121 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 3,210 mL\\n Urine:\\n 1,010 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -3,089 mL\\n Respiratory support\\n SPO2: 100%\\n ABG: 7.40/36/120//-1\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\\n stimuli), moves R>L\\n Labs / Radiology\\n [image002.jpg]\\n 02:25 AM\\n TCO2\\n 23\\n Assessment and Plan\\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\\n ,metastatic breast ca\\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\\n ,. Decrease dex\\n Cardiovascular:goal SBP 140-160\\n Pulmonary:FM\\n Gastrointestinal / Abdomen:NPO ,PPI\\n Nutrition:NPO\\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\\n Hematology:EBL 200 ,F/UP HCT\\n Endocrine:\\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\\n Lines / Tubes / Drains:RIJ/left a line/PIV\\n Wounds:\\n Imaging:CT\\n Fluids:NS\\n Consults:neurosurg\\n Billing Diagnosis:\\n Prophylaxis:\\n DVT:SCD\\n Stress ulcer:PPI\\n VAP bundle: +\\n Comments:\\n Communication:Comments:\\n Code status:FULL\\n Disposition:SICU\\n Time spent: 35\\n ICU Care\\n Lines:\\n Multi Lumen - 12:21 AM\\n Arterial Line - 12:30 AM\\n 20 Gauge - 02:08 AM\\n 18 Gauge - 02:15 AM\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 610530,\n \"text\": \"HPI:\\n Ms. is a 59yo right handed woman with metastatic breast cancer\\n on xeloda now presenting with headache, found to have right frontal\\n brain mass on MRI\\n Chief complaint:\\n presenting with headache\\n PMHx:\\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\\n now complicated by esophageal mets and right\\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\\n Xeloda (capecitabine) oral therapy that she takes\\n . PET from with new FDG avid adrenal mass. Oncologist\\n is Dr. at .\\n 2) ? Aura without migraine-\\n 3) UTI\\n Past Surgical History: None other than her left lumpectomy,\\n esophageal biopsy, and transbronchial biopsy\\n Current medications:\\n :\\n Xeloda PO BID\\n Bactrim (started a few days ago by her PCP)\\n Omeprazole 20mg daily\\n 24 Hour Events:\\n s/p right frontal craniotomy for tumor resection .\\n CT post op final read -.edema +\\n Cancer (Malignant Neoplasm), Brain\\n Assessment:\\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\\n Original OR dsg dry and intact,\\n Action:\\n q 1 hour neuro checks changed to q 2,\\n given morphine 2 mg IV prn pain,\\n turned and repositioned for comfort.\\n started on regular diet,\\n Response:\\n neuro status unchanged.\\n Plan:\\n transfer to 11.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 610536,\n \"text\": \"HPI:\\n Ms. is a 59yo right handed woman with metastatic breast cancer\\n on xeloda now presenting with headache, found to have right frontal\\n brain mass on MRI\\n Chief complaint:\\n presenting with headache\\n PMHx:\\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\\n now complicated by esophageal mets and right\\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\\n Xeloda (capecitabine) oral therapy that she takes\\n . PET from with new FDG avid adrenal mass. Oncologist\\n is Dr. at .\\n 2) ? Aura without migraine-\\n 3) UTI\\n Past Surgical History: None other than her left lumpectomy,\\n esophageal biopsy, and transbronchial biopsy\\n Current medications:\\n :\\n Xeloda PO BID\\n Bactrim (started a few days ago by her PCP)\\n Omeprazole 20mg daily\\n 24 Hour Events:\\n s/p right frontal craniotomy for tumor resection .\\n CT post op final read -.edema +\\n Cancer (Malignant Neoplasm), Brain\\n Assessment:\\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\\n Original OR dsg dry and intact,\\n Action:\\n q 1 hour neuro checks changed to q 2,\\n given morphine 2 mg IV prn pain,\\n turned and repositioned for comfort.\\n started on regular diet,\\n Response:\\n neuro status unchanged.\\n Plan:\\n transfer to 11.\\n Demographics\\n Attending MD:\\n W.\\n Admit diagnosis:\\n BRAIN MASS\\n Code status:\\n Height:\\n Admission weight:\\n 90 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Migraines, systemic metastatic Breast CA initially\\n presented in she had a left mastectomy and Chemo with 5yrs of\\n Tamoxifen. She was well untill when she developed a cough and a\\n chest Xray showed a shadow. Biopsy showed adenocarcinoma treated with\\n Faslodex. Subsequent work up revealed esophageal metastasis for which\\n she received radiation\\n Surgery / Procedure and date: Right frontal Craniotomy for Brain\\n Mass\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:113\\n D:57\\n Temperature:\\n 98\\n Arterial BP:\\n S:119\\n D:62\\n Respiratory rate:\\n 15 insp/min\\n Heart Rate:\\n 80 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 24h total in:\\n 2,844 mL\\n 24h total out:\\n 4,460 mL\\n Pertinent Lab Results:\\n Sodium:\\n 133 mEq/L\\n 02:17 AM\\n Potassium:\\n 3.8 mEq/L\\n 02:17 AM\\n Chloride:\\n 101 mEq/L\\n 02:17 AM\\n CO2:\\n 20 mEq/L\\n 02:17 AM\\n BUN:\\n 19 mg/dL\\n 02:17 AM\\n Creatinine:\\n 1.1 mg/dL\\n 02:17 AM\\n Glucose:\\n 303 mg/dL\\n 02:17 AM\\n Hematocrit:\\n 34.8 %\\n 02:17 AM\\n Finger Stick Glucose:\\n 220\\n 08:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables: OR holding.\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: SICU A\\n Transferred to: 11\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 610475,\n \"text\": \"SICU\\n HPI:\\n Ms. is a 59yo right handed woman with metastatic breast cancer\\n on xeloda now presenting with headache, found to have right frontal\\n brain mass on MRI\\n Chief complaint:\\n presenting with headache\\n PMHx:\\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\\n chemotherapy, now complicated by esophageal mets and right\\n mainstem bronchus mets, s/p mediastinal radiation. She is\\n currently on Xeloda (capecitabine) oral therapy that she takes\\n . PET from with new FDG avid adrenal mass.\\n Oncologist is Dr. at .\\n 2) ? Aura without migraine-\\n 3) UTI\\n Past Surgical History: None other than her left lumpectomy,\\n esophageal biopsy, and transbronchial biopsy\\n Current medications:\\n :\\n Xeloda PO BID\\n Bactrim (started a few days ago by her PCP)\\n Omeprazole 20mg daily\\n 24 Hour Events:\\n s/p right frontal craniotomy for tumor resection .\\n CT post op final read pending.edema +\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 02:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 35.6\\nC (96.1\\n T current: 35.6\\nC (96.1\\n HR: 65 (64 - 87) bpm\\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\\n RR: 14 (13 - 20) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 121 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 121 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 3,210 mL\\n Urine:\\n 1,010 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -3,089 mL\\n Respiratory support\\n SPO2: 100%\\n ABG: 7.40/36/120//-1\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft\\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\\n stimuli), moves R>L\\n Labs / Radiology\\n [image002.jpg]\\n 02:25 AM\\n TCO2\\n 23\\n Assessment and Plan\\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\\n ,metastatic breast ca\\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\\n Cardiovascular:goal SBP 140-160\\n Pulmonary:FM\\n Gastrointestinal / Abdomen:NPO ,PPI\\n Nutrition:NPO\\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\\n Hematology:EBL 200 ,F/UP HCT\\n Endocrine:\\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\\n Lines / Tubes / Drains:RIJ/left a line/PIV\\n Wounds:\\n Imaging:CT\\n Fluids:NS\\n Consults:neurosurg\\n Billing Diagnosis:\\n Prophylaxis:\\n DVT:SCD\\n Stress ulcer:PPI\\n VAP bundle: +\\n Comments:\\n Communication:Comments:\\n Code status:FULL\\n Disposition:SICU\\n Time spent: 35\\n ICU Care\\n Lines:\\n Multi Lumen - 12:21 AM\\n Arterial Line - 12:30 AM\\n 20 Gauge - 02:08 AM\\n 18 Gauge - 02:15 AM\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-21 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1112367,\n \"text\": \" 3:45 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: r/o mets\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with met breast cancer with new onset of headaches, nausea,\\n dizziness and confusion\\n REASON FOR THIS EXAMINATION:\\n r/o mets\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Brain MRI.\\n\\n HISTORY: 59-year-old female with metastatic breast cancer presents with new\\n onset of headaches and confusion.\\n\\n COMPARISON: No prior brain imaging.\\n\\n TECHNIQUE: Sagittal T1, axial pre- and post-gadolinium T1, T2 FSE, T2 FLAIR,\\n T2 GRE, diffusion, sagittal post-gadolinium MP-RAGE with axial and coronal\\n reformatted sequences of the brain were obtained.\\n\\n FINDINGS: There is a heterogeneously enhancing 2.6 x 3.0 mass within the\\n right frontal lobe. There is extensive vasogenic edema extending into the\\n corpus callosum. There is approximately 15 mm of leftward shift of midline\\n structures. There is no significant associated restricted diffusion. No\\n additional enhancing lesions are identified. There are scattered subcortical\\n T2 hyperintensities, which may reflect microvascular disease. Bone marrow\\n signal is lower than expected on T1-weighted sequences, without focal\\n abnormality. There is no hydrocephalus.\\n\\n IMPRESSION: Solitary peripheral right frontal lobe mass with extensive\\n vasogenic edema and mass effect. Given the patient's history, this is\\n concerning for a metastatic tumor, though a primary brain tumor cannot be\\n excluded.\\n\\n The findings were discussed with Dr. immediately upon termination\\n of the examination, at 17:00 hours on . Plans were made to\\n transfer the patient to the emergency department.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1112714,\n \"text\": \" 1:04 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: S/P RESECTION\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with R frontal crani, tumor resection from breast primary.\\n REASON FOR THIS EXAMINATION:\\n please eval for post op hemorrhage.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RSRc FRI 3:24 AM\\n No post-operative hemorrhage, continued left 8mm subfalcine herniation. Post-\\n operative pneumocephalus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 59-year-old female with right frontal craniectomy, tumor resection\\n for breast primary. Evaluate for postoperative hemorrhage.\\n\\n COMPARISON: MRI performed one day prior.\\n\\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\\n vertex without IV contrast.\\n\\n HEAD CT WITHOUT IV CONTRAST: There has been right frontal craniectomy, with\\n resection of a mass in the right frontal lobe. There is expected\\n pneumocephalus, as well as edema in the postoperative site. There has been no\\n significant degree of hemorrhage. However, the right lateral ventricle\\n remains compressed, and there is again shift of midline structures to the\\n right of approximately 9 mm, which is similar to the preoperative study\\n . No other site of hemorrhage is identified. There is no evidence of\\n transtentorial herniation. Osseous structures and soft tissues elsewhere\\n appear unremarkable.\\n\\n IMPRESSION:\\n 1. Status post right frontal craniectomy with expected edema in the\\n postoperative site and continued subfalcine herniation of approximately 8 mm.\\n 2. No unexpected postoperative hemorrhage.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-24 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1112715,\n \"text\": \" 1:38 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: RIJ position\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with right frontal craniotomy\\n REASON FOR THIS EXAMINATION:\\n RIJ position\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Right frontal craniotomy, assess for right IJ position.\\n\\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax or pleural\\n effusion. Cardiomediastinal contours are unchanged. Patient has known\\n mediastinal lymphadenopathy including a large calcified lymph node in the AP\\n window. The lungs are clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-23 00:00:00.000\",\n \"description\": \"MR HEAD W/ CONTRAST\",\n \"row_id\": 1112663,\n \"text\": \" 3:10 PM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: Surgical planning for \\n Admitting Diagnosis: BRAIN MASS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with right frontal lesion, please do on at 3pm\\n for or 5PM\\n REASON FOR THIS EXAMINATION:\\n Surgical planning for \\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right frontal lesion. Presurgical planning.\\n\\n COMPARISON: MRI of the brain from .\\n\\n TECHNIQUE: Post-contrast axial MP-RAGE with coronal and sagittal reformats;\\n and axial, coronal, and sagittal T1 post-contrast images of the brain were\\n obtained.\\n\\n LIMITED POST-CONTRAST MRI OF THE BRAIN: There has been no significant change\\n compared to two days prior. Again seen is a heterogeneously enhancing mass in\\n the right frontal lobe measuring 1.9 cm AP x 2.6 cm TRV x 2.4 cm SI. There is\\n again extensive vasogenic edema extending into the corpus callosum and\\n approximately 12 mm of leftward midline shift. The right lateral ventricle is\\n effaced. No additional enhancing lesions are identified. No hydrocephalus.\\n\\n IMPRESSION: Redemonstration of solitary right frontal mass with extensive\\n vasogenic edema and mass effect with leftward midline shift. No change from 2\\n days prior. Please refer to detailed report of the complete MRI from\\n .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-25 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1112956,\n \"text\": \" 9:35 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: 59 year old woman with s/p right fronatl resection, please c\\n Admitting Diagnosis: BRAIN MASS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with s/p right fronatl resection, please check post op for\\n residual\\n REASON FOR THIS EXAMINATION:\\n 59 year old woman with s/p right fronatl resection, please check post op for\\n residual\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: NPw SUN 9:57 AM\\n Post-surgical changes and hemorrhage in the surgical resection bed;\\n significant surroudning edema, mass effect on the lateral ventricles and\\n leftward subfalcine herniation by 9mm- not significantly changed; at risk for\\n ACA involvement- continued close f/u with CT Head as clinically indicated.\\n Residual tumor not adequately assessed given the hemorrhage in the resection\\n bed. F/u.\\n\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right frontal lesion, status post resection, to evaluate for\\n postop/residual tumor.\\n\\n COMPARISON: MR of the head done on and 17/09.\\n\\n TECHNIQUE: MR of the head without and with contrast.\\n\\n FINDINGS:\\n\\n There is evidence of craniotomy on the right side, in the frontal and the\\n parietal regions, with post-surgical changes. Areas of blood\\n products/hemorrhage are noted in the surgical resection cavity with a fluid\\n level. There is significant vasogenic edema and mass effect on the frontal\\n of the right lateral ventricle and mass effect on the right lateral\\n ventricle, and mild shift of the midline structures to the left side by 9 mm,\\n representing subfalcine herniation. There is no significant change in the\\n mass effect compared to the prior study. A few small scattered FLAIR\\n hyperintense foci are noted in the cerebral white matter, elsewhere, likely\\n related to small vessel ischemic changes.\\n\\n On the post-contrast images, there is mild enhancement in the periphery of the\\n hemahorrhagic focus as well as in the adjacent dura, at the surgical resection\\n site. However, evaluation for residual tumor is limited due to the presence\\n of pre-contrast T1 hyperintense appearance of the areas of hemorrhage.\\n\\n IMPRESSION:\\n 1. Post-surgical changes along with hemorrhage in the surgical resection\\n cavity and significant mass effect on the right lateral ventricle and leftward\\n shift of the midline structures, the latter not significantly changed compared\\n (Over)\\n\\n 9:35 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: 59 year old woman with s/p right fronatl resection, please c\\n Admitting Diagnosis: BRAIN MASS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n to the prior study.\\n\\n Evaluation for residual tumor is limited on the present study. Consider\\n followup, after resolution of the post-surgical changes, to assess for\\n residual tumor.\\n\\n Close followup with CT head to assess for interval change in the mass effect,\\n as clinically indicated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-22 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1112531,\n \"text\": \" 9:21 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: BRAIN MASS\\n Admitting Diagnosis: BRAIN MASS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with metastatic breast ca and new brain met. needs pre-op\\n chest xray.\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 59-year-old female with metastatic breast cancer and new brain\\n metastasis. Preoperative radiograph.\\n\\n COMPARISON: Head CT .\\n\\n TWO VIEWS OF THE CHEST: The cardiomediastinal contour is normal. The heart\\n is not enlarged. The lungs are clear. A calcified aorticopulmonary window\\n node is seen projecting over the left mediastinum. Osseous structures and\\n soft tissues appear unremarkable.\\n\\n IMPRESSION: No evidence of acute process.\\n\\n\"\n }\n]"}}},{"rowIdx":298,"cells":{"subject_id":{"kind":"number","value":56714,"string":"56,714"},"hadm_id":{"kind":"number","value":173051,"string":"173,051"},"target_text":{"kind":"string","value":"48-year-old male with history of type I DM c/b DKA, gastroparesis, neuropathy and retinopathy who presents with DKA. DIABETIC KETOACIDOSIS, TYPE I DIABETES UNCONTROLLED WITH COMPLICATIONS: admitted to ICU and started on an insulin drip. Rehydrated and ACUTE ON CHRONIC RENAL FAILURE improved. He was seen by consult and insulin was transitioned to sc and adjusted. His A1c was noted to be 12.7%. He was discharged home on an increased dose of insulin and adjustments to his sliding scale, and will f/u with his endocrinologist."},"extractive_notes_summ":{"kind":"string","value":"ST-T wave abnormalities. Possible septal myocardialinfarction. Sinus tachycardia. Sinus tachycardia. Sinus rhythm. Since the previous tracing of T waves are more prominenton the present tracing.TRACING #1 Diffuse low amplitude T wavechanges are non-specific. 5:49 AM CT HEAD W/O CONTRAST Clip # Reason: ? Compared to the previous tracing of sinustachycardia is now present and delayed R wave progression pattern is moreprominent. IMPRESSION: No acute intracranial process. Late R wave progression. Delayed R wave progression is non-diagnostic but cannot excludepossible prior anterior myocardial infarction. The cardiomediastinal silhouette, hilar contours and pleural surfaces are normal. Baseline artifact. IMPRESSION: No acute intrathoracic process. 5:51 AM CHEST (PA & LAT) Clip # Reason: ? COMPARISON: Chest radiograph from . Since theprevious tracing T wave abnormalities are more prominent.TRACING #2 ICH, signs of edema No contraindications for IV contrast WET READ: ASpf FRI 6:25 AM no acute intracranial process. TECHNIQUE: MDCT images were acquired through the head without contrast. The visible paranasal sinuses and mastoid air cells are well aerated. FINDINGS: No acute hemorrhage, large vascular territory infarct, shift of midline structures or mass effect is present. pulm path FINAL REPORT INDICATION: 48-year-old man with altered mental status. A needle is noted in the posterior subcutaneous tissues at the thoracolumbar junction. The ventricles and sulci are normal in size and configuration. A needle is noted in the posterior soft tissues near the thoracolumbar junction on the lateral view. COMPARISON: None available. No pleural effusions or pneumothorax is present. FINAL REPORT INDICATION: A 48-year-old man with altered mental status, question intracranial hemorrhage or signs of edema. ICH, signs of edema MEDICAL CONDITION: 48 year old man with AMS REASON FOR THIS EXAMINATION: ? Multiplanar reformations were obtained and reviewed. Healed rib fractures are noted on the left. TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. pulm path MEDICAL CONDITION: 48 year old man with AMS REASON FOR THIS EXAMINATION: ?"},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2132-04-25 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1182712,"text":" 5:51 AM\n CHEST (PA & LAT) Clip # \n Reason: ? pulm path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AMS\n REASON FOR THIS EXAMINATION:\n ? pulm path\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with altered mental status.\n\n COMPARISON: Chest radiograph from .\n\n TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The\n cardiomediastinal silhouette, hilar contours and pleural surfaces are normal.\n No pleural effusions or pneumothorax is present. A needle is noted in the\n posterior soft tissues near the thoracolumbar junction on the lateral view.\n Healed rib fractures are noted on the left.\n\n IMPRESSION: No acute intrathoracic process. A needle is noted in the\n posterior subcutaneous tissues at the thoracolumbar junction.\n\n These findings were communicated to at 6:21 a.m. on\n .\n\n"},{"category":"Radiology","chartdate":"2132-04-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1182711,"text":" 5:49 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH, signs of edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AMS\n REASON FOR THIS EXAMINATION:\n ? ICH, signs of edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf FRI 6:25 AM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old man with altered mental status, question\n intracranial hemorrhage or signs of edema.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Multiplanar reformations were obtained and reviewed.\n\n FINDINGS:\n\n No acute hemorrhage, large vascular territory infarct, shift of midline\n structures or mass effect is present. The ventricles and sulci are normal in\n size and configuration. The visible paranasal sinuses and mastoid air cells\n are well aerated.\n\n IMPRESSION:\n\n No acute intracranial process.\n\n\n"},{"category":"ECG","chartdate":"2132-04-25 00:00:00.000","description":"Report","row_id":125144,"text":"Baseline artifact. Sinus tachycardia. ST-T wave abnormalities. Since the\nprevious tracing T wave abnormalities are more prominent.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2132-04-25 00:00:00.000","description":"Report","row_id":125145,"text":"Sinus tachycardia. Late R wave progression. Possible septal myocardial\ninfarction. Since the previous tracing of T waves are more prominent\non the present tracing.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2132-04-26 00:00:00.000","description":"Report","row_id":126063,"text":"Sinus rhythm. Delayed R wave progression is non-diagnostic but cannot exclude\npossible prior anterior myocardial infarction. Diffuse low amplitude T wave\nchanges are non-specific. Compared to the previous tracing of sinus\ntachycardia is now present and delayed R wave progression pattern is more\nprominent.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-04-25 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1182712,\n \"text\": \" 5:51 AM\\n CHEST (PA & LAT) Clip # \\n Reason: ? pulm path\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man with AMS\\n REASON FOR THIS EXAMINATION:\\n ? pulm path\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 48-year-old man with altered mental status.\\n\\n COMPARISON: Chest radiograph from .\\n\\n TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The\\n cardiomediastinal silhouette, hilar contours and pleural surfaces are normal.\\n No pleural effusions or pneumothorax is present. A needle is noted in the\\n posterior soft tissues near the thoracolumbar junction on the lateral view.\\n Healed rib fractures are noted on the left.\\n\\n IMPRESSION: No acute intrathoracic process. A needle is noted in the\\n posterior subcutaneous tissues at the thoracolumbar junction.\\n\\n These findings were communicated to at 6:21 a.m. on\\n .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-04-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1182711,\n \"text\": \" 5:49 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? ICH, signs of edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old man with AMS\\n REASON FOR THIS EXAMINATION:\\n ? ICH, signs of edema\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: ASpf FRI 6:25 AM\\n no acute intracranial process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 48-year-old man with altered mental status, question\\n intracranial hemorrhage or signs of edema.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: MDCT images were acquired through the head without contrast.\\n Multiplanar reformations were obtained and reviewed.\\n\\n FINDINGS:\\n\\n No acute hemorrhage, large vascular territory infarct, shift of midline\\n structures or mass effect is present. The ventricles and sulci are normal in\\n size and configuration. The visible paranasal sinuses and mastoid air cells\\n are well aerated.\\n\\n IMPRESSION:\\n\\n No acute intracranial process.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-04-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 125144,\n \"text\": \"Baseline artifact. Sinus tachycardia. ST-T wave abnormalities. Since the\\nprevious tracing T wave abnormalities are more prominent.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-04-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 125145,\n \"text\": \"Sinus tachycardia. Late R wave progression. Possible septal myocardial\\ninfarction. Since the previous tracing of T waves are more prominent\\non the present tracing.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-04-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126063,\n \"text\": \"Sinus rhythm. Delayed R wave progression is non-diagnostic but cannot exclude\\npossible prior anterior myocardial infarction. Diffuse low amplitude T wave\\nchanges are non-specific. Compared to the previous tracing of sinus\\ntachycardia is now present and delayed R wave progression pattern is more\\nprominent.\\n\\n\"\n }\n]"}}},{"rowIdx":299,"cells":{"subject_id":{"kind":"number","value":85845,"string":"85,845"},"hadm_id":{"kind":"number","value":156194,"string":"156,194"},"target_text":{"kind":"string","value":"71yo M with CAD, Afib on coumadin, and s/p right inguinal hernia repair on complicated by post-op urinary retention now presenting with 3 days of malaise, nausea, chills and acute on chronic PO intake found to be febrile with pyuria. Stabilized in MICU and transferred to medicine floor. . # SEPSIS: Mr. was admitted to the MICU with hypotension and fever concerning for sepsis. He was started on Cipro for positive UA and blood cultures and was ultimately found to have gram negative rods in his blood and urine (serratia marcesens) susceptible to Cipro. He continued on this abx for intended 14day course. His fevers improved. He was weaned off pressors immediately after ICU admission. Surgery was consulted due to recent inguinal hernia repair. He has a seroma at the site of his prior inguinal hernia repair which did not appear to be infected and surgery did not recommend draining it. His foley was initially removed prior to discharge but a post-void residual was >300 so it was replaced. Urology was called due to urinary retention and recommended waiting 2 days until septic illness has improved, then attempting another voiding trial. While on antibiotics his coumadin dose was decreased to 2mg daily. He was stabilized and transferred to general medicine floors. He was afebrile and continued to show clinical improvement on Ciprofloxacin for 14 day course. Repeat blood cxr pending. MRSA screen negative. CT abdomen/pelvis pending final read, did not show evidence of abscess or other potential infectious site. . # Urinary Retention: Retention since eval by Dr. . Unclear etiology for retention, likely infection. Urine output via foley cath adequate. c/o internal discomfort w/foley. Afebrile. Trial to void on with urine output 250cc and 150cc in first few hours after discontinuation of foley cath. Pt ambulating and reported resolution of severe discomfort from catheter. PVR in afternoon was 58cc. He was monitored for urinary retention with PVR. Plan for retention: update urology, options to replace foley cath or teach self catheterization. Follow up with Dr. as outpatient. . # Hepatic lesions: Incidentally discovered on CT abd/pelvis for evaluation of possible second site of infection and prostate tenderness. Question of cysts vs liver neoplasm on CT. He was sent for MRI abdomen to evaluate for hepatic malignancy given systemic symptoms of malaise, early satiety, decreased po intake, and wt loss for several months. MRI showed multiple liver cysts, no suggestion of malignancy. . #Seroma: Not currently concerning for infection. Surgery is following, thinks it will resolve spontaneously, and if not improved, consider U/S of seroma as an outpatient. . # Hypophosphatemia: Pt has chronic low phosphate levels managed on neutraphos at home. Also labs calcium and slightly elevated PTH. Endocrine consult in MICU suggested evaluation of fasting urine phos/creat with juxtaposed blood phos/creatinine. Per note, differential includes acquired RTA, vitamin D deficiency, and myeloma given anemia. Secondary hyperparathyroidism felt to be unlikely given low/normal Ca. Pt received IV repletion of phos in the unit and on the floor. Total protein 5.6. SPEP and UPEP levels pending, to evaluate myeloma. Endocrine recs are to follow up with Dr. 1 month after discharge for assessment of pending labs and further clinical workup. Vit D levels = pending. . # Weight loss: Patient reports several months of weight loss, nausea, anorexia, and early satiety. PSA 1 yr ago normal. Prostate tender on exam and pt denying pelvic discomfort. CT abdomen/pelvis prelim above suggests ?focal lesions in liver. MRI abd to eval liver lesions, r/o neoplasm vs cysts. MRI showed hepatic cysts, study nonsuggestive of hepatic malignancy. . # AFIB: Rate controlled with metoprolol instead of home atenolol. He was continued on Digoxin and monitored. Coumadin dose reduced to 2mg per day with abx/ciprofloxacin use and with currently therapeutic INR. . # CAD. Continued on asa, statin. . #Hypotension - on admission, likely sepsis. Repleted with IVF. Currently normotensive."},"extractive_notes_summ":{"kind":"string","value":"The spleen appears within normal limits with the exception of a few sub-3-mm T2 hyperintense lesions consistent with cysts along the inferior tip. CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with associated dependent and compressive atelectasis. The kidneys appear within normal limits with the exception of small cysts within the right kidney. A small amount of fat is noted herniating through the inguinal ring, suggestive of persistent inguinal hernia. For example, an 11-mm lesion within medial left hepatic lobe (902, 57) appears multiseptated. MRI ABDOMEN: Small bilateral pleural effusions are present. Mild multilevel degenerative change of the thoracolumbar spine is noted. Small amount of fat herniating through inguinal ring suggestive of persistent partial inguinal hernia. Small amount of fat herniating through inguinal ring suggestive of persistent inguinal hernia. Small amount of fat herniating through inguinal ring suggestive of persistent inguinal hernia. Small bilateral pleural effusions. Small bilateral pleural effusions. Intra-abdominal small and large bowel loops appear normal in caliber. The gallbladder appears unremarkable. REASON FOR THIS EXAMINATION: w contrast please; please eval for etiology of n/v/weight loss No contraindications for IV contrast PFI REPORT Small bilateral pleural effusions. A subcentimeter T2 hyperintense ovoid lesion within L3 vertebral body, upon correlation with CT from , is consistent with hemangioma. Moderate lumbar osteoarthritis. Probable post-operative seroma in the right lower abdominal wall. Probable post-operative seroma in the right lower abdominal wall. Probable post-operative seroma in the right lower abdominal wall. In addition, there is some ill-defined stranding just anterior to the femoral vessels, likely postoperative. Multiple small T2 hyperintense nonenhancing lesions are scattered throughout the liver, consistent with cysts. Sub-3-mm splenic cysts. Atherosclerotic calcification of the abdominal aorta is noted. No free air below the right hemidiaphragm is seen. Non-specific inferior T wave changes.Compared to the previous tracing of no diagnostic interim change. The opacified stomach and intra-abdominal loops of bowel are normal. The distal ureters, seminal vesicles, sigmoid colon, and rectum are normal. Multiple hypodensities are noted throughout the liver, most of which are subcentimeter in size and too small to further characterize. left adrenal gland fullness. Tiny locules of gas are seen tracking into the right hemiscrotum. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but incompletely evaluated on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. IMPRESSION: No acute findings in the chest. No concerning focal liver lesion. The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal. Bone marrow signals are otherwise within normal limits. TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis after administration of 130 cc of IV Optiray contrast. No solid concerning hepatic lesion is identified. There is grade 1 retrolisthesis of L5 on S1. REASON FOR THIS EXAMINATION: w contrast please; please eval for etiology of n/v/weight loss No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 10:55 PM Small bilateral pleural effusions. COMPARISON: CT from . The kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or hydroureter. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but a neoplastic etiology cannot be excluded on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but a neoplastic etiology cannot be excluded on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. This lesion has a low density of 13 Hounsfield units. (Over) 5:10 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: w contrast please; please eval for etiology of n/v/weight lo Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: OPTIRAY Amt: FINAL REPORT (Cont) CT PELVIS WITH IV CONTRAST: In the lower right anterior abdominal wall, just lateral to the lower right rectus muscle, there is a 9.5 x 2.8 x 9.0 cm fluid collection which is likely postoperative given the recent hernia repair. Cardiomediastinal silhouette appears grossly stable and normal. of note, surgical hx +midline abd hernia repair REASON FOR THIS EXAMINATION: liver lesions visualized on ct abd - question of cysts vs liver malignancy No contraindications for IV contrast WET READ: PPcb SUN 1:41 PM multiple liver cysts some with think septations. The pancreas and adrenal glands are unremarkable. No mesenteric or retroperitoneal lymphadenopathy meeting CT criteria for pathological enlargement is noted. The largest lesion is located within segment VIII, measuring 12 mm (902,34). The largest lesion is in segment VIII measuring 10 x 11 mm. Coronal and sagittal reformats were displayed. No pelvic or inguinal lymphadenopathy meeting criteria for pathologic enlargement is noted. FINDINGS: PA and lateral views of the chest were obtained. An additional 10-mm lesion within segment II is also septated. (Over) 1:36 PM MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: liver lesions visualized on ct abd - question of cysts vs li Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: MAGNEVIST Amt: 15 FINAL REPORT (Cont) Marked lumbar spondylosis with endplate degenerative changes are most pronounced at L2-3."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2105-06-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1146512,"text":" 5:02 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, postop, + cough\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: 71-year-old man with fever, postop, positive cough,\n question pneumonia.\n\n FINDINGS: PA and lateral views of the chest were obtained. There is no\n evidence of pneumonia or CHF. No pleural effusion or pneumothorax is seen.\n Cardiomediastinal silhouette appears grossly stable and normal. Bones appear\n intact. No free air below the right hemidiaphragm is seen.\n\n IMPRESSION: No acute findings in the chest.\n\n\n"},{"category":"Radiology","chartdate":"2105-06-27 00:00:00.000","description":"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS","row_id":1146929,"text":" 1:36 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: liver lesions visualized on ct abd - question of cysts vs li\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man adm'd for urosepsis and urinary retention s/p R inguinal hernia\n repair on w c/o nausea, anorexia, wt loss and early satiety x several\n months. ?malignancy given systemic complaints. of note, surgical hx +midline\n abd hernia repair\n REASON FOR THIS EXAMINATION:\n liver lesions visualized on ct abd - question of cysts vs liver malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PPcb SUN 1:41 PM\n multiple liver cysts some with think septations. no enhancement. left adrenal\n gland fullness.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male here for urosepsis, status post right inguinal\n repair on , now presents with nausea, anorexia, and weight loss as well\n as incidental findings of liver cysts on CT. Question further\n characterization of liver lesions.\n\n COMPARISON: CT from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 3D imaging obtained prior to, during, and\n following uneventful intravenous administration of 0.1 mmol/kg (15 mL) of\n Magnevist. Multiplanar 2D and 3D reformations and subtraction images were\n generated on an independent workstation.\n\n MRI ABDOMEN: Small bilateral pleural effusions are present.\n\n Multiple small T2 hyperintense nonenhancing lesions are scattered throughout\n the liver, consistent with cysts. The largest lesion is located within segment\n VIII, measuring 12 mm (902,34). Some of these lesions are septated. For\n example, an 11-mm lesion within medial left hepatic lobe (902, 57) appears\n multiseptated. An additional 10-mm lesion within segment II is also septated.\n No solid concerning hepatic lesion is identified.\n\n There is no intra- or extra-hepatic biliary dilatation. The gallbladder\n appears unremarkable. The spleen appears within normal limits with the\n exception of a few sub-3-mm T2 hyperintense lesions consistent with cysts\n along the inferior tip. The pancreas and adrenal glands are unremarkable.\n The kidneys appear within normal limits with the exception of small cysts\n within the right kidney. There is no hydronephrosis or hydroureter.\n\n Intra-abdominal small and large bowel loops appear normal in caliber. There\n is no lymphadenopathy or free fluid within the abdomen. Great vessels are\n normal in caliber.\n\n (Over)\n\n 1:36 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: liver lesions visualized on ct abd - question of cysts vs li\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Marked lumbar spondylosis with endplate degenerative changes are most\n pronounced at L2-3. A subcentimeter T2 hyperintense ovoid lesion within L3\n vertebral body, upon correlation with CT from , is consistent\n with hemangioma. Bone marrow signals are otherwise within normal limits.\n\n Multiplanar 2D and 3D reformations (185, 186) provided multiple perspectives\n for the dynamic series.\n\n IMPRESSION:\n 1. Numerous sub-1.5-cm liver cysts scattered throughout the liver. No\n concerning focal liver lesion.\n 2. Sub-3-mm splenic cysts.\n 3. Small bilateral pleural effusions.\n 4. Moderate lumbar osteoarthritis.\n\n\n\n"},{"category":"Radiology","chartdate":"2105-06-26 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1146837,"text":" 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\n of decreased apetite and weight loss.\n REASON FOR THIS EXAMINATION:\n w contrast please; please eval for etiology of n/v/weight loss\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 10:55 PM\n Small bilateral pleural effusions. Multiple incompletely evaluated\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\n represent simple cysts but a neoplastic etiology cannot be excluded on this\n limited single-phase CT. Further evaluation could be obtained with MRI or\n ultrasound as clinically indicated. Probable post-operative seroma in the\n right lower abdominal wall. Small amount of fat herniating through inguinal\n ring suggestive of persistent inguinal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with Gram-negative rod bacteremia and urinary\n retention with two months of decreased appetite and weight loss. Evaluate for\n etiology of nausea, vomiting, and weight loss. Patient had right inguinal\n hernia repair 7 days ago.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis after administration of 130 cc of IV Optiray contrast. Oral contrast\n was also administered. Coronal and sagittal reformats were displayed.\n\n CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with\n associated dependent and compressive atelectasis. Lung bases are otherwise\n clear.\n\n Multiple hypodensities are noted throughout the liver, most of which are\n subcentimeter in size and too small to further characterize. The largest\n lesion is in segment VIII measuring 10 x 11 mm. This lesion has a low density\n of 13 Hounsfield units. There is no rim enhancement around these lesions\n which could represent simple cysts or congenital biliary hamartomas, but are\n incompletely evaluated on this single phase CT.\n\n The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.\n The kidneys enhance and excrete contrast symmetrically without evidence of\n hydronephrosis or hydroureter. The opacified stomach and intra-abdominal\n loops of bowel are normal. No mesenteric or retroperitoneal lymphadenopathy\n meeting CT criteria for pathological enlargement is noted. There is no free\n air or fluid in the abdomen. Atherosclerotic calcification of the abdominal\n aorta is noted.\n\n (Over)\n\n 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITH IV CONTRAST: In the lower right anterior abdominal wall, just\n lateral to the lower right rectus muscle, there is a 9.5 x 2.8 x 9.0 cm fluid\n collection which is likely postoperative given the recent hernia repair. There\n is no rim enhancement. Tiny locules of gas are seen tracking into the right\n hemiscrotum. In addition, there is some ill-defined stranding just anterior\n to the femoral vessels, likely postoperative. A small amount of fat is noted\n herniating through the inguinal ring, suggestive of persistent inguinal\n hernia.\n\n The urinary bladder is collapsed around a Foley catheter. The prostate is\n enlarged measuring up to 5.7 cm with calcifications centrally. The distal\n ureters, seminal vesicles, sigmoid colon, and rectum are normal. There is no\n free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting\n criteria for pathologic enlargement is noted.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n Mild multilevel degenerative change of the thoracolumbar spine is noted. There\n is grade 1 retrolisthesis of L5 on S1.\n\n IMPRESSION:\n\n 1. Small bilateral pleural effusions.\n\n 2. Multiple incompletely evaluated hypodensities in the liver measuring up to\n 11 mm without rim enhancement could represent simple cysts but incompletely\n evaluated on this limited single-phase CT. Further evaluation could be\n obtained with MRI or ultrasound as clinically indicated.\n\n 3. Probable post-operative seroma in the right lower abdominal wall. Small\n amount of fat herniating through inguinal ring suggestive of persistent\n partial inguinal hernia.\n\n 4. Enlarged prostate.\n\n Findings discussed with Dr. at 5:30 p.m. on .\n\n"},{"category":"ECG","chartdate":"2105-06-25 00:00:00.000","description":"Report","row_id":109762,"text":"Atrial fibrillation. Rightward axis. Non-specific inferior T wave changes.\nCompared to the previous tracing of no diagnostic interim change.\n\n"},{"category":"Radiology","chartdate":"2105-06-26 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1146838,"text":", MED FA5 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\n of decreased apetite and weight loss.\n REASON FOR THIS EXAMINATION:\n w contrast please; please eval for etiology of n/v/weight loss\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Small bilateral pleural effusions. Multiple incompletely evaluated\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\n represent simple cysts but a neoplastic etiology cannot be excluded on this\n limited single-phase CT. Further evaluation could be obtained with MRI or\n ultrasound as clinically indicated. Probable post-operative seroma in the\n right lower abdominal wall. Small amount of fat herniating through inguinal\n ring suggestive of persistent inguinal hernia.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-06-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1146512,\n \"text\": \" 5:02 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with fever, postop, + cough\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH PERFORMED ON .\\n\\n Comparison is made with a prior study from .\\n\\n CLINICAL HISTORY: 71-year-old man with fever, postop, positive cough,\\n question pneumonia.\\n\\n FINDINGS: PA and lateral views of the chest were obtained. There is no\\n evidence of pneumonia or CHF. No pleural effusion or pneumothorax is seen.\\n Cardiomediastinal silhouette appears grossly stable and normal. Bones appear\\n intact. No free air below the right hemidiaphragm is seen.\\n\\n IMPRESSION: No acute findings in the chest.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-06-27 00:00:00.000\",\n \"description\": \"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\",\n \"row_id\": 1146929,\n \"text\": \" 1:36 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: liver lesions visualized on ct abd - question of cysts vs li\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man adm'd for urosepsis and urinary retention s/p R inguinal hernia\\n repair on w c/o nausea, anorexia, wt loss and early satiety x several\\n months. ?malignancy given systemic complaints. of note, surgical hx +midline\\n abd hernia repair\\n REASON FOR THIS EXAMINATION:\\n liver lesions visualized on ct abd - question of cysts vs liver malignancy\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: PPcb SUN 1:41 PM\\n multiple liver cysts some with think septations. no enhancement. left adrenal\\n gland fullness.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old male here for urosepsis, status post right inguinal\\n repair on , now presents with nausea, anorexia, and weight loss as well\\n as incidental findings of liver cysts on CT. Question further\\n characterization of liver lesions.\\n\\n COMPARISON: CT from .\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\\n Tesla magnet, including dynamic 3D imaging obtained prior to, during, and\\n following uneventful intravenous administration of 0.1 mmol/kg (15 mL) of\\n Magnevist. Multiplanar 2D and 3D reformations and subtraction images were\\n generated on an independent workstation.\\n\\n MRI ABDOMEN: Small bilateral pleural effusions are present.\\n\\n Multiple small T2 hyperintense nonenhancing lesions are scattered throughout\\n the liver, consistent with cysts. The largest lesion is located within segment\\n VIII, measuring 12 mm (902,34). Some of these lesions are septated. For\\n example, an 11-mm lesion within medial left hepatic lobe (902, 57) appears\\n multiseptated. An additional 10-mm lesion within segment II is also septated.\\n No solid concerning hepatic lesion is identified.\\n\\n There is no intra- or extra-hepatic biliary dilatation. The gallbladder\\n appears unremarkable. The spleen appears within normal limits with the\\n exception of a few sub-3-mm T2 hyperintense lesions consistent with cysts\\n along the inferior tip. The pancreas and adrenal glands are unremarkable.\\n The kidneys appear within normal limits with the exception of small cysts\\n within the right kidney. There is no hydronephrosis or hydroureter.\\n\\n Intra-abdominal small and large bowel loops appear normal in caliber. There\\n is no lymphadenopathy or free fluid within the abdomen. Great vessels are\\n normal in caliber.\\n\\n (Over)\\n\\n 1:36 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: liver lesions visualized on ct abd - question of cysts vs li\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Marked lumbar spondylosis with endplate degenerative changes are most\\n pronounced at L2-3. A subcentimeter T2 hyperintense ovoid lesion within L3\\n vertebral body, upon correlation with CT from , is consistent\\n with hemangioma. Bone marrow signals are otherwise within normal limits.\\n\\n Multiplanar 2D and 3D reformations (185, 186) provided multiple perspectives\\n for the dynamic series.\\n\\n IMPRESSION:\\n 1. Numerous sub-1.5-cm liver cysts scattered throughout the liver. No\\n concerning focal liver lesion.\\n 2. Sub-3-mm splenic cysts.\\n 3. Small bilateral pleural effusions.\\n 4. Moderate lumbar osteoarthritis.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-06-26 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1146837,\n \"text\": \" 5:10 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: w contrast please; please eval for etiology of n/v/weight lo\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\\n of decreased apetite and weight loss.\\n REASON FOR THIS EXAMINATION:\\n w contrast please; please eval for etiology of n/v/weight loss\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 10:55 PM\\n Small bilateral pleural effusions. Multiple incompletely evaluated\\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\\n represent simple cysts but a neoplastic etiology cannot be excluded on this\\n limited single-phase CT. Further evaluation could be obtained with MRI or\\n ultrasound as clinically indicated. Probable post-operative seroma in the\\n right lower abdominal wall. Small amount of fat herniating through inguinal\\n ring suggestive of persistent inguinal hernia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old male with Gram-negative rod bacteremia and urinary\\n retention with two months of decreased appetite and weight loss. Evaluate for\\n etiology of nausea, vomiting, and weight loss. Patient had right inguinal\\n hernia repair 7 days ago.\\n\\n COMPARISON: No prior study available for comparison.\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\\n pelvis after administration of 130 cc of IV Optiray contrast. Oral contrast\\n was also administered. Coronal and sagittal reformats were displayed.\\n\\n CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with\\n associated dependent and compressive atelectasis. Lung bases are otherwise\\n clear.\\n\\n Multiple hypodensities are noted throughout the liver, most of which are\\n subcentimeter in size and too small to further characterize. The largest\\n lesion is in segment VIII measuring 10 x 11 mm. This lesion has a low density\\n of 13 Hounsfield units. There is no rim enhancement around these lesions\\n which could represent simple cysts or congenital biliary hamartomas, but are\\n incompletely evaluated on this single phase CT.\\n\\n The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.\\n The kidneys enhance and excrete contrast symmetrically without evidence of\\n hydronephrosis or hydroureter. The opacified stomach and intra-abdominal\\n loops of bowel are normal. No mesenteric or retroperitoneal lymphadenopathy\\n meeting CT criteria for pathological enlargement is noted. There is no free\\n air or fluid in the abdomen. Atherosclerotic calcification of the abdominal\\n aorta is noted.\\n\\n (Over)\\n\\n 5:10 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: w contrast please; please eval for etiology of n/v/weight lo\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT PELVIS WITH IV CONTRAST: In the lower right anterior abdominal wall, just\\n lateral to the lower right rectus muscle, there is a 9.5 x 2.8 x 9.0 cm fluid\\n collection which is likely postoperative given the recent hernia repair. There\\n is no rim enhancement. Tiny locules of gas are seen tracking into the right\\n hemiscrotum. In addition, there is some ill-defined stranding just anterior\\n to the femoral vessels, likely postoperative. A small amount of fat is noted\\n herniating through the inguinal ring, suggestive of persistent inguinal\\n hernia.\\n\\n The urinary bladder is collapsed around a Foley catheter. The prostate is\\n enlarged measuring up to 5.7 cm with calcifications centrally. The distal\\n ureters, seminal vesicles, sigmoid colon, and rectum are normal. There is no\\n free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting\\n criteria for pathologic enlargement is noted.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\\n Mild multilevel degenerative change of the thoracolumbar spine is noted. There\\n is grade 1 retrolisthesis of L5 on S1.\\n\\n IMPRESSION:\\n\\n 1. Small bilateral pleural effusions.\\n\\n 2. Multiple incompletely evaluated hypodensities in the liver measuring up to\\n 11 mm without rim enhancement could represent simple cysts but incompletely\\n evaluated on this limited single-phase CT. Further evaluation could be\\n obtained with MRI or ultrasound as clinically indicated.\\n\\n 3. Probable post-operative seroma in the right lower abdominal wall. Small\\n amount of fat herniating through inguinal ring suggestive of persistent\\n partial inguinal hernia.\\n\\n 4. Enlarged prostate.\\n\\n Findings discussed with Dr. at 5:30 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2105-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 109762,\n \"text\": \"Atrial fibrillation. Rightward axis. Non-specific inferior T wave changes.\\nCompared to the previous tracing of no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-06-26 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1146838,\n \"text\": \", MED FA5 5:10 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: w contrast please; please eval for etiology of n/v/weight lo\\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\\n of decreased apetite and weight loss.\\n REASON FOR THIS EXAMINATION:\\n w contrast please; please eval for etiology of n/v/weight loss\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Small bilateral pleural effusions. Multiple incompletely evaluated\\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\\n represent simple cysts but a neoplastic etiology cannot be excluded on this\\n limited single-phase CT. Further evaluation could be obtained with MRI or\\n ultrasound as clinically indicated. Probable post-operative seroma in the\\n right lower abdominal wall. Small amount of fat herniating through inguinal\\n ring suggestive of persistent inguinal hernia.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":2,"numItemsPerPage":100,"numTotalItems":24993,"offset":200,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMDI5NDgxOSwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMDI5ODQxOSwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.od_57D87xyas5-n98FIg4EoC0FbVjOUZ8GAmU7zUY00IU5QWOBqONne0rg_vHeeRx_w09a0ag7grtlMwClDFAQ","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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25,121 | 152,742 | The patient had been intubated at an outside hospital, and he remained intubated at ; he was admitted to the neuro ICU. His propofol was weaned and he was extubated the following day. His dilantin level was low, and he was given extra doses for the next several days to bring his level up. He had no recurrence of seizure. For diarrhea and abdominal discomfort, a C-Diff toxin was checked and was positive; Metronidazole was started on for a fourteen day course. He was stable and transferred to the floor until his dilantin level was therapeutic. | AP SUPINE CHEST: Compared to . ?extubate in AM.GI: Abdomen soft w/ +bowel sounds. Voiding well and lungs clear. Poor R wave progression - probable normalvariant. ETT retaped. PIV x2.Pulm: Lungs diminished. IMPRESSION: Interval resolution of bibasilar atelectasis. Pt then transferred to EW. There is interval improvement of bibasilar patchy opacities, which are no longer seen. Pt transferred to SICU for close monitoring.Neuro: Pt lightly sedated on Ppf gtt (10mcg/kg/min). Febrile (102.9), Ppf gtt started, dilantin level 15.4. IMPRESSION: 1) ETT and NG tube in satisfactory position. EEG TODAY, ?EXTUBATE. CONT CURRENT MGMT. CONT CURRENT MGMT. Respiratory Care:Pt Extubated to a 505 cool neb. ?extubate in AM. FINDINGS: There is an ET tube with the tip in the thoracic inlet. Pt opens eyes to voice. BP/HR stable and non-labile.Neuro status waxing/ throughout the day. PT LIGHTLY SEDATED ON PROPOFOL, WHEN PROPOFOL OFF PT ABLE TO LIGHTLY SQUEEZE HANDS AND WIGGLE TOES OTHERWISE RESPONDS TO PAINFUL STIMULI APPLIED TO NAILBED BY WITHDRAWING W/ ALL EXTREMETIES.CV: HR 82-97, NSR, NO ECTOPY, SBP 117-124.RESP: REMAINS INTUBATED ON CPAP+PS 5/5, RR 17-19, O2 SAT 97-100%. Support/POC reviewed. Cont ICU care and treatment. Tmax 100.4. Pt withdraws BLE and BUE when nailbed pinched. There is an NG tube with tip in the stomach. NO SEIZURES NOTED.CV: HR 78-92 NSR, NO ECTOPY, SBP 114-122.RESP: LUNG SOUNDS CLEAR BUT DIMINISHED AT BASES, ABLE TO EXPECTORATE SECRETIONS OCC. Cardiac, mediastinal, and hilar contours are stable when compared to the prior study. NBP 110-120s/60s. TECHNIQUE: AP semi-upright single view of the chest. aspiration. NG tube within the stomach. BS diminished. REMAINS NPO. HAD BM X3 GUAIAC +, LOOSE, BROWN AND FOUL SMELLING, CX SENT. Nursing Note 7p-7a:Nursing Assessment:Pt remains stable. +cough +gag. Resp CarePt remains on vent and intubated with 8 ett @ 24. No need for SSRI-FSBS WNL.Turned and repositioned for comfort/skin care.Monitor and support pt. PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.NEURO: OPENS EYES TO VOICE, ABLE TO TRACK, PERL. Plan to wean to extubate depending on neuro status. Normal sinus rhythm, rate 88. UO qs.Integ: Skin warm, dry, and intact. Diarrhea. No seizures noted.CV: Temp 98.8; hr 80-90s (NSR). See carevue for objective data.Extubated at 0800 without incident. FS q6hr w/ RISS.GU: Foley intact w/ clear, yellow urine. He exhibits some expiratory Grunting/resistance for some reason. LUNG SOUNDS DIMINISHED, SXN FOR THICK YELLOW/TAN SECRETIONS.GI: ABD SOFT NT/ND, + BOWEL SOUNDS, NGT TO LCWS W/ BROWNISH LIQUID.GU: FOLEY DRAINING 25-110CC/HR CLEAR YELLOW URINE.ID: TMAX 100.1, CX.PLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. RSBI 44. DP/PT pulses easily palpable. RR13-20, O2 SAT 96-99% ON 4L VIA NC.GI: ABD SOFT NT/ND, +BOWEL SOUNDS. Productive cough; thick, white secretions. PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.NEURO: OPENS EYES TO VOICE, PERL, TRACKING, MAE SPONT/PURP, FOLLOWING COMMANDS CONSISTENTLY, ORIENTED X2-3 HOWEVER SOMETIMES MAKES INAPPROPRIATE COMMENTS. Endotracheal tube is in place 7 cm above the carina. Nonpurposeful spont movement at times. Strong cough. Pt w/ strong cough and gag reflex. 2) Minimal patchy bibasilar opacities, likely secondary to crowding of vessels on this low lung volume study; follow up CXR could be performed to exclude aspiration. Update family w/ plan of care. COMPARISONS: Comparison is made to . Compared to the previous tracing of no significant change. Tylenol given with no effect.IVF patent. The lungs are clear without evidence of definite pneumonia or aspiration. T&R freq to maintain skin integrity.Social: wife and visited; updated w/ plan of care.Plan: Neuro assessment as ordered; notify HO w/ any changes. The heart is enlarged but stable. Wife also in most of day.Febrile 101.8. PERRLA (4mm; briskly reactive to light). Team aware and awaiting iv meds to be changed to po. NGT to LWS w/ light brown drainage. The central pulmonary vasculature is somewhat prominent but this is likely secondary to technique. Pt admitted to Hospital where Dilantin level was subtherapeutic (1.5); Dilantin bolus given. O2 sat = 96% w/a rr = . No emesis since admission. Pt vomited and d/t persistent lethargy, pt intubated for airway protection. PLease continue with all other current nursing care.PLease refer to carevue for details. Monitor VS, I's & O's, and lab results. Nursing Progress Note (1710-1900)Please refer to CareVue for details. Lightly squeezes RN's hand w/ his right hand on command. REASON FOR THIS EXAMINATION: follow-up film to compare with yesterday, eval for progression of aspiration. suctioned large amt of thick tan secretions. Maintaining sats on 4L NC. No edema noted. Pt had an episode of limb shaking in the ED that stopped after receiving 2mg Ativan. IVF to be started tonight. The patient presents with fever and aspiration. Alert and orientated to person place and time. No definite focal consolidation seen. NGT CURRENTLY DRAINING COFFEE GROUND FLUID, DR. AWARE.GU: FOLEY DRAINING ADEQ CLEAR YELLOW URINE.PLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS, NGT OUTPUT, STOOL CX. Appeared encouragement when pt spoke to her and smiled later this afternoon. CPAP: FiO2 50%, PEEP 5, PS 5. FINAL REPORT INDICATION: 37-year-old male with seizures. 5:49 AM CHEST (PORTABLE AP) Clip # Reason: follow-up film to compare with yesterday, eval for progressi Admitting Diagnosis: SEIZURE MEDICAL CONDITION: 37 year old man with fever, seizure, ? Follows commands inconsistenly and verbally responds to questions intermittingly.Answers questions appropriately when he does answer but is lethargic and has difficulty keeping eyes open and drifts back to sleep easily.Mother at all shift and very anxious. 5:37 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, aspiration MEDICAL CONDITION: 37 year old man with fever, seizure REASON FOR THIS EXAMINATION: infiltrate, aspiration FINAL REPORT INDICATION: 37-year-old with fever and seizure, rule out infiltrate or aspiration. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2112-06-07 00:00:00.000",
"description": "Report",
"row_id": 1590221,
"text": "See carevue for objective data.\n\nExtubated at 0800 without incident. Maintaining sats on 4L NC. +cough +gag. BP/HR stable and non-labile.\nNeuro status waxing/ throughout the day. Follows commands inconsistenly and verbally responds to questions intermittingly.\nAnswers questions appropriately when he does answer but is lethargic and has difficulty keeping eyes open and drifts back to sleep easily.\nMother at all shift and very anxious. Appeared encouragement when pt spoke to her and smiled later this afternoon. Support/POC reviewed. Wife also in most of day.\nFebrile 101.8. Tylenol given with no effect.\nIVF patent. No need for SSRI-FSBS WNL.\nTurned and repositioned for comfort/skin care.\n\nMonitor and support pt.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-08 00:00:00.000",
"description": "Report",
"row_id": 1590222,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: OPENS EYES TO VOICE, PERL, TRACKING, MAE SPONT/PURP, FOLLOWING COMMANDS CONSISTENTLY, ORIENTED X2-3 HOWEVER SOMETIMES MAKES INAPPROPRIATE COMMENTS. NO SEIZURES NOTED.\n\nCV: HR 78-92 NSR, NO ECTOPY, SBP 114-122.\n\nRESP: LUNG SOUNDS CLEAR BUT DIMINISHED AT BASES, ABLE TO EXPECTORATE SECRETIONS OCC. RR13-20, O2 SAT 96-99% ON 4L VIA NC.\n\nGI: ABD SOFT NT/ND, +BOWEL SOUNDS. REMAINS NPO. HAD BM X3 GUAIAC +, LOOSE, BROWN AND FOUL SMELLING, CX SENT. NGT CURRENTLY DRAINING COFFEE GROUND FLUID, DR. AWARE.\n\nGU: FOLEY DRAINING ADEQ CLEAR YELLOW URINE.\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS, NGT OUTPUT, STOOL CX. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-10 00:00:00.000",
"description": "Report",
"row_id": 1590223,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt remains stable. Alert and orientated to person place and time. Tmax 100.4. Diarrhea. Voiding well and lungs clear. Awaiting a bed on the floor. Periperal IV fell out and unable to obtain a new iv after three nurse's attempting. Team aware and awaiting iv meds to be changed to po. PLease continue with all other current nursing care.\n\nPLease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-06 00:00:00.000",
"description": "Report",
"row_id": 1590217,
"text": "Nursing Progress Note (1710-1900)\nPlease refer to CareVue for details.\n Pt is a 37yo male w/ 3rd episode of seizure disorder in 2 months. Pt admitted to Hospital where Dilantin level was subtherapeutic (1.5); Dilantin bolus given. Pt vomited and d/t persistent lethargy, pt intubated for airway protection. Pt then transferred to EW. Febrile (102.9), Ppf gtt started, dilantin level 15.4. Pt had an episode of limb shaking in the ED that stopped after receiving 2mg Ativan. Pt transferred to SICU for close monitoring.\n\nNeuro: Pt lightly sedated on Ppf gtt (10mcg/kg/min). Pt opens eyes to voice. Lightly squeezes RN's hand w/ his right hand on command. Pt withdraws BLE and BUE when nailbed pinched. PERRLA (4mm; briskly reactive to light). Nonpurposeful spont movement at times. No seizures noted.\n\nCV: Temp 98.8; hr 80-90s (NSR). NBP 110-120s/60s. No edema noted. DP/PT pulses easily palpable. IVF to be started tonight. PIV x2.\n\nPulm: Lungs diminished. CPAP: FiO2 50%, PEEP 5, PS 5. Pt w/ strong cough and gag reflex. Productive cough; thick, white secretions. ?extubate in AM.\n\nGI: Abdomen soft w/ +bowel sounds. NGT to LWS w/ light brown drainage. No emesis since admission. FS q6hr w/ RISS.\n\nGU: Foley intact w/ clear, yellow urine. UO qs.\n\nInteg: Skin warm, dry, and intact. T&R freq to maintain skin integrity.\n\nSocial: wife and visited; updated w/ plan of care.\n\nPlan: Neuro assessment as ordered; notify HO w/ any changes. ?extubate in AM. Monitor VS, I's & O's, and lab results. Update family w/ plan of care. Cont ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-07 00:00:00.000",
"description": "Report",
"row_id": 1590218,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: OPENS EYES TO VOICE, ABLE TO TRACK, PERL. PT LIGHTLY SEDATED ON PROPOFOL, WHEN PROPOFOL OFF PT ABLE TO LIGHTLY SQUEEZE HANDS AND WIGGLE TOES OTHERWISE RESPONDS TO PAINFUL STIMULI APPLIED TO NAILBED BY WITHDRAWING W/ ALL EXTREMETIES.\n\nCV: HR 82-97, NSR, NO ECTOPY, SBP 117-124.\n\nRESP: REMAINS INTUBATED ON CPAP+PS 5/5, RR 17-19, O2 SAT 97-100%. LUNG SOUNDS DIMINISHED, SXN FOR THICK YELLOW/TAN SECRETIONS.\n\nGI: ABD SOFT NT/ND, + BOWEL SOUNDS, NGT TO LCWS W/ BROWNISH LIQUID.\n\nGU: FOLEY DRAINING 25-110CC/HR CLEAR YELLOW URINE.\n\nID: TMAX 100.1, CX.\n\nPLAN: MONIOTR VS, LABS, RESP STATUS, NEURO STATUS. EEG TODAY, ?EXTUBATE. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-07 00:00:00.000",
"description": "Report",
"row_id": 1590219,
"text": "Resp Care\nPt remains on vent and intubated with 8 ett @ 24. ETT retaped. BS diminished. suctioned large amt of thick tan secretions. Strong cough. RSBI 44. Plan to wean to extubate depending on neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-06-07 00:00:00.000",
"description": "Report",
"row_id": 1590220,
"text": "Respiratory Care:\nPt Extubated to a 50\n5 cool neb. He exhibits some expiratory Grunting/resistance for some reason. O2 sat = 96% w/a rr = .\n"
},
{
"category": "Radiology",
"chartdate": "2112-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872484,
"text": " 5:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow-up film to compare with yesterday, eval for progressi\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with fever, seizure, ? aspiration.\n REASON FOR THIS EXAMINATION:\n follow-up film to compare with yesterday, eval for progression of aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old male with seizures. The patient presents with fever\n and aspiration.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP semi-upright single view of the chest.\n\n FINDINGS: There is an ET tube with the tip in the thoracic inlet. There is\n an NG tube with tip in the stomach. Cardiac, mediastinal, and hilar contours\n are stable when compared to the prior study. There is interval improvement of\n bibasilar patchy opacities, which are no longer seen. No definite focal\n consolidation seen. There is no evidence of pneumothorax.\n\n IMPRESSION: Interval resolution of bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872411,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with fever, seizure\n REASON FOR THIS EXAMINATION:\n infiltrate, aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old with fever and seizure, rule out infiltrate or\n aspiration.\n\n AP SUPINE CHEST: Compared to . Endotracheal tube is in place 7 cm\n above the carina. NG tube within the stomach. The heart is enlarged but\n stable. The central pulmonary vasculature is somewhat prominent but this is\n likely secondary to technique. The lungs are clear without evidence of\n definite pneumonia or aspiration.\n\n IMPRESSION:\n 1) ETT and NG tube in satisfactory position.\n 2) Minimal patchy bibasilar opacities, likely secondary to crowding of\n vessels on this low lung volume study; follow up CXR could be performed to\n exclude aspiration.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2112-06-06 00:00:00.000",
"description": "Report",
"row_id": 163769,
"text": "Normal sinus rhythm, rate 88. Poor R wave progression - probable normal\nvariant. Compared to the previous tracing of no significant change.\n\n"
}
] |
7,853 | 155,928 | ICU course: The patient was admitted directly to the ICU with hypotension secondary to septic shock with a gram negative rod septicemia. The source of her infection was a left lower lobe pneumonia. Initially, there was concern over a possible soft tissue infection of her right leg. Surgery was consult for possible debridement; however, after consultation it was felt that the patient's leg edema and tenderness was secondary to chronic changes from a healing laceration and was only mildly cellulitic. She was initially started on Zosyn, vancomycin, and clindamycin to cover skin flora, typical pulmonic pathogens, and pseudomonas given her diabetes and immune compromised state with chronic prednisone and methotrexate therapy. She was bolused with additional saline upon arrival to the ICU and was quickly weaned off of pressors. She was also started on stress dose hydrocortisone given her daily use of prednsione (35mg/day). She continued to improve clinically, and was transfered to the general medicine floor. | Hypotension resolved w/ NS bolus X2 L. Levo gtt weaned to off. Scheduled albulterol/atrovent nebs given. BP 98-160's systolic. Rec'ed neb. +hypoactive bs. trace pedal edema noted. QRS:0.06 PR: 0.12 QT: 0.32. MD's are aware.CV: Remains in ST with HR 110's -130's with rare to occas. with bronchial noise and exp. dieuresing pt. Nebs ATC. severe rhonchi and coarse rales when awake. M/SICU NPN/Admission note:Rec'ed from EW on Sepsis protocol. Peripheral pulses palpable. +DP. Will f/u in AM with MD's. htn. HO made aware.PLAN: MRI to RLE. sliding scale dc'd. now pt with rhonchi in the upper lobe and diminished at the bases. use lasix if o2 sats decrease. CHF, ? CHF, ? Labia w/ ulcerations. Non-pitting edema. exp wheezes in the am. dieuresis. Afebrile. Afebrile. Afebrile. with insp/exp wheezing throughout. Surgery consulted.GI: Abd obese, soft, +BSX4. Able to min. pt with episodes of ST up to 140s and htn with sbp up to 190 with activity, resolved with rest.resp: lungs with scatt. Drew 1 set from L Rad. ns w-d with dsd kerlix wrap. Lung sounds cont. Lung sounds cont. Palp. Monitor for CHF, I/O's, VS's. IMPRESSION: Satisfactory central line placement without pneumothorax. Diffuse non-specific ST-T wave flattening. 12-lead ECG WNL. AP AND LATERAL CHEST: Comparison is made with . BUN/Cr: 24/1.3. right pupil nonreactive with cateract. B/L BS coarse, slightly diminished w/ expiratory wheezing. Also c/o pain with movement of Right LE. IMPRESSION: 1) Consistent premature spill of thin liquids to the valleculae and occasionally the pyriform sinuses. No edema other than RLE.HEM: H&H WNL.ID: Continues on sepsis protocol. tx x 1 upon arrival. Admitted to Room #11 in critical condition.Neuro: AAOx3, , . left pupil 3mm brisk.cv: hr ranging 106-119 st with rare apc's. Dr. aware. C/o diarrhea in EW, but none at present. Sinus tachycardia. There was temporary hold up at the GE junction of the tablet. + peripheral pulses palpated x4 limbs. MD aware. A-Line in place. +BS x4 quadrants. Has rec'ed several neb. On IV abx. Needs Sputum cx and C. Dif sample sent..... Psych and Derm. Blisters to post. Creat rising to 1.7 at present. Pt. MD's have been made aware.SKIN: Ulcers to mouth and Labia still present (?Behcet's syndrome??). There is persistent elevation of the left hemidiaphragm, with underlying bowel gas. Productive cough, but still needs sputum cx sent. Palp peripherial pulses x 4. IMPRESSION: 1. IMPRESSION: 1. Pt with partially compensated metabolic acidosis. FINDINGS: Grayscale and color Doppler son examination of the right lower extremity venous system was performed. Left A-line also in place. AM ABG on 2L : 7.28/33/88/-. with current plan of care. As long as o2 sats are good, will await a spon. Resolved w/ morphine 2-4mg IV. BP stable. There is normal laryngeal elevation and epiglottic deflection, without evidence of penetration or aspiration. Noted more edema to Right leg.GI: + BS noted. effect. effect. RIJ TLC, RAC #18G, and L. RAD. On Solumedrol 100 Q8hrs. CVP w/ poor tracing, reads . On pureed diet (per pt. AP CHEST: A right IJ central venous catheter terminates in the distal SVC. There is elevation of the left hemidiaphragm. Appears macular, excoriated, pink, no drainage. (trauma?) peripherial pulses x 4. Psych consult, dermatology consult recommended. PAC's. Flushed when c/o pain, but no clots out.Derm: Right LE with wet-dry dsg intact. Repeat Blood cx's x 2 done. Again seen is a right IJ central venous catheter, malpositioned and terminating in the right atrium. PE, infiltrate FINAL REPORT HISTORY: History of shortness of breath with sepsis, hypoxia and CV line placement. There is evidence of normal compressibility, wave form, color flow, and augmentation within the right common femoral vein, superficial femoral vein, and popliteal vein. Wound is a laceration, approx 1 inch with white wound bed and serous drainage per report. 10:11 AM CHEST (PA & LAT) Clip # Reason: ? wheezing throughout. Still c/o right leg pain. Stable cardiac and mediastinal contours. Stable cardiac and mediastinal contour. htn when awake and in pain. eval for pneumo REASON FOR THIS EXAMINATION: eval for pneumothorax FINAL REPORT HISTORY: Central line placement. foley with minimal u.o., irrigated with ns with clear u.o, no clots noted, burning relieved with slight increased u.o. Anxiety episodes X2; Tachypneic not resolved w/ nebs, hypertensive, tachycardic, diaphoretic, verbalized feeling very anxious. Remain on Sepsis MUST protocol. PNA FINAL REPORT INDICATION: Gram negative rod sepsis. Pain med. + doe relieved with rest but with no 02 desatS. request.) Moans and groans, verbalized she's OK when approached. Left lower lobe atelectasis versus consolidation. issue of ? Since the prior film of the same date, there is increased opacity in the left lower zone obscurring the left hemidiaprhagm consistent with atelectasis/consolidation. Need C. dif sample sent with next BM.GU: New Foley cath #18 fr. A-line and 1 from RIJ TLC.PLAN: Cont. Repeat portable chest x-ray done.CV: ST with no ectopy. etc. R eye pupil irreg, 4mm, sluggish response to light. | 17 | [
{
"category": "Radiology",
"chartdate": "2199-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829553,
"text": " 5:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF, ? PE, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with sob,s/p central line placement for sepsis now with\n hypoxia and SOB\n REASON FOR THIS EXAMINATION:\n ? CHF, ? PE, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of shortness of breath with sepsis, hypoxia and CV line\n placement.\n\n The right jugular CV line is in right atrium. No pneumothorax. The heart\n size is normal. Since the prior film of the same date, there is increased\n opacity in the left lower zone obscurring the left hemidiaprhagm consistent\n with atelectasis/consolidation. There is possible associated small pleural\n effusions. In addition, there is pulmonary vascular engorgement which could be\n secondary to CHF or fluid overload. No pneumothorax.\n\n IMPRESSION: Probable CHF or fluid overload with increased\n atelectasis/consolidation in left lower zone since prior films. No\n pneumothorax. CV line is in right atrium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-06-29 00:00:00.000",
"description": "RP TIB/FIB (AP & LAT) RIGHT PORT",
"row_id": 829554,
"text": " 6:15 PM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: ? osteo\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with left leg swelling and fever\n REASON FOR THIS EXAMINATION:\n ? osteo\n ______________________________________________________________________________\n FINAL REPORT\n History of leg swelling and fever.\n\n There is fusion of the knee joint. The bones are well mineralized. There is\n No fracture. No evidence for osteomyelitis. There are phleboliths in\n superficial veins.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-06-29 00:00:00.000",
"description": "RP UNILAT LOWER EXT VEINS RIGHT PORT",
"row_id": 829548,
"text": " 4:02 PM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: R LE pain and swelling - eval for DVT - septic\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with mult med prob\n REASON FOR THIS EXAMINATION:\n R LE pain and swelling - eval for DVT - septic\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leg swelling.\n\n FINDINGS: Grayscale and color Doppler son examination of the right\n lower extremity venous system was performed. There is evidence of normal\n compressibility, wave form, color flow, and augmentation within the right\n common femoral vein, superficial femoral vein, and popliteal vein. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT within the right lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829545,
"text": " 2:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with sob,s/p centrallineplacement. eval for pneumo\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n AP CHEST: A right IJ central venous catheter terminates in the distal SVC.\n There is no definite pneumothorax. There is elevation of the left\n hemidiaphragm. There is a retrocardiac density, which could represent\n atelectasis or infection. Screws are seen within the left humerus. No\n vascular congestion or pleural effusion. Stable cardiac and mediastinal\n contour.\n\n IMPRESSION: Satisfactory central line placement without pneumothorax. Left\n lower lobe atelectasis versus consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 829775,
"text": " 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with GNR sepsis, LLL consolidation\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gram negative rod sepsis.\n\n AP AND LATERAL CHEST: Comparison is made with . Again seen is a\n right IJ central venous catheter, malpositioned and terminating in the right\n atrium. There is persistent elevation of the left hemidiaphragm, with\n underlying bowel gas. The pulmonary vasculature has improved in appearance.\n Stable cardiac and mediastinal contours. No pleural effusions or new\n infiltrates.\n\n IMPRESSION:\n\n 1. The central venous catheter remains in the right atrium.\n\n 2. No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-02 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 829777,
"text": " 10:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Evaluate biliary, GI tract for source of infection\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman p/w N/V/D with GNR sepsis\n REASON FOR THIS EXAMINATION:\n Evaluate biliary, GI tract for source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nausea, vomiting, and diarrhea in patient with gram negative rod\n sepsis.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis following the administration of oral\n contrast and 120 cc IV Optiray. Additional coronal reformatted images were\n performed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a small right pleural effusion\n with adjacent atelectasis. There are confluent air space opacities in the\n left lower lobe and posterior-inferior left upper lobe. The liver,\n gallbladder, pancreas, spleen, adrenal glands, kidneys, and small bowel loops\n and vasculature are unremarkable. No lymphadenopathy, ascites or free air.\n\n CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, are unremarkable. A\n Foley catheter decompresses the bladder. The heterogeneous appearance of the\n cecal and ascending colon contents is due to mixing of contrast and colonic\n contents. No deep pelvic lymphadenopathy or free fluid.\n\n The osseous structures are unremarkable.\n\n CT REFORMATIONS: These images aagain demonmstrate no evidence of bowel or\n biliary abnormality.\n\n IMPRESSION:\n 1. No identifiable source to account for the patient's sepsis.\n 2. Air space consolidations in the left lung base, which likely represent\n atelectasis. However, pneumonia cannot be entirely excluded.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-03 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 829774,
"text": " 10:12 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: pls evaluate for dysphagia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with DM2, asthma, PMR on chronic steroids, hx of esophageal\n stricture s/p dilation , now c/o new dysphagia\n REASON FOR THIS EXAMINATION:\n pls evaluate for dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 year old woman with new dysphagia.\n\n VIDEO OROPHARYNGEAL SWALLOW: This study is performed in conjunction with\n the speech therapist. Various consistencies of barium were administered\n orally.\n\n There is normal oral bolus formation and transfer of liquids, nectar and\n pudding, with consistent premature spillage of thin liquids to the valleculae,\n and occasionally to the pyriform sinuses. There is normal laryngeal elevation\n and epiglottic deflection, without evidence of penetration or aspiration.\n There is occasional vallecula residue, with fairly constant spontaneous second\n swallows.\n\n Although the patient was unable to transfer the 13 mm tablet with thin\n liquids, this was made possible with pudding. There was temporary hold up at\n the GE junction of the tablet.\n\n IMPRESSION:\n 1) Consistent premature spill of thin liquids to the valleculae and\n occasionally the pyriform sinuses.\n 2) No aspiration or penetration.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-02 00:00:00.000",
"description": "Report",
"row_id": 1367413,
"text": "MICU NPN 7p-2a\nNeuro: Pt is confused at times, does not remember where she is, wanted to know why RN was here and how she got in the house, unable to reorient. Follows commands, but forgets what she has said in the last few minutes. Right pupil 3mm, nonreactive r/t cataract, left pupil 3mm briskly reactive. Grips equal. Pt. c/o pain at times at Foley site r/t ulcers on labia. Also c/o pain with movement of Right LE. Refused pain medication so far.\n\nResp: 2L NC, denies SOB. Breath sounds with bilat ronchi, occasional basilar crackles. Scheduled albulterol/atrovent nebs given. No cough noted.\n\nCV: NSR-ST, no ectopy noted. BP stable. trace pedal edema noted. Afebrile. + peripheral pulses palpated x4 limbs. Skin warm, dry.\n\nGI: Pt for swallow eval tomorrow due to coughing with po intake. Pt states she has done that for years. Tolerating a pureed diet. No BM. +BS x4 quadrants. Denies Nausea, vomiting.\n\nGU: Foley in place draining amber urine with sediment. Flushed when c/o pain, but no clots out.\n\nDerm: Right LE with wet-dry dsg intact. Wound is a laceration, approx 1 inch with white wound bed and serous drainage per report. Pt also has white patchy ulcers on labia and in oral cavity.\n\nIV Access:Right IJ TLC in place, Right AC #18g PIV capped & flushed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-02 00:00:00.000",
"description": "Report",
"row_id": 1367414,
"text": "MICU NPN Add 2a-430a\n\nReceived #2 tylenol3 at 0330 for c/o leg pain.\nLabs sent at 0400 pending\nPt is less confused now than she was earlier in the shift and is currently A&Ox3.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-02 00:00:00.000",
"description": "Report",
"row_id": 1367415,
"text": "MICU NPN Add 0430a-0700a\n\nPt is c/o to the floor, report given, transfer orders in. bed ready on 5 . Pt continues to remain a&ox3, currently denies pain. All other assessment details as above, see flow sheet for VS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-06-29 00:00:00.000",
"description": "Report",
"row_id": 1367407,
"text": "M/SICU NPN/Admission note:\n\nRec'ed from EW on Sepsis protocol. Came to EW with c/o diarhea, right leg pain with laceration to lower part. Admitted to Room #11 in critical condition.\n\nNeuro: AAOx3, , . Able to communicate needs effectively. C/o \"severe\" Right leg pain with any type of movement. Introduced to unit and staff. Call bell within reach. Was lethargic in EW, but haven't seen that here. Admitted to MICU at 1720.\n\nResp: Arrived on 70% face mask due to c/o SOB with insp/exp (audible) wheezing. O2 sats 98-100%. Lung sounds cont. with insp/exp wheezing throughout. Rec'ed neb. tx x 1 upon arrival. No c/o SOB at this time. Repeat portable chest x-ray done.\n\nCV: ST with no ectopy. BP systolic 80's-100's on max dose of Levaphed gtt (20mcg/min). Palp peripherial pulses x 4. Given 3L NS in EW and thought to have gone into CHF, but Chest x-ray did not confirm this. Currently, she is rec'ing additional 1l NS bolus at this time thru her RIJ TLC (sepsis) and has one pIV to RAC in place. Left A-line also in place. Noted more edema to Right leg.\n\nGI: + BS noted. C/o diarrhea in EW, but none at present. NO N/V noted. ABD. is large, round, soft, non-tender, non-distended.\n\nGU: Foley in place with dark yellow urine.\n\nSkin: Noted reddness to RIGHT leg from ankle to knee with a 1\" laceration to shin area.\n\nPlan: Monitor per protocol. Remain on Sepsis MUST protocol. Monitor for CHF, I/O's, VS's. etc.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-06-30 00:00:00.000",
"description": "Report",
"row_id": 1367408,
"text": "NPN SHIFT 1900-0730:\n\nNEURO: A&OX3. Very anxious. Moans and groans, verbalized she's OK when approached. Anxiety episodes X2; Tachypneic not resolved w/ nebs, hypertensive, tachycardic, diaphoretic, verbalized feeling very anxious. Resolved w/ morphine 2-4mg IV. HO aware. R eye pupil irreg, 4mm, sluggish response to light. L pupil 2mm, normal shape, brisk. Pt s/p cataract surgery. MAE, equal strength.\n\nRESP: Weaned from 100% NRBM to 2L NC. Tol well, sats 97-99%. AM ABG on 2L : 7.28/33/88/-. Pt with partially compensated metabolic acidosis. B/L BS coarse, slightly diminished w/ expiratory wheezing. Nebs ATC. Dry, unprod cough. Chest x-ray at revealed LLL PNA, no evidence of fluid volume overload.\n\nCV: Pt in sinus tachycardia, occasional multifocal PVC's, PAC's. Rate 100-120. 12-lead ECG WNL. QRS:0.06 PR: 0.12 QT: 0.32. Hypotension resolved w/ NS bolus X2 L. Levo gtt weaned to off. ABP >65 throughout the night. CVP w/ poor tracing, reads . Able to get good tracing once when pt was flat in AM, CVP was 8. Pt unable to tolerate being flat. Peripheral pulses palpable. No edema other than RLE.\n\nHEM: H&H WNL.\n\nID: Continues on sepsis protocol. Afebrile. WBC elevated from 8 to 15.5. On IV abx. RLE erythematis from buttock to ankle sec to anterior, RLE laceration sustained when window pane fell on leg. Pink, no drainage, NS W-D done. Very painful, medicated w/ morphine w/ good relief. Non-pitting edema. +DP. Kept elevated. Surgery consulted.\n\nGI: Abd obese, soft, +BSX4. No c/o N/V/T. No BM. NPO, can have ice chips.\n\nGU: Foley C/D/I. Urine concentrated, yellow-amber, cloudy, marginal output, 30-50cc/hr. BUN/Cr: 24/1.3. Trace protein in urine. 0600 urine 20, bolusing w/ NS 1L as per HO.\n\nSKIN: Mouth mucosa w/ ulcerations, white film. Pt verbalized minimal discomfort. Labia w/ ulcerations. Appears macular, excoriated, pink, no drainage. No blisters. Pt verbalized this is first occurrence, no sexual HX as per pt. HO made aware.\n\nPLAN: MRI to RLE. OR for debridment of wound?, Address anxiety issues. Psych consult, dermatology consult recommended. On celexa at home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-06-30 00:00:00.000",
"description": "Report",
"row_id": 1367409,
"text": "M/SICU NPN for 7a-7p: Hospital Stay Day #2\nFULL CODE: ALLERGIC to Iodine/Contrast\n\nNeuro: AOX3 initially this AM, but has had periods of brief confusion. Does reorient easily. Some inappropriate words r/t situation at times. Pupils remains unequal R 4mm and sluggish and L 2mm Brisk. Has had recent cataract surgery (2wks ago). Able to min. assist with turning and repositioning. Still c/o right leg pain. Given Morphine x 2 doses today with good effect. Pain med. order changed to Percocet (she was taking this med at home). MAE. Able to follow commands. Good hand grips bilat.\n\nResp: Remains on 2l o2 via NC with adequate O2 sats 96-98%. Lung sounds cont. with bronchial noise and exp. wheezing throughout. Wheezing is audible at times. Has rec'ed several neb. treatments via RT throughout the day with min. effect. On Solumedrol 100 Q8hrs. SOB with excertion. Productive cough, but still needs sputum cx sent. Chest X-ray done on admission shows LLL PNA. RR 10's-20's labored most of the day. MD's are aware.\n\nCV: Remains in ST with HR 110's -130's with rare to occas. PAC's. BP 98-160's systolic. Afebrile. Noted Right leg to be large than Left. Palp. peripherial pulses x 4. RIJ TLC, RAC #18G, and L. RAD. A-Line in place. CVP inaccurate and difficult to obtain. Patient needs to be flat, but can't tolerate lying flat for too long.\n\nGI: + BS noted. NO N/V/D. On pureed diet (per pt. request.) Tolerating well, but poor appetite. Abd. obese, round, non-distended, non-tender. Need C. dif sample sent with next BM.\n\nGU: New Foley cath #18 fr. in place. Rec'ed 500c NS for low UO with min. effect. UO has been 20-60cc/hr of , blood . (trauma?) urine. MD's have been made aware.\n\nSKIN: Ulcers to mouth and Labia still present (?Behcet's syndrome??). Blisters to post. thigh bursts x 2. No other skin breakdown noted.\n\nLABS: Lactic acid 4.1/4/2/5.0. (Next due at 1900). Creat rising to 1.7 at present. Blood glucose 108-219.\n\nID: BLOOD cultures from ED showed Gram negative rods. Repeat Blood cx's x 2 done. Drew 1 set from L Rad. A-line and 1 from RIJ TLC.\n\nPLAN: Cont. with current plan of care. Monitor per ICU protocol. Taken off MUST protocol (24hrs was up at 1600). Needs Sputum cx and C. Dif sample sent..... Psych and Derm. consults requested by nursing, but ON HOLD at present. Will f/u in AM with MD's. NO MRI ordered. Attending MD felt in was not necessary at this time. No debridement of R. knee scheduled at this time.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-01 00:00:00.000",
"description": "Report",
"row_id": 1367410,
"text": "neuro Alert and oriented. Slightly confused at times when first awoken. Easily oriented to time and place. Awoke once in severe pain with assoc. htn. med with one time dose of mso4 3 mg iv good effect.\ncv/resp sinus tach no ectopy. htn when awake and in pain. severe rhonchi and coarse rales when awake. moans constantly when awake. Obvious increase in resp effort when awake and exerting energy. o2 sats however are remarkable at 98-99% on 2lnp. recieving albuterol and atrovent by rrt q4h.\ngi/gu no po intake during the night. issue of ? dieuresing pt. was discussed but will defer at this time. As long as o2 sats are good, will await a spon. dieuresis. uop 5-45cc/hr during the night of dk red urine (old blood) no stools noted.\ninteg left lower leg dsg changed at 0400 for lg amt serous drainage. ns w-d with dsd kerlix wrap. wound is clean and pink. a few inches long lac. open blister noted on buttock cleaned with soap and water.\nendo: insulin gtt started to control glu better. sliding scale dc'd. Now on 4units/hr with glu in 120's.\nplan: increase activity as tol. monitor resp status closley for worsening pneumonia/chf. medicate with percocet to control pain flare ups. use lasix if o2 sats decrease. am labs pending still needs sputum spec.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-01 00:00:00.000",
"description": "Report",
"row_id": 1367411,
"text": "micu/sicu nsg note: 0700-1900\nneuro: a&ox3 with cueing. somewhat forgetful at times in the afternoon stating that she just had her blood sugar check, when it had been 4 hours prior that it was checked. easily reoriented. requires 2 assist with boost in bed, otherwise able to mae and turn side to side independently in the bed. right pupil nonreactive with cateract. left pupil 3mm brisk.\n\ncv: hr ranging 106-119 st with rare apc's. bp ranging 124-153/53-71. bp taken via aline until aline d/c'd in afternoon. pt with episodes of ST up to 140s and htn with sbp up to 190 with activity, resolved with rest.\n\nresp: lungs with scatt. exp wheezes in the am. now pt with rhonchi in the upper lobe and diminished at the bases. sp02 ranging 94-100% on 2l 02 nc. + doe relieved with rest but with no 02 desatS. resp following with neb txs q6hrs.\n\ngi/gu: tolerating puree diet, but + choking when swallowing pills which pt reports she has a history of in the past and growing worse recently. swallow eval done at bedside. per speech therapist, barium swallow recommended tomorrow. pt is taking all po intake in upright 90 angle position. abd soft, obese. +hypoactive bs. indwelling foley catheter patent draining dk yellow, red tinged cloudy urine approx 13-80cc/hr this shift (596cc since midnight, 24 hour net body balance + 1363). Dr. aware. at 4pm pt c/o severe burning pain around catheter site rating it a \"10\". foley with minimal u.o., irrigated with ns with clear u.o, no clots noted, burning relieved with slight increased u.o. within the next 1/2 hr.\n\nskin: white patches of ulcers bilaterally to the front of the mouth and the majority of the tongue. pt c/o discomfort in mouth stating she took an oral med to swish and spit. MD aware. pt able to eat puree diet, but with + choking when taking pills, ? r/t mouth ulcers versus risk for aspiration per speech therapist. pt also with white patches of ulcers over sides and on labia, on back and thigh area l>r; ota. right calf with 1 inch laceration with white base draining copious amts of serous drainage when standing at side of bed. redressed after back to bed with wet-dry dsg wrapped in kerlex.\n\ncomfort: pt with right leg pain rated a on 0-10 pain scale. pain decreased to a 2 after medicated with 2 tabs tylenol #3 po x2 this shift. pt had refused taking percocet in the am stating her pain wasn't that severe and she takes tylenol #3 prn at home.\n\nendo: bs rangin 80-262 covered by ssi.\n\nlines: ra piv #18 gauge placed , rt tlcl placed , l aline d/c'd this afternoon.\n\nid: temp ranging 98-99.4 po. iv zosyn changed to po levofloxacin due to results of bcx.\n\nf/e/n: ionized ca= 1.04, repleted with 2gm calcium gluconate, k=3.5, repleted with 20 meq iv kcl.\n\nplan: continue to monitor hemodynamics status, po abx, monitor temp curve, micro data, monitor level of comfort, medicate prn and assess effect, monitor resp status, resp to continue nebs, continue asp precautions with hob at 90degrees upright position with po intake, anticipate swallow\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-07-01 00:00:00.000",
"description": "Report",
"row_id": 1367412,
"text": "micu/sicu nsg note: 0700-1900\n(Continued)\neval tomorrow.\n"
},
{
"category": "ECG",
"chartdate": "2199-06-29 00:00:00.000",
"description": "Report",
"row_id": 116643,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave flattening. Compared to the\nprevious tracing of the rate has increased and atrial ectopy is no\nlonger recorded.\n\n"
}
] |
31,614 | 125,573 | 28M with h/o bipolar d/o, HCV, here with medication overdose, followed by seizure and intubation for airway protection. . # overdose - Ultram, seroquel, and trazodone were taken deliberately by the patient as an intentional overdose. He endorsed SI. TCA was also positive at OSH, and bicarb was given. However, no further evidence of TCA intoxication was noted, and no further intervention was needed. Toxicology was consulted and recommended supportive care. Electrolytes, telemetry, and EKG were monitored closely. Psychiatry was consulted for further management of his SI. . # respiratory - patient was intubated for airway protection following seizure. He was awake and alert later on the day of admission, and was extubated uneventfully. He had a fever on night of admission and there was concern over aspiration pneumonitis. He was briefly treated with unasyn but this was stopped on . The patient remained afeb and stable thereafter. . # seizure - In the setting of medication overdose. Prior history of seizure in the setting of fall/concussion. Head CT negative at OSH. Pt is on depakote, initially not clear if for seizures or for bipolar d/o (or both). We continued it. . . # psych - H/o bipolar d/o. S/p overdose as above. Once extubated, the patient had a 1:1 sitter and suicide precautions. Psychiatry was consulted for further assistance with management. Recommendation was for inpatient admission. Pt was section 12'ed. . . # Fever - On the 2nd day of admission the patient spiked a fever to 102. Concern was for aspiration in the setting of seizure. Cultures were sent. Antibiotics were started to treat ? aspiration pneumonia. These were stopped on as discussed above. The patient remained afebrile off anibiotics for > 24 hours. The most liekly cause was a chemical pneumonitis. . # Dispo: medically cleared for psych transfer | Modest non-specific ST-T wave changes. The left basilar streaky opacities noted on the prior examination have resolved in the interim, likely reflected underlying atelectasis. The cardiomediastinal silhouette is within normal limits. FINDINGS: In comparison with study of , the endotracheal and nasogastric tubes have been removed. Sinus rhythm. Sinus rhythm. IMPRESSION: Standard position of ETT and NGT. CHEST, SINGLE VIEW: There is an endotracheal tube with its tip 3.2 cm from the carina, in standard position. Persistent low lung volumes. Compared to tracing #1 there is no significant diagnosticchange.TRACING #2 Prominence of the superior mediastinum likely relates to supine positioning. IMPRESSION: No acute cardiopulmonary process. No effusions are noted. Clinicalcorrelation is suggested.TRACING #1 Lung fields are clear albeit with low volumes. COMPARISON: None. Compared to the previoustracing of diffuse ST segment elevation has improved. placement. Increasing opacification is seen at the left base medially behind the heart with obscuration of the hemidiaphragm. Osseous structures are grossly unremarkable. The bony thorax is grossly intact. No focal airspace opacities are seen. An NG tube passes below the diaphragm with tip projecting over the gastric bubble and a side port projecting below the diaphragm. This could represent either atelectasis or developing pneumonia. FINDINGS: Three views of the chest were obtained and compared to the prior examinations dated and . 6:56 AM CHEST (PORTABLE AP) Clip # Reason: eval ETT placment MEDICAL CONDITION: 28 year old man with ET intubation transferred from OSH REASON FOR THIS EXAMINATION: eval ETT placment FINAL REPORT INDICATION: Status post endotracheal intubation ? 6:14 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: OVERDOSE MEDICAL CONDITION: 28 year old man with sucicde attempt, s/p extubation, now new fever REASON FOR THIS EXAMINATION: interval change FINAL REPORT HISTORY: Suicide attempt status post extubation, now with fever. | 5 | [
{
"category": "Radiology",
"chartdate": "2140-02-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1002470,
"text": " 9:48 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for developing PNA\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p extubation after suicide attempt with medications, now with\n possible aspiration PNA\n REASON FOR THIS EXAMINATION:\n please eval for developing PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Please evaluate for developing pneumonia in 28-year-old\n male status post extubation after suicide attempt with medications.\n\n FINDINGS: Three views of the chest were obtained and compared to the prior\n examinations dated and . The left basilar streaky opacities\n noted on the prior examination have resolved in the interim, likely reflected\n underlying atelectasis. No focal airspace opacities are seen. No effusions\n are noted. The cardiomediastinal silhouette is within normal limits. The\n bony thorax is grossly intact.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002286,
"text": " 6:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with sucicde attempt, s/p extubation, now new fever\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Suicide attempt status post extubation, now with fever.\n\n FINDINGS: In comparison with study of , the endotracheal and nasogastric\n tubes have been removed. Persistent low lung volumes. Increasing\n opacification is seen at the left base medially behind the heart with\n obscuration of the hemidiaphragm. This could represent either atelectasis or\n developing pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002092,
"text": " 6:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with ET intubation transferred from OSH\n REASON FOR THIS EXAMINATION:\n eval ETT placment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post endotracheal intubation ? placement.\n\n COMPARISON: None.\n\n CHEST, SINGLE VIEW: There is an endotracheal tube with its tip 3.2 cm from\n the carina, in standard position. An NG tube passes below the diaphragm with\n tip projecting over the gastric bubble and a side port projecting below the\n diaphragm. Prominence of the superior mediastinum likely relates to supine\n positioning. Lung fields are clear albeit with low volumes. Osseous\n structures are grossly unremarkable.\n\n IMPRESSION: Standard position of ETT and NGT.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-02-18 00:00:00.000",
"description": "Report",
"row_id": 227694,
"text": "Sinus rhythm. Modest non-specific ST-T wave changes. Compared to the previous\ntracing of diffuse ST segment elevation has improved. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-02-19 00:00:00.000",
"description": "Report",
"row_id": 227693,
"text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"
}
] |
32,707 | 128,977 | 85 year old female with small bowel AVMs, aortic stenosis, CHF, admitted with weakness and acute decrease in Hct due to a GI Bleed. | Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. # Hematocrit drop/GIB/anemia. # Hematocrit drop/GIB/anemia. # Hematocrit drop/GIB/anemia. # Hematocrit drop/GIB/anemia. # Hematocrit drop/GIB/anemia. AVM's mid jejunum -- cauterized. Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Received patient with h/o decrease in HCT, transfusing 1 unit PRBC, vital signs stable. Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Received patient with h/o decrease in HCT, transfusing 1 unit PRBC, vital signs stable. Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Received patient with h/o decrease in HCT, transfusing 1st unit PRBC, vital signs stable. Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Received patient with h/o decrease in HCT, transfusing 1st unit PRBC, vital signs stable. - diuretic for now - Management of LGIB as above. - diuretic for now - Management of LGIB as above. EGD : Normal esophagus. EGD : Normal esophagus. Pt currently on clear liquids but will be made NPO after MN. Pt currently on clear liquids but will be made NPO after MN. Pt currently on clear liquids but will be made NPO after MN. Given Guaiac positive without frank blood, enteroscopy. Given Guaiac positive without frank blood, enteroscopy. Given Guaiac positive without frank blood, enteroscopy. - Check orthostatics in AM if still with symptoms. - Check orthostatics in AM if still with symptoms. Moderate (2+) mitral regurgitation is seen. Moderate (2+) mitral regurgitation is seen. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal half of the inferolateral wall. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal half of the inferolateral wall. Anemia without rapid departure from baseline. Anemia without rapid departure from baseline. Anemia without rapid departure from baseline. Likely related to acute or subacute blood losses and hypovolemia; per patient's decription sounds orthostatic. Likely related to acute or subacute blood losses and hypovolemia; per patient's decription sounds orthostatic. Likely related to acute or subacute blood losses and hypovolemia; per patient's decription sounds orthostatic. Likely related to acute or subacute blood losses and hypovolemia; per patient's decription sounds orthostatic. - Hold diuretic and BB. - Hold diuretic and BB. - Hold diuretic and BB. - Hold diuretic and BB. - Hold diuretic and BB. - Hold diuretic and BB. In the ED, initial vs were: T97.3 P86 121/49 R18 93% RA. In the ED, initial vs were: T97.3 P86 121/49 R18 93% RA. # Hematologic disorder/GI lesion - MGUS soft call - just small lambda spike. Action: She has been maintained on room air with O2 sats of 93-95 but required 2l NC during the EDG so left on. Action: She has been maintained on room air with O2 sats of 93-95 but required 2l NC during the EDG so left on. Images: CXR : no acute process; improvement in interstitial edema compared to previous film. Images: CXR : no acute process; improvement in interstitial edema compared to previous film. Soft +BS, easily reducible hernia. TTE : mild symmetric left ventricular hypertrophy. TTE : mild symmetric left ventricular hypertrophy. Response: Pt currently without adv rxn to first unit of PRBCs thus far. No plasmacytomas ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 04:13 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold off on flex sig or colonoscopy without gross red blood right now. - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold off on flex sig or colonoscopy without gross red blood right now. - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold off on flex sig or colonoscopy without gross red blood right now. Patient alert oriented x3, on clear liquids. Patient alert oriented x3, on clear liquids. Patient alert oriented x3, on clear liquids. # Hematologic disorder/GI lesion - MGUS - just small lambda spike. # Hematologic disorder/GI lesion - MGUS - just small lambda spike. GI loss differential - small bowel AVMs, diverticulosis, colonic mass/?plasmacytoma, gastritis or other upper source. GI loss differential - small bowel AVMs, diverticulosis, colonic mass/?plasmacytoma, gastritis or other upper source. GI loss differential - small bowel AVMs, diverticulosis, colonic mass/?plasmacytoma, gastritis or other upper source. Action: Pt now on clear liquid diet but will be made NPO @ MN and may be given Go-Lytely in AM for possible colonoscopy prep. IMPRESSION: Findings compatible with mild congestive heart failure. IMPRESSION: Findings compatible with mild congestive heart failure. IMPRESSION: Findings compatible with mild congestive heart failure. IMPRESSION: Findings compatible with mild congestive heart failure. Assessment and Plan 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness and acute decrease in Hct, presumed GIB. Assessment and Plan 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness and acute decrease in Hct, presumed GIB. Assessment and Plan 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness and acute decrease in Hct, presumed GIB. | 17 | [
{
"category": "Nursing",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511229,
"text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511231,
"text": "85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n .\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received patient with h/o decrease in HCT, transfusing 1 unit PRBC,\n vital signs stable. Patient alert, oriented x3, on clear liquids. No\n c/o abd pain, abdomen soft distended/obese, BS present.\n Action:\n NPO after midnight, PPI \n Response:\n Plan:\n Continue monitor s/s of bleeding, and labs\n # Hematocrit drop/GIB/anemia. Presumed blood loss from GI source; no\n evidence urinary bleeding (though has had in recent past) or blood loss\n elsewhere. GI loss differential - small bowel AVMs, diverticulosis,\n colonic mass/?plasmacytoma, gastritis or other upper source. Loss\n known to be subacute vs. acute based on previous labs; patient gives no\n history of visible BRB/melena. Has known longstanding iron deficiency\n anemia presumed from GI source. ASA also a new med for patient since\n last admission.\n - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold\n off on flex sig or colonoscopy without gross red blood right now.\n Would likely benefit from future colonoscopy given ongoing anemia and\n past ?plasmacytoma which was not seen on repeat scope.\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI.\n - Will complete 2 units PRBCs given that patient symptomatic. Repeat\n Hct after next transfusion.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511232,
"text": "85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received patient with h/o decrease in HCT, transfusing 1 unit PRBC,\n vital signs stable. Patient alert oriented x3, on clear liquids. No c/o\n abd pain, abdomen soft distended/obese, BS present.\n Action:\n NPO after midnight, PPI , after 1 unit PRBC hct 23.6 and 2 more\n units transfused\n Response:\n Plan:\n Continue monitor s/s of bleeding, labs and transfuse accordingly. GI\n following\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 511345,
"text": "Chief Complaint: Weakness and dizziness, presyncopal\n Reason for MICU admission: anemia/?LGIB in elderly female with CHF\n 24 Hour Events:\n - No events overnight\n - Transfused 2 units overnight and one this a.m. 23 - 29.5\n - Await GI recs for further investigation today\n - Scope early this afternoon - jejunal enteroscopy\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 74 (73 - 101) bpm\n BP: 105/35(53) {92/35(51) - 141/61(70)} mmHg\n RR: 20 (18 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,754 mL\n 709 mL\n PO:\n 200 mL\n 200 mL\n TF:\n IVF:\n 79 mL\n 84 mL\n Blood products:\n 575 mL\n 425 mL\n Total out:\n 1,220 mL\n 760 mL\n Urine:\n 1,220 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 534 mL\n -51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n General: Alert, oriented, no acute distress, very pleasant and well\n appearing\n HEENT: Sclera anicteric, conjunctiva pale, MMM, oropharynx clear, no\n dried blood.\n Neck: supple, JVD flat, no LAD.\n Lungs: Clear to auscultation bilaterally with exception of L base, with\n few inspiratory crackles, improve slightly with cough.\n CV: Regular rate and rhythm, 4/6 systolic murmur best at RUSB with\n radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Rectal: external hemorrhoids present, no rectal masses, no stool\n present.\n Ext: warm, well perfused, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact, strength 5/5 in distal uppers and all lowers,\n oriented x 3.\n Labs / Radiology\n 195 K/uL\n 9.8 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.3 mEq/L\n 35 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.5 %\n 13.1 K/uL\n [image002.jpg]\n 09:37 PM\n 04:22 AM\n WBC\n 13.1\n Hct\n 23.6\n 29.5\n Plt\n 195\n Cr\n 0.9\n 0.8\n TropT\n <0.01\n Glucose\n 150\n 99\n Other labs: PT / PTT / INR:12.0/19.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Imaging: CHEST RADIOGRAPH PERFORMED ON :\n Comparison is made with multiple prior chest radiographs dating back to\n .\n CLINICAL HISTORY: Chest pain, question pneumonia.\n FINDINGS: PA and lateral views of the chest are obtained. There is mild\n prominence of pulmonary vascular markings which is suggestive of mild\n congestive heart failure. No pleural effusions or pneumothorax is\n seen.\n There is no evidence of pneumonia. Cardiomediastinal silhouette is\n normal.\n Osseous structures are diffusely demineralized but appear intact.\n IMPRESSION: Findings compatible with mild congestive heart failure.\n Microbiology: MRSA and blood cultures pending.\n Assessment and Plan\n 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n # Hematocrit drop/GIB/anemia. Anemia without rapid departure from\n baseline. Guaiac positive stool and pellets, but says corresponds to\n iron supplementation. Jejunal AVMs documented previously. Given Guaiac\n positive without frank blood, enteroscopy.\n - Enteroscopy this afternoon\n - Stay in ICU until then and call depending on results\n - Check HCt this afternoon\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI\n # Presyncope. AS with volume depletion likely\n very preload dependent.\n Orthostatics showed small increase of pressure on standing with\n increased HR of 10 BPM. Can imagine quite orthostatic on presentation.\n Likely related to acute or subacute blood losses and hypovolemia; per\n patient's decription sounds orthostatic. No evidence of neurologic\n cause or neuro deficit or arrhythmia. CXR shows no cephalization and\n very clear compared to fluid overloaded film from . We think\n she is likely near euvolemic at the moment.\n - diuretic for now\n - Management of LGIB as above.\n - DC telemetry given just a couple of PVCs and short SVT overnight\n # Congestive heart failure. BNP below previous numbers in the system\n and appears generally hypovolemic. Some vascular engorgement on CXR.\n - Hold Lasix for now\n - Hold beta blocker for now.\n # Hyperglycemia. No diagnosis of diabetes but has had slightly elevated\n A1C in the past.\n - Coverage on ISS for now.\n - PCP .\n # Hematologic disorder/GI lesion\n - MGUS - just small lambda spike. No plasmacytomas\n - Followed by Dr. (BMT here)\n # AS\n Not clear if repair planned.\n - Check in with Dr. (PCP)\n - No plan to contact CT . for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT: Just boots (given bleed)\n Stress ulcer: (IV PPI)\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F aortic stenosis, MGUS, known jejeunal\n AVMs and colonic mass (?plasmacytoma) p/w anemia, weakness, and\n G+stools. Recently started asa 81mg, HCT 34 to 23 over 11 days. Xfused\n total of 3 PRBCs.\n Exam notable for Tm 97.8 BP 113/48 HR 78 (not orthostatic) RR 18 with\n sat 92 on RA. WD woman, NAD. Rales B bases R>L. RRR s1s2 4/6SM, single\n s2. Soft +BS, easily reducible hernia. No edema. Labs notable for WBC\n 13K, HCT 30, K+ 3.3, Cr 0.8. CXR clear lungs.\n Agree with plan to GI bleed / blood loss anemia with serial HCT (),\n BBS, IV access, PPI, EGD / push enteroscopy today while maintaing NPO\n and holding ASA. Given AS, will need to monitor volume status with\n transfusion, hold lasix for now as she is comfortable on RA and CXR is\n clear. AS may benefit from repair over the long-term, will d/w PCP.\n to call pt out to PCP ( ) following endoscopy. Remainder\n of plan as outlined above. Total time: 50 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:36 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511356,
"text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 511222,
"text": "Chief Complaint:\n Chief Complaint: weakness and dizziness\n Reason for MICU admission: anemia/?LGIB in elderly female with CHF\n HPI:\n 85F with CHF, aortic stenosis, known jejunal AVMs and history of\n ?colonic plasmacytoma presenting with one day of dizziness and leg\n weakness. Yesterday doing fine. Got up today and was very lightheaded\n with standing, felt presyncopal. Felt generalized weakness when\n upright, okay when supine. Family members also thought she looked more\n pale than usual. No abdominal pain, N/V, diarrhea. Last bowel\n movement this morning, describes as black pellets which she has\n attributed to iron pills. No hematochezia or melena. No hematemesis.\n No syncope or vertigo. No CP, palps, dyspnea. Has not noted any\n hematuria since recent admission. No vaginal bleeding. No NSAIDs\n other than 81 mg ASA (started about 2 weeks ago), no EtOH.\n .\n She was recently admitted to from for CHF\n exacerbation and was diuresed. She was also treated with a 5 day\n course of levofloxacin for ?pneumonia. Aspirin and lasix were started\n with this admission.\n .\n In the ED, initial vs were: T97.3 P86 121/49 R18 93% RA. She was found\n to be guaiac positive. Neurologically intact. Hct returned at 23 -\n 11.5 points lower than value from 11 days ago. Lactate 3.5. Remained\n hemodynamically stable. Patient was given protonix 40 mg IV, 40 mEQ\n potassium.\n .\n On the floor, patient feeling well lying supine. No abdominal pain or\n current dizziness.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n - allopurinol 150 mg daily\n - atenolol 25 mg daily\n - ASA 81 mg daily\n - lasix 40 mg daily\n - pantoprazole 40 mg \n - iron 325 mg \n - psyllium daily\n - vitamin D 400 units daily\n Past medical history:\n Family history:\n Social History:\n - Congestive heart failure, systolic and valvular dysfunction\n - Aortic stenosis - moderate in echo.\n - AVMs - jejunal, cauterized in \n - Fe deficiency anemia\n - MGUS - plasma cell infilatrate/mass on colonoscopy in ; SPEP\n showing MGUS. repeat biopsy not c/w plasmacytoma.\n - History of ischemic colitis x 2 episodes.\n - Gout\n - HTN\n - Hyperlipidemia\n - Hematuria of unclear etiology\n - disease involving L iliac bone\n Mother died of disease. Father died of unknown form of\n cancer. She had a brother who had a melanoma. Another brother died of\n a myocardial infarction.\n Previously worked in electronic assembly and in an office setting.\n -pack-year history of smoking, none currently (quit 80 years ago).\n No alcohol. No children but very close to niece and extended family.\n Review of systems:\n (+) Per HPI. Thinks she may have lost a few pounds since recent\n hospital discharge attributed to poor appetite.\n (-) Denies fever, chills, recent weight gain. Denies headache, visual\n changes, cough, shortness of breath, or wheezing. Denies chest pain,\n chest pressure, palpitations, nausea, vomiting, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 06:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 101) bpm\n BP: 98/61(70) {98/42(55) - 141/61(70)} mmHg\n RR: 21 (21 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,377 mL\n PO:\n 200 mL\n TF:\n IVF:\n 21 mL\n Blood products:\n 256 mL\n Total out:\n 0 mL\n 660 mL\n Urine:\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 717 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n General: Alert, oriented, no acute distress, very pleasant and well\n appearing\n HEENT: Sclera anicteric, PERRL with small pupils 2->1, conjunctiva\n pale, MMM, oropharynx clear, no dried blood.\n Neck: supple, JVD flat, no LAD.\n Lungs: Clear to auscultation bilaterally with exception of L base, with\n few inspiratory crackles, improve slightly with cough.\n CV: Regular rate and rhythm, 3/6 systolic murmur best at RUSB with\n radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Rectal: external hemorrhoids present, no rectal masses, no stool\n present.\n Ext: warm, well perfused, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact, strength 5/5 in distal uppers and all lowers,\n oriented x 3.\n Labs / Radiology\n Trop-T: <0.01\n 140\n [image002.gif]\n 97\n [image002.gif]\n 55\n [image004.gif]\n 277\n AGap=14\n [image005.gif]\n 3.1\n [image002.gif]\n 32\n [image002.gif]\n 1.1\n [image007.gif]\n CK: 42\n MB: Notdone\n Ca: 9.0 Mg: 1.6 P: 2.8\n Other Blood Chemistry:\n proBNP: 1723\n 89\n 10.9\n [image007.gif]\n 6.9\n [image004.gif]\n 263\n [image008.gif]\n [image004.gif]\n 23.0\n [image007.gif]\n N:84.3 L:12.1 M:3.0 E:0.4 Bas:0.3\n PT: 13.0\n PTT: 20.8\n INR: 1.1\n Micro:\n blood culture x 1 pending\n .\n Images:\n CXR : no acute process; improvement in interstitial edema\n compared to previous film.\n .\n TTE : mild symmetric left ventricular hypertrophy. There is\n mild regional left ventricular systolic dysfunction with hypokinesis of\n the distal half of the inferolateral wall. The remaining segments\n contract normally (LVEF = 55-60 %). There is moderate to severe aortic\n valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation\n is seen. There is mild functional mitral stenosis (mean gradient 4\n mmHg) due to mitral annular calcification. Moderate (2+) mitral\n regurgitation is seen.\n .\n EGD : Normal esophagus. Normal stomach. Duodenum: The duodenum\n and jejunum were examined. The pediatric variable colonoscope was\n advanced up to 100 cm from the incisors (mid jejunum). Multiple AVM's\n were seen and cauterized eith BICAP probe.\n .\n Colonoscopy : A single sessile 3 mm non-bleeding polyp of\n diminutive appearance was found in the descending colon. Hot forceps\n biopsies were performed for histology at the sigmoid colon. A single\n sessile 6 mm non-bleeding polyp of benign appearance was found in the\n sigmoid colon. Cold forceps biopsies were performed for histology. A\n single-piece polypectomy was performed using a hot snare. The polyp was\n completely removed. Multiple non-bleeding diverticula with medium\n openings were seen in the sigmoid colon. Some of the diverticula had\n signs of inflammation. Overall, the diverticulosis appeared to be of\n moderate severity.\n .\n EKG: NSR at 84, LBBB, no significant change from prior.\n Assessment and Plan\n 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n .\n # Hematocrit drop/GIB/anemia. Presumed blood loss from GI source; no\n evidence urinary bleeding (though has had in recent past) or blood loss\n elsewhere. GI loss differential - small bowel AVMs, diverticulosis,\n colonic mass/?plasmacytoma, gastritis or other upper source. Loss\n known to be subacute vs. acute based on previous labs; patient gives no\n history of visible BRB/melena. Has known longstanding iron deficiency\n anemia presumed from GI source. ASA also a new med for patient since\n last admission.\n - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold\n off on flex sig or colonoscopy without gross red blood right now.\n Would likely benefit from future colonoscopy given ongoing anemia and\n past ?plasmacytoma which was not seen on repeat scope.\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI.\n - Will complete 2 units PRBCs given that patient symptomatic. Repeat\n Hct after next transfusion.\n .\n # Presyncope. Likely related to acute or subacute blood losses and\n hypovolemia; per patient's decription sounds orthostatic. No evidence\n of neurologic cause or neuro deficit or arrhythmia. Patient does have\n moderate AS and thus preload dependent, also contributing.\n - Management of LGIB as above.\n - Check orthostatics in AM if still with symptoms.\n - Monitor on tele; continue cardiac enzymes x 1 more set.\n .\n # Congestive heart failure. BNP below previous numbers in the system\n and appears generally hypovolemic. No evidence of pulmonary edema on\n CXR.\n - Hold Lasix for now; IV if needed with blood products.\n - Hold beta blocker for now.\n .\n # Hyperglycemia. No diagnosis of diabetes but has had slightly elevated\n A1C in the past.\n - Coverage on ISS for now.\n - PCP .\n .\n # FEN: No IVF, replete electrolytes, NPO for now.\n # Prophylaxis: boots, PPI.\n # Access: peripherals - 18 gauge x 2\n # Communication: Patient, niece \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement, likely callout in AM\n ICU Care\n Nutrition: NPO may take ice chips\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU, to floor tomorrow\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 511309,
"text": "Chief Complaint: Weakness and dizziness, presyncopal\n Reason for MICU admission: anemia/?LGIB in elderly female with CHF\n 24 Hour Events:\n - No events overnight\n - Transfused 2 units overnight and one this a.m. 23 - 29.5\n - Await GI recs for further investigation today\n - Scope early this afternoon - jejunal enteroscopy\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 74 (73 - 101) bpm\n BP: 105/35(53) {92/35(51) - 141/61(70)} mmHg\n RR: 20 (18 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,754 mL\n 709 mL\n PO:\n 200 mL\n 200 mL\n TF:\n IVF:\n 79 mL\n 84 mL\n Blood products:\n 575 mL\n 425 mL\n Total out:\n 1,220 mL\n 760 mL\n Urine:\n 1,220 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 534 mL\n -51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 195 K/uL\n 9.8 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.3 mEq/L\n 35 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.5 %\n 13.1 K/uL\n [image002.jpg]\n 09:37 PM\n 04:22 AM\n WBC\n 13.1\n Hct\n 23.6\n 29.5\n Plt\n 195\n Cr\n 0.9\n 0.8\n TropT\n <0.01\n Glucose\n 150\n 99\n Other labs: PT / PTT / INR:12.0/19.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Imaging: CHEST RADIOGRAPH PERFORMED ON :\n Comparison is made with multiple prior chest radiographs dating back to\n .\n CLINICAL HISTORY: Chest pain, question pneumonia.\n FINDINGS: PA and lateral views of the chest are obtained. There is mild\n prominence of pulmonary vascular markings which is suggestive of mild\n congestive heart failure. No pleural effusions or pneumothorax is\n seen.\n There is no evidence of pneumonia. Cardiomediastinal silhouette is\n normal.\n Osseous structures are diffusely demineralized but appear intact.\n IMPRESSION: Findings compatible with mild congestive heart failure.\n Microbiology: MRSA and blood cultures pending.\n Assessment and Plan\n 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n # Hematocrit drop/GIB/anemia. Anemia without rapid departure from\n baseline. Guaiac positive stool and pellets, but says corresponds to\n iron supplementation. Jejunal AVMs documented previously. Given Guaiac\n positive without frank blood, enteroscopy.\n - Enteroscopy this afternoon\n - Stay in ICU until then (but consider call-out prior)\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI\n # Presyncope. Likely related to acute or subacute blood losses and\n hypovolemia; per patient's decription sounds orthostatic. No evidence\n of neurologic cause or neuro deficit or arrhythmia. Patient does have\n moderate AS and thus preload dependent, also contributing.\n - Management of LGIB as above.\n - Check orthostatics in AM if still with symptoms.\n - DC telemetry given just a couple of PVCs and short SVT overnight\n # Congestive heart failure. BNP below previous numbers in the system\n and appears generally hypovolemic. Some vascular engorgement on CXR.\n - Hold Lasix for now; IV if needed with blood products.\n - Hold beta blocker for now.\n # Hyperglycemia. No diagnosis of diabetes but has had slightly elevated\n A1C in the past.\n - Coverage on ISS for now.\n - PCP .\n # Hematologic disorder/GI lesion\n - MGUS soft call - just small lambda spike. No plasmacytomas\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 511326,
"text": "Chief Complaint: Weakness and dizziness, presyncopal\n Reason for MICU admission: anemia/?LGIB in elderly female with CHF\n 24 Hour Events:\n - No events overnight\n - Transfused 2 units overnight and one this a.m. 23 - 29.5\n - Await GI recs for further investigation today\n - Scope early this afternoon - jejunal enteroscopy\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 74 (73 - 101) bpm\n BP: 105/35(53) {92/35(51) - 141/61(70)} mmHg\n RR: 20 (18 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,754 mL\n 709 mL\n PO:\n 200 mL\n 200 mL\n TF:\n IVF:\n 79 mL\n 84 mL\n Blood products:\n 575 mL\n 425 mL\n Total out:\n 1,220 mL\n 760 mL\n Urine:\n 1,220 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n 534 mL\n -51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n General: Alert, oriented, no acute distress, very pleasant and well\n appearing\n HEENT: Sclera anicteric, conjunctiva pale, MMM, oropharynx clear, no\n dried blood.\n Neck: supple, JVD flat, no LAD.\n Lungs: Clear to auscultation bilaterally with exception of L base, with\n few inspiratory crackles, improve slightly with cough.\n CV: Regular rate and rhythm, 4/6 systolic murmur best at RUSB with\n radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Rectal: external hemorrhoids present, no rectal masses, no stool\n present.\n Ext: warm, well perfused, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact, strength 5/5 in distal uppers and all lowers,\n oriented x 3.\n Labs / Radiology\n 195 K/uL\n 9.8 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.3 mEq/L\n 35 mg/dL\n 105 mEq/L\n 141 mEq/L\n 29.5 %\n 13.1 K/uL\n [image002.jpg]\n 09:37 PM\n 04:22 AM\n WBC\n 13.1\n Hct\n 23.6\n 29.5\n Plt\n 195\n Cr\n 0.9\n 0.8\n TropT\n <0.01\n Glucose\n 150\n 99\n Other labs: PT / PTT / INR:12.0/19.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Imaging: CHEST RADIOGRAPH PERFORMED ON :\n Comparison is made with multiple prior chest radiographs dating back to\n .\n CLINICAL HISTORY: Chest pain, question pneumonia.\n FINDINGS: PA and lateral views of the chest are obtained. There is mild\n prominence of pulmonary vascular markings which is suggestive of mild\n congestive heart failure. No pleural effusions or pneumothorax is\n seen.\n There is no evidence of pneumonia. Cardiomediastinal silhouette is\n normal.\n Osseous structures are diffusely demineralized but appear intact.\n IMPRESSION: Findings compatible with mild congestive heart failure.\n Microbiology: MRSA and blood cultures pending.\n Assessment and Plan\n 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n # Hematocrit drop/GIB/anemia. Anemia without rapid departure from\n baseline. Guaiac positive stool and pellets, but says corresponds to\n iron supplementation. Jejunal AVMs documented previously. Given Guaiac\n positive without frank blood, enteroscopy.\n - Enteroscopy this afternoon\n - Stay in ICU until then and call depending on results\n - Check HCt this afternoon\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI\n # Presyncope. AS with volume depletion likely\n very preload dependent.\n Orthostatics showed small increase of pressure on standing with\n increased HR of 10 BPM. Can imagine quite orthostatic on presentation.\n Likely related to acute or subacute blood losses and hypovolemia; per\n patient's decription sounds orthostatic. No evidence of neurologic\n cause or neuro deficit or arrhythmia. CXR shows no cephalization and\n very clear compared to fluid overloaded film from . We think\n she is likely near euvolemic at the moment.\n - diuretic for now\n - Management of LGIB as above.\n - DC telemetry given just a couple of PVCs and short SVT overnight\n # Congestive heart failure. BNP below previous numbers in the system\n and appears generally hypovolemic. Some vascular engorgement on CXR.\n - Hold Lasix for now\n - Hold beta blocker for now.\n # Hyperglycemia. No diagnosis of diabetes but has had slightly elevated\n A1C in the past.\n - Coverage on ISS for now.\n - PCP .\n # Hematologic disorder/GI lesion\n - MGUS - just small lambda spike. No plasmacytomas\n - Followed by Dr. (BMT here)\n # AS\n Not clear if repair planned.\n - Check in with Dr. (PCP)\n - No plan to contact CT . for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT: Just boots (given bleed)\n Stress ulcer: (IV PPI)\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 511211,
"text": "Chief Complaint:\n Chief Complaint: weakness and dizziness\n Reason for MICU admission: anemia/?LGIB in elderly female with CHF\n HPI:\n 85F with CHF, aortic stenosis, known jejunal AVMs and history of\n ?colonic plasmacytoma presenting with one day of dizziness and leg\n weakness. Yesterday doing fine. Got up today and was very lightheaded\n with standing, felt presyncopal. Felt generalized weakness when\n upright, okay when supine. Family members also thought she looked more\n pale than usual. No abdominal pain, N/V, diarrhea. Last bowel\n movement this morning, describes as black pellets which she has\n attributed to iron pills. No hematochezia or melena. No hematemesis.\n No syncope or vertigo. No CP, palps, dyspnea. Has not noted any\n hematuria since recent admission. No vaginal bleeding. No NSAIDs\n other than 81 mg ASA (started about 2 weeks ago), no EtOH.\n .\n She was recently admitted to from for CHF\n exacerbation and was diuresed. She was also treated with a 5 day\n course of levofloxacin for ?pneumonia. Aspirin and lasix were started\n with this admission.\n .\n In the ED, initial vs were: T97.3 P86 121/49 R18 93% RA. She was found\n to be guaiac positive. Neurologically intact. Hct returned at 23 -\n 11.5 points lower than value from 11 days ago. Lactate 3.5. Remained\n hemodynamically stable. Patient was given protonix 40 mg IV, 40 mEQ\n potassium.\n .\n On the floor, patient feeling well lying supine. No abdominal pain or\n current dizziness.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n - allopurinol 150 mg daily\n - atenolol 25 mg daily\n - ASA 81 mg daily\n - lasix 40 mg daily\n - pantoprazole 40 mg \n - iron 325 mg \n - psyllium daily\n - vitamin D 400 units daily\n Past medical history:\n Family history:\n Social History:\n - Congestive heart failure, systolic and valvular dysfunction\n - Aortic stenosis - moderate in echo.\n - AVMs - jejunal, cauterized in \n - Fe deficiency anemia\n - MGUS - plasma cell infilatrate/mass on colonoscopy in ; SPEP\n showing MGUS. repeat biopsy not c/w plasmacytoma.\n - History of ischemic colitis x 2 episodes.\n - Gout\n - HTN\n - Hyperlipidemia\n - Hematuria of unclear etiology\n - disease involving L iliac bone\n Mother died of disease. Father died of unknown form of\n cancer. She had a brother who had a melanoma. Another brother died of\n a myocardial infarction.\n Previously worked in electronic assembly and in an office setting.\n -pack-year history of smoking, none currently (quit 80 years ago).\n No alcohol. No children but very close to niece and extended family.\n Review of systems:\n (+) Per HPI. Thinks she may have lost a few pounds since recent\n hospital discharge attributed to poor appetite.\n (-) Denies fever, chills, recent weight gain. Denies headache, visual\n changes, cough, shortness of breath, or wheezing. Denies chest pain,\n chest pressure, palpitations, nausea, vomiting, constipation, abdominal\n pain, or changes in bowel habits. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 06:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 101) bpm\n BP: 98/61(70) {98/42(55) - 141/61(70)} mmHg\n RR: 21 (21 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,377 mL\n PO:\n 200 mL\n TF:\n IVF:\n 21 mL\n Blood products:\n 256 mL\n Total out:\n 0 mL\n 660 mL\n Urine:\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 717 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n General: Alert, oriented, no acute distress, very pleasant and well\n appearing\n HEENT: Sclera anicteric, PERRL with small pupils 2->1, conjunctiva\n pale, MMM, oropharynx clear, no dried blood.\n Neck: supple, JVD flat, no LAD.\n Lungs: Clear to auscultation bilaterally with exception of L base, with\n few inspiratory crackles, improve slightly with cough.\n CV: Regular rate and rhythm, 3/6 systolic murmur best at RUSB with\n radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Rectal: external hemorrhoids present, no rectal masses, no stool\n present.\n Ext: warm, well perfused, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact, strength 5/5 in distal uppers and all lowers,\n oriented x 3.\n Labs / Radiology\n Trop-T: <0.01\n 140\n [image002.gif]\n 97\n [image002.gif]\n 55\n [image004.gif]\n 277\n AGap=14\n [image005.gif]\n 3.1\n [image002.gif]\n 32\n [image002.gif]\n 1.1\n [image007.gif]\n CK: 42\n MB: Notdone\n Ca: 9.0 Mg: 1.6 P: 2.8\n Other Blood Chemistry:\n proBNP: 1723\n 89\n 10.9\n [image007.gif]\n 6.9\n [image004.gif]\n 263\n [image008.gif]\n [image004.gif]\n 23.0\n [image007.gif]\n N:84.3 L:12.1 M:3.0 E:0.4 Bas:0.3\n PT: 13.0\n PTT: 20.8\n INR: 1.1\n Micro:\n blood culture x 1 pending\n .\n Images:\n CXR : no acute process; improvement in interstitial edema\n compared to previous film.\n .\n TTE : mild symmetric left ventricular hypertrophy. There is\n mild regional left ventricular systolic dysfunction with hypokinesis of\n the distal half of the inferolateral wall. The remaining segments\n contract normally (LVEF = 55-60 %). There is moderate to severe aortic\n valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation\n is seen. There is mild functional mitral stenosis (mean gradient 4\n mmHg) due to mitral annular calcification. Moderate (2+) mitral\n regurgitation is seen.\n .\n EGD : Normal esophagus. Normal stomach. Duodenum: The duodenum\n and jejunum were examined. The pediatric variable colonoscope was\n advanced up to 100 cm from the incisors (mid jejunum). Multiple AVM's\n were seen and cauterized eith BICAP probe.\n .\n Colonoscopy : A single sessile 3 mm non-bleeding polyp of\n diminutive appearance was found in the descending colon. Hot forceps\n biopsies were performed for histology at the sigmoid colon. A single\n sessile 6 mm non-bleeding polyp of benign appearance was found in the\n sigmoid colon. Cold forceps biopsies were performed for histology. A\n single-piece polypectomy was performed using a hot snare. The polyp was\n completely removed. Multiple non-bleeding diverticula with medium\n openings were seen in the sigmoid colon. Some of the diverticula had\n signs of inflammation. Overall, the diverticulosis appeared to be of\n moderate severity.\n .\n EKG: NSR at 84, LBBB, no significant change from prior.\n Assessment and Plan\n Assessment and Plan:\n 85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n .\n # Hematocrit drop/GIB/anemia. Presumed blood loss from GI source; no\n evidence urinary bleeding (though has had in past) or blood loss\n elsewhere. GI loss differential - small bowel AVMs, diverticulosis,\n colonic mass/?plasmacytoma, gastritis or other upper source. Loss\n known to be subacute vs. acute based on previous labs; patient gives no\n history of visible BRB/melena. Has known longstanding iron deficiency\n anemia presumed from GI source. ASA also a new med for patient since\n last admission.\n - GI consult - prelim thought is to EGD/?enteroscopy in the AM, hold\n off on flex sig or colonoscopy without gross red blood right now.\n Would likely benefit from future colonoscopy given ongoing anemia and\n past ?plasmacytoma which was not seen on repeat scope.\n - Consider nuclear/tagged scan if bleeding source unclear; currently\n much too slow for IR/angio.\n - Maintain 18 gauge x 2.\n - Hold ASA.\n - Hold diuretic and BB.\n - Continue IV PPI.\n - Will complete 2 units PRBCs given that patient symptomatic. Repeat\n Hct after next transfusion.\n .\n # Presyncope. Likely related to acute or subacute blood losses and\n subtle hypovolemia. No evidence of neurologic cause or neuro deficit.\n - Management of LGIB as above.\n .\n # Congestive heart failure. BNP below previous numbers in the system\n and appears generally hypovolemic. No evidence of pulmonary edema on\n CXR.\n - Hold Lasix for now; IV if needed with blood products.\n - Hold beta blocker for now.\n .\n # Hyperglycemia. No diagnosis of diabetes but has had slightly elevated\n A1C in the past.\n - Coverage on ISS for now.\n - PCP .\n .\n # FEN: No IVF, replete electrolytes, NPO for now.\n # Prophylaxis: boots, PPI.\n # Access: peripherals - 18 gauge x 2\n # Communication: Patient, niece \n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement, likely callout in AM\n ICU Care\n Nutrition: NPO may take ice chips\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU, to floor tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511208,
"text": "TITLE: Briefly, this is a pleasant/conversant 85 yr old female admitted\n to today with chief c/o weakness/dizziness. Work up revealed a\n HCT of 23 (HCT of 34 recorded in late ) and BRBPR. EKG in ED\n without ischemic changes. CXR was unremarkable. Pt is s/p recent hosp\n admit to for PNA/pulm edema/CHF exacerbation and d/c\ned to home one\n week ago. Pt recently dx with bladder tumors/polyps. Significant PMH\n includes; hypercholesterolemia, gout, CHF, HTN, GIB on Protonix. The\n pt has a Lisinopril allergy which causes tounge swelling. HCP is\n who is visiting @ the BS. The pt is times three,\n asking appropriate questions, following commands. LSCTA with sats in\n the mid 90\ns on RA. Pt currently on clear liquids but will be made NPO\n after MN. The pt is a Full Code.\n Anemia, other\n Assessment:\n Admit HCT of 23 recorded in ED today with a HCT of 34 in . The\n pt has two 18# PIV in her RUE.\n Action:\n Pt now receiving one unit of PRBC\ns via PIV. An additional unit of\n PRBC\ns is now on hold in the BB.\n Response:\n Pt currently without adv rxn to first unit of PRBC\ns thus far.\n Plan:\n Pt will likely receive another unit of PRBC\ns later this evening.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt reported to be having guaic positive stools in ED and was BRBPR.\n Pt has nl BS. Pt not stooling at this time.\n Action:\n Pt now on clear liquid diet but will be made NPO @ MN and may be given\n Go-Lytely in AM for possible colonoscopy prep.\n Response:\n The pt is currently hemodynamically stable without evidence of active\n GI bleeding @ this time.\n Plan:\n Make pt NPO after MN. Awaiting GI consult for recommendations.\n"
},
{
"category": "Physician ",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 511204,
"text": "Chief Complaint:\n HPI:\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Lisinopril\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 101) bpm\n BP: 98/61(70) {98/42(55) - 141/61(70)} mmHg\n RR: 21 (21 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,377 mL\n PO:\n 200 mL\n TF:\n IVF:\n 21 mL\n Blood products:\n 256 mL\n Total out:\n 0 mL\n 660 mL\n Urine:\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 717 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ANEMIA, OTHER\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511363,
"text": "This is a pleasant/conversant 85 yr old female admitted to today\n with chief c/o weakness/dizziness. Work up revealed a HCT of 23 (HCT\n of 34 recorded in late ) and BRBPR. EKG in ED without ischemic\n changes. CXR was unremarkable. Pt is s/p recent hosp admit to for\n PNA/pulm edema/CHF exacerbation and d/c\ned to home one week ago. Pt\n recently dx with bladder tumors/polyps. Significant PMH includes;\n hypercholesterolemia, gout, CHF, HTN, GIB on Protonix. The pt has a\n Lisinopril allergy which causes tongue swelling. HCP is \n who lives in . The pt is times three, asking appropriate\n questions, following commands. LSCTA with sats in the mid 90\ns on RA.\n Pt currently on clear liquids but will be made NPO after MN. The pt is\n a Full Code.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Her HCT at the low was 23. She has not had any bleeding since arrival\n in MICU.\n Action:\n She received 3units of RNC\ns since admission. She had and EDG today\n which showed two areas that could have been the sites of her bleeding.\n Response:\n Last Hct was 29.5. The two sites were cauterized and stopped\n bleeding.\n Plan:\n Monitor HCT over the weekend, if it drifts down then she would have a\n repeat EDG on Monday. HCT drawn at 1700 in MICU.\n Anemia, other\n Assessment:\n Hct has been monitored while in MICU. B/P has been 100-140/47-61, HR\n 78-86.\n Action:\n She has been maintained on room air with O2 sats of 93-95 but required\n 2l NC during the EDG so left on.\n Response:\n O2 sats have been 96-97%.\n Plan:\n Continue to monitor.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ANEMIA\n Code status:\n Height:\n 61 Inch\n Admission weight:\n 62.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n throat swelling\n Precautions:\n PMH: Anemia, GI Bleed\n CV-PMH: CHF\n Additional history: Hypercholesterolemia. Gout. Recent dx of\n tumor/polyps in bladder. AVM's mid jejunum -- cauterized. Heart\n murmur.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:59\n Temperature:\n 96.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,045 mL\n 24h total out:\n 1,340 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:22 AM\n Potassium:\n 3.3 mEq/L\n 04:22 AM\n Chloride:\n 105 mEq/L\n 04:22 AM\n CO2:\n 29 mEq/L\n 04:22 AM\n BUN:\n 35 mg/dL\n 04:22 AM\n Creatinine:\n 0.8 mg/dL\n 04:22 AM\n Glucose:\n 99 mg/dL\n 04:22 AM\n Hematocrit:\n 29.5 %\n 04:22 AM\n Finger Stick Glucose:\n 128\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 684\n Transferred to: CC 716\n Date & time of Transfer: 18:00 PM\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511263,
"text": "85F with small bowel AVMs, aortic stenosis, CHF, admitted with weakness\n and acute decrease in Hct, presumed GIB.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received patient with h/o decrease in HCT, transfusing 1st unit PRBC,\n vital signs stable. Patient alert oriented x3, on clear liquids. No c/o\n abd pain, abdomen soft distended/obese, BS present.\n Action:\n NPO after midnight, PPI , after 1 unit PRBC hct 23.6 and 2 more\n units transfused\n Response:\n Post transfusion HCt thisAM 29.5, no signs of bleeding\n Plan:\n Continue monitor s/s of bleeding, labs and transfuse accordingly. GI\n following ? scope in AM\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511264,
"text": "TITLE: Briefly, this is a pleasant/conversant 85 yr old female admitted\n to today with chief c/o weakness/dizziness. Work up revealed a\n HCT of 23 (HCT of 34 recorded in late ) and BRBPR. EKG in ED\n without ischemic changes. CXR was unremarkable. Pt is s/p recent hosp\n admit to for PNA/pulm edema/CHF exacerbation and d/c\ned to home one\n week ago. Pt recently dx with bladder tumors/polyps. Significant PMH\n includes; hypercholesterolemia, gout, CHF, HTN, GIB on Protonix. The\n pt has a Lisinopril allergy which causes tongue swelling.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received patient with h/o decrease in HCT, transfusing 1st unit PRBC,\n vital signs stable. Patient alert oriented x3, on clear liquids. No c/o\n abd pain, abdomen soft distended/obese, BS present.\n Action:\n NPO after midnight, PPI , after 1 unit PRBC hct 23.6 and 2 more\n units transfused\n Response:\n Post transfusion HCt thisAM 29.5, no signs of bleeding\n Plan:\n Continue monitor s/s of bleeding, labs and transfuse accordingly. GI\n following ? scope in AM\n"
},
{
"category": "Nursing",
"chartdate": "2128-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511361,
"text": "This is a pleasant/conversant 85 yr old female admitted to today\n with chief c/o weakness/dizziness. Work up revealed a HCT of 23 (HCT\n of 34 recorded in late ) and BRBPR. EKG in ED without ischemic\n changes. CXR was unremarkable. Pt is s/p recent hosp admit to for\n PNA/pulm edema/CHF exacerbation and d/c\ned to home one week ago. Pt\n recently dx with bladder tumors/polyps. Significant PMH includes;\n hypercholesterolemia, gout, CHF, HTN, GIB on Protonix. The pt has a\n Lisinopril allergy which causes tongue swelling. HCP is \n who lives in . The pt is times three, asking appropriate\n questions, following commands. LSCTA with sats in the mid 90\ns on RA.\n Pt currently on clear liquids but will be made NPO after MN. The pt is\n a Full Code.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Her HCT at the low was 23. She has not had any bleeding since arrival\n in MICU.\n Action:\n She received 3units of RNC\ns since admission. She had and EDG today\n which showed two areas that could have been the sites of her bleeding.\n Response:\n Last Hct was 29.5. The two sites were cauterized and stopped\n bleeding.\n Plan:\n Monitor HCT over the weekend, if it drifts down then she would have a\n repeat EDG on Monday. HCT drawn at 1700 in MICU.\n Anemia, other\n Assessment:\n Hct has been monitored while in MICU. B/P has been 100-140/47-61, HR\n 78-86.\n Action:\n She has been maintained on room air with O2 sats of 93-95 but required\n 2l NC during the EDG so left on.\n Response:\n O2 sats have been 96-97%.\n Plan:\n Continue to monitor.\n"
},
{
"category": "ECG",
"chartdate": "2128-02-12 00:00:00.000",
"description": "Report",
"row_id": 141092,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nthere is no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-02-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1115445,
"text": " 1:24 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with s/p CP\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON :\n\n Comparison is made with multiple prior chest radiographs dating back to\n .\n\n CLINICAL HISTORY: Chest pain, question pneumonia.\n\n FINDINGS: PA and lateral views of the chest are obtained. There is mild\n prominence of pulmonary vascular markings which is suggestive of mild\n congestive heart failure. No pleural effusions or pneumothorax is seen.\n There is no evidence of pneumonia. Cardiomediastinal silhouette is normal.\n Osseous structures are diffusely demineralized but appear intact.\n\n IMPRESSION: Findings compatible with mild congestive heart failure.\n\n\n"
}
] |
77,067 | 140,990 | SEVERE ACUTE PANCREATITIS WITH FORMING PSEUDOCYST AND ASSOCIATED PANCREATIC NECROSIS: the patient was initially septic with ARDS, she was in distributive shock and intubated for hypoxemic respiratory failure. She required massive fluid resuscitation with 19 liters of IVF and vasopressor agents. She was treated also with bowel rest and meropenem for antibiotics. She had ongoing fevers for several weeks that had eventually resolved. Her diet was advanced to clear liquids, she refused nasojejunal feeding and therefore was initiated on TPN and discharged on this. She will follow up with general surgery in 3 weeks with a repeat CT scan of her abdomen with contrast, if her pseudocyst is fully formed Dr. may perform surgery for symptomatic treatment of a large pseudocyst. Her pancreatitis was likely related to ETOH use and possible contribution from hypertriglyceridemia. | Left lower lobe opacity that is unchanged is a combination of pleural effusion and atelectasis. An ET tube terminates in the mid intrathoracic trachea appropriately. Right IJ catheter tip is in the mid-to-lower SVC. FRONTAL CHEST RADIOGRAPH: Again seen are an endotracheal tube, orogastric tube, and left-sided PICC line. FINDINGS: The Dobbhoff tube is now present in the stomach; however, it is looped within the stomach and is not in the post-pyloric position. The tip of the wire cannulates the azygous vein, no less than 7 cm from its insertion with the superior vena cava: Severe left lower lobe atelectasis, small-to-moderate left pleural effusion and mild right lower lobe atelectasis are unchanged. A right IJ catheter terminates in the distal SVC appropriately as well. An NG tube terminates in the stomach appropriately. FINDINGS: A left-sided PICC, right-sided IJ, esophageal manometer catheter, and OG tube all appear stable in configuration. FINDINGS: In comparison with study of , the endotracheal tube and intestinal tube have been removed. whether in lungs of esophagus FINAL REPORT HISTORY: Evaluate Dobbhoff. IMPRESSION: Right-sided PICC with tip in the left brachiocephalic vein. Left pleural effusion and basilar opacity persists. IMPRESSION: Dobbhoff within the stomach, however, the catheter is looped on itself and not post pyloric. A Foley catheter is noted (Over) 3:34 PM CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # Reason: any evidence of abscess or ileus Admitting Diagnosis: PANCREATITIS FINAL REPORT (Cont) within the bladder appropriately. Trace pericardial effusion is present, likely physiologic. Persistent left basilar opacity and effusion and right hilar opacity. Left lower lung opacity with volume loss persists. An aberrant right hepatic duct arises from the mid CBD at the same level as the cystic duct (series 10 image 1). Aberrant right hepatic duct arises from the mid CBD. Left pleural effusion persists. Stable bilateral simple pleural effusions with basal atelectasis. Areas of reduced enhancement are present in the head and neck of the pancreas which may represent early necrosis (series 19 image 16). Right lower lobe consolidation is probably atelectasis. There is associated bibasilar atelectasis, left greater than right, similar to the prior study. Dual channel right supraclavicular central venous line ends in the SVC. Collapse of the left lower lobe with moderate left pleural effusion persists. Collapse of the left lower lobe with moderate pleural effusion and shift of the mediastinum to this side persists. FINDINGS: There has been interval placement of a right-sided PICC line. FINDINGS: The imaged lung bases demonstrate moderate-sized left and a small right pleural effusions, which are unchanged since the prior study. There is evidence of severe pancreatitis with reduced enhancement of the head and neck of the pancreas. There is mild edema of the subcutaneous tissues. Left lower lobe remains consolidated, probably collapsed. IMPRESSION: Right-sided PICC visible only into the right subclavian vein with tip not identified. Small left pleural effusion is presumed. Bilateral pleural effusions are present with associated atelectasis. Right-sided PICC with tip either in the upper or upper-to-mid SVC. Bilateral simple pleural effusions with basal atelectasis, stable. There is now question of the left suprahilar pneumonia. No contraindications for IV contrast PFI REPORT PFI: There is evidence of severe pancreatitis with reduced enhancement of the head and neck of the pancreas. Dual-channel right supraclavicular central venous line ends low in the SVC. Moderate right and small left simple pleural effusions. Moderate right and small left simple pleural effusions. Moderate right and small left simple pleural effusions. FINDINGS: Although difficult to evaluate due to the co-existent presence of a left subclavian central catheter the tip of the left PIC catheter appears to be in the mid to upper SVC. Unchanged right basilar opacity (DDx atelectasis vs. PNA). The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present. Non-specificST-T wave flattening as compared with previous tracing of . There are small R waves in the anteriorleads consistent with possible prior myocardial infarction. Physiologic mitral regurgitation is seen (withinnormal limits). FINDINGS: CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: There is left greater than right moderate bilateral simple pleural effusions with associated compressive atelectasis. Small left pleural effusion. Small left pleural effusion. Normal PAsystolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the mid abdomen initially without and subsequently after the uneventful administration of 130 cc of Optiray intravenous contrast. Cannot exclude prioranterior wall myocardial infarction. IMPRESSION: Left PIC catheter tip at the mid to upper SVC. Left subclavian and right internal jugular catheters are in unchanged positions. ET tube is in standard placement and a nasogastric tube ends in the region of the pylorus. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 65Weight (lb): 170BSA (m2): 1.85 m2BP (mm Hg): 110/60HR (bpm): 104Status: OutpatientDate/Time: at 10:27Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.MITRAL VALVE: Normal mitral valve leaflets. The left ventricular cavity is unusually small.Regional left ventricular wall motion is normal. There is inferolateral ST segmentflattening and slight depression. | 43 | [
{
"category": "Radiology",
"chartdate": "2130-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179351,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n r/o interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to assess for change.\n\n FINDINGS: In comparison with study of , the endotracheal tube and\n intestinal tube have been removed. The tips of the subclavian catheters\n appear to extend to the lower portion of the SVC. Bilateral pleural effusions\n persist, though they appear less prominent than on the prior study.\n Retrocardiac opacification is consistent with some volume loss at the left\n base. Prominence of central hilar vessels suggests some elevation of\n pulmonary venous pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178759,
"text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, respiratory distress\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe pancreatitis with respiratory distress.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Again seen are an endotracheal tube, orogastric\n tube, and left-sided PICC line. There is a dense retrocardiac opacity with\n left-sided pleural effusion which is not significantly changed. Vascular\n congestion is also stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178137,
"text": " 4:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: location of dubhoff\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis requiring intubation and now s/p\n dubhoff placement\n REASON FOR THIS EXAMINATION:\n location of dubhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph at 3:45 p.m.\n\n FINDINGS: The Dobbhoff tube is now present in the stomach; however, it is\n looped within the stomach and is not in the post-pyloric position. A\n left-sided PICC catheter, right IJ catheter, and nasogastric tube are stable\n and satisfactory in position. The ET tube tip is at the level of the\n clavicles. A retrocardiac consolidation is stable. No pneumothorax is\n present.\n\n IMPRESSION: Dobbhoff within the stomach, however, the catheter is looped on\n itself and not post pyloric. Other support lines stable with the ET tube tip\n at the level of the clavicles.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1180486,
"text": " 5:03 PM\n CHEST (PA & LAT) Clip # \n Reason: pls obtain oblique/lateral film to confirm tip of pt's rue\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with rue picc, difficult to see tip\n REASON FOR THIS EXAMINATION:\n pls obtain oblique/lateral film to confirm tip of pt's rue picc\n ______________________________________________________________________________\n WET READ: IPf WED 5:45 PM\n Unusual PICC course; it appears it goes down presumably in the svc; however,\n makes unusual curvature to the left (90degrees angle ) cross the mediastinum\n and tip projects to the left of the carina on frontal view.\n d/ at 5:43 pm on \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:07 P.M. ON \n\n HISTORY: Right upper extremity PIC line. Assess tip position.\n\n IMPRESSION:\n AP chest compared to at 3:22 p.m.:\n\n Right PIC line has been adjusted. The tip of the wire cannulates the azygous\n vein, no less than 7 cm from its insertion with the superior vena cava:\n\n Severe left lower lobe atelectasis, small-to-moderate left pleural effusion\n and mild right lower lobe atelectasis are unchanged. Upper lungs clear.\n Heart size normal. A member of the venous access team was paged to correct\n the initial communication, at the time of formal dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-22 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1178293,
"text": " 3:34 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: any evidence of abscess or ileus\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 yo with severe pancreatitis, tachycardic with fever and increasing WBC, MSSA\n in the sputum, on CVVH\n REASON FOR THIS EXAMINATION:\n any evidence of abscess or ileus\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old with severe pancreatitis, tachycardia with fevers,\n and rising white blood count.\n\n COMPARISON: Chest radiograph from , CT of the abdomen and\n pelvis from .\n\n TECHNIQUE: MDCT images were acquired through the chest, abdomen and pelvis\n without IV or oral contrast. Multiplanar reformations were obtained and\n reviewed.\n\n CT OF THE CHEST WITHOUT IV CONTRAST:\n\n The partially imaged thyroid gland appears unremarkable. There is no axillary\n or mediastinal lymphadenopathy by CT size criteria. The heart and great\n vessels are unremarkable. A pericardial lymph node is not enlarged by CT size\n criteria (2:34). There is a tiny pleural effusion. A left-sided PICC line\n terminates in the distal SVC appropriately. A right IJ catheter terminates in\n the distal SVC appropriately as well. An NG tube terminates in the stomach\n appropriately. An ET tube terminates in the mid intrathoracic trachea\n appropriately.\n\n The visible lungs show left greater than right small pleural effusions with\n associated compressive atelectasis. No nodules or effusions are noted.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST:\n\n The pancreas is swollen and edematous with significant surrounding stranding\n and a large amount of free fluid, consistent with pancreatitis. No stones or\n calcifications in the pancreatic parenchyma to suggest pancreatic ductal\n obstruction from a calculus is noted. No pseudocyst formation is noted. The\n spleen, liver, both adrenals, both kidneys, and gallbladder are unremarkable\n given this non-contrast examination. The small and large bowel loops are\n unremarkable. No abdominal free air is present.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST:\n\n There is simple free fluid in the pelvis. The rectum, sigmoid colon, uterus,\n bladder, and both adnexa are unremarkable. No pelvic or inguinal\n lymphadenopathy or pelvic free fluid is present. A Foley catheter is noted\n (Over)\n\n 3:34 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: any evidence of abscess or ileus\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n within the bladder appropriately.\n\n IMPRESSION:\n\n 1. Swollen edematous pancreas with significant surrounding stranding and\n moderate free fluid consistent with severe pancreatitis. Evaluation for\n necrosis is limited in the absence of IV contrast.\n\n 2. Left greater than right small pleural effusions with associated left\n greater than right compressive atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178238,
"text": " 11:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitis. This morning new fever spike and\n sepsis phiysology.\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Fever, acute bronchitis.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiac size is normal. Right IJ catheter tip is in the mid-to-lower SVC. NG\n tube tip is out of view below the diaphragm. ET tube is in standard position.\n Left lower lobe opacity that is unchanged is a combination of pleural effusion\n and atelectasis. Left PICC tip is in the lower SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178128,
"text": " 3:31 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? whether in lungs of esophagus\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman s/p dubhoff partially placed\n REASON FOR THIS EXAMINATION:\n ? whether in lungs of esophagus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate Dobbhoff.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph at 9 a.m.\n\n FINDINGS: A left-sided PICC, right-sided IJ, esophageal manometer catheter,\n and OG tube all appear stable in configuration. The ETT is somewhat higher in\n position than on the prior study, now slighly above the clavicles. A newly\n placed Dobbhoff catheter is just at or below the GE junction and could be\n advanced further. Retrocardiac atelectasis and left basilar atelectasis is\n stable. There is no pneumothorax. There may be a small left pleural\n effusion.\n\n IMPRESSION: Dobbhoff tube at or just below the GE junction and could be\n further advanced. ETT above the level of the clavicles, may require\n repositioning.\n\n Findings were discussed via telephone with Dr. at 4 p.m.\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-23 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1178417,
"text": ", MED 10:45 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post-pyloric Dobhoff tube placement\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitis and starting enteral feeds.\n REASON FOR THIS EXAMINATION:\n post-pyloric Dobhoff tube placement\n ______________________________________________________________________________\n PFI REPORT\n Successful placement of nasointestinal tube into the small bowel.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-23 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1178416,
"text": " 10:45 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post-pyloric Dobhoff tube placement\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitis and starting enteral feeds.\n REASON FOR THIS EXAMINATION:\n post-pyloric Dobhoff tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:31 PM\n Successful placement of nasointestinal tube into the small bowel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute pancreatitis, starting enteral feeds. Please place\n post-pyloric Dobbhoff tube.\n\n TECHNIQUE: Fluoroscopic-guided nasointestinal tube placement.\n\n FINDINGS: Under fluoroscopic guidance, an 8 French - catheter\n was advanced until the distal tip was in the duodenum. 10 cc of Optiray was\n instilled to confirm placement. Tube was then flushed with normal saline.\n\n IMPRESSION: Successful placement of nasointestinal tube into the duodenum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-17 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1177595,
"text": " 1:03 PM\n RENAL U.S. PORT Clip # \n Reason: blood flow to kidneys? urinary obstruction?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis and no UOP.\n REASON FOR THIS EXAMINATION:\n blood flow to kidneys? urinary obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe pancreatitis and no urine output. Evaluate blood flow to\n kidneys and for the possibility of urinary obstruction.\n\n COMPARISON: No prior ultrasound available for comparison, a CT abdomen dated\n is available for review.\n\n FINDINGS: While this study is technically limited, the right kidney measures\n 12.6 cm without evidence of hydronephrosis, renal calculi or mass. The left\n kidney measures 12.3 cm without evidence of hydronephrosis. There is normal\n color flow in the main renal arteries and veins bilaterally.\n\n IMPRESSION:\n 1. Normal renal , without evidence of hydronephrosis.\n 2. Doppler interrogation confirms patency of main renal arteries and veins\n bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-10 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 1181099,
"text": " 11:10 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: evaluate for DVT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with bilat lower ext edema\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old female with bilateral lower extremity edema.\n\n COMPARISON: None available.\n\n BILATERAL VENOUS DUPLEX ULTRASOUND: -scale and Doppler son of the\n bilateral common femoral, superficial femoral, popliteal, posterior tibial,\n and peroneal veins were performed. There is normal compressibility, flow and\n augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1180617,
"text": " 2:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 42cm new picc exchanged right arm. tip?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 42cm new picc exchanged right arm. tip?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old female with new PICC.\n\n COMPARISON: at 1:20 p.m.\n\n TECHNIQUE: AP radiograph of the chest was obtained.\n\n FINDINGS: There is a right-sided PICC coursing into the left brachiocephalic\n vein. Left pleural effusion and basilar opacity persists.\n\n IMPRESSION: Right-sided PICC with tip in the left brachiocephalic vein.\n\n This finding was reported to of the IV team by Dr. by\n telephone at 3:05 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178785,
"text": " 9:04 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: worsening/change on CXR\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, intubated and increased 02\n requirement today\n REASON FOR THIS EXAMINATION:\n worsening/change on CXR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe pancreatitis, intubated.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Lines and tubes are in unchanged position. The\n examination is stable in appearance with a persistent left retrocardiac\n opacity and small left-sided pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177428,
"text": " 2:34 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: repeat CXT after advancement of ET tube\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitis, intubated, ventilated\n REASON FOR THIS EXAMINATION:\n repeat CXT after advancement of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate ET tube.\n\n Comparison is made with prior study performed 6 hours earlier.\n\n ET tube tip is 4.5 cm above the carina. Of note, left lateral aspect of the\n left hemithorax was not included on the film. There are no other acute\n interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179087,
"text": " 1:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check placemetn of dobhoff & OGT.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, resp failure s/p responsitioning of\n dobhoff tube.\n REASON FOR THIS EXAMINATION:\n check placemetn of dobhoff & OGT.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure in patient with severe\n pancreatitis.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is 4 cm above the carina. The Dobbhoff tube tip is in the\n distal duodenum/proximal jejunum. The NG tube tip is in the stomach.\n\n There is still present left lower lobe atelectasis. Right basal atelectasis\n has progressed since the prior study. Bilateral pleural effusions are seen as\n well as there is still presence of pulmonary edema, interstitial, moderate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1180471,
"text": " 3:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt. had a right sided picc line placed,42cm and needs tip co\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with PICC for tpn.\n REASON FOR THIS EXAMINATION:\n Pt. had a right sided picc line placed,42cm and needs tip confirmation please\n at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old female, status post PICC placement.\n\n COMPARISON: .\n\n TECHNIQUE: Frontal view of the chest was obtained.\n\n FINDINGS: There has been interval placement of a right-sided PICC line. The\n tip is not definitively visualized, but may be in the vicinity of the\n confluence of the brachiocephalic vein and upper SVC or alternatively in the\n upper-to-mid SVC. If definitive localization is desired, oblique or lateral\n views are recommended. Left lower lung opacity with volume loss persists.\n There is likely also a left pleural effusion. Underlying consolidation cannot\n be excluded. Opacity in the region of the right hilum may represent\n atelectasis, but consolidation cannot be excluded.\n\n IMPRESSION:\n 1. Right-sided PICC with tip either in the upper or upper-to-mid SVC. If\n definitive localization is desired, lateral or oblique views are recommended.\n This finding was discussed with of the IV team by Dr. by\n telephone at 4:00 p.m. on .\n\n 2. Persistent left basilar opacity and effusion and right hilar opacity.\n These likely represent atelectasis, although consolidations cannot be\n excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178566,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis and respiratory distress\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory distress with severe pancreatitis.\n\n Comparison is made with prior study .\n\n Cardiomediastinal contours are normal. Left pleural effusion is small.\n Bilateral basal atelectasis have worsened. There is mild vascular congestion.\n Lines and tubes remain in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177923,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with developing PNA\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n FINDINGS: In comparison with the study of , the esophageal manometer\n appears to have been pulled back so that the tip lies above the\n esophagogastric junction. Other monitoring and support devices remain in\n place. Collapse of the left lower lobe with moderate left pleural effusion\n persists. No evidence of pulmonary vascular congestion.\n\n The area of questioned consolidation in the suprahilar portion of the left\n upper lobe is no longer appreciated. Opacification at the right base most\n likely represents atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178028,
"text": " 6:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis, to assess for change.\n\n FINDINGS: In comparison with the study of , there is little change in the\n monitoring and support devices. Collapse of the left lower lobe with moderate\n pleural effusion and shift of the mediastinum to this side persists. Area of\n opacification at the right base medially may merely reflect crowding of\n vessels, though the possibility of supervening pneumonia would have to be\n considered.\n\n No evidence of pulmonary vascular congestion or right effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-07 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1180774,
"text": " 3:07 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Malpositioned PICC line, please position correctly\n Admitting Diagnosis: PANCREATITIS\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with PICC line\n REASON FOR THIS EXAMINATION:\n Malpositioned PICC line, please position correctly\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE EXCHANGE\n\n INDICATION: Malposition of indwelling PICC line.\n\n RADIOLOGISTS: Dr. , Dr. , and Dr. \n (attending physician).\n\n TECHNIQUE:\n The procedure was explained to the patient. A timeout was performed. Using\n sterile technique and local anesthesia, a guide wire was advanced through the\n indwelling right arm PICC line, and subsequently into the SVC under\n fluoroscopic guidance. The old PICC line was then removed and a peel-away\n sheath was then placed over the guide wire. A new double-lumen PICC line\n measuring 38 cm in length was then placed through the peel-away sheath with\n its tip positioned in the SVC under fluoroscopic guidance. Position of the\n catheter was confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guide wire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\n new double-lumen PICC line. Final internal length is 38 cm, with the tip\n positioned in the SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179659,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, recently extubated\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:49 A.M., \n\n HISTORY: Severe pancreatitis, recently extubated.\n\n IMPRESSION: AP chest compared to through :\n\n Right lung is clear. Left lower lobe remains consolidated, probably\n collapsed. Small left pleural effusion is presumed. Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1180600,
"text": " 12:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Picc repo\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n Picc repo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old female with new PICC line.\n\n COMPARISON: .\n\n TECHNIQUE: Frontal radiograph of the chest was obtained.\n\n FINDINGS: A right-sided PICC line is seen in the right subclavian vein;\n however, the tip is not definitively visualized. It appears that the wire has\n been removed. Lateral view may be helpful in identifying the tip location.\n Left pleural effusion persists. Left basilar opacity likely corresponds to\n compressive atelectasis.\n\n IMPRESSION: Right-sided PICC visible only into the right subclavian vein with\n tip not identified. Lateral view may be helpful in identifying the tip.\n\n These findings were reported to of the IV team by Dr. by\n telephone at 2:00 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-14 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1181842,
"text": " 10:54 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Assess pancreatitis, pseudocyst formation, retroperitoneal b\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year-old woman with necrotizing pancreatitis, improving, also with\n thrombocytopenia with increasing abdominal pain and worsening anemia.\n REASON FOR THIS EXAMINATION:\n Assess pancreatitis, pseudocyst formation, retroperitoneal bleeding, or\n abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SAT 3:03 AM\n 1. Limited study due to the lack of intravenous contrast. Extensive\n peripancreatic fat stranding and retroperitoneal and intraperitoneal fluid\n collections, stable since the prior study, and are consistent with acute\n pancreatitis.\n 2. No evidence of retroperitoneal bleed.\n 3. Mild diffuse thickening of the colonic wall, likely due to third spacing\n or inflammation. However, acute colitis cannot be excluded.\n 4. Mild splenomegaly.\n 5. Bilateral simple pleural effusions with basal atelectasis, stable.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 42 -year-old woman with necrotizing pancreatitis, although\n improving, now has increasing abdominal pain and worsening anemia. The\n patient also has thrombocytopenia. Assess for retroperitoneal bleeding or\n worsening pancreatitis.\n\n COMPARISON: CT of the abdomen with contrast .\n\n TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis\n without intravenous contrast as an IV access could not be obtained. Oral\n contrast was administered for this study. Sagittal and coronal reformats were\n generated and reviewed.\n\n FINDINGS: The imaged lung bases demonstrate moderate-sized left and a small\n right pleural effusions, which are unchanged since the prior study. There is\n associated bibasilar atelectasis, left greater than right, similar to the\n prior study. Trace pericardial effusion is present, likely physiologic.\n\n Within the limitations of a non-contrast study, the liver, both adrenal glands\n and kidneys are normal in appearance. The spleen is enlarged measuring 14.6\n cm. The gallbladder is unremarkable. The assessment of the pancreas,\n especially of the enhancement, is extremely limited due to the lack of\n intravenous contrast. Again seen are extensive peripancreatic fat standing,\n retroperitoneal fluid collections involving the anterior pararenal space and\n bilateral paracolic gutters, which are similar in appearance and extent\n compared to the prior study. Also seen are some intraperitoneal fluid\n collections surrounding the stomach and spleen, similar in appearance to the\n prior study. All of these fluid collections demonstrate attenuation values\n ranging from , consistent with simple fluid. There is no evidence of\n (Over)\n\n 10:54 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Assess pancreatitis, pseudocyst formation, retroperitoneal b\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n retroperitoneal hemorrhage. There is no intra-abdominal free air. The small\n bowel loops are unremarkable without evidence of bowel obstruction. There is\n no evidence of pneumatosis or portal venous gas. The abdominal aorta\n demonstrates scattered atherosclerotic calcification without aneurysmal\n dilation. No significant adenopathy is seen. There is mild edema of the\n subcutaneous tissues.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder, the\n uterus, and adnexa are unremarkable. The rectum and sigmoid colon are normal.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected.\n\n IMPRESSION:\n 1. Limited study due to the lack of intravenous contrast. Extensive\n peripancreatic fat stranding and retroperitoneal and intraperitoneal fluid\n collections, stable since the prior study, and are consistent with acute\n pancreatitis.\n 2. No evidence of retroperitoneal bleed.\n 3. Mild splenomegaly.\n 4. Stable bilateral simple pleural effusions with basal atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179191,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate or other interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate or other interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , the tip of the endotracheal\n tube now measures only about 1.6 cm above the carina. Dobbhoff tube and left\n subclavian catheter remain in place, as does the nasogastric tube. There are\n lower lung volumes. Evidence of pulmonary vascular congestion persists.\n Continued opacification at the left base is consistent with lower lobe volume\n loss and effusion. The right hemidiaphragm is more sharply seen. This could\n reflect some improving atelectasis and effusion, though it also might be a\n manifestation of a different position of the patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177783,
"text": " 12:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with pancreatitis and increased WOB on vent\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:41 A.M. ON \n\n HISTORY: Pancreatitis. Increasing shortness of breath.\n\n IMPRESSION: AP chest compared to through 19:\n\n Left lower lobe collapse and moderate left pleural effusion are unchanged.\n Question of new consolidation in the suprahilar left upper lobe is still\n present, though no larger than it was on . Right lower lobe\n consolidation is probably atelectasis. The heart is borderline enlarged. ET\n tube is in standard placement. Esophageal manometer ends in the upper\n stomach. Nasogastric tube passes below the diaphragm and out of view. Dual\n channel right supraclavicular central venous line ends in the SVC. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177363,
"text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ET placement & subclavian line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman intubated after severe pancreatitis\n REASON FOR THIS EXAMINATION:\n check ET placement & subclavian line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\n Appropriate location of lines and tubes. Lung volumes and mild pulmonary\n vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe pancreatitis. New lines and tubes.\n\n COMPARISON: None at this institution.\n\n An endotracheal tube terminates in appropriate location, 6 cm above the\n carina. A left subclavian line terminates at the low SVC. An orogastric tube\n extends inferiorly off the film. Lung volumes are low with crowding of the\n pulmonary vasculature and pulmonary vascular congestion. Small bilateral\n pleural effusions and retrocardiac opacity are present, no pneumothorax is\n seen.\n\n IMPRESSION: Appropriate location of lines and tubes. Lung volumes and mild\n pulmonary vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177364,
"text": ", MED 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ET placement & subclavian line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman intubated after severe pancreatitis\n REASON FOR THIS EXAMINATION:\n check ET placement & subclavian line placement\n ______________________________________________________________________________\n PFI REPORT\n Appropriate location of lines and tubes. Lung volumes and mild pulmonary\n vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177707,
"text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any change in lung appearance\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with pancreatitis, 3-pressor requirement\n REASON FOR THIS EXAMINATION:\n any change in lung appearance\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:29 A.M., \n\n HISTORY: Pancreatitis, on pressors. Any change in atelectasis.\n\n IMPRESSION: AP chest compared to :\n\n Left lower lobe is still collapsed and the bronchial tree opacified beyond the\n upper lobe takeoff, suggesting retained secretions. Moderately severe\n atelectasis at the base of the right lung is only minimally better than\n yesterday. Moderate left pleural effusion is larger. There is now question\n of the left suprahilar pneumonia. Right lung does not show pulmonary edema.\n ET tube ends at the upper margin of the clavicles, no less than 4 cm from the\n carina.\n\n Right internal jugular line ends low in the SVC and a left subclavian line\n extends beyond it, though the tip is not visible. Nasogastric tube runs into\n the stomach and out of view.\n\n Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-25 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1178822,
"text": " 2:01 PM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: degree of pancreatic necrosis? loculated collections? blood?\n Admitting Diagnosis: PANCREATITIS\n Contrast: PROHANCE Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe acute pancreatitis, now week 2 of illness spiking\n high fevers, dropping Hct, septic physiology\n REASON FOR THIS EXAMINATION:\n degree of pancreatic necrosis? loculated collections? blood?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PJBj SAT 9:23 PM\n PFI:\n\n There is evidence of severe pancreatitis with reduced enhancement of the head\n and neck of the pancreas. High signal intensity fluid is present in the\n retroperitoneum, consistent with hemorrhagic fluid. This may simply be\n related to hemorrhagic pancreatitis, but has increased since the CT from\n .\n\n Case discussed with resident on call ( ) at 1900 \n PFI VERSION #1 PJBj SAT 7:31 PM\n PFI:\n\n There is evidence of severe pancreatitis with reduced enhancement of the head\n and neck of the pancreas. High signal intensity fluid is present in the\n retroperitoneum, consistent with hemorrhagic fluid. This may simply be\n related to hemorrhagic pancreatitis, but has increased since the CT from\n .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old woman with severe acute pancreatitis, week 2 of\n illness and spiking fevers. Dropping hematocrit. ? Query loculated\n collections.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 T\n magnet. A breath-hold independent technique was employed due to inability of\n patient to adequately breathhold. Sequental post contrast imaging was\n performed before and after the uneventful intravenous administration of 0.1\n mmol/kg gadolinium-DTPA.\n\n FINDINGS: The pancreas is significantly edematous with high signal intensity\n present in the head, body and tail on T2-weighted imaging. Areas of reduced\n enhancement are present in the head and neck of the pancreas which may\n represent early necrosis (series 19 image 16). There is extensive free fluid\n but no evidence of a walled off collection. Extensive peripancreatic high\n signal intensity fluid is present on T1-weighted imaging suggestive of\n hemorrhagic fluid or perhaps necrotic fat.\n\n The mesenteric vessels enhance normally and no aneurysm is identified, however\n the technique is suboptimal to assess the vessels.\n (Over)\n\n 2:01 PM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: degree of pancreatic necrosis? loculated collections? blood?\n Admitting Diagnosis: PANCREATITIS\n Contrast: PROHANCE Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Liver parenchyma appears normal with mild periportal edema. No significant\n biliary dilatation. An aberrant right hepatic duct arises from the mid CBD at\n the same level as the cystic duct (series 10 image 1). No gallstones are\n identified. Splenomegaly of 14 cm is present.\n\n The kidneys appear normal. Bilateral pleural effusions are present with\n associated atelectasis.\n\n\n IMPRESSION:\n 1. There is severe pancreatitis with areas of reduced enhancement in the head\n and neck which may represent early necrosis/ischemia.\n\n 2. High signal intensity peripancreatic fluid is present, either hemorrhagic\n fluid or fat necrosis. If there is concern about active bleeding, a CTA could\n be performed to further evaluate.\n\n 3. Aberrant right hepatic duct arises from the mid CBD.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-25 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1178823,
"text": "There is evidence of severe pancreatitis with reduced enhancement of the head\n and neck of the pancreas. High signal intensity fluid is present in the\n retroperitoneum, consistent with hemorrhagic fluid. This may simply be\n related to hemorrhagic pancreatitis, but has increased since the CT from\n . Page: 3\n\n , F 42 () \n , MED 2:01 PM\n MRCP (MR ABD W&W/OC) Clip # \n Reason: degree of pancreatic necrosis? loculated collections? blood?\n Admitting Diagnosis: PANCREATITIS\n Contrast: PROHANCE Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe acute pancreatitis, now week 2 of illness spiking\n high fevers, dropping Hct, septic physiology\n REASON FOR THIS EXAMINATION:\n degree of pancreatic necrosis? loculated collections? blood?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n There is evidence of severe pancreatitis with reduced enhancement of the head\n and neck of the pancreas. High signal intensity fluid is present in the\n retroperitoneum, consistent with hemorrhagic fluid. This may simply be\n related to hemorrhagic pancreatitis, but has increased since the CT from\n .\n\n Case discussed with resident on call ( ) at 1900 \n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177660,
"text": " 7:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with acute pancreatitis and worsening resp failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: JBRe FRI 10:28 PM\n 1. Unchanged right basilar opacity (DDx atelectasis vs. PNA).\n 2. Lower lung volumes with associated widending of the cardiac shilouette and\n worsening left retrocardiac opacity (DDx atelectasis vs. PNA).\n 3. Small left effusion.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:31 P.M. \n\n HISTORY: Acute pancreatitis and worsening respiratory failure.\n\n IMPRESSION: AP chest compared to through 18:\n\n Clear bilateral lower lobe atelectasis is more pronounced today than it has\n been over the past 24 hours and would explain respiratory insufficiency as\n well as increasing small bilateral pleural effusions. Upper lobes show mild\n vascular congestion, not surprising given the need for redirection of blood\n flow, though the heart is larger today and there may be a component of volume\n overload. ET tube is in standard placement and a nasogastric tube ends in the\n region of the pylorus. Dual-channel right supraclavicular central venous line\n ends low in the SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1179008,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA? ETT placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis\n REASON FOR THIS EXAMINATION:\n PNA? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:16 A.M. ON .\n\n HISTORY: Severe pancreatitis, pneumonia. Check ET tube placement.\n\n IMPRESSION: AP chest compared to through 26:\n\n Mild pulmonary edema is new. Moderate left pleural effusion has increased,\n probably a function of persistent left lower lobe collapse. Right lower lobe\n atelectasis which developed between and 25 has not improved.\n\n ET tube tip at the upper margin of the clavicles is no less than 4.5 cm above\n the carina, could be advanced 2 cm for more secure seating. Nasogastric tube\n and feeding tube pass into the stomach and out of view. No pneumothorax.\n Left PIC line ends in the mid to low SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-01 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1179902,
"text": " 2:34 PM\n CT ABD W&W/O C Clip # \n Reason: Is there evidence of pancreatic necrosis, pseudocyst formati\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, improving, though remains febrile.\n REASON FOR THIS EXAMINATION:\n Is there evidence of pancreatic necrosis, pseudocyst formation?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc SAT 8:05 PM\n 1. Findings compatible with acute pancreatitis with an approximately 25% area\n of decreased attenuation within the pancreatic head and neck, compatible with\n necrosis. Extensive peripancreatic fluid demonstrates a forming rim,\n compatible with a large developing peripancreatic fluid collection/pseudocyst.\n No discrete pockets of fluid are identified.\n 2. Moderate right and small left simple pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 42-year-old female with severe pancreatitis,\n remaining febrile. Evaluate for pancreatic necrosis or pseudocyst formation.\n\n EXAMINATION: CT of the abdomen with and without intravenous contrast.\n\n COMPARISONS: Comparison is made to CT torso from and MRCP from\n .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the mid abdomen initially without and subsequently after the uneventful\n administration of 130 cc of Optiray intravenous contrast. Coronal and\n sagittal reformations are provided for review.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:\n There is left greater than right moderate bilateral simple pleural effusions\n with associated compressive atelectasis. The lung bases are otherwise clear\n with no focal consolidations.\n\n The liver is unremarkable with no intra- or extra-hepatic biliary dilatation.\n The gallbladder, spleen, both adrenal glands, both kidneys are unremarkable.\n The visualized loops of intra-abdominal small and large bowel are\n unremarkable.\n\n The pancreatic tail and body enhance homogeneously after contrast\n administration, though regions of the pancreatic neck and head appear to have\n diminished enhancement compatible with a component of moderate necrosis. There\n is marked improvement in pancreatic edema in the body and tail. There is no\n associated pancreatic ductal dilation. The adjacent celiac axis, common\n hepatic and splenic arteries and gastroduodenal artery are patent with no\n evidence of pseudoaneurysm formation. There is extensive peripancreatic fluid\n (Over)\n\n 2:34 PM\n CT ABD W&W/O C Clip # \n Reason: Is there evidence of pancreatic necrosis, pseudocyst formati\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrated bilaterally extending across the bilateral pararenal spaces,\n encompassing the pancreas, and demonstrating mass effect with rightward\n displacement of the stomach. This fluid demonstrates a forming wall\n suggestive of a forming contained peripancreatic fluid collection/pseudocyst.\n The fluid appears to be contiguous with no discrete separated pocket.\n\n There are mild degenerative changes at the sacroiliac joints as manifested by\n sclerosis. There are no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Improved acute pancreatitis. Moderate necrosis of the pancreatic\n head/neck.\n 2. Extensive peripancreatic fluid demonstrates a forming rim, compatible with\n a large developing peripancreatic fluid collection/pseudocyst. No other\n separate discrete pockets of fluid are identified.\n 3. Moderate right and small left simple pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-04-01 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1179903,
"text": ", C. MED 12R 2:34 PM\n CT ABD W&W/O C Clip # \n Reason: Is there evidence of pancreatic necrosis, pseudocyst formati\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with severe pancreatitis, improving, though remains febrile.\n REASON FOR THIS EXAMINATION:\n Is there evidence of pancreatic necrosis, pseudocyst formation?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Findings compatible with acute pancreatitis with an approximately 25% area\n of decreased attenuation within the pancreatic head and neck, compatible with\n necrosis. Extensive peripancreatic fluid demonstrates a forming rim,\n compatible with a large developing peripancreatic fluid collection/pseudocyst.\n No discrete pockets of fluid are identified.\n 2. Moderate right and small left simple pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1177462,
"text": " 5:45 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new pheresis cath, please check placemeent\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with pancreatitis\n REASON FOR THIS EXAMINATION:\n new pheresis cath, please check placemeent\n ______________________________________________________________________________\n WET READ: 6:51 PM\n 1. Right pheresis catheter at the distal SVC.\n 2. Bibasilar opacities, likely atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:06 P.M., \n\n HISTORY: New pancreatitis and pheresis catheter.\n\n IMPRESSION: AP chest compared to :\n\n The lung volumes are low, though some of the right lower lobe atelectasis has\n improved. Moderate bilateral pleural effusions, stable on the left and\n increased on the right. Heart size normal. Left subclavian line ends in the\n region of the superior cavoatrial junction. New right jugular line ends\n higher in the SVC. No pneumothorax or mediastinal widening. Heart size\n normal. Nasogastric tube passes into the stomach and out of view. ET tube\n tip at the thoracic inlet is no less than 4 cm from the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1178052,
"text": " 9:01 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 42cm L brachial DL PICC \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with pancreatitis, R temp HD line, L subclavian in place.\n REASON FOR THIS EXAMINATION:\n 42cm L brachial DL PICC \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate left PICC.\n\n AP SUPINE CHEST RADIOGRAPH.\n\n COMPARISON: , approximately three hours prior.\n\n FINDINGS: Although difficult to evaluate due to the co-existent presence of a\n left subclavian central catheter the tip of the left PIC catheter appears to\n be in the mid to upper SVC. A right-sided IJ catheter is stable in\n configuration and appearance. An esophageal manometer tip is just above the\n GE junction. An NG tube extends below the left hemidiaphragm. An\n endotracheal tube is at the level of the clavicles. Left basilar atelectasis\n remains present as well as some right basilar atelectasis. No pleural\n effusions or pneumothorax appear present.\n\n IMPRESSION: Left PIC catheter tip at the mid to upper SVC. Other findings\n little changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177528,
"text": " 6:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change, development of ARDS?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with pancreatitis, 3-pressor requirement\n REASON FOR THIS EXAMINATION:\n ?interval change, development of ARDS?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old female with pancreatitis requiring pressors, query ARDS.\n\n TECHNIQUE: Portable AP chest radiograph submitted for review and compared to\n prior study of .\n\n FINDINGS:\n\n An endotracheal tube lies 3.3 cm proximal to the carina. An NG tube lies with\n its tip below the diaphragm. Left subclavian and right internal jugular\n catheters are in unchanged positions. The lung volumes remain low; however,\n there has been some improvement in the right lower lobe atelectasis. There is\n persistent airspace opacity seen in the right lower lobe however. In\n addition, there is silhouetting of the left hemidiaphragm with increased\n retrocardiac opacity consistent with a left lower lobe airspace opacity.\n While this may reflect atelectasis, in the appropriate clinical setting,\n pneumonia should be considered. Small left pleural effusion.\n\n IMPRESSION: Slight interval improvement in the right basilar atelectasis, but\n with persistent airspace opacities in the right lower lobe and left lower lobe\n which may reflect either atelectasis or consolidation. Small left pleural\n effusion.\n\n"
},
{
"category": "Echo",
"chartdate": "2130-04-04 00:00:00.000",
"description": "Report",
"row_id": 92956,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 170\nBSA (m2): 1.85 m2\nBP (mm Hg): 110/60\nHR (bpm): 104\nStatus: Outpatient\nDate/Time: at 10:27\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. No valvular AS. The increased transaortic velocity is related\nto high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nPhysiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses are normal. The left ventricular cavity is unusually small.\nRegional left ventricular wall motion is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. There is no valvular aortic\nstenosis. The increased transaortic velocity is likely related to high cardiac\noutput. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. No masses or\nvegetations are seen on the mitral valve, but cannot be fully excluded due to\nsuboptimal image quality. Physiologic mitral regurgitation is seen (within\nnormal limits). The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis. Normal regional and\nglobal biventricular systolic function.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-16 00:00:00.000",
"description": "Report",
"row_id": 255831,
"text": "Sinus tachycardia. Delayed precordial R wave transition. Cannot exclude prior\nanterior wall myocardial infarction. There is inferolateral ST segment\nflattening and slight depression. No previous tracing available for comparison.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-29 00:00:00.000",
"description": "Report",
"row_id": 255622,
"text": "Sinus tachycardia. There is an abnormal transition across the precordium\nconsistent with possible prior anterior infarction. Compared to the previous\ntracing of the same date there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-29 00:00:00.000",
"description": "Report",
"row_id": 255623,
"text": "Artifact is present. Sinus tachycardia. There are small R waves in the anterior\nleads consistent with possible prior myocardial infarction. Compared to the\nprevious tracing of the rate is slower and the transition across the\nprecordium is now abnormal but may be related to lead placement.\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-22 00:00:00.000",
"description": "Report",
"row_id": 255624,
"text": "Sinus tachycardia. Left atrial abnormality and increase in rate as compared to\nthe previous tracing of . There is improved limb lead voltage. The\ninferolateral ST-T wave changes are more prominent. Followup and clinical\ncorrelation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-17 00:00:00.000",
"description": "Report",
"row_id": 255830,
"text": "Sinus tachycardia. Delayed precordial R wave transition. Non-specific\nST-T wave flattening as compared with previous tracing of . Otherwise,\nno diagnostic interim change.\n\n"
}
] |
46,089 | 187,568 | This is an 82 year-old male with a history of prostate cancer who presented with lower extremity weakness and was admitted from OSH with severe hyperkalemia to 8.9. | - repeat lytes K 7.2-->6.7-->6.5--.5.5 - renaul u/s showing no hydro Allergies: Iodine; Iodine Containing Unknown; hibes; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:17 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.7C (98.1 Tcurrent: 36.4C (97.5 HR: 52 (52 - 75) bpm BP: 126/45(66) {99/45(66) - 164/76(102)} mmHg RR: 15 (12 - 24) insp/min SpO2: 96% Heart rhythm: SB (Sinus Bradycardia) Height: 67 Inch Total In: 1,351 mL 615 mL PO: 120 mL 100 mL TF: IVF: 1,111 mL 485 mL Blood products: Total out: 2,270 mL 400 mL Urine: 2,270 mL 400 mL NG: Stool: Drains: Balance: -919 mL 215 mL Respiratory support O2 Delivery Device: None SpO2: 96% ABG: ///18/ Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 135 K/uL 12.7 g/dL 117 mg/dL 1.5 mg/dL 18 mEq/L 5.6 mEq/L 37 mg/dL 112 mEq/L 136 mEq/L 38.1 % 7.2 K/uL [image002.jpg] 02:05 PM 07:16 PM 11:06 PM 04:27 AM WBC 8.2 7.2 Hct 39.9 38.1 Plt 160 135 Cr 1.6 1.7 1.6 1.5 Glucose 91 117 Other labs: PT / PTT / INR:23.6/38.2/2.3, Albumin:3.7 g/dL, Ca++:8.4 mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL Assessment and Plan HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA) his is an 82 year-old male with a history of prostate cancer who presented with lower extremity weakness and is admitted with hyperkalemia. | 17 | [
{
"category": "Physician ",
"chartdate": "2181-01-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 436214,
"text": "Chief Complaint: hyperkalemia\n HPI:\n This is an 82 year old male with a history of prostate cancer who\n presented to an OSH with lower extremity weakness and was transfered to\n for hyperkalemia.\n .\n The patient states that over the last few weeks, he has had occasional\n lower extremity weakness which only occurs at night. He has had no\n difficulty during the days, and when it does occur, it has resolved by\n morning. However, on the day of admission, the patient states he felt\n weak during the day, and in fact required use of his wife's walker.\n Even with the walker, he had difficulty with ambulation and fell (he\n states his legs crumpled - non-traumatic, did not hit his head, no\n LOC). This prompted her to call an ambulance for evaluation at the\n hospital.\n .\n At the OSH, the patient was found to have a K of 8.9, other labs as\n below. He was given albuterol nebs, 1 amp dextrose, 10 units of\n insulin sub q, kayexelate 30 mg x1, 1 amp of NaBicarb and 1 amp of\n calcium gluconate. Repeat K was 7.6. ECG's showing mild peaking of T\n waves. The patient was then transfered to .\n .\n In the ED here, initial K was 7.2. He was given repeat doses of 10\n units insulin IV, 1 amp of D50, Calcium gluconate 1 amp and bicarb 1\n amp. Repeat K was 6.4 prior to transfer to the ICU. ECGs with\n improvement from prior, no peaking of T waves here.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, constipation, melena, hematochezia, chest\n pain, shortness of breath, orthopnea, PND, lower extremity oedema,\n cough, lightheadedness, gait unsteadiness, vision changes, headache,\n rash or skin changes. He does report 3 days of loose stools prior to\n admission, up in frequency from once daily to 3 times daily. He was\n taking Immodium for his symptoms. Pertinent positives as per HPI.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME:\n Amlodipine 5 mg daily\n Calcium/vitamin D 5000 units (started )\n Metoprolol 50 mg \n B12 250 mcg daily\n Allopurinol 300 mg daily\n ASA 81 daily\n Flomax 0.4 mg daily\n Betoptic eye drops\n Coumadin 5 mg daily\n MVI\n Past medical history:\n Family history:\n Social History:\n -Atrial fibrillation on coumadin\n -Prostate ca, diagnosed in ( 6 (3+3)) underwent radiation\n therapy in , in placed on vaccine protocol with no improvement\n in his progression. He then began a dietary intervention protocol in\n which was stopped in due to lack of improvement. Followed by\n regular bone scans and CT scans without evidence of metastatic\n disease. Of note, in the patient was hospitalized with urosepsis\n presumably from a urethral stricture, in he had an acute\n bladder outlet obstruction which resulted in an increase in his\n creatinine, though this has since resolved. He also had an SBO in\n which was treated with NGT. Last PSA in was 75\n -Spinal stenosis - recent lumbar spinal steroid injection on , no\n complications\n -Hypertension\n -Bowel obstruction during childhood, s/p resection\n NC\n Occupation: Retired\n Drugs: Denies\n Tobacco: 30 pack year history, quit 35 years ago\n Alcohol: Rare\n Other: Lives at home with his wife\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Diarrhea\n Genitourinary: Dysuria\n Musculoskeletal: No(t) Joint pain\n Endocrine: No(t) Hyperglycemia\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 01:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 53 (53 - 66) bpm\n BP: 121/62(77) {121/62(73) - 155/64(85)} mmHg\n RR: 15 (15 - 24) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -600 mL\n Respiratory\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: voice, follows commands, full range of motion,\n full range of motion and strength in lower extremities, no saddle\n anesthesia\n Labs / Radiology\n 6.4 mEq/L\n [image002.jpg]\n ECG: Sinus rhythm at 57 bpm, LAD, prolonged PR interval, narrow QRS,\n and QT interval wnl, poor R-wave progress, currently, no evidence of\n peaked T waves or ischemic changes. No ECGs from prior to this\n admission for comparison.\n Assessment and Plan\n Assesment: This is an 82 year-old male with a history of prostate\n cancer who presented with lower extremity weakness and is admitted with\n hyperkalemia.\n .\n Plan:\n # Hyperkalemia: Unclear etiology. Renal function appears to be close\n to baseline (most recent labs at show Creatinine of 1.8, last\n here was 1.6). No new medications other than vitamin D. Patient\n denies any high potassium food intake. Has been having frequent loose\n stools so should be wasting K. Has been on metoprolol for a long time\n so acute increased K is not likely related. Also with non-AG acidosis\n even after bicarb administration here and at the OSH.\n - Another dose of kayexelate now\n - Check renal ultrasound now\n - Repeat ECG now\n - Check TTKG for possible hypoaldosteronism\n - Renal recommendations, no urgent HD need as potassium is downtrending\n - Q4H K checks for now with ECG monitoring, continue telemetry\n - Plan to re-dose with calcium gluconate, insulin, bicarb, kayexelate\n prn\n - IVF now\n .\n # Diarrhea: Ongoing for several weeks. Likely the cause of his non-AG\n acidosis.\n - Send stool cultures, C. diff, etc.\n - IVF as above\n .\n # Lower extremity weakness: Patient reports this has been ongoing for\n several weeks to months. He has had frequent surveillance PET scans\n and CT scans, last in of this year, without evidence of metastatic\n disease. Acute exacerbation of his symptoms is likely secondary to his\n severe hyperkalemia, though other possibilities on the differential\n include metastatic disease causing compression or even medication\n induced (ie amlodipine). Also had recent lumbar spinal cortisone\n injection, though he states there were no complications, no focal pain\n on palpation of lumbar spine. Symptoms are currently resolved at this\n time, and exam is non-focal.\n - Continue to monitor\n - Correct hyperkalemia as above\n - Consider MR imaging spine if symptoms recur\n .\n # Prostate cancer: Followed by Dr. at . No evidence of\n metastatic disease at this time, though PSA has been increasing over\n time, most recently 75.\n - Contact primary oncologist regarding admission\n - Consider imaging lumbar spine as above given increased PSA and lower\n extremity weakness\n .\n # ?ARF: Unclear baseline, though has been elevated recently. Per the\n patient, he had been seen by his urologist recently and had a positive\n post-void residual. This may explain his increased creatinine.\n - WIll check post-void residual\n - Consider urine lytes\n - Renally dose meds\n - continue to trend\n - Renal Ultrasound\n - IVF\n .\n # Atrial fibrillation: Continue coumadin, currently subtherapeutic,\n continue metoprolol\n .\n # FEN: low potassium diet/cardiac, follow K, replete lytes prn\n .\n # Access: PIV\n .\n # PPx: systemic anticoagulation on coumadin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:29 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-04 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 436215,
"text": "Chief Complaint: Hyperkalemia\n HPI:\n 82 yr man with prostate CA went to local ED with leg weakness and found\n to have elevated K. Transferred for w/u. Fell at home - non-traumatic -\n did not hit head or loose consciousnesss. Iniital lab K was 8.9 -\n treated aggresssively with multiple modalities and k 7.6 - transferred\n to because no ICU beds. Initial K in ED here was 7.2. Tx'd again\n with insulin/glucose/bicarb with K down to 6.4. ECG - unremarkable.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n flomax, docusate, ASA, Vit D, CaCO3, b12, Warfarin, Allopurinol,\n Metoprolol, Amlodipine\n Past medical history:\n Family history:\n Social History:\n A fib on coumadin\n Prostate CA - tx'd with radiation\n PSA rising - most recently 75\n - urosepsis\n SBO - resolved with gastric drainage\n Lumbar Spinal Stenosis - tx'd with epidural steroid\n Hypertension\n Not relevant to current admit\n Occupation: retired; handyman at community\n Drugs: none\n Tobacco: 30 pk yrs, quit 30 yrs ago\n Alcohol: rare\n Other:\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Diarrhea\n Neurologic: weakness\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 53 (53 - 66) bpm\n BP: 121/62(77) {121/62(73) - 155/64(85)} mmHg\n RR: 15 (15 - 24) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -600 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 186\n 41.4\n 1.7\n 46\n 14\n 117\n 6.4 mEq/L\n 138\n 7.7\n [image002.jpg]\n Other labs: PT / PTT / INR://1.8\n Imaging: CXR Normal\n ECG: No peaked T's\n Assessment and Plan\n HYPERKALEMIA\n Unclear etiology, renal function needs to be investigated ?RTA as a\n consequence obstructive uropathy\n Kayexalate\n Follow monitor, check K at 6 hr intervals\n DEHYDRATION\n From persistent diarrhea - repleting his fluids\n Check for C Difficile, Infectious diarrhea\n Elevated Creat likely from dehtdration\n Diarrhea\n Workup noted above\n LE Weakness\n Now resolved\n Prostate CA\n PSA rising, Contact his opt Urologist for suggestions\n A fib\n On Coumadin, Metoprolol\n Currently in sinus (bradycardic)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 12:29 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436302,
"text": "82 yr man with prostate Ca presented to local ED with diarrhea, leg\n weakness resulting in non-traumatic fall at home (did not hit head or\n lose consciousness). In ED was found to have elevated K of 8.9. Treated\n aggressively with insulin/glucose/bicarb and K down to 7.6 and\n transferred to . Initial K @ was 7.2. Tx'd again with\n insulin/glucose/bicarb with K down to 6.4. No EKG changed noted.\n Admitted to M/SICU for close monitoring.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt 3, pleasant and cooperative, ambulates OOB to commode w/\n supervision.\n PM labs: K = 6.7, HCO3 = 19, ph 7.27, no anion gap.\n Vitals stable.\n Action:\n Received 30g kayexalate\n Received lactulose dose x1 to stimulate BM.\n Receiving HCO3 gtt @ 100cc/hr per renal recs.\n Response:\n Repeat K = 6.5\n Had several large loose stools following repeat labs.\n Plan:\n f/u w/ AM labs for improvement in hyperkalemia.\n Cont to monitor vitals.\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 436346,
"text": "TITLE:\n Chief Complaint: Hyperkalemia\n 24 Hour Events:\n ULTRASOUND - At 04:23 PM\n NASAL SWAB - At 07:35 PM\n STOOL CULTURE - At 01:56 AM\n - renal recs: serum and plasma K, serum , random cortisol, TTKG,\n likely severe metabolic acidosis 2.2 diarrhea with underlying\n hypoaldo/hyporenin state.\n - repeat lytes K 7.2-->6.7-->6.5--.5.5\n - renaul u/s showing no hydro\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 52 (52 - 75) bpm\n BP: 126/45(66) {99/45(66) - 164/76(102)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n Total In:\n 1,351 mL\n 615 mL\n PO:\n 120 mL\n 100 mL\n TF:\n IVF:\n 1,111 mL\n 485 mL\n Blood products:\n Total out:\n 2,270 mL\n 400 mL\n Urine:\n 2,270 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -919 mL\n 215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 135 K/uL\n 12.7 g/dL\n 117 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 112 mEq/L\n 136 mEq/L\n 38.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:05 PM\n 07:16 PM\n 11:06 PM\n 04:27 AM\n WBC\n 8.2\n 7.2\n Hct\n 39.9\n 38.1\n Plt\n 160\n 135\n Cr\n 1.6\n 1.7\n 1.6\n 1.5\n Glucose\n 91\n 117\n Other labs: PT / PTT / INR:23.6/38.2/2.3, Albumin:3.7 g/dL, Ca++:8.4\n mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n his is an 82 year-old male with a history of prostate cancer who\n presented with lower extremity weakness and is admitted with\n hyperkalemia.\n # Hyperkalemia: Improving, at 5.6 this morning. Cr at 1.5. Per renal\n consult likely severe metabolic acidosis prolonged diarrhea. Renal\n function appears to be close to baseline (most recent labs at \n show Creatinine of 1.8, last here was 1.6). No new medications other\n than vitamin D. Patient denies any high potassium food intake. Has\n been having frequent loose stools so should be wasting K. Has been on\n metoprolol for a long time so acute increased K is not likely related.\n Also with non-AG acidosis even after bicarb administration here and at\n the OSH. Renal u/s without hydropenphrosis.\n - TTKG pending\n - Renal follwing, appreciate recs\n - can check lytes q8\n # Diarrhea: Ongoing for several weeks. Likely the cause of his non-AG\n acidosis. Had several large BM in response to kayexate.\n - stool cultures, C. diff, giardia pending\n # Lower extremity weakness: Resolved. On admission, patient\n reportedthis has been ongoing for several weeks to months. He has had\n frequent surveillance PET scans and CT scans, last in of this\n year, without evidence of metastatic disease. Acute exacerbation of\n his symptoms is likely secondary to his severe hyperkalemia, though\n other possibilities on the differential include metastatic\n disease causing compression or even medication induced (ie amlodipine).\n Also had recent lumbar spinal cortisone injection, though he states\n there were no complications, no focal pain on palpation of lumbar\n spine. Symptoms are currently resolved at this time, and exam is\n non-focal.\n - Continue to monitor\n - Consider MR imaging spine if symptoms recur\n # Prostate cancer: Followed by Dr. at . No evidence of\n metastatic disease at this time, though PSA has been increasing over\n time, most recently 75. Will hold of for imgaing for now.\n - Dr. , primary oncologist aware of admission, would like to be\n contact regarding diagnosis of hyper - k\n # ARF: Resolved, Cr 1.5 which appears to be patient's baselin. Per the\n patient, he had been seen by his urologist recently and had a positive\n post-void residual. This may explain his increased creatinine. Renal\n us showing no hydro\n - Renally dose meds\n - continue to trend\n ICU Care\n Nutrition:\n Comments: low potassium diet\n Glycemic Control:\n Lines:\n 20 Gauge - 05:44 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 436347,
"text": "TITLE:\n Chief Complaint: Hyperkalemia\n 24 Hour Events:\n ULTRASOUND - At 04:23 PM\n NASAL SWAB - At 07:35 PM\n STOOL CULTURE - At 01:56 AM\n - renal recs: serum and plasma K, serum , random cortisol, TTKG,\n likely severe metabolic acidosis 2.2 diarrhea with underlying\n hypoaldo/hyporenin state.\n - repeat lytes K 7.2-->6.7-->6.5--.5.5\n - renaul u/s showing no hydro\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 52 (52 - 75) bpm\n BP: 126/45(66) {99/45(66) - 164/76(102)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n Total In:\n 1,351 mL\n 615 mL\n PO:\n 120 mL\n 100 mL\n TF:\n IVF:\n 1,111 mL\n 485 mL\n Blood products:\n Total out:\n 2,270 mL\n 400 mL\n Urine:\n 2,270 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -919 mL\n 215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: voice, follows commands, full range of motion,\n full range of motion and strength in lower extremities,\n Labs / Radiology\n 135 K/uL\n 12.7 g/dL\n 117 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 112 mEq/L\n 136 mEq/L\n 38.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:05 PM\n 07:16 PM\n 11:06 PM\n 04:27 AM\n WBC\n 8.2\n 7.2\n Hct\n 39.9\n 38.1\n Plt\n 160\n 135\n Cr\n 1.6\n 1.7\n 1.6\n 1.5\n Glucose\n 91\n 117\n Other labs: PT / PTT / INR:23.6/38.2/2.3, Albumin:3.7 g/dL, Ca++:8.4\n mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n his is an 82 year-old male with a history of prostate cancer who\n presented with lower extremity weakness and is admitted with\n hyperkalemia.\n # Hyperkalemia: Improving, at 5.6 this morning. Cr at 1.5. Per renal\n consult likely severe metabolic acidosis prolonged diarrhea. Renal\n function appears to be close to baseline (most recent labs at \n show Creatinine of 1.8, last here was 1.6). No new medications other\n than vitamin D. Patient denies any high potassium food intake. Has\n been having frequent loose stools so should be wasting K. Has been on\n metoprolol for a long time so acute increased K is not likely related.\n Also with non-AG acidosis even after bicarb administration here and at\n the OSH. Renal u/s without hydropenphrosis.\n - TTKG pending\n - Renal follwing, appreciate recs\n - can check lytes q8\n # Diarrhea: Ongoing for several weeks. Likely the cause of his non-AG\n acidosis. Had several large BM in response to kayexate.\n - stool cultures, C. diff, giardia pending\n # Lower extremity weakness: Resolved. On admission, patient\n reportedthis has been ongoing for several weeks to months. He has had\n frequent surveillance PET scans and CT scans, last in of this\n year, without evidence of metastatic disease. Acute exacerbation of\n his symptoms is likely secondary to his severe hyperkalemia, though\n other possibilities on the differential include metastatic\n disease causing compression or even medication induced (ie amlodipine).\n Also had recent lumbar spinal cortisone injection, though he states\n there were no complications, no focal pain on palpation of lumbar\n spine. Symptoms are currently resolved at this time, and exam is\n non-focal.\n - Continue to monitor\n - Consider MR imaging spine if symptoms recur\n # Prostate cancer: Followed by Dr. at . No evidence of\n metastatic disease at this time, though PSA has been increasing over\n time, most recently 75. Will hold of for imgaing for now.\n - Dr. , primary oncologist aware of admission, would like to be\n contact regarding diagnosis of hyper - k\n # ARF: Resolved, Cr 1.5 which appears to be patient's baselin. Per the\n patient, he had been seen by his urologist recently and had a positive\n post-void residual. This may explain his increased creatinine. Renal\n us showing no hydro\n - Renally dose meds\n - continue to trend\n ICU Care\n Nutrition:\n Comments: low potassium diet\n Glycemic Control:\n Lines:\n 20 Gauge - 05:44 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 436378,
"text": "Chief Complaint: Hyperkalemia\n HPI:\n 82 yr man with prostate CA went to local ED with leg weakness and found\n to have elevated K. Transferred for w/u. Fell at home - non-traumatic -\n did not hit head or loose consciousnesss. Iniital lab K was 8.9 -\n treated aggresssively with multiple modalities and k 7.6 - transferred\n to because no ICU beds. Initial K in ED here was 7.2. Tx'd again\n with insulin/glucose/bicarb with K down to 6.4. ECG - unremarkable.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n flomax, docusate, ASA, Vit D, CaCO3, b12, Warfarin, Allopurinol,\n Metoprolol, Amlodipine\n Past medical history:\n Family history:\n Social History:\n A fib on coumadin\n Prostate CA - tx'd with radiation\n PSA rising - most recently 75\n - urosepsis\n SBO - resolved with gastric drainage\n Lumbar Spinal Stenosis - tx'd with epidural steroid\n Hypertension\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 436379,
"text": "TITLE:\n Chief Complaint: Hyperkalemia\n 24 Hour Events:\n ULTRASOUND - At 04:23 PM\n NASAL SWAB - At 07:35 PM\n STOOL CULTURE - At 01:56 AM\n - renal recs: serum and plasma K, serum , random cortisol, TTKG,\n likely severe metabolic acidosis 2.2 diarrhea with underlying\n hypoaldo/hyporenin state.\n - repeat lytes K 7.2-->6.7-->6.5--.5.5\n - renal u/s showing no hydro\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 52 (52 - 75) bpm\n BP: 126/45(66) {99/45(66) - 164/76(102)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n Total In:\n 1,351 mL\n 615 mL\n PO:\n 120 mL\n 100 mL\n TF:\n IVF:\n 1,111 mL\n 485 mL\n Blood products:\n Total out:\n 2,270 mL\n 400 mL\n Urine:\n 2,270 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -919 mL\n 215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: regular rate, no mrg\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTAB\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no \n Skin: Warm\n Neurologic: A/o x3\n Labs / Radiology\n 135 K/uL\n 12.7 g/dL\n 117 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 112 mEq/L\n 136 mEq/L\n 38.1 %\n 7.2 K/uL\n [image002.jpg]\n 02:05 PM\n 07:16 PM\n 11:06 PM\n 04:27 AM\n WBC\n 8.2\n 7.2\n Hct\n 39.9\n 38.1\n Plt\n 160\n 135\n Cr\n 1.6\n 1.7\n 1.6\n 1.5\n Glucose\n 91\n 117\n Other labs: PT / PTT / INR:23.6/38.2/2.3, Albumin:3.7 g/dL, Ca++:8.4\n mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n 82 year-old male with a history of prostate cancer who presented with\n lower extremity weakness and is admitted with hyperkalemia.\n # Hyperkalemia: Improving, at 5.6 this morning. Cr at 1.5. Per renal\n consult likely severe metabolic acidosis prolonged diarrhea. Renal\n function appears to be close to baseline (most recent labs at \n show Creatinine of 1.8, last here was 1.6). No new medications other\n than vitamin D. Patient denies any high potassium food intake. Has\n been having frequent loose stools so should be wasting K. Has been on\n metoprolol for a long time so acute increased K is not likely related.\n Also with non-AG acidosis even after bicarb administration here and at\n the OSH. Renal u/s without hydropenphrosis.\n - TTKG pending\n - Renal follwing, appreciate recs\n - can check lytes q8\n # Diarrhea: Ongoing for several weeks. Likely the cause of his non-AG\n acidosis. Had several large BM in response to kayexate.\n - stool cultures, C. diff, giardia pending\n # Lower extremity weakness: Resolved. On admission, patient\n reportedthis has been ongoing for several weeks to months. He has had\n frequent surveillance PET scans and CT scans, last in of this\n year, without evidence of metastatic disease. Acute exacerbation of\n his symptoms is likely secondary to his severe hyperkalemia, though\n other possibilities on the differential include metastatic\n disease causing compression or even medication induced (ie amlodipine).\n Also had recent lumbar spinal cortisone injection, though he states\n there were no complications, no focal pain on palpation of lumbar\n spine. Symptoms are currently resolved at this time, and exam is\n non-focal.\n - Continue to monitor\n - Consider MR imaging spine if symptoms recur\n # Prostate cancer: Followed by Dr. at . No evidence of\n metastatic disease at this time, though PSA has been increasing over\n time, most recently 75. Will hold of for imgaing for now.\n - Dr. , primary oncologist aware of admission, would like to be\n contact regarding diagnosis of hyper - k\n # ARF: Resolved, Cr 1.5 which appears to be patient's baselin. Per the\n patient, he had been seen by his urologist recently and had a positive\n post-void residual. This may explain his increased creatinine. Renal\n us showing no hydro\n - Renally dose meds\n - continue to trend\n ICU Care\n Nutrition: low potassium diet\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 05:44 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 436382,
"text": "Chief Complaint: Hyperkalemia\n HPI:\n 82 yr man with prostate CA went to local ED with leg weakness and found\n to have elevated K. Transferred for w/u. Fell at home - non-traumatic -\n did not hit head or loose consciousnesss. Iniital lab K was 8.9 -\n treated aggresssively with multiple modalities and k 7.6 - transferred\n to because no ICU beds. Initial K in ED here was 7.2. Tx'd again\n with insulin/glucose/bicarb with K down to 6.4. ECG - unremarkable.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n flomax, docusate, ASA, Vit D, CaCO3, b12, Warfarin, Allopurinol,\n Metoprolol, Amlodipine\n Past medical history:\n Family history:\n Social History:\n A fib on coumadin\n Prostate CA - tx'd with radiation\n PSA rising - most recently 75\n - urosepsis\n SBO - resolved with gastric drainage\n Lumbar Spinal Stenosis - tx'd with epidural steroid\n Hypertension\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Severe metabolic acidosis secondary to diarrhea with underlying\n hypoaldo/hyporenin state. K+ this am=5.and creat to 1.5.renal u/s\n without hydronephrosis. Mg=1.5\n Action:\n Pt had completed iv infusion of d5w with 3 amps na hco3 on previous\n shift on nocs and was also medicated with additional dose of kaexolate\n and lactulose. Pt given 2 gm iv mag\n Response:\n Improving k+ and creat\n Plan:\n Transfer to medical floor bed. Renal consult team to follow pt for now\n on daily basis. Continue to check lytes as ordered and replete as\n needed.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 92.3 kg\n Daily weight:\n Allergies/Reactions:\n Iodine; Iodine Containing\n Unknown; hibes;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CAD, Hypertension, PVD\n Additional history: prostate Ca\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:146\n D:61\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 53 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 975 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:27 AM\n Potassium:\n 5.6 mEq/L\n 04:27 AM\n Chloride:\n 112 mEq/L\n 04:27 AM\n CO2:\n 18 mEq/L\n 04:27 AM\n BUN:\n 37 mg/dL\n 04:27 AM\n Creatinine:\n 1.5 mg/dL\n 04:27 AM\n Glucose:\n 117 mg/dL\n 04:27 AM\n Hematocrit:\n 38.1 %\n 04:27 AM\n Valuables / Signature\n Patient valuables: eyeglasses,upper and lower dentures\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: no\n Transferred from: 409\n Transferred to: 1186\n Date & time of Transfer: 1030\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436390,
"text": "Chief Complaint: Hyperkalemia\n HPI:\n 82 yr man with prostate CA went to local ED with leg weakness and found\n to have elevated K. Transferred for w/u. Fell at home - non-traumatic -\n did not hit head or loose consciousnesss. Iniital lab K was 8.9 -\n treated aggresssively with multiple modalities and k 7.6 - transferred\n to because no ICU beds. Initial K in ED here was 7.2. Tx'd again\n with insulin/glucose/bicarb with K down to 6.4. ECG - unremarkable.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Unknown; hibes;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n flomax, docusate, ASA, Vit D, CaCO3, b12, Warfarin, Allopurinol,\n Metoprolol, Amlodipine\n Past medical history:\n Family history:\n Social History:\n A fib on coumadin\n Prostate CA - tx'd with radiation\n PSA rising - most recently 75\n - urosepsis\n SBO - resolved with gastric drainage\n Lumbar Spinal Stenosis - tx'd with epidural steroid\n Hypertension\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Severe metabolic acidosis secondary to diarrhea with underlying\n hypoaldo/hyporenin state. K+ this am=5.and creat to 1.5.renal u/s\n without hydronephrosis. Mg=1.5\n Action:\n Pt had completed iv infusion of d5w with 3 amps na hco3 on previous\n shift on nocs and was also medicated with additional dose of kaexolate\n and lactulose. Pt given 2 gm iv mag\n Response:\n Improving k+ and creat\n Plan\n Transfer to medical floor bed when available. Check lytes as ordered\n and replete as needed, renal consult te,a to follow pt on daily basis\n"
},
{
"category": "Nursing",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 436291,
"text": "82 yr man with prostate Ca presented to local ED with diarrhea, leg\n weakness resulting in non-traumatic fall at home (did not hit head or\n lose consciousness). In ED was found to have elevated K of 8.9. Treated\n aggressively with insulin/glucose/bicarb and K down to 7.6 and\n transferred to . Initial K @ was 7.2. Tx'd again with\n insulin/glucose/bicarb with K down to 6.4. No EKG changed noted.\n Admitted to M/SICU for close monitoring.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt 3, pleasant and cooperative, ambulates OOB to commode w/\n supervision.\n PM labs: K = 6.7, HCO3 = 19, ph 7.27, no anion gap.\n Vitals stable.\n Action:\n Received 30g kayexalate\n Received lactulose dose x1 to stimulate BM.\n Receiving HCO3 gtt @ 100cc/hr per renal recs.\n Response:\n Repeat K = 6.5\n Had several large loose stools following repeat labs.\n Plan:\n f/u w/ AM labs for improvement in hyperkalemia.\n Cont to monitor vitals.\n"
},
{
"category": "Case Management ",
"chartdate": "2181-01-05 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 436437,
"text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance: MEDEX DEDUCT/CO-INS\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services:\n DME / Home O[2]: walker\n Functional Status / Home / Family Assessment:\n Lives with his wife in . He has been independnt with his ADL's.\n Primary Contact(s): (wife) (\n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended: Physical Therapy\n Current plan: Home\n Home, when treatment completed, likely with services. Case Management\n will folllow for DC needs\n If VNA services needed can use:\n Home Care - \n Area VNA - \n Americare at home - \n Patient (s) to Discharge:\n none\n Patient discussed with multidisciplinary team: Yes\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1056876,
"text": " 8:36 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for intrathoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hyperkalemia\n REASON FOR THIS EXAMINATION:\n assess for intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old man with hyperkalemia, assess for intrathoracic\n pathology.\n\n STUDY: Chest radiograph, PA and lateral views.\n\n COMPARISON: No prior comparison available.\n\n FINDINGS:\n\n The cardiac silhouette is of upper normal limits. There is a slightly\n tortuous thoracic aortic contour. The hilar and mediastinal contours are\n otherwise unremarkable. The pulmonary vasculature is normal. The lungs are\n clear bilaterally without pleural effusion or pneumothorax. There are mild\n degenerative changes in the underlying osseous structures. There is normal\n bowel gas in the visualized abdomen.\n\n IMPRESSION:\n\n No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-04 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1057009,
"text": ", D. MED 4:05 PM\n RENAL U.S. Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with prostate CA, admitted with isolated hyperkalemia, Cr at\n baseline.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n PFI REPORT\n PFI: No hydronephrosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-04 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1057008,
"text": " 4:05 PM\n RENAL U.S. Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with prostate CA, admitted with isolated hyperkalemia, Cr at\n baseline.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:56 PM\n PFI: No hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND.\n\n INDICATION: Prostate cancer with acute renal failure. Please evaluate for\n hydronephrosis.\n\n COMPARISON: CT abdomen and pelvis, .\n\n FINDINGS: Limited study given habitus and poor acoustic window performed\n without a radiologist present. The right kidney measures 9.5 cm. The left\n kidney measures 10.2 cm. No mass, stone or hydronephrosis detected within the\n kidneys. The bladder is moderately distended with fluid without focal lesion\n detected within.\n\n IMPRESSION: Mildly limited study. No hydronephrosis.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-04 00:00:00.000",
"description": "Report",
"row_id": 164800,
"text": "TRACING IS SUBMITTED LATE AND OUT OF SEQUENCE. Sinus bradycardia. Left axis\ndeviation. There are Q waves in the inferior leads consistent with prior\nmyocardial infarction. There is a late transition which is probably normal.\nCompared to the subsequent tracing there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-04 00:00:00.000",
"description": "Report",
"row_id": 164801,
"text": "TRACING IS SUBMITTED LATE AND OUT OF SEQUENCE. Sinus bradycardia. Left axis\ndeviation. There are Q waves in the inferior leads consisent with prior\nmyocardial infarction. There is a late transition which is probably normal.\nCompared to the subsequent tracing there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-04 00:00:00.000",
"description": "Report",
"row_id": 164802,
"text": "Sinus bradycardia\nLeft axis deviation\nLeft anterior fascicular block\nPossible old inferior infarct\nPoor R wave progression - possible anterior infarct\nNo previous tracing available for comparison\n\n"
}
] |
26,398 | 116,339 | The patient was admitted to the hospital on . She was started on vancomycin, levofloxacin, and Flagyl. Cardiology was consulted for preoperative clearance. They recommended a Persantine MIBI study preoperatively, increasing the patient's Enalapril from 5 mg p.o. q.d. to b.i.d., and also starting a statin after lipid profile. The patient underwent a left lower extremity angiogram via a right femoral approach on by Dr. . Postoperatively, the patient had a right groin hematoma. Pressure was held approximately 45 minutes in total and the hematoma resolved. On the following day, while the patient was out of bed to chair, the patient started to bleed from the right groin puncture site again. This was resolved with holding pressure. The patient's Persantine MIBI study was normal with an ejection fraction of 63%. The Cardiology Service cleared her for surgery. The patient was reluctant to start a statin without first consulting her local cardiologist, Dr. and this was deferred. On , the patient underwent a left femoral to popliteal bypass graft with nonreverse saphenous vein. Postoperatively, she had a palpable left anterior tibial pulse. Immediately postoperatively, the patient had an episode of hypotension which was treated with an IV fluid bolus. The patient developed some oozing from her left groin incision. Her hematocrit was 26 with a PTT of 150. The patient received several units of fresh frozen plasma, packed red blood cells, and lactate Ringer's solution. On postoperative day number one, , the patient was brought to the Operating Room again for evacuation of left thigh hematoma. Postoperatively, she was treated with fresh frozen plasma and DDAVP (desmopressin), for oozing which was successful. On , the Hematology Service was consulted regarding the patient's apparent coagulopathy which had been successfully treated with the fresh frozen plasma and DDAVP. After reviewing the medical records, it appeared that the patient had an episode of a right groin hematoma following her cardiac catheterization in . After careful review, it appeared that the patient was extremely sensitive to heparin. After stopping all heparin, the patient's coagulations returned to . On , Cardiology was reconsulted because the patient had developed extrasystoles which had also occurred preoperatively. Cardiology started the patient on Diltiazem 30 mg q.i.d. and recommended titration to keep the heart rate less than 100. They also noted that the patient was 9.5 liters up and 8 kilograms up from her preoperative weight. they recommended gentle diuresis with Lasix and keeping her hematocrit greater than 30. The patient was again transfused for a hematocrit of 27. Post transfusion hematocrit was 34. The patient's Diltiazem was titrated to keep the heart rate less than 80 and systolic blood pressure greater than 100 with Diltiazem SR 120 mg p.o. q.d. The patient will follow-up with her local cardiologist, Dr. ..................... At the time of dictation, the patient's left leg incision is clean, dry, and intact. She has a palpable graft. The cellulitis had improved. She had been ambulating with physical therapy who suggested a rehabilitation stay. The patient will be discharged to rehabilitation on two more weeks of levofloxacin. She will follow-up with Dr. in the office for surgical staple removal in two weeks. | Sinus rhythm - supraventricular extrasystolesIncomplete right bundle branch blockBorderline low voltageSince previous tracing of , no significant change Sinus rhythmSupraventricular extrasystolesRight bundle branch blockSince previous tracing of same date, no significant change Sinus rhythmLeft axis deviationConduction defect of RBBB typeSince previous tracing of , the heart rate has decreased | 4 | [
{
"category": "ECG",
"chartdate": "2112-11-17 00:00:00.000",
"description": "Report",
"row_id": 302621,
"text": "Sinus rhythm with atrial premature complex and runs of probable multifocal\natrial tachycardia\nVentricular premature complexes\nIncomplete right bundle branch block\nSince previous tracing of , ventricular ectopy increased\n\n"
},
{
"category": "ECG",
"chartdate": "2112-11-16 00:00:00.000",
"description": "Report",
"row_id": 302622,
"text": "Sinus rhythm\nSupraventricular extrasystoles\nRight bundle branch block\nSince previous tracing of same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2112-11-16 00:00:00.000",
"description": "Report",
"row_id": 302623,
"text": "Sinus rhythm\n - supraventricular extrasystoles\nIncomplete right bundle branch block\nBorderline low voltage\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2112-11-09 00:00:00.000",
"description": "Report",
"row_id": 302624,
"text": "Sinus rhythm\nLeft axis deviation\nConduction defect of RBBB type\nSince previous tracing of , the heart rate has decreased\n\n"
}
] |
45,032 | 198,439 | Pt was admitted electively and brought to the OR where under general anestheisa he underwent a LATERAL EXTRACAVITARY T8-T9 FUSION T5-T11 without complications. Post operatively he went to the ICU for close neurological observation and he was intubated. Immediately post operatively he was moving all extremeties symmetrically and full strength. His dressing was dry and his drains were putting out serosanguous fluid. He was extubated on post operative day 1 and transferred to the surgical floor. His diet and activity were increased. JP drains were removed POD#2. Incision was clean and dry. Foley was dc'd. Pt was out of bed to chair. He was transitioned to PO pain medication. Post op xrays were done and showed good hardware alignment. His motor exam continued to be full strength. He was high risk for clotting with h/o PE and after speaking with his hematologist it was decided to resume lovenox bridge to therapeutic coumadin. PT evaluated him and cleared him for discharge to home. On the day of his discharge he was neurologically intact with some mild decreased sensation over his right posterior and lateral chest wall, but otherwise was intact. His reflexes were normal and symmetric.There was no clonus. His strength was full. He was ambulating in the hallway without difficulty. | Presents to TSICU s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11. Presents to TSICU s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11. TSICU HPI: ADMISSION NOTE Pt is 58yo M h/o renal cell ca with multiple mets includingT9-10 level. TSICU HPI: ADMISSION NOTE Pt is 58yo M h/o renal cell ca with multiple mets includingT9-10 level. FINAL REPORT PORTABLE AP CHEST INDICATION: Thoracic fusion and ET tube placement. Clip # Reason: T5-T11 FUSION Admitting Diagnosis: RENAL CELL METASTASES/SDA FINAL REPORT STUDY: Thoracic spine intraoperative study . KVO and diurese 1-2 L today Hematology: EBL 1.5-2L, transfused 3uPRBC intraop. Labs / Radiology [image002.jpg] Assessment and Plan Assessment and Plan: 58yo M h/o renal cell ca with bony mets to T8-9 who is s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11 Neurologic: Neuro checks Q: 4 hr, s/p T8-9 corpectomy and T5-11 fusion. Labs / Radiology [image002.jpg] Assessment and Plan Assessment and Plan: 58yo M h/o renal cell ca with bony mets to T8-9 who is s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11 Neurologic: Neuro checks Q: 4 hr, s/p T8-9 corpectomy and T5-11 fusion. Chief complaint: s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11 PMHx: PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung nodule; h/o PE on coumadin PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection for mets Current medications: 24 Hour Events: Post operative day: POD#0 - T5-11 Fusion Allergies: Morphine insomnia; Last dose of Antibiotics: Infusions: Fentanyl - 100 mcg/hour Midazolam (Versed) - 2 mg/hour Other ICU medications: Pantoprazole (Protonix) - 10:05 PM Other medications: Flowsheet Data as of 10:27 PM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 36.1C (96.9 T current: 36.1C (96.9 HR: 71 (69 - 81) bpm BP: 99/75(81) {99/73(81) - 115/75(82)} mmHg RR: 10 (8 - 10) insp/min SPO2: 100% Heart rhythm: SR (Sinus Rhythm) Total In: 6,594 mL PO: Tube feeding: IV Fluid: 5,614 mL Blood products: 980 mL Total out: 0 mL 2,675 mL Urine: 60 mL NG: Stool: Drains: 115 mL Balance: 0 mL 3,919 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: SIMV/PSV/AutoFlow Vt (Set): 600 (600 - 700) mL PS : 5 cmH2O RR (Set): 10 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 50% PIP: 23 cmH2O Plateau: 14 cmH2O SPO2: 100% ABG: //// Ve: 5.8 L/min Physical Examination General Appearance: intubated, sedated HEENT: PERRL, edemetous sclera Cardiovascular: (Rhythm: Regular) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA bilateral : ) Abdominal: Soft, Non-distended, Non-tender Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse - Dorsalis pedis: Present) Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse - Dorsalis pedis: Present) Neurologic: Follows simple commands, (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves all extremities, Sedated, When sedation decreased, moves all extremities on command. | 16 | [
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565905,
"text": "Mr. is a 58-year-old man with a long\n history of metastatic kidney cancer. In the past, he has been\n managed with surgical resection, radiation therapy to multiple\n bone metastases and Avastin every two weeks. He has been on\n Avastin for over two years now. Over the last six months, he has\n had gradual progression of his disease mostly in bone. Despite\n radiation, he has had progression of his vertebral body disease\n at T9 and T10.\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n T5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n spinal fusion Bone/Spine mets to T9/impaired physical mobility\n Assessment:\n Post T5-T11 Fusion,, lost blood in OR, on Neo on and off during\n the case., was proned for 10 hours on the table. Remains intubated,\n moving both legs, reacts to cold with both feet, MAE, purposeful,\n follows commands , grimaces while turned, nods when having pain\n Action:\n Neurochcks, sedation, turned q2h,pain control on fentanyl and midaz gtt\n , range of motion, assessment and adjustment of vent setting done-see\n ABGs\n Response:\n Mobility maintained all extremeties/joints, pain was assessed/\n controlled effectively by titrating fentanyl gtt\n Plan:\n Patient will keep maintaining full mobility of joints, try to\n wean/extubate, switch to PCA for Pain control\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565899,
"text": "5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n"
},
{
"category": "ECG",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Report",
"row_id": 135358,
"text": "Sinus rhythm\nModest nonspecific low amplitude inferolateral lead T wave changes\nSince previous tracing of , modest T wave changes now present\n\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565903,
"text": "T5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n PMHx:\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n spinal fusion Bone/Spine mets to T9/impaired physical mobility\n Assessment:\n Post T5-T11 Fusion,, lost blood in OR, on Neo on and off during\n the case., was proned for 10 hours on the table. Remains intubated,\n moving both legs, reacts to cold with both feet, MAE, purposeful,\n follows commands , grimaces while turned, nods when having pain\n Action:\n Neurochcks, sedation, turned q2h,pain control on fentanyl and midaz gtt\n , range of motion, assessment and adjustment of vent setting done-see\n ABGs\n Response:\n Mobility maintained all extremeties/joints, pain was assessed/\n controlled effectively by titrating fentanyl gtt\n Plan:\n Patient will keep maintaining full mobility of joints, try to\n wean/extubate, switch to PCA for Pain control\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565904,
"text": "T5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n PMHx:\n Mr. is a 58-year-old man with a long\n history of metastatic kidney cancer. In the past, he has been\n managed with surgical resection, radiation therapy to multiple\n bone metastases and Avastin every two weeks. He has been on\n Avastin for over two years now. Over the last six months, he has\n had gradual progression of his disease mostly in bone. Despite\n radiation, he has had progression of his vertebral body disease\n at T9 and T10.\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n spinal fusion Bone/Spine mets to T9/impaired physical mobility\n Assessment:\n Post T5-T11 Fusion,, lost blood in OR, on Neo on and off during\n the case., was proned for 10 hours on the table. Remains intubated,\n moving both legs, reacts to cold with both feet, MAE, purposeful,\n follows commands , grimaces while turned, nods when having pain\n Action:\n Neurochcks, sedation, turned q2h,pain control on fentanyl and midaz gtt\n , range of motion, assessment and adjustment of vent setting done-see\n ABGs\n Response:\n Mobility maintained all extremeties/joints, pain was assessed/\n controlled effectively by titrating fentanyl gtt\n Plan:\n Patient will keep maintaining full mobility of joints, try to\n wean/extubate, switch to PCA for Pain control\n"
},
{
"category": "Respiratory ",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 565934,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt to a 35% cool neb at this time\n"
},
{
"category": "General",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Generic Note",
"row_id": 565936,
"text": "TSICU\n HPI:\n ADMISSION NOTE\n Pt is 58yo M h/o renal cell ca with multiple mets includingT9-10\n level. Tumor invaded spinal canal w/o cord compression. Presents to\n TSICU s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion\n T5-11. EBL 1.5-2L, 6L crystoid, 3units PRBC.\n Chief complaint:\n s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11\n PMHx:\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#0 - T5-11 Fusion\n Allergies:\n Morphine\n insomnia;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:05 PM\n Other medications:\n Flowsheet Data as of 10:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (96.9\n T current: 36.1\nC (96.9\n HR: 71 (69 - 81) bpm\n BP: 99/75(81) {99/73(81) - 115/75(82)} mmHg\n RR: 10 (8 - 10) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,594 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,614 mL\n Blood products:\n 980 mL\n Total out:\n 0 mL\n 2,675 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n 115 mL\n Balance:\n 0 mL\n 3,919 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 600 (600 - 700) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, edemetous sclera\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), Moves all extremities, Sedated, When\n sedation decreased, moves all extremities on command.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 58yo M h/o renal cell ca with bony mets to T8-9\n who is s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion\n T5-11\n Neurologic: Neuro checks Q: 4 hr, s/p T8-9 corpectomy and T5-11\n fusion. currently moves all 4 extremities on command. neuro after\n extubation.\n Cardiovascular: hemodynamically stable, Stable anemia. Check PM Hct.\n hold home BP meds for now\n Pulmonary: Pt got extubated during morning rounds\n Gastrointestinal / Abdomen: PPI proph; place NG/DHT if will remain\n intubated tomorrow.\n Nutrition: NPO\n Renal: Foley, Adequate UO. KVO and diurese 1-2 L today\n Hematology: EBL 1.5-2L, transfused 3uPRBC intraop. follow postop HCT\n in PM.\n Endocrine: RISS with adequate glucose control\n Infectious Disease: Cefazolin 1g IV q8 x2doses for periop\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP), PIV\n Wounds:\n Imaging: CXR today\n Fluids: D5NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:18 PM\n 16 Gauge - 09:18 PM\n 14 Gauge - 09:18 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n d/c as no indication\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 25 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 565919,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: extubation in the am.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 565924,
"text": "Mr. is a 58-year-old man with a long\n history of metastatic kidney cancer. In the past, he has been\n managed with surgical resection, radiation therapy to multiple\n bone metastases and Avastin every two weeks. He has been on\n Avastin for over two years now. Over the last six months, he has\n had gradual progression of his disease mostly in bone. Despite\n radiation, he has had progression of his vertebral body disease\n at T9 and T10.\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n T5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n spinal fusion Bone/Spine mets to T9/impaired physical mobility\n Assessment:\n Post T5-T11 Fusion,, lost blood in OR, on Neo on and off during\n the case., was proned for 10 hours on the table. Remains intubated,\n moving both legs, reacts to cold with both feet, MAE, purposeful,\n follows commands , grimaces while turned, nods when having pain\n Action:\n Neurochcks, sedation, turned q2h,pain control on fentanyl and midaz gtt\n , range of motion, assessment and adjustment of vent setting done-see\n ABGs\n Response:\n Mobility maintained all extremeties/joints, pain was assessed/\n controlled effectively by titrating fentanyl gtt\n Plan:\n Patient will keep maintaining full mobility of joints, try to\n wean/extubate, switch to PCA for Pain control\n"
},
{
"category": "Physician ",
"chartdate": "2185-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 565886,
"text": "TSICU\n HPI:\n ADMISSION NOTE\n Pt is 58yo M h/o renal cell ca with multiple mets includingT9-10\n level. Tumor invaded spinal canal w/o cord compression. Presents to\n TSICU s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion\n T5-11. EBL 1.5-2L, 6L crystoid, 3units PRBC.\n Chief complaint:\n s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion T5-11\n PMHx:\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n Current medications:\n 24 Hour Events:\n Post operative day:\n POD#0 - T5-11 Fusion\n Allergies:\n Morphine\n insomnia;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:05 PM\n Other medications:\n Flowsheet Data as of 10:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (96.9\n T current: 36.1\nC (96.9\n HR: 71 (69 - 81) bpm\n BP: 99/75(81) {99/73(81) - 115/75(82)} mmHg\n RR: 10 (8 - 10) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,594 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,614 mL\n Blood products:\n 980 mL\n Total out:\n 0 mL\n 2,675 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n 115 mL\n Balance:\n 0 mL\n 3,919 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 600 (600 - 700) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, edemetous sclera\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), Moves all extremities, Sedated, When\n sedation decreased, moves all extremities on command.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 58yo M h/o renal cell ca with bony mets to T8-9\n who is s/p Lateral Extracavity T8-9 corpectomy and Instrumented Fusion\n T5-11\n Neurologic: Neuro checks Q: 4 hr, s/p T8-9 corpectomy and T5-11\n fusion. currently moves all 4 extremities on command. neuro check\n q4hrs; sedation while intubated with midaz/fent gtt. Dilaudid bolus\n then PCA when extubated. Neurontin when extubated\n Cardiovascular: hemodynamically stable, follow up post-op HCT. hold\n home BP meds for now\n Pulmonary: Cont ETT, 600x10; Plan to ween to CPAP/PS in AM. Assess\n cuff leak prior to extubation\n Gastrointestinal / Abdomen: PPI proph; place NG/DHT if will remain\n intubated tomorrow.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: EBL 1.5-2L, transfused 3uPRBC intraop. follow postop HCT.\n Endocrine: RISS\n Infectious Disease: Cefazolin 1g IV q8 x2doses for postop\n Lines / Tubes / Drains: Foley, ETT, Surgical drains (hemovac, JP), PIV\n Wounds:\n Imaging: CXR today\n Fluids: D5NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:18 PM\n 16 Gauge - 09:18 PM\n 14 Gauge - 09:18 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 27 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565989,
"text": "Mr. is a 58-year-old man with a long\n history of metastatic kidney cancer. In the past, he has been\n managed with surgical resection, radiation therapy to multiple\n bone metastases and Avastin every two weeks. He has been on\n Avastin for over two years now. Over the last six months, he has\n had gradual progression of his disease mostly in bone. Despite\n radiation, he has had progression of his vertebral body disease\n at T9 and T10.\n PMH: HTN, OSA (CPAP x3yrs, retested and neg for OSA), Renal CA s/p\n interleukon/XRT/nephrectomy and mets to T8-9 and R ribs; LLL lung\n nodule; h/o PE on coumadin\n PSH: ' nephrectomy; reexcision of mass in ', ' R wedge resection\n for mets\n T5-T11 Fusion by Dr , lost blood in OR, on Neo on and\n off during the case., was proned for 10 hours on the table-> to Tsicu\n intubated in stable condition\n .H/O cancer (Malignant Neoplasm), Bone\n Assessment:\n Pt post op day one. Extubated at 0800 and stable respiratory exam.\n Strong cough, 1500+ on IS, lungs clear, slightly raspy voice otherwise\n coherent. Post-op dressing intact on upper back and neck. Small amt\n serosang drainage. JP x 2.\n Action:\n Pt OOB at 1600. Transferred with minimal assist and able 20 steps\n around chair with minimal discomfort. HCT and coags repeated at 1400,\n team aware of results.\n Response:\n Pt tolerating chair well.\n Plan:\n Cont to stay OOB as tolerated. Continue IS and pulmonary toileting.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt fentanyl gtt off this am and dilaudid PCA started. Pain slowly\n climbing to in lower neck and upper back. Pt very stiff in bed and\n little spontaneous movement of neck pain.\n Action:\n Fentanyl patch added (pt wears 12mcg/h patch at home prior to surgery).\n Dilaudid PCA increased and breakthrough dose of 1mg given x 1. Tylenol\n 1gm po added to regimen.\n Response:\n Within an hour pt pain down to 3/10 and reports pain as much better.\n Moving neck and arms normally.\n Plan:\n Continue Fentanyl patch, PCA and Tylenol.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n RENAL CELL METASTASES/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 76 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n insomnia;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Mr. is a 58-year-old man with a long\n history of metastatic kidney cancer. In the past, he has been\n managed with surgical resection, radiation therapy to multiple\n bone metastases and Avastin every two weeks. He has been on\n Avastin for over two years now. Over the last six months, he has\n had gradual progression of his disease mostly in bone. Despite\n radiation, he has had progression of his vertebral body disease\n at T9 and T10.\n Surgery / Procedure and date: R. nephrectomy/mass removal\n thoracothomy R. apical/wedge resection\n cyber nife 9th rib lesion\n cyber nife\n T5-T11 fusion + T8-T9 vertobrectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:71\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 40% %\n 24h total in:\n 2,608 mL\n 24h total out:\n 1,345 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:09 AM\n Potassium:\n 4.9 mEq/L\n 04:13 AM\n Chloride:\n 112 mEq/L\n 09:51 PM\n CO2:\n 23 mEq/L\n 09:51 PM\n BUN:\n 16 mg/dL\n 09:51 PM\n Creatinine:\n 0.9 mg/dL\n 09:51 PM\n Glucose:\n 132 mg/dL\n 02:09 AM\n Hematocrit:\n 25.6 %\n 01:35 PM\n Finger Stick Glucose:\n 126\n 04:00 PM\n Valuables / Signature\n Patient valuables: Wife brought in overnight bag with change of\n clothing and cell phone. Pt states he has a bag of clothes and glasses\n in preop holding from yesterday.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: @ 1800\n"
},
{
"category": "Radiology",
"chartdate": "2185-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070976,
"text": " 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film. ETT placement.\n Admitting Diagnosis: RENAL CELL METASTASES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p thoracic spinal fusion.\n REASON FOR THIS EXAMINATION:\n postop film. ETT placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:23 PM\n PFI: ET tube is 6.8 cm from the carina.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: Thoracic fusion and ET tube placement.\n\n FINDINGS: Comparison is made with prior radiograph from , prior CT\n from , and MR of the thoracic spine from . The\n ET tube is 6.8 cm from the carina. The numerous right-sided nodules are\n minimally larger. Several left-sided pulmonary nodules are also noted. The\n vague opacity in the right lower lung is likely the posterior chest wall mass\n seen on the prior CT scan. Surgical clips and fiducial markers are seen\n throughout the right hemithorax. The cardiomediastinal silhouette is normal.\n There has been interval thoracic spinal fusion.\n\n IMPRESSION: No pneumothorax. Minimal size increase in the diffuse pulmonary\n nodules, some of which correlate to known chest wall masses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-03-11 00:00:00.000",
"description": "T-SPINE",
"row_id": 1071258,
"text": " 10:34 AM\n T-SPINE Clip # \n Reason: 58 year old man s/p Thoracic vertebrectomy T8-9 with fusion\n Admitting Diagnosis: RENAL CELL METASTASES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p Thoracic vertebrectomy T8-9 with fusion T5-11, please check\n post op standing AP/lat and visualise both ends of hardware in view\n REASON FOR THIS EXAMINATION:\n 58 year old man s/p Thoracic vertebrectomy T8-9 with fusion T5-11, please check\n post op standing AP/lat and visualise both ends of hardware in view\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man status post thoracic vertebrectomy of T8 and 9\n with fusion of T5 through 11.\n\n COMPARISON: PA and lateral VIEWS OF THE THORACIC SPINE:\n\n FINDINGS: The patient is status post placement of posterior spinal rods and\n pedicle screws within T5-T6, T7, T10, and T11. Intervertebral disc spacers\n are noted at T7-8 and T9-10. Stable loss of height of vertebral body at T8 is\n again demonstrated. No hardware complications are noted. At least two drains\n are noted posteriorly. Multiple surgical clips are seen overlying the\n posterior aspect of the spine.\n\n IMPRESSION: Satisfactory postoperative appearance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-03-09 00:00:00.000",
"description": "O T-SPINE IN O.R.",
"row_id": 1070862,
"text": " 11:20 AM\n T-SPINE IN O.R. Clip # \n Reason: T5-T11 FUSION\n Admitting Diagnosis: RENAL CELL METASTASES/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Thoracic spine intraoperative study .\n\n HISTORY: Patient with T5-T11 fusion.\n\n FINDINGS: Seven images from the operating room demonstrates interval\n placement of pedicle screws within T5, T6, T7, T10 and T11 with paired spinal\n rods. Loss of intervertebral disc height of T9, T8, and T7 is seen. There\n are no signs of hardware-related complications. Please refer to the operative\n note for additional details.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070977,
"text": ", W. NSURG TSICU 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film. ETT placement.\n Admitting Diagnosis: RENAL CELL METASTASES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p thoracic spinal fusion.\n REASON FOR THIS EXAMINATION:\n postop film. ETT placement.\n ______________________________________________________________________________\n PFI REPORT\n PFI: ET tube is 6.8 cm from the carina.\n\n"
},
{
"category": "Nursing",
"chartdate": "2185-03-10 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 565987,
"text": ".H/O cancer (Malignant Neoplasm), Bone\n Assessment:\n Pt post op day one. Extubated at 0800 and stable respiratory exam.\n Strong cough, 1500+ on IS, lungs clear, slightly raspy voice otherwise\n coherent. Post-op dressing intact on upper back and neck. Small amt\n serosang drainage. JP x 2.\n Action:\n Pt OOB at 1600. Transferred with minimal assist and able 20 steps\n around chair with minimal discomfort. HCT and coags repeated at 1400,\n team aware of results.\n Response:\n Pt tolerating chair well.\n Plan:\n Cont to stay OOB as tolerated. Continue IS and pulmonary toileting.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt fentanyl gtt off this am and dilaudid PCA started. Pain slowly\n climbing to in lower neck and upper back. Pt very stiff in bed and\n little spontaneous movement of neck pain.\n Action:\n Fentanyl patch added (pt wears 12mcg/h patch at home prior to surgery).\n Dilaudid PCA increased and breakthrough dose of 1mg given x 1. Tylenol\n 1gm po added to regimen.\n Response:\n Within an hour pt pain down to 3/10 and reports pain as much better.\n Moving neck and arms normally.\n Plan:\n Continue Fentanyl patch, PCA and Tylenol.\n"
}
] |
19,060 | 195,456 | 78 yM with rt foot ischemia with with dry gangrenous ulceration secondary to heel pressure during hospitalization for MI/CHF/CABG"Sx1 Patient with known aorto-iliac and femoral disease s/p ABF returns for angio and possible surgery. Patient was admitted and pre-hydrated for an angiogram. Angio on revealed angio: patent aobifem, occluded sfa, disease, patent distal AT. AT & peroneal runoff. The patient also had a carotid US which revelaed 80-99% stenosis of his left carotid aretery. On Mr. was consented, prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. He was noted to have a left neck hematoma, and was given 2u of PRBC for a HCT of 23. He was then transferred to the VICU for further recovery. On the floor, he remained hemodynamically stable with his pain controlled. His Vitals remained stable and his diet was advanced. On he returned to the OR for a R fem-AT bypass. The patient was monitored intraoperatively with a PA catheter and remained stable. HE tolerated wht procedure without complication and was transferred to the PACU then ICU pos-op due to hypotension requiring pressor support. On POD #1 he remained stable and was transferred to the VICU. He received 2u PRBC's. His blood pressure was kept under tight control and diuresis was begun on POD #2. On POD #3 the patient's PA catheter and CVL were removed. His labs remained stable with the exception of a slightly elevated WBC, which he had on admission, and he was OOB. A PT consult was obtained, and his diet was advanced. His pain was control on PO pain medications. The patient had a palpable RLE graft and pulses on doppler. The patient continued to progress well and was cleared for home with PT. His labs remained stable, and on POD #4 he was discharged to home with VNA/PT. He will be partial weight bearing on his RLE for essential distances until followup. He will be sent on a 10 day course of bactrim. He will followup with Dr. in weeks. | Normal ascending aortadiameter. There is mild global right ventricularfree wall hypokinesis. Normal descending aorta diameter. Mild to moderate(+) MR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. There are simple atheroma in the descending thoracicaorta. pvc's,resolved after elyte replacement.carotid site c & d,staples intact. LUE GROSSLY ECCHYMOTIC/EDEMATOUS FROM BRACHIAL SHEATH(FOR ANGIOGRAM) SITE DC'D ON . R ANTERIOR TIBIAL PULSE PALPATED, ALL OTHERS DOPPLED. BS 78 AT 0300, RX'D WITH OJ, REPEAT BS 67 AT 0400(DENIES SX HYPOGLYCEMIA), RX'D WITH 1/2 AMP D50.GI: ABDOMEN SOFT, + BS. Simple atheroma in descendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3).MITRAL VALVE: Moderately thickened mitral valve leaflets. vascular team updated re: above. The is apicalakinesia and global hypokinesia of the left ventricle. DSG CHANGED X 1 FOR SMALL AT SANGUINOUS DRAINAGE. WJMLEFT ATRIUM: Mild LA enlargement. Compared with , an ET tube has been placed. arrived from or hypothermic with ci < 2,elevated svr on dobutamine. PULM HYGIENE. Tissue Doppler imagingsuggests an increased left ventricular filling pressure (PCWP>18mmHg).Transmitral Doppler and tissue velocity imaging are consistent with Grade II(moderate) LV diastolic dysfunction. The Vp is 38cm/secsuggesting diastolic dysfunction.Slight hypokinesia of the free wall of the right ventricle.There is mild to moderate mitral regurgitation with a central jet. lt. brachial angio site eccymotic but soft. There is dense right carotid artery calcification. Compared to theprevious tracing of inferior and lateral repolarization changes are morestriking and ventricular ectopy is no longer present. placed on simv mode,adjusted per abg. Borderline left atrial abnormality. lt. foot cooler with dopplerable pulses,occasionally monophasic & fleeting.rt. The right hemidiaphragm is elevated, unchanged. : R femoral-tibial BPG complicated by hypotension/bradycardia/low hct. strongly palpable anterior tibial & dorsalis pulse. Sinus rhythm. Mild to moderate (+) mitralregurgitation is seen. The patient was undergeneral anesthesia throughout the procedure.Conclusions:The left atrium is mildly dilated. Billing error corrected. Hypertension. 8:49 AM CAROTID SERIES COMPLETE Clip # Reason: ? GOOD COUGH EFFORT.CV: NSR 80'S-100, RARE PVC. LUNGS DIMINSHED BASES. as tolerated & start ntg if unable. Again seen is prominence of the cardiomediastinal silhouette, with cardiomegaly and sternotomy wires. Similar values in the left are 276, 48 and 138 cm/s. HCT DOWN TO 26.8, REPORTED TO MD AND MD . resp carept received from O.R. with #7.5 ETT/23 lip. Significant calcific left ICA plaque with an associated stenosis of 80-99% 2. Occasional ventricularpremature beats. dsd replaced,vascular resident() aware.morphine given for grimacing with procedures.reversed in o.r.,weaning begun. L NECK CAROTID ENDARECTOMY SITE ECCHYMOTIC, STAPLES INTACT, NO DRAINAGE, OPEN TO AIR.ENDO: HX IDDM. as tolerated for svo2 > 60%,fick ci > 2. bp creeping up with vent weaning,plan to wean dobut. The peak systolic velocities on the right are 116, 44 and 132 cm/s for the ICA, CCA and ECA respectively. DOBUTAMINE GTT WEANED OFF BY 2100, MV02 67-72, FICK CI > 2.6. Normal sinus rhythm, rate 95. The aortic valve leaflets (3) are mildly thickened. initially with freq. A right IJ Swan-Ganz catheter is present, tip over proximal right pulmonary artery. IMPRESSION: Minimal blunting of posterior costophrenic sulcus (likely left side), which may be due to small amount of pleural thickening or a small effusion. : L carotid endarectomy. TDI E/e' >15, suggesting PCWP>18mmHg.Transmitral Doppler and TVI c/w Grade II (moderate) LV diastolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -hypo;RIGHT VENTRICLE: Mild global RV free wall hypokinesis.AORTA: Normal aortic diameter at the sinus level. PRBC x 3, Dobutamine gtt.NEURO: A&O X 3, MAE, PLEASANT AND COOPERATIVE WITH CARE. Sinus rhythmLeft atrial abnormalityNonspecific intraventricular conduction delayLeft ventricular hypertrophy with ST-T abnormalitiesCannot exclude in part ischemia - clinical correlation is suggestedSince previous tracing of , intraventricular conduction delay, moreprominent QRS voltage and further ST-T wave abnormalities present Theanterior and posterior leaflets are calcified at the base. Intraventricular conduction delay. HALF DOLLAR SIZED DRY NECROTIC AREA R HEEL. PERCOCET 2 PO X 2 FOR PAIN.PULM: EXTUBATED AT 1900 TO N/C, TOLERATED WELL. There has been interval median sternotomy and coronary artery bypass surgery. ABG'S WNL. serial mb's begun,ecg c/w pre op. TAKING LIQUIDS WELL.GU: FOLEY TO CD, URINE AMBER. COMPARISON: chest x-ray. warmed with bair hugger,prbc's ( from or) infused with improved hemodynamics,adequate huo,svo2 > 60%. CHEST, SINGLE AP VIEW. Pleural surfaces are otherwise clear and skeletal structures are remarkable only for post-sternotomy changes. Left ventricular function.Status: InpatientDate/Time: at 15:14Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Severely depressed LV systolic function with EF of 20-25%. IMPRESSION: 1. Otherwise unremarkable chest radiograph. There is soft tissue swelling, subcutaneous emphysema and skin staples over the left neck. INCISION LINE FROM R GROIN TO R ANKLE, STAPLED, CLEAN. leg incision staining dsgs with mod. There is antegrade flow involving both vertebral arteries. pip/plateau wnl. clear BBS. FREQUENT BLD SUGARS UNTIL BD MORE REGULATED, AC AND HS HUMALOG COVERAGE, FIXED 70/30 DOSES. amts blood,esp. carotid dz FINAL REPORT CAROTID STUDY DATED THE 6TH HISTORY: Stroke and carotid bruit. H/O cardiac surgery. The tip lies approximately 2.6 cm above the carina, in satisfactory position. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2161-07-19 00:00:00.000",
"description": "Report",
"row_id": 1513532,
"text": ": L carotid endarectomy.\n: R femoral-tibial BPG complicated by hypotension/bradycardia/low hct. TEE EF 15%, CI < 2.0. PRBC x 3, Dobutamine gtt.\n\nNEURO: A&O X 3, MAE, PLEASANT AND COOPERATIVE WITH CARE. \"I HURT ALL OVER.\" PERCOCET 2 PO X 2 FOR PAIN.\n\nPULM: EXTUBATED AT 1900 TO N/C, TOLERATED WELL. ABG'S WNL. LUNGS DIMINSHED BASES. GOOD COUGH EFFORT.\n\nCV: NSR 80'S-100, RARE PVC. DOBUTAMINE GTT WEANED OFF BY 2100, MV02 67-72, FICK CI > 2.6. INCISION LINE FROM R GROIN TO R ANKLE, STAPLED, CLEAN. DSG CHANGED X 1 FOR SMALL AT SANGUINOUS DRAINAGE. R ANTERIOR TIBIAL PULSE PALPATED, ALL OTHERS DOPPLED. HALF DOLLAR SIZED DRY NECROTIC AREA R HEEL. HCT DOWN TO 26.8, REPORTED TO MD AND MD . LUE GROSSLY ECCHYMOTIC/EDEMATOUS FROM BRACHIAL SHEATH(FOR ANGIOGRAM) SITE DC'D ON . L NECK CAROTID ENDARECTOMY SITE ECCHYMOTIC, STAPLES INTACT, NO DRAINAGE, OPEN TO AIR.\n\nENDO: HX IDDM. BS 144 AT , PT DRINKING WELL, EATING . 30 UNITS 70/30 INSULIN SC AT 2100. BS 78 AT 0300, RX'D WITH OJ, REPEAT BS 67 AT 0400(DENIES SX HYPOGLYCEMIA), RX'D WITH 1/2 AMP D50.\n\nGI: ABDOMEN SOFT, + BS. TAKING LIQUIDS WELL.\n\nGU: FOLEY TO CD, URINE AMBER. CREATININE UP TO 1.3.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: DC SWAN THIS AM. PULM HYGIENE. CHANGE RLE DSG DAILY AND PRN, MONITOR PULSES Q4H. FREQUENT BLD SUGARS UNTIL BD MORE REGULATED, AC AND HS HUMALOG COVERAGE, FIXED 70/30 DOSES. ? DECREASE PM DOSE INSULIN AS PT STATES AM BLD SUGARS TEND TO BE LOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-07-18 00:00:00.000",
"description": "Report",
"row_id": 1513529,
"text": "resp care\npt received from O.R. with #7.5 ETT/23 lip. placed on simv mode,adjusted per abg. clear BBS. pip/plateau wnl. plan is to wake/wean this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-07-18 00:00:00.000",
"description": "Report",
"row_id": 1513530,
"text": "arrived from or hypothermic with ci < 2,elevated svr on dobutamine. warmed with bair hugger,prbc's ( from or) infused with improved hemodynamics,adequate huo,svo2 > 60%. serial mb's begun,ecg c/w pre op. initially with freq. pvc's,resolved after elyte replacement.carotid site c & d,staples intact. lt. brachial angio site eccymotic but soft. rt. leg & foot warm,ruborous toes. strongly palpable anterior tibial & dorsalis pulse. lt. foot cooler with dopplerable pulses,occasionally monophasic & fleeting.rt. leg incision staining dsgs with mod. amts blood,esp. @ knee area. dsd replaced,vascular resident() aware.morphine given for grimacing with procedures.reversed in o.r.,weaning begun. opens eyes to command,nods appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-07-18 00:00:00.000",
"description": "Report",
"row_id": 1513531,
"text": "anesthesia reports ef 15-20%,will follow fick & svo2. vascular team updated re: above. plan to wean dobut. as tolerated for svo2 > 60%,fick ci > 2. bp creeping up with vent weaning,plan to wean dobut. as tolerated & start ntg if unable. goal sbp < 150.\n"
},
{
"category": "Radiology",
"chartdate": "2161-07-14 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 964043,
"text": " 3:27 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: GANGRENE, RIGHT LOWER EXTREMITY\n Admitting Diagnosis: GANGRENE, RIGHT LOWER EXTREMITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with rt. foot infection and PVD for angio \n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST OF \n\n INDICATION: Pre-operative assessment prior to right lower extremity angio\n procedure.\n\n COMPARISON: chest x-ray.\n\n There has been interval median sternotomy and coronary artery bypass surgery.\n Heart size is normal. Lungs are clear. There is minimal blunting of\n posterior costophrenic sulcus, probably the left, visualized only on the\n lateral view. Pleural surfaces are otherwise clear and skeletal structures\n are remarkable only for post-sternotomy changes.\n\n IMPRESSION: Minimal blunting of posterior costophrenic sulcus (likely left\n side), which may be due to small amount of pleural thickening or a small\n effusion. Otherwise unremarkable chest radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-07-15 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 964119,
"text": " 8:49 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: ? carotid dz\n Admitting Diagnosis: GANGRENE, RIGHT LOWER EXTREMITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hx CVA and left carotid briut,preop for vascular bpg\n REASON FOR THIS EXAMINATION:\n ? carotid dz\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY DATED THE 6TH\n\n HISTORY: Stroke and carotid bruit.\n\n FINDINGS: Heavily calcified plaque involving the carotid bulbs and extending\n into the external and internal carotid arteries bilaterally. The peak\n systolic velocities on the right are 116, 44 and 132 cm/s for the ICA, CCA and\n ECA respectively. Similar values in the left are 276, 48 and 138 cm/s. The\n ICA to CCA ratio is 2.6 on the right and 5.8 on the left. There is antegrade\n flow involving both vertebral arteries.\n\n IMPRESSION:\n 1. Significant calcific left ICA plaque with an associated stenosis of 80-99%\n 2. Similar plaque but to a lesser extent involving the right ICA with a\n 40-59% stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 964596,
"text": " 1:44 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for ptx and line placement\n Admitting Diagnosis: GANGRENE, RIGHT LOWER EXTREMITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with distal bypass\n REASON FOR THIS EXAMINATION:\n eval for ptx and line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Distal bypass, evaluate for pneumothorax and line placement.\n\n CHEST, SINGLE AP VIEW.\n\n Compared with , an ET tube has been placed. The tip lies approximately\n 2.6 cm above the carina, in satisfactory position. A right IJ Swan-Ganz\n catheter is present, tip over proximal right pulmonary artery. No\n pneumothorax is detected. Again seen is prominence of the cardiomediastinal\n silhouette, with cardiomegaly and sternotomy wires. No overt CHF, focal\n infiltrate or effusion is identified. The right hemidiaphragm is elevated,\n unchanged. There is dense right carotid artery calcification. There is soft\n tissue swelling, subcutaneous emphysema and skin staples over the left neck.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2161-07-18 00:00:00.000",
"description": "Report",
"row_id": 73969,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. H/O cardiac surgery. Hypertension. Left ventricular function.\nStatus: Inpatient\nDate/Time: at 15:14\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSeverely depressed LV systolic function with EF of 20-25%. The is apical\nakinesia and global hypokinesia of the left ventricle. The Vp is 38cm/sec\nsuggesting diastolic dysfunction.\nSlight hypokinesia of the free wall of the right ventricle.\nThere is mild to moderate mitral regurgitation with a central jet. The\nanterior and posterior leaflets are calcified at the base.\n\n Billing error corrected. No changes made in findings. WJM\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the\nLAA. All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Severely depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg.\nTransmitral Doppler and TVI c/w Grade II (moderate) LV diastolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter. Simple atheroma in descending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild to moderate\n(+) MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast is seen in the\nleft atrial appendage. No atrial septal defect or patent foramen ovale is seen\nby 2D, color Doppler or saline contrast with maneuvers. Overall left\nventricular systolic function is severely depressed. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg).\nTransmitral Doppler and tissue velocity imaging are consistent with Grade II\n(moderate) LV diastolic dysfunction. There is mild global right ventricular\nfree wall hypokinesis. There are simple atheroma in the descending thoracic\naorta. The aortic valve leaflets (3) are mildly thickened. The mitral valve\nleaflets are moderately thickened. Mild to moderate (+) mitral\nregurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-07-22 00:00:00.000",
"description": "Report",
"row_id": 171399,
"text": "Normal sinus rhythm, rate 95. Borderline left atrial abnormality. Incomplete\nleft bundle-branch block. Non-specific repolarization changes. Compared to the\nprevious tracing of inferior and lateral repolarization changes are more\nstriking and ventricular ectopy is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-07-18 00:00:00.000",
"description": "Report",
"row_id": 171400,
"text": "Sinus rhythm. Intraventricular conduction delay. Occasional ventricular\npremature beats. Compared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-07-14 00:00:00.000",
"description": "Report",
"row_id": 171401,
"text": "Sinus rhythm\nLeft atrial abnormality\nNonspecific intraventricular conduction delay\nLeft ventricular hypertrophy with ST-T abnormalities\nCannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , intraventricular conduction delay, more\nprominent QRS voltage and further ST-T wave abnormalities present\n\n"
}
] |
93,387 | 113,894 | 80 yo M with a h/o nephrolithiasis, chronic renal insufficiency, hypertension, angina, and BPH p/w diaphoresis nausea and chest pain. Found to have a bradycardia and hyperkalemia initially refractory to standard maneuvers.He also noted vertigo on position changes whch was felt likely secondary to bradycardia. Hyperkalemia was successfully treated with Ca gluconate, Insulin/dextrose, Kayexalate and furosemide and he had no further episodes of this and potassium remained in the normal range to discharge. Bradycardia was felt to be secondary to atenolol toxicity and atenolol was held and his bradycardia improved to the 60s by discharge. He was advised to make an appointment to see his PCP 1 week. . # Hyperkalemia: Initial hyperkalemia to 6.8 in ED in the setting of worsening renal function(creatinine 3.3 on admission) and was treated in the ED with 2 g CaGlu, 10 u regular insulin x 2, 30 g of kayexalate x 2 and 40mg of furosemide IV with 1L NS. By arrival in the ICU, this had resolved to 4.4. THis continued to be stable and was thought to have been a result of the combination of atenolol toxicity and renal failure. On stopping the atenolol, his potassium remained stably within the normal range and improved as his renal function improved to 4.2 on discharge. ECG showed sinus bradycardia and this was felt to be atenolol toxicity and not due to hyperkalemia. He was advised to make an appointment to see his PCP 1 week. . # Bradycardia: Mr initially presented with vertigo, diaphoresis and chest pain in the context of bradycardia to 40-48 and was admitted to the MICU for management of hyperkalemia (which improved after treatment) and bradycardia which improved following stopping atenolol. His initial ECGs showed appearances which appeared to alternate between what was thought to be a slow AF to what resembled a Mobitz 2 with 2:1 block and was latterly seen to be Sinus rhythm with bigeminal PACs and first degree AV block, PR interval= 230 ms. had a negative MI workup with negative cardiac enzymes x3. He was observed with telemetry. Electrophysiology were consulted for further evaluation of persistent bradycardia to the 50s after discontinuation of atenolol. Atenolol is a renally cleared beta blocker which was felt likely to have accumulated to high levels given the patient's poor renal clearance of the drug in the setting of acute kidney injury. In addition, it was felt that the patient also likely had baseline sinus node dysfunction making him more sensitive to the effect of the beta blockade. On reviewing previous results, he has had longstanding AV node delay and bradycardia as evidenced on a Holter recording from . Barring any further progression of his underlying nodal dysfunction, it is likely that the patient will return to his baseline once the atenolol effect has fully cleared and indeed by the day of discharge, his heart rate was increasing to the 60s. The plan was therefore to continue to hold all beta blockers for now and use non renally excreted beta blockers in the future such as metoprolol if clinically indicated. There was no need for a pacemaker but if his nodal disease worsens, this can be addressed as an out-patient. He was advised to make an appointment to see his PCP 1 week. . # Renal Insufficiency: The patient has nephrolithiasis and is s/p left nephrostomy for hydronephrosis. From a baseline of 1.6 in , the patient had a recent admission for with possible new baseline of 3.0. Creatinien was 3.3 on anmission and had hyperkalemia as described above with a K 6.8. A renal ultrasound was performed on showed interval improvement in left sided hydronephrosis and nonobstructing renal calculi and renal cysts in the right kidney were unchanged from prior studies. FeNa was 7.2% and uninformative. His medications were renally dosed and his creatinine improved following treatment of teh hyperkalemis and stoping atenolol. His creatinine on discharge was 2.3. He should follow-up with renal in the community. He was advised to make an appointment to see his PCP 1 week. . # Vertigo: The patinet noted vertiginous symptoms on sitting forward with no change on head-turing. Initial considerations included BPPV although abrupt head turning demonstrated no nystagmus and did not bring on symptoms. Latterly this was felt to be the result of his bradycardia and was recovering as his heart rate increased. . # Weight loss: Patient claimed he had lost 40 pounds in ~ 2 years. He had evidence of temporal wasting and denied depression. Albumin was 2.6 on admission and improved to 3.4. He was advised to make an appointment to see his PCP 1 week. . # Dyslipidemia: We continued simvastatin. . # Coronary artery disease: Mr had episodes of chest pain on admission which was felt to be likely due to his bradycardia and he was ruled out for MI with negative cardiac enzymes x3. His isosorbide mononitrate was held due to low BP and should be restarted in the community by his PCP. was advised to make an appointment to see his PCP 1 week. . # Hypothyroidism: Was hypothermic at 95.6F and rapidly became normothermic. TSH was 1.1. We continued home levothyroxine. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min as needed for chest pain: Please take one tablet every five minutes as needed for chest pain for up to three tablets, if still having pain call your doctor or 911. 8. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 10. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 12 days. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CP. 7. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Bradycardia likely due to atenolol toxicity Hyperkalemia Acute on chronic renal failure . Secondary diagnoses: Hypertension Bilateral Total Hip Replacement s/p DVT following right primary Total Hip Replacement s/p clipping procedures to ? cerebral aneurysms Nephrolithiasis causing hydronephrosis s/p left nephrostomy tube insertion Hypothyroidism Benign Prostatic Hyperplasia Cataracts (blind in L eye) Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your stay at the . You presented following an episode of dizziness followed by chest pain in your PCP's office. You were noted to have a very slow pulse. You were taken to the emergency department and you were found to have worsening of your renal failure and a high potassium level. You received treatment which successfully lowered your potassium level. You continued to have a low pulse and you were admitted overnight for observation in the Intensive Care Unit. You had an ultrasound of your kidneys which showed improved distension of your left kidney. It was felt that your symptoms could be accounted for by toxic levels of your atenolol and this was stopped. It will be reviewed by your PCP regarding similar drug which is not processed through the kidneys. There was no evidence of a heart attack on blood tests. BY your heart rate had improved and you were reviewed by cardiology regarding you low pulse and they felt that this was due to your atenolol. Your dizziness improved and this was felt likely due to your low pulse. You felt better and you were discharged home on . You should make an appointment to see your PCP 1 week. . Changes to mediations: We stopped your atenolol permanently We held your isosorbide mononitrate and this should b restarted by your PCP . . Instructions to patient: If you have further worsening symptom or further chest pain, you should seek medical attention. Followup Instructions: You should make an appointment to see our PCP 1 week | Sinus bradycardia with atrial premature beats. Sinus bradycardia with atrial premature beats. Sinus bradycardia with atrial premature beats. Sinus bradycardia with atrial premature beats. Compared to tracing #3 nodiagnostic interval change, except for the rhythm and the atrial prematurebeats. Sinus bradycardia with occasional atrial premature beats. Sinus bradycardia with marked A-V conduction delay and occasional atrialpremature beats in a bigeminal pattern. Noother diagnostic abnormality. Compared to tracing #1 nodiagnostic interval change.TRACING #2 Compared to tracing #2 nodiagnostic interval change.TRACING #3 A-V conductiondelay. Normal sinus rhythm with occasional atrial premature beats. Compared to the previous tracing of ,except for the change in rate and atrial premature beats, no diagnosticinterval change.TRACING #1 Compared to the previous tracing of no diagnostic interimchange.TRACING #1 Compared to tracing #2 no diagnosticchange.TRACING #3 Prolonged A-V conduction. Compared totracing #1 there is no diagnostic change.TRACING #2 This tracing is within normal limits.TRACING #4 ECG interpreted by ordering physician. | 8 | [
{
"category": "ECG",
"chartdate": "2100-10-23 00:00:00.000",
"description": "Report",
"row_id": 276178,
"text": "Sinus bradycardia with marked A-V conduction delay and occasional atrial\npremature beats in a bigeminal pattern. Compared to tracing #2 no diagnostic\nchange.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-22 00:00:00.000",
"description": "Report",
"row_id": 276179,
"text": "Sinus bradycardia with occasional atrial premature beats. Compared to\ntracing #1 there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-22 00:00:00.000",
"description": "Report",
"row_id": 276180,
"text": "Normal sinus rhythm with occasional atrial premature beats. A-V conduction\ndelay. Compared to the previous tracing of no diagnostic interim\nchange.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-20 00:00:00.000",
"description": "Report",
"row_id": 276181,
"text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-21 00:00:00.000",
"description": "Report",
"row_id": 276182,
"text": "Sinus bradycardia with atrial premature beats. Compared to tracing #3 no\ndiagnostic interval change, except for the rhythm and the atrial premature\nbeats. This tracing is within normal limits.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-20 00:00:00.000",
"description": "Report",
"row_id": 276418,
"text": "Sinus bradycardia with atrial premature beats. Prolonged A-V conduction. No\nother diagnostic abnormality. Compared to the previous tracing of ,\nexcept for the change in rate and atrial premature beats, no diagnostic\ninterval change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-20 00:00:00.000",
"description": "Report",
"row_id": 276416,
"text": "Sinus bradycardia with atrial premature beats. Compared to tracing #2 no\ndiagnostic interval change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2100-10-20 00:00:00.000",
"description": "Report",
"row_id": 276417,
"text": "Sinus bradycardia with atrial premature beats. Compared to tracing #1 no\ndiagnostic interval change.\nTRACING #2\n\n"
}
] |
6,554 | 191,911 | She was admitted on for a right total mastectomy and bilateral reconstruction with TRAM bilaterally. The patient did well postoperatively. She had a right free TRAM flap and a left pedicle to TRAM flap. The patient was admitted to the Intensive Care Unit postoperatively for frequent monitoring of her free flap. She remained afebrile. Her vital signs were stable and her flaps were warm and with good capillary refill and good venous outflow by doppler throughout the course of her hospital stay. As per protocol she remained in the Unit for two days for constant monitoring of her free flaps and was transferred to the floor on postoperative day three. In the evening of postoperative day one the patient developed a temperature to 102 F but this was thought due to the fact the patient was kept immobilized and was not taking deep inspiration and was thought to be due to atelectasis. Of note on postoperative day one the patient did not have Venodyne boots on due to lack of supply within the hospital so a lower extremity ultrasound was done to just to confirm there were no deep venous thrombosis. It sowed no deep venous thrombosis. With aggressive pulmonary toilet the patient's fever subsided and she was transferred to the floor. She did well and was discharged home On postoperative day five. She was afebrile. Vital signs were stable. All JPs were removed. | GOOD HUO, ESP POST FLUID BOLUSES. IS GIVEN AND PULM HYGIENE ENC. PULM HYGIENE ENC. HYPOACTIVE BS. SKIN W+D. SKIN W+D. +PULSES BILAT WITH DOPPLER. NARD NOTED. IS AND PULM HYGIENE ENC.GI-ABD SOFT, APPROP TENDER. LUNGS CLEAR, OCC DECREASED BASILAR SOUNDS. Normal flow, compressibility, augmentation and respiratory variability of Doppler signal is demonstrated. +PP. +PP. FLAP CHECKS Q 1HR. MAE.CV-TEMP UP TO 101.1. ADAT. NARD NOTED.GI-ABD SOFT, ND, APPROP TENDER. PT , THOUGH RELATIVELY HYPOTENSIVE. + PULSES VIA DOPPLER. The mediastinal, hilar and cardiac contours are within normal limits. +BS. PBOOTS ON. PBOOTS ON. PT A RIGHT MASTECTOMY AND BILAT FREE FLAP ON . CONT. ALINE D/C'D. AP CHEST: Comparison . DOPPLER AND FLAP CHECKS CONT. PT C/O NAUSEA THIS AM, GIVEN DROP WITH + EFFECT. NEURO UNCHANGED; A & O X3, PEERLA, MAEW, ROUSES EASILY. LS CLEAR BUT DECREASED AT BILAT BASES. RESIDENTS AWARE OF LOWER HCT. APS AWARE. The osseous structures are within normal limits. PT ARRIVED FORM PACU @ . CALCIUM REPLETED THIS AM. FLAP CHECKS. TO ROUSE WITH NEUROS INTACT, AND HAVING GOOD PULSES BY DOPPLER DESPITE LOWERED PRESSURES. PT C/O PAIN. JP X2 WITH SEROUSSANG DRG.PALN-CON'T WITH CURRENT PLAN. NPO. R/o infiltrate,mass. NEURO INTACT, THOUGH DROWSY. SITE WNL. GOOD IE USAGE. HR 100'S, ST, NO ECTOPY. 2) Bilateral chest wall drains. MUCH BETTER PAIN CONTROL POST THIS. IV SITE WNL, SL. 2) Small pleural effusions cannot be excluded. Swelling. JP X4 WITH SEROUS SANG DRG.PLAN-CON'T WITH CURRENT PLAN. WILL FOLLOW.-BREAST INCISIONS AND ABD INCISION WNL. VSS, AFEBRILE, THOUGH COOL TO TOUCH. NPO WITHOUT N/V.GU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.ACT-BR MAINTAINED. LEVEL T4 BILAT. RESIDENT AWARE. IMPRESSION: 1) No acute pneumonia. DENIES FLATUS. LS CTA BUT DECREASED AT BASES. PT REPORTS PAIN CONTROL. DENIES CARDIAC COMPLAINTS. NOT OOB TODAY.COMFORT-HAS EPIDURAL CURRENTLY AT 10CC/HR. SEVERAL LR FLUID BOLUSES GIVEN WITH GOOD IMMEDIATE RESULT, WITH PT LATER SLOWLY DROPPING PRESSURE AGAIN. TO BE POSITIVE FOR GOOD PERFUSION. HRR 90-100'S, SINUS, NO ECTOPY. RIGHT FLAP SITE SOMEWHAT WHITER IN APPEARANCE THAN THE LEFT-UNCHANGED THROUGHOUT SHIFT. WILL FOLLOW. ABD INCISON WNL, NO DRG NOTED. SBP 80-100'S. + MENSES.ACT-BED REMAINS FLEXED. DENIES CARDIAC COMPLAINTS.RESP-O2 SAT 97% RA. FINDINGS: scale, color flow and Doppler assessment of the bilateral common femoral, superficial femoral, and popliteal veins is obtained. RIGHT BREAST CON'T PALER THAN LEFT. RIGHT BREAST CON'T PALER THAN LEFT. MINIMAL C/O PAIN/DISCOMFORT, ONLY WITH ACTIVITY. PE AS FOLLOWS:ALLERGIES: CODEINE-HALLUCINATIONS.NEURO-A+OX3.CV-TMAX 101.3 CULTURES SENT OVER NOC, PENDING. FLAP WARM WITH GOOD CAP REFILL. FLAP WARM WITH GOOD CAP REFILL. TEAM AWARE. TEAM AWARE. nsg noteSEE FLOWSHEET FOR SPECIFICS.NEURO-A+OX3. APS FOLLOWING.-BREAST INCISIONS WNL, NO DRG NOTED. ON DILAUDID EPIDURAL @ 6MG/HR. NOW TOL LG AMTS G-ALE WITHOUT INCIDENT. The lungs are clear. Without a lateral projection small pleural effusions cannot be excluded. BED FLEXED.COMFORT-HAS EPIDURAL. REASON FOR THIS EXAMINATION: 39 y.o. WILL ADAT.GU-VOIDING VIA FOLEY AMTS CL YELLOW URINE. NO VOMITING. FINAL REPORT INDICATION: S/P mastectomy, increased temperature. ASSESS PAIN CONTROL. ASSESS PAIN. ICU COURSE UNEVENTFUL. PT BEGAN TO SUSTAIN SBP IN THE HIGH 80'S/LOW 90'S. EPIDURAL RATE INCREASED. MAP>60. MAP> 60. RIGHT AND LEFT PLANTED SHOWING GOOD PULSES ON CONSTANT MONITORING, FLAPS WARM TO TOUCH, GOOD PULSES BY . INSERT SITE WNL, WITH OLD DRIED BLOOD UNDER DSG. CON'T FLAP CHECKS. NO S/S HEMATOMA NOTED.RESP-O2 SAT 94-98% RA. 7:14 PM CHEST (PORTABLE AP) Clip # Reason: 39 y.o. EPIDURAL FOR PAIN CONTROL-RATE TO 10CC/HR AND 6CC BOLUS GIVEN AT PER PAIN SERVICE. PT ALSO WITH INTERNAL DOPPLER FOR VENOUS BLOOD FLOW WITH + PULSES. AUDIBLE FLAP PULSES AND THEY HAVE GOOD CAPILLARY REFILL WITH R SIDE PALER IN COLOR.A: TYLENOL FOR FEVER PORT CXR DONE AND TO CULTURE SPUTUM, URINE AND BLOOD. Evaluate for deep venous thrombosis. NO S/S HEMATOMA NOTED. IMPRESSION: No evidence of bilateral lower extremity deep venous thrombosis. NONPRODUCTIVE COUGH, UNABLE TO SEND SPUTUM FOR CX. status updateD: FEBRILE 102 TACHYCARDIC 110-118 MAP 65-69 BREATH SOUNDS DIMINISHED AT BASES O2 SAT 97-98% ON RM AIR C/O ABDOMINAL DISCOMFORTWHEN DEEP BREATHING AND COUGHING DESPITE ^ EPIDURAL RATE TO 8CC. URINE AND BLOOD CX SENT FOR TEMP SPIKES OF YESTERDAY, APAP GIVEN WITH GOOD RESULTS. SITE WITH FOUR PROTRUDING JP DRAINS; RIGHT, LEFT, AND TWO MEDIAL. S/P RIGHT MASTECTOMY AND BILAT FLAP/RECONSTRUCTION FROM BREAST CA NOT RESPONSIVE TO CHEMO. nsg transfer noteSEE FLOWSHEET FOR SPECIFICS.PT IS A 39 Y/O FEMALE WITH PMH BREAST CA S/P LEFT MASTECTOMY IN PAST. Drains are seen overlying the lower chest relating to the patient's recent procedure. SHE WAS ADMITTED TO THE ICU FOR FREQ FLAP CHECKS. TRANSFER TO FLOOR AFTER 6PM WITH Q 2HR FLAP CHECKS. female s/p mastectomy, b/l tram flaps, spiking fever. TO HAVE PAIN SERVICE COME TO PT DUE TO CONTINUED DISCOMFORTR: POOR PAIN CONTROL ON EPIDURAL RATE 8CCPLAN: PAIN SERVICE TO COME TO SEE PT SEND CULTURES MONITOR PULSE CHECKS CLOSELY THROUGH THE NIGHT 3:51 PM BILAT LOWER EXT VEINS Clip # Reason: S/P CANCER AND RECONSRUCTION SURGERY ON BED REST ASSESS FOR DVT MEDICAL CONDITION: 39 year old woman with s/p b/l free TRAM flaps PD#2 REASON FOR THIS EXAMINATION: please evaluate for DVT FINAL REPORT INDICATION: Status post bilateral free TRAM flap, post op day #2. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2157-01-21 00:00:00.000",
"description": "Report",
"row_id": 1348719,
"text": "nsg transfer note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 39 Y/O FEMALE WITH PMH BREAST CA S/P LEFT MASTECTOMY IN PAST. PT A RIGHT MASTECTOMY AND BILAT FREE FLAP ON . SHE WAS ADMITTED TO THE ICU FOR FREQ FLAP CHECKS. ICU COURSE UNEVENTFUL. PE AS FOLLOWS:\n\nALLERGIES: CODEINE-HALLUCINATIONS.\n\nNEURO-A+OX3.\n\nCV-TMAX 101.3 CULTURES SENT OVER NOC, PENDING. HRR 90-100'S, SINUS, NO ECTOPY. ALINE D/C'D. SBP 80-100'S. TEAM AWARE. MAP> 60. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS. PBOOTS ON. IV SITE WNL, SL. FLAP CHECKS Q 1HR. + PULSES VIA DOPPLER. PT ALSO WITH INTERNAL DOPPLER FOR VENOUS BLOOD FLOW WITH + PULSES. FLAP WARM WITH GOOD CAP REFILL. RIGHT BREAST CON'T PALER THAN LEFT. NO S/S HEMATOMA NOTED.\n\nRESP-O2 SAT 94-98% RA. LS CTA BUT DECREASED AT BASES. NARD NOTED. IS AND PULM HYGIENE ENC.\n\nGI-ABD SOFT, APPROP TENDER. +BS. DENIES FLATUS. PT C/O NAUSEA THIS AM, GIVEN DROP WITH + EFFECT. NO VOMITING. NOW TOL LG AMTS G-ALE WITHOUT INCIDENT. WILL ADAT.\n\nGU-VOIDING VIA FOLEY AMTS CL YELLOW URINE. + MENSES.\n\nACT-BED REMAINS FLEXED. NOT OOB TODAY.\n\nCOMFORT-HAS EPIDURAL CURRENTLY AT 10CC/HR. PT REPORTS PAIN CONTROL. SITE WNL. APS FOLLOWING.\n\n-BREAST INCISIONS WNL, NO DRG NOTED. ABD INCISON WNL, NO DRG NOTED. JP X2 WITH SEROUSSANG DRG.\n\nPALN-CON'T WITH CURRENT PLAN. ASSESS PAIN. ADAT. CON'T FLAP CHECKS. TRANSFER TO FLOOR AFTER 6PM WITH Q 2HR FLAP CHECKS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-01-20 00:00:00.000",
"description": "Report",
"row_id": 1348715,
"text": "PT ARRIVED FORM PACU @ . S/P RIGHT MASTECTOMY AND BILAT FLAP/RECONSTRUCTION FROM BREAST CA NOT RESPONSIVE TO CHEMO. ON DILAUDID EPIDURAL @ 6MG/HR. VSS, AFEBRILE, THOUGH COOL TO TOUCH. NEURO INTACT, THOUGH DROWSY. SITE WITH FOUR PROTRUDING JP DRAINS; RIGHT, LEFT, AND TWO MEDIAL. RIGHT AND LEFT PLANTED SHOWING GOOD PULSES ON CONSTANT MONITORING, FLAPS WARM TO TOUCH, GOOD PULSES BY . RIGHT FLAP SITE SOMEWHAT WHITER IN APPEARANCE THAN THE LEFT-UNCHANGED THROUGHOUT SHIFT. MINIMAL C/O PAIN/DISCOMFORT, ONLY WITH ACTIVITY. PT BEGAN TO SUSTAIN SBP IN THE HIGH 80'S/LOW 90'S. SEVERAL LR FLUID BOLUSES GIVEN WITH GOOD IMMEDIATE RESULT, WITH PT LATER SLOWLY DROPPING PRESSURE AGAIN. RESIDENT AWARE. CONT. TO ROUSE WITH NEUROS INTACT, AND HAVING GOOD PULSES BY DOPPLER DESPITE LOWERED PRESSURES. GOOD HUO, ESP POST FLUID BOLUSES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-01-20 00:00:00.000",
"description": "Report",
"row_id": 1348716,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-A+OX3. MAE.\n\nCV-TEMP UP TO 101.1. TEAM AWARE. PULM HYGIENE ENC. WILL FOLLOW. HR 100'S, ST, NO ECTOPY. MAP>60. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 97% RA. LS CLEAR BUT DECREASED AT BILAT BASES. IS GIVEN AND PULM HYGIENE ENC. NARD NOTED.\n\nGI-ABD SOFT, ND, APPROP TENDER. HYPOACTIVE BS. NPO WITHOUT N/V.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-BR MAINTAINED. BED FLEXED.\n\nCOMFORT-HAS EPIDURAL. INSERT SITE WNL, WITH OLD DRIED BLOOD UNDER DSG. PT C/O PAIN. APS AWARE. LEVEL T4 BILAT. EPIDURAL RATE INCREASED. WILL FOLLOW.\n\n-BREAST INCISIONS AND ABD INCISION WNL. NO S/S HEMATOMA NOTED. +PULSES BILAT WITH DOPPLER. FLAP WARM WITH GOOD CAP REFILL. RIGHT BREAST CON'T PALER THAN LEFT. JP X4 WITH SEROUS SANG DRG.\n\nPLAN-CON'T WITH CURRENT PLAN. FLAP CHECKS. NPO. ASSESS PAIN CONTROL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-01-20 00:00:00.000",
"description": "Report",
"row_id": 1348717,
"text": "status update\nD: FEBRILE 102 TACHYCARDIC 110-118 MAP 65-69 BREATH SOUNDS DIMINISHED AT BASES O2 SAT 97-98% ON RM AIR C/O ABDOMINAL DISCOMFORT\nWHEN DEEP BREATHING AND COUGHING DESPITE ^ EPIDURAL RATE TO 8CC. AUDIBLE FLAP PULSES AND THEY HAVE GOOD CAPILLARY REFILL WITH R SIDE PALER IN COLOR.\nA: TYLENOL FOR FEVER PORT CXR DONE AND TO CULTURE SPUTUM, URINE AND BLOOD. TO HAVE PAIN SERVICE COME TO PT DUE TO CONTINUED DISCOMFORT\nR: POOR PAIN CONTROL ON EPIDURAL RATE 8CC\nPLAN: PAIN SERVICE TO COME TO SEE PT SEND CULTURES MONITOR PULSE CHECKS CLOSELY THROUGH THE NIGHT\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-01-21 00:00:00.000",
"description": "Report",
"row_id": 1348718,
"text": "PT , THOUGH RELATIVELY HYPOTENSIVE. URINE AND BLOOD CX SENT FOR TEMP SPIKES OF YESTERDAY, APAP GIVEN WITH GOOD RESULTS. NEURO UNCHANGED; A & O X3, PEERLA, MAEW, ROUSES EASILY. LUNGS CLEAR, OCC DECREASED BASILAR SOUNDS. GOOD IE USAGE. NONPRODUCTIVE COUGH, UNABLE TO SEND SPUTUM FOR CX. EPIDURAL FOR PAIN CONTROL-RATE TO 10CC/HR AND 6CC BOLUS GIVEN AT PER PAIN SERVICE. MUCH BETTER PAIN CONTROL POST THIS. DOPPLER AND FLAP CHECKS CONT. TO BE POSITIVE FOR GOOD PERFUSION. CALCIUM REPLETED THIS AM. RESIDENTS AWARE OF LOWER HCT.\n"
},
{
"category": "Radiology",
"chartdate": "2157-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 752703,
"text": " 7:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 39 y.o. female s/p mastectomy, b/l tram flaps, spiking fever\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with mastectomy, inc temp.\n REASON FOR THIS EXAMINATION:\n 39 y.o. female s/p mastectomy, b/l tram flaps, spiking fever. R/o\n infiltrate,mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P mastectomy, increased temperature.\n\n AP CHEST: Comparison . The mediastinal, hilar and cardiac contours\n are within normal limits. The lungs are clear. Without a lateral projection\n small pleural effusions cannot be excluded. Drains are seen overlying the\n lower chest relating to the patient's recent procedure. The osseous\n structures are within normal limits.\n\n IMPRESSION:\n 1) No acute pneumonia.\n\n 2) Small pleural effusions cannot be excluded.\n\n 2) Bilateral chest wall drains.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-01-21 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 752754,
"text": " 3:51 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: S/P CANCER AND RECONSRUCTION SURGERY ON BED REST ASSESS FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with\n s/p b/l free TRAM flaps PD#2\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post bilateral free TRAM flap, post op day #2. Swelling.\n Evaluate for deep venous thrombosis.\n\n FINDINGS: scale, color flow and Doppler assessment of the bilateral\n common femoral, superficial femoral, and popliteal veins is obtained. Normal\n flow, compressibility, augmentation and respiratory variability of Doppler\n signal is demonstrated.\n\n IMPRESSION: No evidence of bilateral lower extremity deep venous thrombosis.\n\n\n"
}
] |
50,962 | 110,351 | The patient was admitted to the hospital for eval of intraparenchymal and diffuse right frontoparietal subarachnoid hemorrhage. 47M intoxicated and fell down approx 15 steps. At OSH he was found to have RR 8 intubated. ETOH 350. Was found to have R frontoparietal SDH with traumatic SAH. He receieved cerebrex and transferred to for further evaluation. On hospital day number one, , the pt underwent a head CT w/o contrast which demonstrated multifocal right temporal hemorrhagic contusions, multifocal SAH and slight generalized edema. He was admitted to the trauma ICU and started on phenytoin. Later that day, a repeat CT was stable and the patient was extubated and transferred to the neurosurgery service. On , the patient was transferred to the stepdown unit. The patient was started on a CIWA scale. On and the patient's neuro exam remained stable. He had episodes of asymptomatic bradycardia into the 30's-40's. The patient's cardiac medications were held. A cardiology consult was obtained. The patient was cleared by cardiology to go home with the recommendation that beta blockers are discontinued until further outpatient evaluation. The rest of his hospital stay was uneventful with his lab data and vital signs within baseline values, and his pain controlled. He is being discharged today in stable condition. | There is a moderate left frontoparietal subgaleal hematoma, presumably, the site of "coup." PMHx: HTN, Hyperlipidemia Current medications: 1. Stable thin subdural hematoma along the right tentorium, falx cerebri and cerebral convexity as well slight shift of normally midline structures. Chief complaint: PMHx: HTN, Hyperlipidemia Current medications: 1. Stable degree of right cerebral edema and slight shift of normally midline structures. Please get at NOON at No contraindications for IV contrast PFI REPORT Similar extent of multifocal right temporal parenchymal hemorrhages with surrounding edema, multifocal subarachnoid hemorrhage and generalized right hemispheric edema as well as degree of shift of normally midline structures. FINDINGS: Again noted are multiple foci and right temporal parenchymal hemorrhage, which are not significantly changed, given difference in technique. Please get at NOON at No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 1:53 PM Similar extent of multifocal right temporal parenchymal hemorrhages with surrounding edema, multifocal subarachnoid hemorrhage and generalized right hemispheric edema as well as degree of shift of normally midline structures. There is multifocal mild degenerative change, most prominent at C5-6 and C6-7, with small anterior osteophytes noted. There is a left subgaleal parietal hematoma, as before. An 11.5 mm well- corticated ossific fragment projecting just cephalad to the dens, may represent an os odontoideum vs. the sequela of remote trauma (which may be the selfsame). EtOH in ED at 0200 is 311 Trauma, s/p Assessment: Pt A/Ox3. EtOH in ED at 0200 is 311 Trauma, s/p Assessment: Pt A/Ox3. R temporal hemorrhage; multifocal right frontoparietal SAH, right hemispheric SDH. +ETOH PMHx includes hypertension and dyslipidemia on lipitor and an unknown antihypertensive. MAE, Neurologic: Neuro checks Q: 1 hr. Action: Neuro checks q1hrs, dilantin 100mg q8hrs. EtOH in ED at 0200 is 311 Chief complaint: IPH, SDH PMHx: HTN, Hyperlipidemia Current medications: Calcium Gluconate 2. EtOH in ED at 0200 is 311 Chief complaint: IPH, SDH PMHx: HTN, Hyperlipidemia Current medications: Calcium Gluconate 2. Associated right convexity subarachnoid hemorrhage as well as subdural hemorrhage layering along the right falx cerebri and right tentorium is also unchanged. Atherosclerotic calcification involve the abdominal aorta but the aorta is of normal caliber. Neurologic: Neuro checks Q: 1 hr. Neurologic: Neuro checks Q: 1 hr. Neurologic: Neuro checks Q: 1 hr. 1:59 AM TRAUMA #3 (PORT CHEST ONLY) Clip # Reason: TRAUMA FINAL REPORT INDICATION: Trauma. 12:09 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: evaluation of progression of bleed. An endotracheal tube remains in place, terminating at the thoracic inlet. There is mild mass effect on the right lateral ventricle with 3 mm of leftward shift of normally-midline structures. A small amount of subdural blood layer along the right cerebral convexity, as well as along the tentorium and falx cerebri. Neuro checks Q2hr. Neuro checks Q2hr. IMPRESSION: Similar appearance of right temporal multifocal hemorrhagic contusions and diffuse right frontoparietal subarachnoid hemorrhage, as well as thin subdural hematoma along the right tentorium, falx cerebri and cerebral convexity. Probable os odontoideum, unrelated to acute trauma. An endotracheal tube terminates near the thoracic inlet. Mild ethmoid air cell thickening is again noted. , J. TSICU 12:09 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # Reason: evaluation of progression of bleed. The subdural hemorrhage layering along the right falx cerebri, right tentorium and right cerebral convexity is stable. Associated right convexity subarachnoid hemorrhage is slightly less apparent. The extent of generalized edema involving the right hemisphere is stable, as is the mass effect on the right lateral ventricle and 3 mm shift of normally midline structures. Assessment and Plan Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. Assessment and Plan Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. Moderate mucosal thickening involves the maxillary sinuses and ethmoid air cells bilaterally, as well as the right sphenoid and bifrontal air cells. CT Torso (our rads read of OSH scan):Wet Read: No acute trauma. CT Torso (our rads read of OSH scan):Wet Read: No acute trauma. Right hemispheric subdural hemorrhage measuring up to 3-4 mm with subdural hemorrhage along tentorium and falx. Action: Neuro checks Q2hr now. Action: Neuro checks Q2hr now. Trauma, s/p Assessment: Sedated on propofol. FINDINGS: There are multiple foci of right temporal parenchymal hemorrhage, which given differences in patient positioning, do not appear significantly changed from the prior. | 19 | [
{
"category": "Physician ",
"chartdate": "2143-06-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 462648,
"text": "TSICU\n HPI:\n 47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311\n Chief complaint:\n IPH, SDH\n PMHx:\n HTN, Hyperlipidemia\n Current medications:\n Calcium Gluconate 2. Famotidine 3. Insulin 4. Lorazepam 5. Magnesium\n Sulfate 6. Oxycodone-Acetaminophen 7. Phenytoin 8. Potassium Phosphate\n 24 Hour Events:\n EXTUBATION - At 01:25 PM\n INVASIVE VENTILATION - STOP 01:25 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:45 AM\n Dilantin - 04:00 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.3\nC (97.4\n HR: 58 (58 - 91) bpm\n BP: 108/58(70) {91/51(61) - 144/91(105)} mmHg\n RR: 13 (10 - 23) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,288 mL\n 200 mL\n PO:\n 1,040 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n 1,248 mL\n Blood products:\n Total out:\n 1,580 mL\n 350 mL\n Urine:\n 1,580 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 708 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 14 cmH2O\n SPO2: 94%\n ABG: ///28/\n Ve: 11.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 273 K/uL\n 15.2 g/dL\n 142 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 103 mEq/L\n 141 mEq/L\n 42.9 %\n 10.7 K/uL\n [image002.jpg]\n 02:34 AM\n 03:07 AM\n 04:10 AM\n 04:22 AM\n 02:31 AM\n 04:03 AM\n WBC\n 13.1\n 10.7\n Hct\n 52\n 44.7\n 42.9\n Plt\n 296\n 273\n Creatinine\n 0.7\n 0.8\n TCO2\n 30\n 26\n Glucose\n 152\n 187\n 165\n 142\n Other labs: PT / PTT / INR:14.8/24.7/1.3, ALT / AST:85/45, Alk-Phos / T\n bili:56/0.7, Differential-Neuts:76.4 %, Lymph:18.7 %, Mono:3.6 %,\n Eos:0.8 %, Lactic Acid:2.8 mmol/L, Albumin:5.1 g/dL, LDH:283 IU/L,\n Ca:8.8 mg/dL, Mg:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. MAE,\n Neurologic: Neuro checks Q: 1 hr. Pain: currently not complaining of\n pain, percocet for pain. Dilantin. repeat head CT stable\n Cardiovascular: HD stable\n Pulmonary: extubated yesterday, stable on RA\n Gastrointestinal / Abdomen: H2\n Nutrition: Regular diet\n Renal: Adequate UO\n Hematology: Serial Hct, stable anemia\n Endocrine: RISS, keep bg<150\n Infectious Disease: no active issues\n Lines / Tubes / Drains:\n Wounds:\n Imaging: Repeat CT today?\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-06-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 462587,
"text": "Trauma, s/p\n Assessment:\n No appreciable neurologic deficits except headache, other exam\n unremarkable.\n Action:\n Percocet\n Response:\n Pain after percocet\n Plan:\n Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2143-06-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 462479,
"text": "SICU\n HPI:\n 47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311.\n PMHx:\n HTN, Hyperlipidemia\n Current medications:\n 1. Famotidine 2. Fentanyl Citrate 3. Folic\n Acid/Multivitamin/Thiamine-1000mL NS 4. Insulin 5. Phenytoin 6.\n Propofol\n 24 Hour Events:\n : admit to TSICU at 0430, needs repeat CT scan at 1200.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.8\nC (98.2\n HR: 78 (70 - 78) bpm\n BP: 94/52(62) {94/52(62) - 112/64(75)} mmHg\n RR: 22 (20 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 29 mL\n PO:\n Tube feeding:\n IV Fluid:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 765 mL\n Urine:\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -736 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/43/305/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 762\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 296 K/uL\n 15.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 107 mEq/L\n 145 mEq/L\n 44.7 %\n 13.1 K/uL\n [image002.jpg]\n 02:34 AM\n 03:07 AM\n 04:10 AM\n 04:22 AM\n WBC\n 13.1\n Hct\n 52\n 44.7\n Plt\n 296\n Creatinine\n 0.7\n TCO2\n 30\n 26\n Glucose\n 152\n 187\n 165\n Other labs: PT / PTT / INR:14.8/24.7/1.3, ALT / AST:85/45, Alk-Phos / T\n bili:56/0.7, Differential-Neuts:76.4 %, Lymph:18.7 %, Mono:3.6 %,\n Eos:0.8 %, Lactic Acid:2.8 mmol/L, Albumin:5.1 g/dL, LDH:283 IU/L,\n Ca:8.9 mg/dL, Mg:2.5 mg/dL, PO4:4.3 mg/dL\n Imaging: CT Head 0215: Multiple foci of right temporal hemorrhage\n with multifocal right frontparietal SAH. Right hemispheric SDH\n measuring up to 3-4 mm with SDH along tentorium and falx.\n CT Head 1200: PENDING\n .\n CT CSpine: No fracture or acute alignment abnormality. Prominent\n posterior osteophyte at C6 could cause cord injury w/ appropriate\n traumatic mechanism, Consider MRI if concern for cord injury.\n CT Torso (our rads read of OSH scan):Wet Read: No acute trauma.\n Assessment and Plan\n Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. MAE,\n following commands on propofol.\n Neurologic: Neuro checks Q: 1 hr. Pain: currently not complaining of\n pain, fentanyl prn. pC02 goal 35, HOB > 30 degrees. Dilantin. repeat\n head CT at noon.\n Cardiovascular: HD stable. Goal BP < 140 per admit, will double check\n re: allow to autoregulate given traumatic nature of bleed.\n Pulmonary: intubated, comfortable on the vent. wean to extubate after\n repeat CT.\n Gastrointestinal / Abdomen: npo\n Nutrition: NPO\n Renal: good UOP, added thiamine, folate, multivitamins to fluids.\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV, ETT, OGT\n Imaging: CT scan head today\n Fluids: NS at 150 with thiamine, folate, multivitamins x 1 liter, then\n kvo.\n Billing Diagnosis: Closed head injury\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:11 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2143-06-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 462464,
"text": "Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2143-06-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 462465,
"text": "SICU\n HPI:\n 47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311.\n Chief complaint:\n PMHx:\n HTN, Hyperlipidemia\n Current medications:\n 1. Famotidine 2. Fentanyl Citrate 3. Folic\n Acid/Multivitamin/Thiamine-1000mL NS 4. Insulin 5. Phenytoin\n 6. Propofol\n 24 Hour Events:\n : admit to TSICU at 0430, needs repeat CT scan at 1200.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.8\nC (98.2\n HR: 78 (70 - 78) bpm\n BP: 94/52(62) {94/52(62) - 112/64(75)} mmHg\n RR: 22 (20 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 29 mL\n PO:\n Tube feeding:\n IV Fluid:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 765 mL\n Urine:\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -736 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42 cmH2O/mL\n SPO2: 97%\n ABG: 7.37/43/305/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 762\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Temperature: Warm)\n Right Extremities: (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 296 K/uL\n 15.5 g/dL\n 165 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 107 mEq/L\n 145 mEq/L\n 44.7 %\n 13.1 K/uL\n [image002.jpg]\n 02:34 AM\n 03:07 AM\n 04:10 AM\n 04:22 AM\n WBC\n 13.1\n Hct\n 52\n 44.7\n Plt\n 296\n Creatinine\n 0.7\n TCO2\n 30\n 26\n Glucose\n 152\n 187\n 165\n Other labs: PT / PTT / INR:14.8/24.7/1.3, ALT / AST:85/45, Alk-Phos / T\n bili:56/0.7, Differential-Neuts:76.4 %, Lymph:18.7 %, Mono:3.6 %,\n Eos:0.8 %, Lactic Acid:2.8 mmol/L, Albumin:5.1 g/dL, LDH:283 IU/L,\n Ca:8.9 mg/dL, Mg:2.5 mg/dL, PO4:4.3 mg/dL\n Imaging: CT Head 0215: Multiple foci of right temporal hemorrhage\n with multifocal right frontparietal SAH. Right hemispheric SDH\n measuring up to 3-4 mm with SDH along tentorium and falx.\n CT Head 1200: PENDING\n .\n CT CSpine: No fracture or acute alignment abnormality. Prominent\n posterior osteophyte at C6 could cause cord injury w/ appropriate\n traumatic mechanism, Consider MRI if concern for cord injury.\n CT Torso (our rads read of OSH scan):Wet Read: No acute trauma.\n Assessment and Plan\n Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. MAE,\n following commands on propofol.\n Neurologic: Neuro checks Q: 1 hr. Pain: currently not complaining of\n pain, fentanyl prn. pC02 goal 35, HOB > 30 degrees. Dilantin. repeat\n head CT at noon.\n Cardiovascular: HD stable. Goal BP < 140 per admit, will double check\n re: allow to autoregulate given traumatic nature of bleed.\n Pulmonary: intubated, comfortable on the vent. wean to extubate after\n repeat CT.\n Gastrointestinal / Abdomen: npo\n Nutrition: NPO\n Renal: good UOP, added thiamine, folate, multivitamins to fluids.\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV, ETT, OGT\n Wounds:\n Imaging: CT scan head today\n Fluids: NS at 150 with thiamine, folate, multivitamins x 1 liter, then\n kvo.\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:11 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2143-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 462467,
"text": "47M s/p fall down 12 stairs landing on concrete deck. R temporal\n hemorrhage; multifocal right frontoparietal SAH, right hemispheric SDH.\n +ETOH\n PMHx includes hypertension and dyslipidemia on lipitor and an unknown\n antihypertensive.\n Trauma, s/p\n Assessment:\n Sedated on propofol. When lightened, opens eyes spontaneously, moves\n all extremities, attempts to sit up and remove ETT. Follows commands\n inconsistently. Pupils 5mm, equal, round, briskly reactive to light. No\n external signs of trauma except contusion to left posterior scalp.\n Action:\n Q1 neuro checks\n Propofol for sedation\n Logroll/cspine precautions\n Lg bore IV x3\n Goal SBP<140\n Banana bag\n Response:\n No acute changes\n No intervention for SBP required\n Plan:\n Repeat CT head at 1200\n Wean to extubate when sober\n"
},
{
"category": "Nursing",
"chartdate": "2143-06-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 462552,
"text": "Trauma, s/p rt sah/sdh/intraparenchymal bleed after fall down flight of\n stairs\n Assessment:\n When lightened from propofol gtt, pt not fc\ns though mae\n purposefully. Repeat head ct done at 12p with no change per Dr\n . Pt weaned/extubated and consistently fc\n Alert/oriented x3. Normal strengths x4 extremities. Perrl 3-4mm/brisk.\n No seizure activity noted. Pt c/o headache. Relieved with percocet\n prn.\n Action:\n Neuro checks q1hrs, dilantin 100mg q8hrs.\n Response:\n Neuro status unchanged.\n Plan:\n Cont to monitor neuro status q1hrs, Pain mgmt for headaches.\n"
},
{
"category": "Physician ",
"chartdate": "2143-06-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 462609,
"text": "TSICU\n HPI:\n 47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311\n Chief complaint:\n IPH, SDH\n PMHx:\n HTN, Hyperlipidemia\n Current medications:\n Calcium Gluconate 2. Famotidine 3. Insulin 4. Lorazepam 5. Magnesium\n Sulfate 6. Oxycodone-Acetaminophen\n 7. Phenytoin 8. Potassium Phosphate\n 24 Hour Events:\n EXTUBATION - At 01:25 PM\n INVASIVE VENTILATION - STOP 01:25 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:45 AM\n Dilantin - 04:00 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.3\nC (97.4\n HR: 58 (58 - 91) bpm\n BP: 108/58(70) {91/51(61) - 144/91(105)} mmHg\n RR: 13 (10 - 23) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,288 mL\n 200 mL\n PO:\n 1,040 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n 1,248 mL\n Blood products:\n Total out:\n 1,580 mL\n 350 mL\n Urine:\n 1,580 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 708 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 14 cmH2O\n SPO2: 94%\n ABG: ///28/\n Ve: 11.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 273 K/uL\n 15.2 g/dL\n 142 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 103 mEq/L\n 141 mEq/L\n 42.9 %\n 10.7 K/uL\n [image002.jpg]\n 02:34 AM\n 03:07 AM\n 04:10 AM\n 04:22 AM\n 02:31 AM\n 04:03 AM\n WBC\n 13.1\n 10.7\n Hct\n 52\n 44.7\n 42.9\n Plt\n 296\n 273\n Creatinine\n 0.7\n 0.8\n TCO2\n 30\n 26\n Glucose\n 152\n 187\n 165\n 142\n Other labs: PT / PTT / INR:14.8/24.7/1.3, ALT / AST:85/45, Alk-Phos / T\n bili:56/0.7, Differential-Neuts:76.4 %, Lymph:18.7 %, Mono:3.6 %,\n Eos:0.8 %, Lactic Acid:2.8 mmol/L, Albumin:5.1 g/dL, LDH:283 IU/L,\n Ca:8.8 mg/dL, Mg:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 47 M s/p fall + EtOH, with R SAH/SDH. MAE,\n following commands on propofol.\n Neurologic:\n Neuro checks Q: 1 hr. Pain: currently not complaining of pain,\n percocet for pain. Dilantin. repeat head CT stable\n Cardiovascular: HD stable\n Pulmonary: extubated yesterday, stable on RA\n Gastrointestinal / Abdomen: H2\n Nutrition: Regular diet\n Renal: Adequate UO\n Hematology: Serial Hct, anemia\n Endocrine: RISS, keep bg<150\n Infectious Disease: no active issues\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 24 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-06-10 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 462694,
"text": "47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311\n Trauma, s/p\n Assessment:\n Pt A/Ox3. MAE. Equal strength x4. Denies pain at this time. Pt c/o HA\n . Taking 2 tab of Percocet for pain. Good pain control. Some\n brusing on pt left eye.\n Action:\n Neuro checks Q2hr now. Pupils 3 and brisk.\n Response:\n No change in pt status\n Plan:\n Continue to monitor pt. Neuro checks Q2hr. ? Head CT tomorrow. Plan to\n transfer out of ICU today.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n S/P FALL\n Code status:\n Height:\n Admission weight:\n 83 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: dyslipidemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:74\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 51 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n FiO2 set:\n 40% %\n 24h total in:\n 1,090 mL\n 24h total out:\n 350 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:03 AM\n Potassium:\n 3.6 mEq/L\n 04:03 AM\n Chloride:\n 103 mEq/L\n 04:03 AM\n CO2:\n 28 mEq/L\n 04:03 AM\n BUN:\n 13 mg/dL\n 04:03 AM\n Creatinine:\n 0.8 mg/dL\n 04:03 AM\n Glucose:\n 142 mg/dL\n 04:03 AM\n Hematocrit:\n 42.9 %\n 02:31 AM\n Finger Stick Glucose:\n 130\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: t/sicu\n Transferred to: \n Date & time of Transfer: 1630\n"
},
{
"category": "Nursing",
"chartdate": "2143-06-10 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 462678,
"text": "47 yo M s/p fall down 12 steps, witnessed, + LOC. Intubated at OSH for\n GCS 8. EtOH in ED at 0200 is 311\n Trauma, s/p\n Assessment:\n Pt A/Ox3. MAE. Equal strength x4. Denies pain at this time. Pt c/o HA\n . Taking 2 tab of Percocet for pain. Good pain control. Some\n brusing on pt left eye.\n Action:\n Neuro checks Q2hr now. Pupils 3 and brisk.\n Response:\n No change in pt status\n Plan:\n Continue to monitor pt. Neuro checks Q2hr. ? Head CT tomorrow. Plan to\n transfer out of ICU today.\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1081222,
"text": " 12:09 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluation of progression of bleed. Please get at NOON at 5\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall down the stairs with intraparenchymal bleed\n REASON FOR THIS EXAMINATION:\n evaluation of progression of bleed. Please get at NOON at \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 1:53 PM\n Similar extent of multifocal right temporal parenchymal hemorrhages with\n surrounding edema, multifocal subarachnoid hemorrhage and generalized right\n hemispheric edema as well as degree of shift of normally midline structures.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 47-year-old man status post fall with parenchymal bleed.\n\n COMPARISON: , roughly 9.5 hrs earlier.\n\n TECHNIQUE: Head CT without intravenous contrast.\n\n FINDINGS: There are multiple foci of right temporal parenchymal hemorrhage,\n which given differences in patient positioning, do not appear significantly\n changed from the prior. Associated right convexity subarachnoid hemorrhage as\n well as subdural hemorrhage layering along the right falx cerebri and right\n tentorium is also unchanged. The extent of generalized edema involving the\n right hemisphere is stable, as is the mass effect on the right lateral\n ventricle and 3 mm shift of normally midline structures. There is a left\n subgaleal parietal hematoma, as before. Imaged osseous structures are intact.\n There is opacification of several ethmoidal air cells and polypoid mucosal\n thickening in the maxillary sinuses bilaterally.\n\n IMPRESSION: Similar appearance of right temporal multifocal hemorrhagic\n contusions and diffuse right frontoparietal subarachnoid hemorrhage, as well\n as thin subdural hematoma along the right tentorium, falx cerebri and cerebral\n convexity. Stable degree of right cerebral edema and slight shift of normally\n midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1081223,
"text": ", J. TSICU 12:09 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluation of progression of bleed. Please get at NOON at 5\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall down the stairs with intraparenchymal bleed\n REASON FOR THIS EXAMINATION:\n evaluation of progression of bleed. Please get at NOON at \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Similar extent of multifocal right temporal parenchymal hemorrhages with\n surrounding edema, multifocal subarachnoid hemorrhage and generalized right\n hemispheric edema as well as degree of shift of normally midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1081627,
"text": " 3:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 47 year old man with multiple brain contusions, evaluate sta\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple brain contusions, evaluate status\n REASON FOR THIS EXAMINATION:\n 47 year old man with multiple brain contusions, evaluate status\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf TUE 5:16 PM\n Evolution of multiple parenchymal contusions with slight increase in\n surrounding edema.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 47-year-old male with multiple brain contusions, followup.\n\n COMPARISON: .\n\n TECHNIQUE: Head CT without intravenous contrast.\n\n FINDINGS: Again noted are multiple foci and right temporal parenchymal\n hemorrhage, which are not significantly changed, given difference in\n technique. Associated right convexity subarachnoid hemorrhage is slightly\n less apparent. There is continued sulcal effacement, consistent with edema,\n as well as mass effect on the right lateral ventricle, with 2-mm shift of\n normally midline structures. The degree of vasogenic edema surrounding\n contusions has slightly increased. The subdural hemorrhage layering along the\n right falx cerebri, right tentorium and right cerebral convexity is stable.\n There is no new hemorrhage.\n\n There is no evidence of major vascular territorial infarction. Mild ethmoid\n air cell thickening is again noted.\n\n IMPRESSION:\n Interval evolution of right multifocal hemorrhagic contusion with slightly\n increased surrounding vasogenic edema. Stable thin subdural hematoma along the\n right tentorium, falx cerebri and cerebral convexity as well slight shift of\n normally midline structures. Previously seen diffuse right frontoparietal\n subarachnoid hemorrhage is less apparent.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1081146,
"text": " 2:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? SDH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fall and head trauma\n REASON FOR THIS EXAMINATION:\n Evaluate for ICH/Fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SUN 3:14 AM\n Multiple foci of right temporal hemorrhage with multifocal right frontparietal\n subarrachnoid hemorrhage. Right hemispheric subdural hemorrhage measuring up\n to 3-4 mm with subdural hemorrhage along tentorium and falx.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 47-year-old male with fall and head trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast axial images of the head are obtained with 5-mm\n section thickness with 2.5 mm bone algorithm reconstructions.\n\n FINDINGS: There are extensive foci of subarachnoid hemorrhage throughout the\n right frontotemporal region with a thin right hemispheric subdural hemorrhage\n measuring up to 4 mm. Subdural hemorrhage also layers along the tentorium\n with a thin layer along the falx cerebri. Multiple foci of right temporal\n intraparenchymal hemorrhage measure up to 3.8 x 1.4 cm with surrounding\n vasogenic edema. There is mild mass effect on the right lateral ventricle\n with 3 mm of leftward shift of normally-midline structures. The basilar\n cisterns appear grossly patent.\n\n The calvaria appear intact. There is a moderate left frontoparietal subgaleal\n hematoma, presumably, the site of \"coup.\" Moderate mucosal thickening\n involves the maxillary sinuses and ethmoid air cells bilaterally, as well as\n the right sphenoid and bifrontal air cells. There may be a few opacified right\n mastoid air cells.\n\n IMPRESSION: Multiple foci of right temporal intraparenchymal hemorrhage with\n multifocal right frontoparietal subarachnoid hemorrhage. A small amount of\n subdural blood layer along the right cerebral convexity, as well as along the\n tentorium and falx cerebri. 3-mm of leftward shift of midline structures is\n associated.\n\n NOTE ADDED IN ATTENDING REVIEW: Comparison with the Hospital NECT,\n performed some 2.5 hrs earlier (and since uploaded into PACS) demonstrates\n significant interval evolution of, particularly, the multifocal right temporal\n hemorrhagic contusions with surrounding edema, as well as the multifocal SAH\n and slight generalized edema involving the right hemisphere, which could\n reflect underlying . The slight shift of normally-midline structures is\n also new over the short-interval.\n (Over)\n\n 2:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? SDH\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1081147,
"text": " 2:35 AM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: 2ND READ\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n CT torso\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SUN 3:36 AM\n No acute traumatic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transfer for fall.\n\n TECHNIQUE: A contrast-enhanced CT of the chest, abdomen, and pelvis was\n obtained at Hospital earlier today at 12:15 a.m. While no formal\n interpretation of that study is available at the time of review, by verbal\n report, there was no concern for acute injuries. Of note, only axial images\n are submitted and reformatted images are not available.\n\n CT CHEST WITH CONTRAST: The heart and great vessels are unremarkable. While\n evaluation is somewhat technically limited, especially in the dependent\n portion of the lungs, no large pleural effusion is detected. There is no\n evidence for pericardial or large pleural effusion. An endotracheal tube\n terminates near the thoracic inlet. There are no pathologically enlarged\n axillary or mediastinal lymph nodes. Hypoventilatory changes are noted at the\n lung bases bilaterally. The upper lungs appear clear.\n\n CT ABDOMEN WITH CONTRAST: Aside from a 5-mm right hepoatic hypodensity,\n the liver is unremarkable. The gallbladder, spleen, pancreas, adrenal glands,\n and kidneys appear normal There is no hydronephrosis or hydroureter.\n Intraabdominal loops of large and small bowel are of normal caliber. There is\n no free air or free fluid. A nasogastric tube terminates in the gastric body.\n Atherosclerotic calcification involve the abdominal aorta but the aorta is of\n normal caliber. No pathologically enlarged mesenteric or retroperitoneal lymph\n nodes.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, distal ureters, and\n prostate are unremarkable. The bladder contains a Foley and is partially\n collapsed.\n\n Bone windows reveal no worrisome lytic or sclerotic lesions. No fracture is\n detected, although evaluation is limited without reformatted images.\n\n IMPRESSION: No evidence for acute traumatic injury.\n\n (Over)\n\n 2:35 AM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: 2ND READ\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1081150,
"text": " 3:30 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall down 12 steps\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SUN 3:53 AM\n No fracture or acute alignment abnormality. Prominent posterior osteophyte at\n C6 could cause cord injury with the appropriate traumatic mechanism, though\n evaluation of intrathecal details is limited on CT. Consider MRI if there is\n concern for cord injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Noncontrast axial images of the cervical spine are obtained with\n multiplanar reformatted images.\n\n FINDINGS: There is no acute fracture or dislocation. An 11.5 mm well-\n corticated ossific fragment projecting just cephalad to the dens, may\n represent an os odontoideum vs. the sequela of remote trauma (which may be\n the selfsame). The atlantoaxial and atlantooccipital articulations are\n maintained. Vertebral body heights are maintained. Though the evaluation for\n prevertebral soft tissue edema is limited by the presence of nasogastric and\n endotracheal tubes, no discrete prevertebral or epidural hematoma is seen.\n There is multifocal mild degenerative change, most prominent at C5-6 and C6-7,\n with small anterior osteophytes noted. A prominent left paracentral disc-\n endplate osteophyte complex significantly narrows the ventral canal at this\n site (2:57). There are small mucus-retention cysts in the maxillary sinuses\n bilaterally with trace maxillary fluid noted.\n\n IMPRESSION:\n 1. No fracture or acute alignment abnormality.\n 2. Mild multilevel cervical spondylosis. A prominent left\n paracentral/proximal foraminal disc-osteophyte complex at C5-6 could produce\n spinal cord (or exiting nerve root) injury, given the appropriate traumatic\n mechanism. If there is clinical concern for cord injury, consider MRI with\n edema-sensitive sequence.\n 3. Probable os odontoideum, unrelated to acute trauma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1081164,
"text": " 5:23 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT placement\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with s/p fall, intubated, transferred to TSICU\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Status post fall, intubated. Evaluate ET tube placement.\n\n One portable view. Comparison with the previous study done earlier the same\n day. The lungs remain clear except for minimal streaky density at the left\n base consistent with subsegmental atelectasis or scarring. The heart and\n mediastinal structures are unremarkable in appearance as before. An\n endotracheal tube remains in place, terminating at the thoracic inlet. A\n nasogastric tube is present terminating off the bottom of the image. The side\n hole of the tube is at or just below the level of the diaphragm.\n\n IMPRESSION: Nasogastric tube slightly high.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-06-09 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1081144,
"text": " 1:59 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n INDICATION: Trauma.\n\n TRAUMA CHEST: The cardiac silhouette is normal in size. An endotracheal tube\n terminates approximately 5.4 cm above the carina and a nasogastric tube\n courses below the diaphragm into the body of the stomach. Prominent\n mediastinal contours are likely technical, in conjunction with the recent\n outside hospital CT torso. The lungs are grossly clear, and there is no\n pleural effusion or pneumothorax.\n\n IMPRESSION: No acute process.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-06-12 00:00:00.000",
"description": "Report",
"row_id": 243487,
"text": "Sinus bradycardia. Borderline left axis deviation. Possible left anterior\nfascicular block. No previous tracing available for comparison.\n\n"
}
] |
31,413 | 114,287 | 42 year old male presented to PCP with transferred to ED with chest pain. Admitted for cardiac work up and underwent cardiac catherization . In catherization lab had cardiac arrest secondary to left main dissection and ECMO was inserted. He went directly to the operating room where he had a biventricular assist device placed, coronary artery bypass graft, removal of ECMO, and repair right CFA. Please see operative report for details of operation. Postoperatively, he was taken to the CSRU in critical condition with his chest left open. He continued to bleed, and was re-explored at the bedside the night of surgery. He returned to the OR the following day again for re-exploration for bleeding. The bleeding has since subsided. He was weaned from vasoactive drips, and has remained hemodynamically stable on the BiVAD's, with flows in the 4.5 liter per minute range. On POD # 1, the patient had progressed into renal failure, and CVVH was initiated. A CT scan of his brain was obtained to r/o significant infarct or bleed. This revealed a Right PCA infarct. The neurology service was consulted, and it was their belief that the patient would be left with a left visual field deficit, did not expect pt. to have permanent disability. He is being transferred to for continued treatment, and possible transplant evaluation. | There is a trivial/physiologic pericardial effusion.POST- BiVAD:1. Rhythm was V. Fib initially.LEFT ATRIUM: Marked LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal descending aorta diameter.AORTIC VALVE: Significant AR, but cannot be quantified.MITRAL VALVE: MR present but cannot be quantified.TRICUSPID VALVE: TR present - cannot be quantified.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Normal ascending aortadiameter. IMPRESSION: AP chest compared to and 1:22 a.m. today: ET tube has been partially withdrawn, to a standard position, ending between 2 and 3 cm from the carina. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Depressed LVEF.RIGHT VENTRICLE: RV function depressed.AORTA: Normal aortic diameter at the sinus level. Again noted is poorly defined superior mediastinal widening and left pleural fluid which may be loculated. Again noted is the apparently partially loculated left effusion. There is an air-fluid level in the left maxillary sinus and a smaller air-fluid level in the left sphenoid sinus presumably from prior intubation. bilateral vads in place with dsd cdi, right flow 4-4.5 and left flow 4.2-5.4. chest remains open with esmar dressing. Normal aortic arch diameter. AP SUPINE CHEST RADIOGRAPH. Right ventricular systolic function appears depressed.4. 2) Two small hypodensities in the anterior aspect of the centrum semiovale bilaterally, likely representing small infarcts, age indeterminate. Hct 29, treated with 1 unit prbc's. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for emergent CABG, LVAD palcement, Pt placed emergently on ECMO in cath labHeight: (in) 68Weight (lb): 244BSA (m2): 2.23 m2Status: InpatientDate/Time: at 17:42Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Pt was placed on emergent ECMO in the cath lab. Note is made that the ETT was subsequently pulled back as seen on subsequent chest x-rays. AP BEDSIDE SUPINE CHEST RADIOGRAPH. sedation stopped and pt mae and followed commands.cv: sr 70-80, rare pvc's noted. Significant aortic regurgitation is present, but cannot be quantified giventhat pt is on ECMO.5. LV appears distended.3. FINDINGS: The patient is recently postop. There is a small pneumothorax seen along the left chest wall, and a small pneumopericardium around the cardiac apex. Tiny hypodensities involving the anterior aspects of the centrum semiovale bilaterally likely relate to small infarcts, acuity indeterminate. left eye 3 mm and reactive, right pupil with prior eye surgery. 11:44 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: check ett placement . Tricuspid regurgitation is present but cannot be quantified.7. REASON FOR THIS EXAMINATION: r/o PTX/Effusion FINAL REPORT PORTABLE SEMIUPRIGHT CHEST 11:33 P.M., INDICATION: Status post emergent CABG and bilateral VAD placement. The Heart is decompressed. Nasogastric tube ends in the stomach. HCT STABLE 29.5.RESP: VENT SETTINGS AS NOTED. remains on Cisatracurium, Versed & Fentanyl. LEFT LUNG DOWN POST-OP WASH OUT -> BRONCHED AND FOUND TO BE IN RT AGAIN. tapering this pm, see carevue. MIN DNG FROM OGT. Left flows ~4 with occ. Right sided flows dropping gradually to 3.6; Dr. & Dr. aware. ETT REPOSION. ETT REPOSTION ONCE AGAIN. ANOTHER DOSE NOT GIVEN YET R/T INCREASING CREAT. pt resedated and paralytics resumed. Non-specific lateral repolarization changesconsistent with ischemia. BP stable and tol. LT PUPIL REACTIVE.CV: VS/VAD FLOWS AS NOTED. The tip of the new left CVL projects at the upper SVC level. L&R. Neuro) Pt. Neuro) Pt. foley to gravity, minimal uo. ON NTG FOR HYPERTENSION. CREAT UP 1.9 FROM 1.5. remains on bilateral vad. Resp CarePt received from OR s/p CABG and BIVAD placement. Recent ETT repositioning and central line placement. moderate amount of sanguinous drainage from or. RANDOM VANCO LEVEL PENDING.ASSESS: POST-OP BLEEDING W/ DRIFTING VAD FLOWS.PLAN: TO OR FOR REASSESS. Sinus rhythm. ABG GOOD W/ PIP LOW 30'S.GI/GU: ABD OBESE, SOFTLY DISTENDED. Pt on cvvhd. REQUIRING MULTI PRBC AND ALBUMIN. anticoagulate.above with np . OGT advanced slightly to ensure auscultation and proper drng.GU) CRRT continues. 7.33-45. site cdi. RT EYE W/ ? BIVAD function with flows > 4L/min. heparin started through cvvhdf with goal ptt 55-70. dopplerable pedal pulses bilaterally.resp: lungs coarse, exp wheezes noted on left. Pt. Pt. Cisatra titrated according to TOF; to achieve 2 twitches. Compared to the previous tracing sinus tachycardia has given wayto Normal sinus rhythm, rate 80, and ischemic type lateral repolarizationchanges have resolved.TRACING #2 map remains 60-70 with sbp 80-90. flow rates dropped to 3.8, treated with volume and albumin with good effect. Natrecor d'cd when SBP started to drift to low 90's. CSRU ADM/UPDATEPT ADM FROM OR W/ BIVAD.NEURO: REMAINED SEDATED THEN ON PARALYTICS/SEDATION. movements.CV) Rhythm is NSR. Plan for head ct in am. Pt bagged during procedure. Tube now at 24 @ lip. creat > 3 today.Anticoagulation continues via CRRT machine. drifting to 3.8. Sinus tachycardia, rate 108. Respiratory CarePt went to oR in AM for washout, returned with decreased sats. Compared to the previous tracing lateral ST segmentdepressions consistent with ischemia are less prominent.TRACING #1 rare pvc's noted. Chest tubes with minimal drng. t max 99.3.cv: sb 40-st 120's. Give colloid for fluid if necessary. It was observed that the L Lung was down, therefore pt bronched for tube placement. FLOWS DRIFTING TO HIGH 3'S. Monitor VAD flows and keep >4l. hourly BS's checked.Heme) HCT >30 and stable. cr 2.4. lasix challenged with minimal results. FINDINGS: Compared with the previous study at 11:33 p.m. on , the tip of the ETT has been repositioned and now lies approximately 2 cm above the carina. Dose of cisatra now at .26mg.kg. electrolytes wnl. Utilize colloid if needed for fluids (PRBC, albumin). LABS AS NOTED. natrecor gtt started with minimal effect. | 22 | [
{
"category": "Radiology",
"chartdate": "2187-07-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 967110,
"text": " 10:59 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LM dissection s/p Emergent -VAD placement/CABG x 2.\n Please at with abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMIUPRIGHT CHEST 11:33 P.M., \n\n INDICATION: Status post emergent CABG and bilateral VAD placement. Evaluate\n for pneumothorax.\n\n COMPARISON: No prior comparisons.\n\n FINDINGS: The patient is recently postop. The tip of the ETT is within the\n proximal right main stem bronchus and needs to be pulled back. An NGT passes\n into the proximal stomach. A mediastinal drainage tube is present in\n unremarkable position. Two venous access device tubings are seen with the\n tips projecting over the right atrial and right pulmonary venous/left atrial\n junction. There is a small pneumothorax seen along the left chest wall, and a\n small pneumopericardium around the cardiac apex.\n\n The mediastinum is widened, especially on the left, which may represent a\n hematoma and/or left upper lobe collapse.\n\n Note is made that the ETT was subsequently pulled back as seen on subsequent\n chest x-rays.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 967210,
"text": " 2:24 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for collapse\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LM dissection s/p Emergent -VAD placement/CABG x 2.\n\n REASON FOR THIS EXAMINATION:\n assess for collapse\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG x 2.\n\n AP SUPINE CHEST RADIOGRAPH. This is the fourth examination done thus far\n today (), there remained prominence of the superior mediastinum and\n the left upper thorax is opacified consistent with several etiologies\n including atelectasis. Multiple tubes and catheters are little changed in\n position. There are extensive skin staples on either side of the mediastinum.\n Appearances are little change from exams three hours and seven hours earlier.\n Again noted is the apparently partially loculated left effusion. Additional\n clinical history might be helpful as regards why these short interval\n radiographs are being obtained.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 967330,
"text": " 10:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o cva\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man cardiac arrest w/VAD placement\n REASON FOR THIS EXAMINATION:\n r/o cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man status post cardiac arrest with VAD placement,\n rule out stroke.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images were performed through the brain without IV\n contrast.\n\n FINDINGS: There is a large evolving right PCA distribution infarction, with\n significant mass effect, effacing the right ambiant cistern and effacing the\n right lateral ventricle. There is no herniation at this time and no\n hydrocephalus in the contralateral ventricular system. No evidence of\n hemorrhagic transformation or acute hemorrhage elsewhere in the brain. Tiny\n hypodensities involving the anterior aspects of the centrum semiovale\n bilaterally likely relate to small infarcts, acuity indeterminate. Globally,\n the sulci appear slightly effaced, however, this may be a normal variant,\n however, given the history provided, diffuse global edema is also a\n consideration. -white matter differentiation remains preserved at this\n time. There is an air-fluid level in the left maxillary sinus and a smaller\n air-fluid level in the left sphenoid sinus presumably from prior intubation.\n\n IMPRESSION:\n 1) Large evolving right PCA distribution infarction, with significant local\n mass effect, effacing the right lateral ventricle and right ambient cistern,\n without CT evidence of herniation at this time. No evidence of hemorrhagic\n transformation or acute intracranial hemorrhage elsewhere in the brain.\n\n 2) Two small hypodensities in the anterior aspect of the centrum semiovale\n bilaterally, likely representing small infarcts, age indeterminate.\n\n 3) The sulci appear somewhat effaced globally; this could be a normal variant,\n however, given the history of cardiac arrest, global edema must be considered.\n\n Findings were discussed with the covering nurse practitioner () at the CT\n scanner at the time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 967188,
"text": " 11:44 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check ett placement . post-op\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LM dissection s/p Emergent -VAD placement/CABG x 2.\n\n REASON FOR THIS EXAMINATION:\n check ett placement . post-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement. CABG x 2.\n\n AP BEDSIDE SUPINE CHEST RADIOGRAPH. This is the second of four examinations\n thus far on . Allowing for technical differences, this supine exam\n is unchanged from study of five hours earlier. Multiple tubes and catheters,\n including the ET tube, are in satisfactory position. Again noted is poorly\n defined superior mediastinal widening and left pleural fluid which may be\n loculated. Possible left upper lobe atelectasis. No vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 967132,
"text": " 5:44 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ETT reposition-check placement\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LM dissection s/p Emergent -VAD placement/CABG x 2.\n REASON FOR THIS EXAMINATION:\n s/p ETT reposition-check placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:21 A.M., \n\n HISTORY: Biventricular assist device. Check ET tube position.\n\n IMPRESSION: AP chest compared to and 1:22 a.m. today:\n\n ET tube has been partially withdrawn, to a standard position, ending between 2\n and 3 cm from the carina. Cannulae project over the atria. Nasogastric tube\n ends in the stomach. Midline mediastinal drains are still in place. Overall\n caliber, cardiac silhouette is slightly smaller, due in part to decreasing\n pericardial effusion. The upper mediastinum is still severely widened. This\n could be due, in large part, to distended mediastinal vessels, as well as\n hematoma. Left subclavian line follows the expected course to the origin of\n the superior vena cava. Lungs are low in volume but clear of any focal\n abnormality aside from vascular congestion on the right. Small left pleural\n effusion is stable. No pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2187-07-24 00:00:00.000",
"description": "Report",
"row_id": 83617,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for emergent CABG, LVAD palcement, Pt placed emergently on ECMO in cath lab\nHeight: (in) 68\nWeight (lb): 244\nBSA (m2): 2.23 m2\nStatus: Inpatient\nDate/Time: at 17:42\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPt was placed on emergent ECMO in the cath lab. Rhythm was V. Fib initially.\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Significant AR, but cannot be quantified.\n\nMITRAL VALVE: MR present but cannot be quantified.\n\nTRICUSPID VALVE: TR present - cannot be quantified.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient. See Conclusions for post-bypass data The post-bypass study was\nperformed while the patient was receiving vasoactive infusions (see\nConclusions for listing of medications).\n\nConclusions:\nPOST-ECMO:\n1. The left atrium is markedly dilated. No atrial septal defect is seen by 2D\nor color Doppler.\n2. LV systolic function appears depressed. The entire LV lateral, inferior &\nanterior wall appear akinetic. LV appears distended.\n3. Right ventricular systolic function appears depressed.\n4. Significant aortic regurgitation is present, but cannot be quantified given\nthat pt is on ECMO.\n5. Mitral regurgitation is present but cannot be quantified.\n6. Tricuspid regurgitation is present but cannot be quantified.\n7. There is a trivial/physiologic pericardial effusion.\n\nPOST- BiVAD:\n\n1. BiVAD cannulas are seen in position. The Heart is decompressed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Report",
"row_id": 1663067,
"text": "1400\npt transferred to for transplant workup via . np present with transfer. family aware and report called to cardiac team at .\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Report",
"row_id": 1663061,
"text": "Respiratory Care:\nPatient remains intubated, sedated, paralyzed and ventilated on A/C of 500 by rate of 20, 50% and +20 PEEP. Pulmonary compliance measured at midnight via esophageal balloon on +20cmH20 PEEP and found to be +3 with plateau of +13. PEEP left at 20 as optimal settings. See Carevue flowsheet for abgs. Plan to maintain supportive care and monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Report",
"row_id": 1663062,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. Esoph balloon in place and numbers obtained PtP -1.2 no changes made. B/S ess clear Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Report",
"row_id": 1663063,
"text": "0700-1900:\ncisatracurium gtt at .22 mg/kg/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Report",
"row_id": 1663064,
"text": "0700-1900:\nneuro: sedated on fentanyl and versed gtts. cisatracurium gtt at .22 mcg/kg/min, titrated up secondary to 4 eyelid twitches. left eye 3 mm and reactive, right pupil with prior eye surgery. ct scan of head done showing right PCA distribution infarct. sedation stopped and pt mae and followed commands.\n\ncv: sr 70-80, rare pvc's noted. sbp 90-130. Hct 29, treated with 1 unit prbc's. plts 74. hit screen cancelled secondary to increased plt level. bilateral vads in place with dsd cdi, right flow 4-4.5 and left flow 4.2-5.4. chest remains open with esmar dressing. heparin gtt increased to 800 units per hour, ptt 45. repeat ptt at 2100. Tmax 100 to 96.9. ct to 20 cm sxn, no airleak. minimal drainage.\n\nresp: lungs clear, diminished at times. remains on ac 50%, 500 x 20, peep 20. po2 80-160. o2 sat 95-100%.\n\ngi/gu: abd soft, obese. bs absent. ogt to lws draining bilious drainage. foley to gravity, no uo. remains on crrt. cr 3 this am.\n\nendo: remains on regular insulin gtt per protocol.\n\nplan: monitor hemodynamics, monitor vad flows, continue with crrt. transfer to in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Report",
"row_id": 1663065,
"text": "Neuro) Pt. remains on Cisatracurium, Versed & Fentanyl. Cisatra titrated according to TOF; to achieve 2 twitches. Dose of cisatra now at .26mg.kg. Pt. not overbreathing the vent. no spont. movements.\n\nCV) Rhythm is NSR. BIVAD function with flows > 4L/min. L&R. BP stable and tol. increase fluid removal from CRRT.\n\nPulm) no vent changes other than rate increase due to slight resp. acidosis on abg. 7.33-45. Chest tubes with minimal drng. No air leaks.\nInhalers via vent circuit.\n\nGI) OGT with dark green drng. Flexiseal rectal tube drng brown liquid stool. Difficulty in hearing bowel sounds due to background noise from BIVAD.\n\nGU) CRRT in progress. Attempting to take upwards to 100cc per hour if BP tol. and BIVAD flows stay above 4L.\n\nEndocrine) insulin drip on at low dose according to protocol. hourly BS's checked.\n\nHeme) HCT >30 and stable. Plts continue to drop <70. Heparin titrated to achieve range 55-75.\n\nI.D. Vanco level to be drawn this morning prior to daily dose.\n\nPlan) Transfer to today for transplant eval. continue to watch abg's Hct K+ ion Ca++ bs. Monitor VAD flows and keep >4l. Give colloid for fluid if necessary.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Report",
"row_id": 1663066,
"text": "Resp Care\nPt remains intubated and ventilated on a/c with no remarkable changes overnight. Peak pressures 36/Pplat 34 on 20 cm peep/500 x 22 50% Started on albuterol/atrovent and QVar inhalers. Esoph balloon in place, will repeat later this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Report",
"row_id": 1663059,
"text": "0700-1900:\nneuro: attempted to wake to evaluate neuro status, pt became profoundly hypertensive with profound hypoxemia. sedation off x 1.5 hours with no response. left pupil reactive, right eye with h/o eye surgery. t max 99.3.\n\ncv: sb 40-st 120's. rare pvc's noted. electrolytes wnl. remains on bilateral vad. site cdi. labile bp treated with nitro initially then switched to nicardipine with drop in hr to 40 noted. nicardipine d/c'd and prn hydralazine started with good effect. pt resedated and paralytics resumed. no twitches noted ( same as baseline ). map remains 60-70 with sbp 80-90. flow rates dropped to 3.8, treated with volume and albumin with good effect. ct x 3 to 20 cm sxn, no airleak. moderate amount of sanguinous drainage from or. tapering this pm, see carevue. hct > 30. ptt > 150 treated with 50 mg protamine with ptt normalized. heparin started through cvvhdf with goal ptt 55-70. dopplerable pedal pulses bilaterally.\n\nresp: lungs coarse, exp wheezes noted on left. after return from or noted to have profound hypoxemia with po2 60. desat to 88% noted. resedated and paralyzed. esophageal balloon placed and peep increased to 20, fio2 increased to 100%. improved oxygenation with po2 > 170. able to wean fio2 to 50%. remains on ac 50% 500 x 24 peep 20. cxr x 2.\n\ngi/gu: abd obese. bs absent. ogt to lws, brown drainage. foley to gravity, minimal uo. cr 2.4. lasix challenged with minimal results. natrecor gtt started with minimal effect. left groin line changed over to quinton catheter and cvvhdf initiated.\n\nendo: remains on regular insulin gtt per protocol.\n\nplan: monitor hemodynamics and bivad flow rates. monitor oxygenation. anticoagulate.\n\nabove with np .\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Report",
"row_id": 1663060,
"text": "Neuro) Pt. is sedated and paralyzed. Initially there were no twitches with TOF but leads were repositioned and Right eyelid twitched x1.\nDoses unchanged.\n\nCV) BIVAD system operating without difficulty. Left flows ~4 with occ. drifting to 3.8. Right sided flows dropping gradually to 3.6; Dr. & Dr. aware. Natrecor d'cd when SBP started to drift to low 90's. CVP remaining 25-27 throughout. Heart rhythm NSR 70-80's. Pt. skin warm & dry with doppler pedal pulses.\n\nPulm) Remains on CMV with high peep; currently weaned to 20cm peep. ABG had become alkalotic (resp) therefore rate decreased to 20 PBM.\nMinimal secretions. Sao2 100%. CHest tubes to 20 cm sx; no air leaks.\n\nGI) OGT drng thick bilious drng. OGT advanced slightly to ensure auscultation and proper drng.\n\nGU) CRRT continues. HUO ~ 15-30cc/hr. creat > 3 today.\nAnticoagulation continues via CRRT machine. ADjusted heparin dose per sliding scale.\n\nEndocrine) On & Off insulin drip with hourly sugars monitored.\n\nSocial) family in last evening with clergy for bedside prayers.\n\nPlan) Head CT today. Utilize colloid if needed for fluids (PRBC, albumin).\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Report",
"row_id": 1663056,
"text": "Resp Care\nPt received from OR s/p CABG and BIVAD placement. Pt remains intubated, sedated and paralyzed. ETT pulled back 2 cm per team. Chest opened up at bedside for chest drainage. Pt bagged during procedure. It was observed that the L Lung was down, therefore pt bronched for tube placement. Tube now at 24 @ lip. ABG shows mild Metabolic Alkalosis with good oxygenation. See CareVue for details and specifics.\nPlan: ?? OR again this am for continued drainage of chest.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Report",
"row_id": 1663057,
"text": "CSRU ADM/UPDATE\nPT ADM FROM OR W/ BIVAD.\n\nNEURO: REMAINED SEDATED THEN ON PARALYTICS/SEDATION. RT EYE W/ ? CATARCT. LT PUPIL REACTIVE.\n\nCV: VS/VAD FLOWS AS NOTED. REQUIRING MULTI PRBC AND ALBUMIN. FLOWS DRIFTING TO HIGH 3'S. TEAM AT BEDSIDE MUCH OF SHIFT. CONT BLEEDING FROM MEDIASTINALS W/ BULGING OF ESMARK. DECISION MADE TO WASH OUT/EVACUATE CLOT IN ROOM. ON NTG FOR HYPERTENSION. LABS AS NOTED. HCT STABLE 29.5.\n\nRESP: VENT SETTINGS AS NOTED. INITIALLY REQUIRNG FREQ SX FROTHY PINK SECRETIONS. LUNGS COARSE. ETT REPOSION. LEFT LUNG DOWN POST-OP WASH OUT -> BRONCHED AND FOUND TO BE IN RT AGAIN. ETT REPOSTION ONCE AGAIN. ABG GOOD W/ PIP LOW 30'S.\n\nGI/GU: ABD OBESE, SOFTLY DISTENDED. NO BSP. MIN DNG FROM OGT. CREAT UP 1.9 FROM 1.5. NO UOP LAST SEVERAL HOURS AND TEAM AWARE. K+ YO TO 4.9,\n\nSOCIAL: BROTHER /NEPHEW IN AND INFO GIVEN.\n\nID: VANCO DOSING DONE IN OR. ANOTHER DOSE NOT GIVEN YET R/T INCREASING CREAT. RANDOM VANCO LEVEL PENDING.\n\nASSESS: POST-OP BLEEDING W/ DRIFTING VAD FLOWS.\n\nPLAN: TO OR FOR REASSESS. CONT AGGRESSIVE SUPPORT. AWAKE TO EAVAL BRAIN FUNCTION/\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Report",
"row_id": 1663058,
"text": "Respiratory Care\nPt went to oR in AM for washout, returned with decreased sats. Peep increased to 24 cm with eso. balloon revealing pplex= +2, pplins=+14.\nLUL still show collaspe on cxr after et has been moved to 21cm. Plan for head ct in am. Pt on cvvhd.\n"
},
{
"category": "ECG",
"chartdate": "2187-07-24 00:00:00.000",
"description": "Report",
"row_id": 225403,
"text": "Sinus rhythm. Compared to the previous tracing sinus tachycardia has given way\nto Normal sinus rhythm, rate 80, and ischemic type lateral repolarization\nchanges have resolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-23 00:00:00.000",
"description": "Report",
"row_id": 225628,
"text": "Sinus tachycardia. Compared to the previous tracing lateral ST segment\ndepressions consistent with ischemia are less prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-23 00:00:00.000",
"description": "Report",
"row_id": 225629,
"text": "Sinus tachycardia, rate 108. Non-specific lateral repolarization changes\nconsistent with ischemia. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 967114,
"text": " 1:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p TLC insertion and ETT reposition-check placement\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LM dissection s/p Emergent -VAD placement/CABG x 2.\n Please at with abnormalities.\n REASON FOR THIS EXAMINATION:\n s/p TLC insertion and ETT reposition-check placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST 1:22 A.M. \n\n INDICATION: Recently status post emergent cardiac surgery. Recent ETT\n repositioning and central line placement.\n\n FINDINGS: Compared with the previous study at 11:33 p.m. on , the\n tip of the ETT has been repositioned and now lies approximately 2 cm above the\n carina. The tip of the new left CVL projects at the upper SVC level.\n\n Otherwise, no obvious interval changes, as detailed in previous report.\n\n"
}
] |
77,046 | 191,926 | 22 YO RHW presented with L sided weakness. NIHSS of 11 (4 for left arm,4 for left leg, 2 for L facial palsy, 1 for mild dysarthria). She was immediately taken for head CT and CTA which showed right MCA infarct, right ICA dissection, and large clot within the right MCA. Brain MRI showed no evidence of hemorrhagic conversion. Her exam was significant for left facial droop, mild dysarthria, left hemiplegia, and upgoing left toe. Head kept down in Trendelenberg position to increase blood perfusion. As patient was out of the therapeutic time window, tPA was not given. For this reason, she was also not a candidate for intervention. She was started on a heparin drip and admitted to the neuro ICU. Since her blood pressure was low, as per her baseline, she was given IVF and then low dose pressors to maintain SBP 120-140. This was continued for 24 hours to order to optimize perfusion pressures and reduce any potentially at risk brain infarct area. She remained neurologically stable. A head CT at 48 hours showed no hemorrhage transformation. At this point she was started on coumadin. She was transferred to the neurology floor. Her INR remained subtherapeutic. In order to facilitate discharge to , she was switched from heparin to Lovenox for bridge. Her neurologic examination improved. At discharge, her mental status, and language were intact without dysarthria. Vision was normal. Her sensory exam was normal without extinction to double simultaneous stimuli. She had no movement in the left upper extremity, but she did have antigravity strength in the left quadriceps, and some movement in the more proximal and distal left leg. She will follow up with Dr. in stroke clinic. At this point, genetic testing for possible fibrodysplasias will be discussed. | Right ICA dissection. Right ICA dissection. Non-visualization of the right internal carotid artery, better evaluated on the prior CTA study. FINDINGS: NON-CONTRAST CT HEAD: There are hypodense areas noted in the right middle cerebral artery territory involving the right frontal lobe and the right basal ganglia, which correspond with areas of decreased diffusion on the subsequent MR study, representing acute infarcts. Right MCA distribution infarction. Rule out hemorrhagic transformation. Hypodense areas in the right MCA territory, representing acute infarcts, better evaluated on the subsequent MR study. Contrast: OPTIRAY Amt: FINAL REPORT (Cont) etc. WET READ VERSION #1 DLrc 7:37 PM Non Contrast: Areas of loss of the grey white matter differentiation in the right frontal and insular cortex and basilar ganglia compatible with acute/subacute infarction. This may relate to thrombosis/dissection. WET READ VERSION #2 DLrc 7:38 PM Non Contrast: Areas of loss of the grey white matter differentiation in the right frontal and insular cortex and basilar ganglia compatible with acute/subacute infarction. Subtle hypointense foci within are of equivocal significance and correlation with a non-contrast CT can be helpful. IMPRESSION: Expected evolution of right MCA territory infarction with no acute intracranial hemorrhage. No contraindications for IV contrast WET READ: DLrc 7:43 PM Non Contrast: Areas of loss of the grey white matter differentiation in the right frontal and insular cortex and basilar ganglia compatible with acute/subacute infarction. FINDINGS: There is a moderate-large area of decreased diffusion, in the right MCA territory involving the right frontal lobe and right basal ganglia, without associated significant mass effect. More acute cortical components. There is nonvisualization of the right cervical internal carotid artery, soon after its origin, throughout its course. The major arteries of the posterior circulation intracranially are patent. Contrast: OPTIRAY Amt: FINAL REPORT (Cont) CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch vessels are patent. FINDINGS: There is interval evolution of a right MCA territory infarction involving the right lentiform nuclei and right frontal cortex. aphasia. Follow up as clinically indicated. FINAL REPORT INDICATION: Right MCA stroke, to evaluate for hemorrhagic transformation. There is reformation of the supraclinoid portion, with patent ophthalmic artery on the right side. Right MCA distribution infarction affection the left frontal lobe, left basal ganglia and insular cortex. The anterior cerebral artery on the right side is patent. FINAL REPORT INDICATION: Left-sided weakness, aphasia, question bleed. There is a filling defect in the right M1 segment with non-visualization of some of the M2 branches (series 4, image 219). Filling defect in the right middle cerebral artery M1 segment, likely from thrombus within. The ventricles and extra-axial CSF spaces are better seen on the subsequent MR study. Acute infarcts in the right MCA territory involving the right frontal lobe and the right basal ganglia. COMPARISON: Prior CT and CTA head study. 2D and 3D reformations of the intra- and extra-cranial arteries were obtained. CTA Pending. CTA Pending. CTA Pending. TECHNIQUE: Axial images were acquired of the head without contrast. TECHNIQUE: Non-contrast CT head, followed by CT angiogram of the head and neck. Right internal carotid artery flow void is not seen and is better assessed on the prior CTA study. Right ICA dissection with complete distal occlusion originating approximately 2.3cm from the carotid bifurcation. Intermediate density is seen within the hypodense right lentiform nuclei, but this is not dense enough to be consistent with hemorrhagic transformation. IMPRESSION: 1. IMPRESSION: 1. To correlate clinically. REASON FOR THIS EXAMINATION: ? Correlation with non-contrast CT head can be helpful for better assessment of hemorrhage. The common carotid arteries are patent without focal flow-limiting stenosis or occlusion. Mild surrounding edema is noted. COMPARISON: . To correlate clinically for underlying etiology such as vasculitis, collagen vascular disorders or any predisposing factors, hypercoagulability conditions, (Over) 7:18 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: ? CTA: Large right MCA clot. CTA: Large right MCA clot. The left cervical internal carotid artery and the intracranial portions are patent without focal flow-limiting stenosis or occlusion. On the GRE sequence, there are few tiny foci of negative susceptibility with slightly heterogeneous appearance of the right lentiform nucleus. The left middle cerebral artery and the anterior cerebral arteries are patent without focal flow-limiting stenosis or occlusion. Lack of enhancement in the right cervical internal carotid artery, soon after its origin throughout its entire course, with reformation in the supraclinoid segment close to its termination. Pending reformations. TECHNIQUE: MR of the head without contrast. Large clot within the right MCA. Elsewhere in the brain, matter/white matter differentiation appears preserved. Assess followup. Bleed. Bleed. Bleed. Bleed. Pl. No large focus of negative susceptibility is noted to suggest an obvious hemorrhage. The patient is status post left hemithyroidectomy. 7:18 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: ? | 3 | [
{
"category": "Radiology",
"chartdate": "2182-12-13 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1173539,
"text": " 8:14 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: Eval for hemorragic transformation.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with carotid dissection and Right MCA stroke\n REASON FOR THIS EXAMINATION:\n Eval for hemorragic transformation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc 9:45 PM\n No evidence of hemorrhagic conversation. Right MCA distribution infarction\n affection the left frontal lobe, left basal ganglia and insular cortex. More\n acute cortical components.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right MCA stroke, to evaluate for hemorrhagic transformation.\n\n COMPARISON: Prior CT and CTA head study.\n\n TECHNIQUE: MR of the head without contrast.\n\n FINDINGS: There is a moderate-large area of decreased diffusion, in the right\n MCA territory involving the right frontal lobe and right basal ganglia,\n without associated significant mass effect. Mild surrounding edema is noted.\n\n On the GRE sequence, there are few tiny foci of negative susceptibility with\n slightly heterogeneous appearance of the right lentiform nucleus. Correlation\n with non-contrast CT head can be helpful for better assessment of hemorrhage.\n Assess followup. No large focus of negative susceptibility is noted within,\n to suggest an obvious focus of blood products.\n\n The ventricles and extra-axial CSF spaces are unremarkable. Right internal\n carotid artery flow void is not seen and is better assessed on the prior CTA\n study. Increased signal is noted within the right internal carotid artery and\n in some of the M2 branches, on the FLAIR sequence.\n\n IMPRESSION:\n\n 1. Acute infarcts in the right MCA territory involving the right frontal lobe\n and the right basal ganglia. No large focus of negative susceptibility is\n noted to suggest an obvious hemorrhage. Subtle hypointense foci within are of\n equivocal significance and correlation with a non-contrast CT can be helpful.\n\n 2. Non-visualization of the right internal carotid artery, better evaluated\n on the prior CTA study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1173685,
"text": " 10:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change - r/o hemorrhagic conversion\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;CAROTID DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with Right MCA infarction and Right ICA dissection with left\n sided hemiplegia, now on hep gtt>24hrs\n REASON FOR THIS EXAMINATION:\n interval change - r/o hemorrhagic conversion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg 11:13 AM\n Evolution of right MCA territory infarct involving right frontal cortex and\n lentiform nuclei without hemorrhagic transformation or significant mass\n effect.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 22-year-old female with right internal carotid artery\n dissection and right MCA territory infarction, on a heparin drip. Rule out\n hemorrhagic transformation.\n\n COMPARISON: .\n\n TECHNIQUE: Axial images were acquired of the head without contrast.\n\n FINDINGS: There is interval evolution of a right MCA territory infarction\n involving the right lentiform nuclei and right frontal cortex. Intermediate\n density is seen within the hypodense right lentiform nuclei, but this is not\n dense enough to be consistent with hemorrhagic transformation. No acute\n intracranial hemorrhage is seen. There is no extra-axial collection or\n significant mass effect. The ventricles and sulci are normal in size and\n configuration. Elsewhere in the brain, matter/white matter\n differentiation appears preserved.\n\n The visualized orbits and soft tissues appear normal. The mastoid air cells\n are clear bilaterally. The visualized paranasal sinuses remain clear.\n\n IMPRESSION: Expected evolution of right MCA territory infarction with no\n acute intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-13 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1173536,
"text": " 7:18 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? Bleed.\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with L sided weakness. aphasia.\n REASON FOR THIS EXAMINATION:\n ? Bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc 7:43 PM\n Non Contrast: Areas of loss of the grey white matter differentiation in the\n right frontal and insular cortex and basilar ganglia compatible with\n acute/subacute infarction. CTA Pending.\n\n CTA: Large right MCA clot. Right ICA dissection.\n\n Right ICA dissection with complete distal occlusion originating approximately\n 2.3cm from the carotid bifurcation. Large clot within the right MCA. Right MCA\n distribution infarction.\n WET READ VERSION #1 DLrc 7:37 PM\n Non Contrast: Areas of loss of the grey white matter differentiation in the\n right frontal and insular cortex and basilar ganglia compatible with\n acute/subacute infarction. CTA Pending.\n WET READ VERSION #2 DLrc 7:38 PM\n Non Contrast: Areas of loss of the grey white matter differentiation in the\n right frontal and insular cortex and basilar ganglia compatible with\n acute/subacute infarction. CTA Pending.\n\n CTA: Large right MCA clot. Right ICA dissection. Pending reformations.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left-sided weakness, aphasia, question bleed.\n\n COMPARISON: None. History of recent biopsy of thyroid two days earlier,\n details not known.\n\n TECHNIQUE: Non-contrast CT head, followed by CT angiogram of the head and\n neck. 2D and 3D reformations of the intra- and extra-cranial arteries were\n obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: There are hypodense areas noted in the right middle\n cerebral artery territory involving the right frontal lobe and the right basal\n ganglia, which correspond with areas of decreased diffusion on the subsequent\n MR study, representing acute infarcts. There is no evidence of acute\n intracranial hemorrhage. There is mild mass effect with no significant shift\n of midline structures. The ventricles and extra-axial CSF spaces are better\n seen on the subsequent MR study. No osseous lytic or sclerotic lesions are\n noted.\n\n (Over)\n\n 7:18 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? Bleed.\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT ANGIOGRAM OF THE HEAD AND NECK:\n\n The origins of the arch vessels are patent. The common carotid arteries are\n patent without focal flow-limiting stenosis or occlusion.\n\n There is nonvisualization of the right cervical internal carotid artery, soon\n after its origin, throughout its course. There is reformation of the\n supraclinoid portion, with patent ophthalmic artery on the right side. The\n anterior cerebral artery on the right side is patent.\n\n There is a filling defect in the right M1 segment with non-visualization of\n some of the M2 branches (series 4, image 219). The left middle cerebral\n artery and the anterior cerebral arteries are patent without focal\n flow-limiting stenosis or occlusion.\n The left cervical internal carotid artery and the intracranial portions are\n patent without focal flow-limiting stenosis or occlusion. Left cervical\n internal carotid artery is slightly tortuous and coarse which is somewhat\n unusual for the patient's age.\n\n The vertebral arteries are patent throughout their course, from their origins\n till the to form the Basilar artery. The major arteries of the\n posterior circulation intracranially are patent.\n\n The patient is status post left hemithyroidectomy. A few radiopaque foci are\n noted adjacent to the left internal jugular vein, to correlate with details of\n surgery/trauma (series 4, image 109).\n A few small nodes and multiple small nodes are noted in both sides of the\n neck, some of which are borderline to minimally enlarged. To correlate\n clinically.\n\n\n IMPRESSION:\n\n 1. Lack of enhancement in the right cervical internal carotid artery, soon\n after its origin throughout its entire course, with reformation in the\n supraclinoid segment close to its termination. This may relate to\n thrombosis/dissection.\n\n 2. Filling defect in the right middle cerebral artery M1 segment, likely from\n thrombus within.\n Non-visualization/decreased caliber of some of the M2 branches.\n 3. Hypodense areas in the right MCA territory, representing acute infarcts,\n better evaluated on the subsequent MR study.\n\n To correlate clinically for underlying etiology such as vasculitis, collagen\n vascular disorders or any predisposing factors, hypercoagulability conditions,\n (Over)\n\n 7:18 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? Bleed.\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n etc. Interventional neuroradiology consult can also be considered if\n clinically appropriate. Follow up as clinically indicated. MRA with fat sat\n sequences can be more helpful for better assessment of the abnormality if\n clinically necessary and not CI.\n\n 4. Pl. see other incidental details and rec. above\n\n"
}
] |
4,976 | 147,702 | Assessment and Plan: yo female with PMH HTN, Afib s/p pacer adm wtih episode of unresponsiveness/syncope thought to be secondary to cardiac arrest. . 1. ?Posturing/syncopal episode: Unclear if secondary to VFA, rapid afib, or brainstem stroke. Per neuro, findings on neuro exam were worrisome for brainstem injury secondary to hypotensive stroke. Other possibility is diffuse anoxic brain injury. EEG performed indicated encephalopathy. Repeat head CT showed no evidence of bleed or mass effect. . Regarding cardiogenic causes of syncope, arrythmia is very likely. Interrogation of pacer shows several episodes of Vtach, which could be etiology of syncope; however, the timing of Vtach does not correlate with time of syncope. Rapid afib is also a possibility since pt seems to have had episodes of rapid afib around time of syncope. Pt has valvular abnormalities on echo. Ischemia unlikely given negative cardiac enzymes. Pt was taken off sedation to follow neuro exam. On HD2, pt became aggitated and was given propofol. Pt also began to respond to voice and some commands. She was slowly weaned off of all sedating medications and began to respond to basic commands. . She was extubated when her RSVI was less than 100. However her respiratory status and mental status worsened over the course of the day and following night. The following day she was re-intubated for respiratory support. She was fighting the vent and sedated with Propofol. She required Neo, Levo, and Dopa to maintain her blood pressure. Overnight her creatinine continued to increased, her Lactate trended upward, her LFTs were elevated. The following morning her family decided to withdraw care as she was doing worse and they felt that she would not have wanted the level of care being performed. She expired shortly after. . 2. Rhythm: Question of Vfib arrest per EMT report. Vtach and rapid afib seen on pacer. Vtach may be potential cause of cardiac arrest. Pt was continued on IV amio. Digoxin was discontinued. On HD2, pt was noted to be tachycardic in the setting of hypotension immediately after being given propofol for agitation. Pt was restarted on beta-blocker: metoprolol 5mg IV q6h for rate control. She was continued on Amiodarone and beta blocker (briefly on an Esmolol drip) however her rate was difficult to control with continued afib with RVR. . 3. ?CHF: Pt had preserved EF by initial echo. Pt is most likely volume overloaded from chest x-ray. She was given small dose of lasix for diuresis. On hospital day 4 she was febrile with decreased urine output she was given IV fluids. . 4. Hypotension: On HD2, pt developed hypotension and tachycardia immediately after being given propofol for aggitation. Pressures returned to after fluid bolus. Unlikely to be septic or in cardiogenic shock. She later had recurrence of hypotension requiring three pressors for support. . 5. CAD: No hx of CAD. Cardiac enyzmes have been flat. Ischemia is unlikely to be cause of cardiac arrest. . 6. Tracheal perforation: Intubation on the field for airway protection was attempted but failed. Pt was intubated in the ED, but suffered traumatic intubation. Trachea was perforated with resulting subcutaneous emphysema and pneumonmediastinum. CT surgery was consulted who recommended conservative management. At the time of extubation interventional pulmonary was around in case of needed re-intubation. At the time of re-intubation interventional pulmonary performed the proceedure with a bronchoscope. 7. ?cervical spine injury: Cervical spine CT showed subluxation C3 vertebral body on Cr and subluxation of C5 on C6. Pt was put on C-spine collar until she is able to be cleared. On HD2, pt's family stated that they felt the subluxations were old. They stated that they wanted to switch to soft collar and that they would assume responsibility for any injuries. She eventually had a neck CT and denied any further pain so that she was cleared from the soft collar. . 8. ?Aspiration pneumonia: Given traumatic intubation, pt most likely aspirated gastric contents. Respiratory therapist suctioned gastric contents from airway. Pt was started on empiric Flagyl and Levo for potential development of aspiration pneumonitis. . 9. Leukocytosis: Pt had elevated WBC of unclear etiology. Has only had few low grade temps. We are following blood and urine cultures which are no growth to date. . 10. GI: Pt has abdominal distension since admission. Several attempts were made to pass OGT without success. NGT was also unable to be passed by CT surgery. Finally interventional pulmonary passed an NGT under bronchoscopic guidance. | Shortness of breath.BP (mm Hg): 76/48HR (bpm): 115Status: InpatientDate/Time: at 14:07Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. RV functiondepressed.AORTA: Moderately dilated aortic root. S/p arrest.BP (mm Hg): 150/72HR (bpm): 90Status: InpatientDate/Time: at 16:19Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Echocardiographic signs of tamponade may be absent in the presenceof elevated right sided pressures.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). RV function depressed.AORTA: Normal aortic root diameter. DRY OR IN NEED OF MORE LASIXTO OBTAIN CXR THIS AM.TO DISCUSS WITH TEAMAM CREATININE ALSO TO BE DRAWN CURRENTLY. REMAINS AT STEADY LEVEL CURRENTLY- SEE FLOWSHEET.HR- 140-170'S BURSTS- AFIB, BP- 69/40-106/62 VIA RT RADIAL ALINEPA- HIGH FILLING PRESSURES WITH PAD 30-35, UNABLE TO UNLOAD D/T MARGINAL PERFUSION PRESSURES.HAD BEEN ON HEPARIN FOR (+) AFIB, BUT NOW OFF D/T INR ELEVATION - AWAIT DIC SCREEN.LAST CO- 3/1.8/1253- AM NUMBERS PENDING. CCU NSG PROGRESS NOTE 7P-7A/ S/P CV ARREST/PNAS- NODDING YES/NO- NOT SPEAKINGO- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS WITH RAPID AFIB WITH BURSTS UP TO 140-150 IN SPITE OF INCREASING OF B BLOCKER.CURRENTLY UP TO 100 MG TID AND HR- 110- 120 AFIB WITH BP- 120/50-140/70 VIA RT RADIAL ALINE. CCU NSG NOTE: ALT IN RESP/CVO: For complete VS see CCU flow sheet.ID: T-max 100.8 R. Tylenol given. flaggyl and levofloxacin d/c'd, started on zosyn. NPNCCU7 PM - 7 AMORALLY INTUBATEDANSWERING QUESTIONS APPROP..SQUEEZING HANDS WITH EQUAL STRENGTH..MOVING LEGS ABOUT THE BED ...WITHDRAWING TO PLANTAR STIMULATION...PUPILS EQUAL AND REACTIVE TO LIGHT ....CV HR 100-120'S..AFIB ...HEART RATE UNAFFECTED BY SLIGHT INCREASE INIV LOPRESSOR DOSE ..SBP 90-110'S/60'S...GU MINIMAL URINE OUTPUT..URINE CONCENTRATED ...GI PASSING GAS ..SOFT STOOL TIMES 3 ..LOOSE ..OB NEGSEDATED WITH 2 MG OF IV VERSED Q2 WITH GOOD AFFECTRESP ON AC MODE ..RATE OF 16 ..TV OF 500 ..40%..PEEP 5 ..LUNGS COARSE ..MINIMAL ETT/ORAL SXNSID TEMP 100.4..ABXS CONTINUE ..TYLENOL RTC ..A/P BETTER RATE CONTROL NEEDEDCONSIDER GENTLE HYDRATION? PT ON MAX VENTILATORY SUPPORT- 100/480/32 WITH PEEP 8, A/C.SUCTIONED FOR THICK TANNISH SECRETIONS, BILATERAL LUNG SOUNDS COARSE.PEAK PRESSURES ON VENT - 30-34. More inferiorly, the ET tube re-enters the air filled tracheal lumen. More inferiorly, the ET tube re-enters the air filled tracheal lumen. There is evidence of discontinuity of the posterior trachea (7 o'clock position) at the level of the upper sternoclavicular joints with adjacent extraluminal air, consistent with traumatic break-through. Surgery called for perfortated trachia. Bilat SWR d/t difficult intubation. LS clear to coarse at apices, coarse to bronchial at bases, crackles noted this am in LLL. Lactic acid 2.6RESP: intubated, ventilated on AC 500x16/., LS clear, initially rhonchrous, most recent ABG 7.36/34/111/20. Cont to monitor neuro signs q2hr, hold sedation. Cardiomegaly and interstitial edema. CCU NPN 7a-7pS: orally intubatedO: see carevue for VS trends/event dataNEURO: lethargic, awakes to loud voice, tactile stim. Please assess for ileus. Marked subcutaneous air in neck and edema of the larynx. Marked subcutaneous air in neck and edema of the larynx. Subdiaphragmatic structures are notable for a marked gasseous distention. Transiently hypotensive, responsive to fluid boluses. Lg audible cuff leak noted when PT coughs. ADDENDUM #1: On the sagittal images, the C3 vertebral body appears to be subluxed anteriorly on C4. The prevertebral soft tissues appear edematous, likely relating to known traumatic intubation. More inferiorly, the endotracheal tube is seen within the trachea. H/H stable, K+ 4.9.RESP: orally intubated AC 500x14/. had lymphoma years ago w/ lymph node dissection and this is pt. R radial a-line sharp, WNL, R posterior forarm, L wrist, L hand PIV patent and intact.A/P: s/p VF arrest, traumanic intubation. There is bronchomalacia. Termination of endotracheal tube of approximately 4.8 cm above the level of the carina. At the time of this preliminary report, coronal and sagittal reconstructions were available. CCU NPN 7A-7PS: Pt orally intubated and mechanically ventilated.O: Please see flowsheet for additional data. and family, plan for extubation once laryngeal edema improved. COMPARISON: FINDINGS: Endotracheal tube terminates approximately 4.8 cm above the level of the carina. ABG reveals Resp Alkalosis w/ normoxia. REASON FOR THIS EXAMINATION: eval subcut empysema secondary to trach. Cardiomegaly and arteriosclerotic changes involving thoracic aorta are noted. Persistent small amount of mediastinal air adjacent to the right lateral wall of the trachea. There are calcifications of the thoracic aorta consistent with atheromatous disease, unchanged from the previous examination. 11:33 AM CT CHEST W/O CONTRAST Clip # Reason: eval subcut empysema secondary to trach. IMPRESSION: Interval placement of an endotracheal tube. COMPARISON: Radiograph dated . COMPARISON: Radiograph dated . Intubated. There is diffuse prominence of the ventricles and sulci, consistent with age-related involutional change. Stable bilateral pleural effusions. Atrial fibrillation with conducted complexes showing low limb lead voltage andST-T wave abnormalities. The aorta is calcified and unfolded. There is indistinctness of the central pulmonary vasculature. Normal augmentation, waveforms, flow, and compressibility were identified. There has been placement of an endotracheal tube; the tip is 7.4 cm above the carina. The tip of the endotracheal tube still appears to be at the level of the medial ends of the clavicles. Admitting Diagnosis: S/P CARDIAC ARREST FINAL REPORT (Cont) bilaterally, and stable compressive atelectasis within the lower lobes bilaterally. Cardiomegaly is again noted. FINDINGS: Grayscale and Doppler color/waveform images of the right and left common femoral, superficial femoral, popliteal, deep femoral, and greater saphenous veins was performed. There is continued compressive atelectasis within the lower lobes bilaterally, posteriorly. Subcutaneous emphysema. REASON FOR THIS EXAMINATION: eval for interval change retrocardiac density, effusions FINAL REPORT INDICATION: Status post cardiac arrest. | 60 | [
{
"category": "Nursing/other",
"chartdate": "2179-11-26 00:00:00.000",
"description": "Report",
"row_id": 1327490,
"text": "CCU NPN 7a-1p\nPlease see flowsheet for VS and additional data. y/o pt in septic/cardiogenic shock, intubated, sedated and on vasopressin, levophed and dopamine gtts. Pt code status was changed from a full code to DNR at approx 1000, in family meeting between MD and 2 sons and , RN present at bedside. At approx 1230, Dr. met with family and family decided to put pt on comfort measures. All gtts and IVF were stopped. Dr. pronounced the pt expired at 1255. Family was present at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-24 00:00:00.000",
"description": "Report",
"row_id": 1327482,
"text": "Respiratory Care Note:\n Patient weaned and extubated today. She tolerated extubation over catheter with bronch cart at bedside. She is awake and alert. Cough and voice intact. ABG adequate on 80% cool neb. Plan to wean FIO2 as tolerated. BS with good aeration, no stridor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-24 00:00:00.000",
"description": "Report",
"row_id": 1327483,
"text": "CCU NPN 3-11pm\nResp: pt remains extubated, RR 30's, LS coarse throughout, congested cough, not expectorating, but cough has strengthened through the evening. Wearing 70% CN, sats 98-100%, ABG: 77/32/7.35. Turned S-S and given gentle CPT, enc cough and dep breath.\n\nCV: HR 105-130 A.fib, occ PVC's, occ bursts into 140's, increased lopressor to 100mg, dose given at 2200. All meds via NGT. Lasix earlier today, neg ~1L, POS 9L LOS, total body anasarca. Hep gtt 1100U, no bolus, started at 1700, PTT 77.4 at 2230.\n\nNeuro: alert, voice a whisper, did tell me she had to go to the bathroom. Recognizes family, knows she is in the hospital. Follow commands consistantly. Can squeeze hands, not moving, very weak.\n\nGI: NGT, left NPO for tonight given recent extubation and pot for reintubation. Start Promote with fiber at 30cc in AM, goal 50cc/hr. Has had 2 loose stools, OB (-), incontinent.\n\nSkin: as noted in above note.\n\nEndo: BS WNL, no reg ins required.\n\nStatus: pt full code.\n\nA/P: Tenuous Resp status post extubation, sating well, weak cough, treating Pneumonia, cont AB, enc C&DB. Follow HR, lopressor increased, PTT theraputic after ~6hrs on 1100U hep, recheck in AM. Reorient and explain events as needed, side rails up, restraints off.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 1327484,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV ARREST/PNA\n\nS- NODDING YES/NO- NOT SPEAKING\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS WITH RAPID AFIB WITH BURSTS UP TO 140-150 IN SPITE OF INCREASING OF B BLOCKER.\nCURRENTLY UP TO 100 MG TID AND HR- 110- 120 AFIB WITH BP- 120/50-140/70 VIA RT RADIAL ALINE. CALLED HO- TO REDISCUSS RATE CONTROL CURRENTLY.\nHEPARIN STARTED FOR AFIB COVERAGE ON EVES - 1100U WITH PTT 77.\n\n PT WITH TENUOUS RESP STATUS- ON 70% COOL MIST MASK INITIALLY AND CHANGING OVER TO HIGH FLOW 70-95%- WEAK INEFFECTIVE COUGH.\nATTEMPTING TO SUCTION PHARYNX- THICK TANNISH SPUTUM- MODERATE AMOUNT.\nGENTLE CPT Q 3 HOURS PERFORMED- NO RAISING OF ADDITIONAL SPUTUM AT ALL WITH CPT.\nSTARTED ON ATROVENT PRN, UNABLE TO GIVE ALBUTEROL D/T HEART RATE ISSUES\nDESATURATION TO MID 80'S AT TIMES WITH MASK SLIGHTLY OFF MOUTH, REARRANGED AND GRADUAL IMPROVEMENT OF O2 SATS.\n\n PT REMAINS ON BROAD SPECTRUM ANTIBX- RESUMED IV LEVO AND FLAGYL INSTEAD OF PO FORM.\n100.8 R T MAX\n\nGU- I/O (-)890CC AS OF 12AM\nNO IVF NOR LASIX THIS SHIFT.\nUO FAIR- 20-30/HOUR\n? DRY OR IN NEED OF MORE LASIX\nTO OBTAIN CXR THIS AM.\nTO DISCUSS WITH TEAM\nAM CREATININE ALSO TO BE DRAWN CURRENTLY.\n\n PT QUIET,NOT SPEAKING- NODDING VERY WEAKLY YES/NO, MOVING EVER SO SLIGHTLY EXTREMITIES, OPENING EYES.\nDENIES PAIN.\nNO FAMILY CALLS THIS SHIFT.\nDIFFICULT TO ASSESS LEVEL OF ORIENTATION OR AWARENESS OR COMPREHENSION OF STATUS/? NEED TO REINTUBATE /PLAN OF CARE ETC.\nPT VERY WEAK AND TIRED AND NOT INTERACTIVE AT ALL THIS SHIFT.\n\nA/ PT S/P CV ARREST C/B DIFFICULT INTUBATION AND ASP PNA CURRENTLY REMAINS EXTUBATED WITH TENUOUS RESP STATUS\nAND NOT WELL CONTROLLED HEART RATE/AFIB\n\nCONTINUE TO DISCUSS PLAN FOR MEDICALLY TX OF AFIB/RATE\nCONTINUE PULM TOILET/CPT/ANTIBX TO TX PRESUMED PNA.\nDISCUSS WITH TEAM ? WET/DRY AND POSSIBLE NEED FOR LASIX VS/ GENTLE HYDRATION.\nCOMFORT FOR PT, WATCH FOR FURTHER TEMP SPIKES/REPEAT CULTURES AS NEEDED.\nNUTRITION VIA NG TUBE IF NOT NEEDED TO REINTUBATE TODAY.\nKEEP FAMILY AWARE OF PLAN OF CARE AS WELL AS PT.\nRE DISCUSS FULL IMPLICATION OF FULL CODE/DNR WITH FAMILY DAILY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 1327485,
"text": "RESPIRATORY CARE NOTE\n\nPt received on 80% cool aerosol. Required increasing amounts of O2 during the noc. ? pt's ability to handle secretions in near future. Now on 95% Hi- Nebulizer with SaO2=93-94%. ABG this AM shows metabolic acidosis with mild hypoxia. Atrovent nebulizers initiated. No albuterol d/t tachycardia >125.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 1327486,
"text": "RESPIRATORY CARE: PT REINTUBATED FOR IMPENDING\nRESPIRATORY FAILURE THIS AM W/ FIBEROPTIC\nBRONCOSCOPE. REMAINS ON AC MODE 32/450/1.0/5.\nABG C/W A SEVERE METABOLIC ACIDOSIS ONLY\nPARTIALLY COMPENSATED AND POOR OXYGENATION.\nGROSSLY FLUID POSITIVE W/ MINIMAL UO. PLATEAU\nPRESSURES 20-25 AND MINIMAL AUTOPEEP NOW\nTHAT SEDATED W/ FETANYL AND PROPOFOL. REMAINS\nW/ VERY POOR CARDIAC/HEMODYNAMIC FUNCTION.\nWILL C/W VENTILATORY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 1327487,
"text": "CCU NPN 7a-7p\nS: orally intubated and sedated\nO: see carevue for VS trends/event data\nPt initially lethargic, not arousable, no response to nail bed pressure, not moving extremities, discoordinate respiratory pattern LS coarse/bronchial w/ end-expiratory wheezes and scattered rhonchi w/ RR 30's. ABG 7.27/33/80/16/92. Electively re-intubated for pending respiratory failure. ABG showed worsening metabloic acidosis after intubation, pt. not ventilating well d/t tachypnea given versed for sedation w/ minimal effect, started propofol @ 25mcg. Pt. febrile to 103.8, ?sepsis, started sepsis workup Lactic acid 3.5, LFT's elevated, H/H up, PLT 976. PA catheter placement to eval fluid sts, CV fxn showed PCWP 20, CO/CI 2.7/1.6/1452. ECHO showed dilated RV and severely depressed LV fxn. Workup indicative of cardiogenic over septic shock.\nPt. sedated on 25mcg propofol w/ 50mcg fentanylx1 and 2mg versed x1 to aid mech. ventilation, requiring vasopressor support to maintain MAP, started on levo, w/ mod response, neo added transiently and changed to vasopressin per team. MAP 50's-65 on double pressors, dopa @ 5mcg's started @ 1730. Cont in rapid AF 110's-130's w/ bursts into 140's. MAPs up w/ addition of dopa, HR consistently in 150's, bursting to 160's, levo weaned down as bp tol, dopa titrated down d/t tachycardia, as tol. Heparin off @ 0800, PTT 150, remained off for line placement, restarted @ 1600 @ 800u/hr.\nID: WBC up 33.4 (19.7), Tmax 105.3, started on cooling blanket w/ good response, temp decreasing slowly, tcurrent 100.8 Cont vanco, noon dose held d/t high trough (18.9), repeate trough pending. flaggyl and levofloxacin d/c'd, started on zosyn. blood and urine cultures sent.\nGI: coffee ground gastric aspirate noted t/o shift. held afternoon PNGT meds d/t ? gastric bleeding. +BS/-BM, abd soft/distended.\nGU: u/o cont. lowm +865 for 24hr, + almost 10L for LOS. Cr bumped 2.1 from 1.4. Urine dark amber.\nENDO: BG 120's-130's, not requiring RISS coverage.\nSKIN: RIJ PA catheter. R-radial a-line, R forearm PIV. multiple ecchymotic areas, r wrist skin tear covered w/ steri-strips and tegaderm. No breakdown noted.\nSOCIAL: family met w/ SW today, handling crisis appropriately. family ?ing if care is appropriate re: pt. wishes. Discussed w/team? withdrawal of care. Awaiting Dr. for further discussion before decision made.\nA: re-intubated pending resp. failure, cont tenuous resp sts. Hemodynamically unstable requiring multiple pressor therapy to maintain MAP >60. ?Acute renal failure.\nP: cont mechanical ventilation, monitor ABG's resp sts. Cont to titrate vasopressor and monitor hemodynamic sts. Monitor temp, cont tylenol PR, abx, f/u cultures. PTT due 2200. F/u w/ family and team re: cont w/ aggressive care v. comfort measures. Continue to support pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-26 00:00:00.000",
"description": "Report",
"row_id": 1327488,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. No vent changes made during the noc. ABG shows metabolic acidosis. BLBS are coarse with crackles at the bases. Sxn for thick blood tinged secretions.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-26 00:00:00.000",
"description": "Report",
"row_id": 1327489,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ CV/SEPTIC SHOCK\n\nS- INTUBATED, NONRESPONSIVE\n\nO-\n\n PT FAILING AGGRESSIVE CARE WITH HEART FAILURE/FEVER/SEPSIS S/P CV ARREST/CPR/DIFFICULT INTUBATION AND PRESUMED ASPIRATION PNA\nREINTUBATED AND STARTED ON PRESSORS, PA LINE INSERTED.\nCURRENTLY, ABG'S REVEAL WORSENING PH, WORSENING LACTIC ACID AND MARGINAL BP/ABG'S ON VASOPRESSIN, DOPA AND LEVO.\nWITH DROP IN PH TO LESS THAN 7.20, BP DROPPING , REQUIRING INCREASE OF PRESSORS, SINCE 12AM. REMAINS AT STEADY LEVEL CURRENTLY- SEE FLOWSHEET.\nHR- 140-170'S BURSTS- AFIB, BP- 69/40-106/62 VIA RT RADIAL ALINE\nPA- HIGH FILLING PRESSURES WITH PAD 30-35, UNABLE TO UNLOAD D/T MARGINAL PERFUSION PRESSURES.\nHAD BEEN ON HEPARIN FOR (+) AFIB, BUT NOW OFF D/T INR ELEVATION - AWAIT DIC SCREEN.\nLAST CO- 3/1.8/1253- AM NUMBERS PENDING.\n\n PT ON MAX VENTILATORY SUPPORT- 100/480/32 WITH PEEP 8, A/C.\nSUCTIONED FOR THICK TANNISH SECRETIONS, BILATERAL LUNG SOUNDS COARSE.\nPEAK PRESSURES ON VENT - 30-34. LAST ABG- 7.16-32-75 -16 89%...TRENDING DOWN OVER COURSE OF ENTIRE DAY SINCE INTUBATION YESTERDAY MORNING.\nUNABLE TO FURTHER USE VENT TO HELP COMPENSATE FOR OVERWHELMING METABOLIC ACIDOSIS. HOLDING OFF ON HCO3 GTT PER TEAM CURRENTLY.\nSERUM HCO3 -.\n\nID- T MAX- 100.8- REMAINS ON ZOSYN AND VANCO.\nUNCLEAR ETIOLOGY FOR SEPSIS BUT PRESUMED (+) PNA FROM PROLONGED AND DIFFICULT 1ST INTUBATION WHEN ADMITTED INITIALLY.\nWHITE COUNT CLIMBING- 20-30-40'S TODAY.\nCOOLING BLANKET AS NEEDED.\n\nGU- 4-5CC/HOUR\nCREATININE 2.3- AM LEVEL PENDING.\nFOLEY CATH IN PLACE.\nNO LASIX D/T HYPOTENSION\n\nGI- NPO- COFFEE (+) EARLIER ASPIRATED.\n\n PT APPEARS SEDATE/NONRESPONSIVE\nON PROPOFOL MINIMAL DOSE- 25 MCG.\nPUPILS 2MM-PIN- VERY SLUGGISH REACTIVE.\n\nSOCIAL- DAUGHTERIN LAW AND 2 SONS PRESENT AND HAD FAMILY MEETING WITH CCU NSG/MED TEAM AS WELL AS DR .\nWOULD LIKE TO CONTINUE AGGRESSIVE CARE AS CURRENTLY AND REASSESS THIS MORNING.\nTO CALL FAMILY THIS AM WITH POOR RESULTS OVERNITE -WORSENING ABG/ACIDOSIS.\n\nA/ PT S/P CV ARREST CURRENTLY IN SEVERE SEPTIC SHOCK/CV SHOCK STATE WITH WORSENING ACIDOSIS IN SPITE OF AGGRESSIVE ANTIBX/PRESSOR/HEART SUPPORT AND VENTILATORY SUPPORTS\n\nPLAN TO CALL FAMILY AND REDISCUSS PLAN OF ACTION.\nCONTINUE CURRENT PLAN FOR VENT/PRESSORS/LAB DRAWS/ANTIBX AND TREATMENTS/FULL CODE UNTIL NOTIFIED OTHERWISE.\nKEEP PT COMFORTABLE WITH PROPOFOL AS ABLE. ASSIST FAMILY COPING.\n"
},
{
"category": "Echo",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 69062,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\nBP (mm Hg): 76/48\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 14:07\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA and/or RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mildly depressed\nLVEF.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. Moderate to severe [3+] TR. Severe PA\nsystolic hypertension.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nThe right atrium is dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular ejection fraction is mildly-to-moderately depressed (40 percent).\nThe right ventricular free wall is hypertrophied. The right ventricular cavity\nis dilated. Right ventricular systolic function appears depressed. The number\nof aortic valve leaflets cannot be determined. The aortic valve leaflets are\nmoderately thickened. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. The tricuspid valve leaflets are mildly thickened.\nThe supporting structures of the tricuspid valve are thickened/fibrotic.\nModerate to severe [3+] tricuspid regurgitation is seen. There is severe\npulmonary artery systolic hypertension. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade. Echocardiographic signs of\ntamponade may be absent in the presence of elevated right sided pressures.\n\nCompared with the findings of the prior study (tape reviewed) of , the right ventricle is now more dilated and hypocontractile, suggestive\nof acute-on-chronic right heart pressure overload/strain.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 69063,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pacer. S/p arrest.\nBP (mm Hg): 150/72\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 16:19\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and/or RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Moderate to severe [3+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS.\nSignificant PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is low\nnormal (LVEF 50%). Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed. The aortic root is moderately dilated.\nThere are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is mild aortic valve stenosis. Mild to moderate\n(+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\nto severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. The pulmonic valve leaflets are thickened.\nSignificant pulmonic regurgitation is seen. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 1327460,
"text": " yr old female found unresponsive by family and CPR started. Upon arrival of medical personels intubation attemted without success. Patient transported to ER while being manually ventilated. several attempts to intubate patient in the ER failed.Finally patient was intubated with #6 ETT over bourgie rod.#6ETT taped at 23 cm.Patient went to CT scan for head and abdominal films then transported to CCU due to cardiac abnomalities.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-21 00:00:00.000",
"description": "Report",
"row_id": 1327468,
"text": "NPN\nCCU\n7 PM - 7 AM\nORALLY INTUBATED\nANSWERING QUESTIONS APPROP..SQUEEZING HANDS WITH EQUAL STRENGTH..MOVING LEGS ABOUT THE BED ...WITHDRAWING TO PLANTAR STIMULATION...PUPILS EQUAL AND REACTIVE TO LIGHT ....\nCV HR 100-120'S..AFIB ...HEART RATE UNAFFECTED BY SLIGHT INCREASE INIV LOPRESSOR DOSE ..SBP 90-110'S/60'S...\nGU MINIMAL URINE OUTPUT..URINE CONCENTRATED ...\nGI PASSING GAS ..SOFT STOOL TIMES 3 ..LOOSE ..OB NEG\nSEDATED WITH 2 MG OF IV VERSED Q2 WITH GOOD AFFECT\nRESP ON AC MODE ..RATE OF 16 ..TV OF 500 ..40%..PEEP 5 ..LUNGS COARSE ..MINIMAL ETT/ORAL SXNS\nID TEMP 100.4..ABXS CONTINUE ..TYLENOL RTC ..\nA/P BETTER RATE CONTROL NEEDED\nCONSIDER GENTLE HYDRATION\n? REPEAT CHEST CT ? IV STEROIDS\nFAMILY/PATIENT TO CONTINUE DISCUSSION WITH TEAM REGARDING HER WISHES ABOUT RE-INTUBATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-21 00:00:00.000",
"description": "Report",
"row_id": 1327469,
"text": "Post Cardiac arrest difficult intubation and tracheal perforation.Patient weaning on PSV with ATC added due to low spt vt and concern of ETT resistance. #6 ETT taped @ 24cm.Patient alert,coop,she went to CT scan this AM result not worse then yesterday.Febrile with temp 100.8,has occasional PVCs.ABG ok,has adequate cuff leak when assessed on AC or SIMV.Cxr pneumonitis,suctioned for moderate to scant amount of secretion.Has copious amount of nasal dischrge.Alert,reoponds to commands by nodding. will continue to closely monitor patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-21 00:00:00.000",
"description": "Report",
"row_id": 1327470,
"text": "CCU NPN 7a-7p\nS: orally intubated\nO: see carevue for VS trends/event data\nNEURO: Alert or easily awoken to verbal stim, lift/hold UE's, moving LE's on bed. Equal strength bilat. Cough and gag intact. PERRLA Nodding appropriately to questions and mouthing words at times. Recieved 2mg Versed prior to CT scan and 1mg x2 in evening for anxiety/biting at tube. Head CT showed no intercranial hemorrhage/evidence of CVA. Soft cervical collar on. Bilat SWR applied later in evening d/t grabbing @ tube.\n\nCV: Afib, 90's-130's rare PVC's noted, 7.5mg lopressor changed to q4hr w/ minimal effect, additional 5mg IVP given @ 1630, HR transiently down to 80's (? effect of Versed/Lopressor). Unable to give 2nd 5mg d/t BP low 90's. BP stable 90's-120's/50's. D/c'd fem. TCL, site w/o ecchymosis/hematomma, DSD C/D/I.\n\nRESP: orally intubated on CPAP 5 PEEP/14 PS/.4 Fi02. Vt 300-500, SpO2 95-99%, RR 20's-30's. Most recent ABG 7.37/36/105/22/99. LS rhonchii/rales R base, bronchial L base, clear upper lobes. CT c-spine showed no cervical fx, old subluxation injury. Chest CT showed improved SQ emphysema w/ worsening laryngeal edema. +cuff leak @ 1600. Sxn'd deep and oralpharyngeal for minimal secretions. Oral/nasal bleeding stopped. Lidocaine solution applied to oral cavity to aid irritation.\n\nGI: abd s/nt/distended. +BS/small soft BM x2, guiac + x1. Cont NPO. Skin around rectum and in gluteal fold pink/macerated d/t loose stool, barrier cream applied.\n\nGU: foley draining amber urine 10-70cc/hr. Started gentle hydration D5 1/2 NS @ 75cc/hr x 1L. No diuresis today, + 1150cc for 24hr. BUN/Cr 41/1.5.\n\nENDO: FS QID 124-190, covered w/ RISS.\n\nID: WBC 21.5 (13.7) tmax 101.6, recieving 650mg tylenol PR ATC q6hr. Cont flaggyl and levoflaxacin, added vanco today and sent new blood/urine cultures. urine from no growth, other cultures pending.\n\nLABS: K+ 3.9, repleated w/ 10meq KCl IV, Mg++ 1.9 (repleated w/ 1gm MgSO4, Ca++ 7.9, ionized Ca++ 0.89 repleated w/ 2gm calcium gluconate. No post repletion labs ordered. PTT cont elevated 57.1, ?hepatic insult, add on and AM liver enzymes ordered.\n\nA/P: Improving neuro sts, no evidence of cerebral injury/infarct s/p VF arrest. Cont to monitor mental sts, discussed DNR/DNI sts w/ pt. & family, family feels that reintubation ok at this time should self-extubation occur. Cont to monitor resp sts, ? rest on AC overnoc. Monitor HR/rhythm ?need for different /larger dose if rate uncontrolled on lopressor. Cont to monitor temp, tylenol ACT:PRN, cont abx, f/u cultures. ?nutritional sts if unable to pass NG/OGT. PT consult and OOB tomorrow. Cont to support pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-22 00:00:00.000",
"description": "Report",
"row_id": 1327471,
"text": "Resp Care Note\n\nPt rested overnight on AC 14, 500, 40% 5 peep. A.M. RSBI was 141, Plan is to resume PSV settings this A.M., extubate if indicated\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-22 00:00:00.000",
"description": "Report",
"row_id": 1327472,
"text": "NPN\nCCU\n7 PM - 7 AM\nVT EVENT CAUSING UNRESPONSIVENESS\nEVENT C/B PROLONGED AND DIFFICULT INTUBATION\nCAUSING LARYNGEAL EDEMA AND TRACHEAL TEAR\nRECEIVED PATIENT AWAKE AND ANSWERING ( YES/NO ) TO QUESTIONS ASKED ...\nCV HR 90-100'S..AFIB WITH UNIFOCAL PVCS ...RATE CONTROL ATTEMPTED WITH 10-20 MG OF IV LOPRESSOR WITHOUT MUCH AFFECT ..CONTINUES ON AMIODARONE AT .5 MG/MIN..SBP BY RIGHT RADIAL ALINE 90-110'S/60'S...\nRESP VENT MODE CHANGED TO AC AT A RATE OF 14 ..OVERBREATHING ..TV OF 500..40% ..5 PEEP..ABGS PER FLOWSHEET ...BRONCHIAL BREATH SOUNDS ^ O THE LEFT/ ^ ON THE RIGHT ..MINIMAL ORAL/ETT SXNS\nGI ABD SOFT AND DISTENDED ..BOWEL SOUNDS PRESENT ..NO STOOL\nGU MINIMAL URINE OUTPUT 30-50 CC Q2 ..DESPITE GENTLE HYDRATION OF D5 AT 75 CC/HR\nTEMP MAX 100 R ..ALL CXS WITH NO GROWTH TO DATE ..CONTINUES ON FLAGYL/LEVAQUIN/VANCO ...\nPATIENT ABLE TO QUEEZE HANDS WITH EQUAL STRENTH ..MOVING LOWER EXTREMITIES ABOUT THE BED ..WIGGLING TOES ON COMMAND ..PUPILS 3+ BILAT AND BRISKLY REACTIVE TO LIGHT\nVENT CHANGED AC MODE FROM CPAP AND PS FOR THE NIGHT AND VERSED AT 4 MG/HR OVERNIGHT\nA ANTICIPATE EXTUBATION TODAY\nP VERSED INFUSION STOPPED AT 0600\nCHANGED BACK TO CPAP AND PS\nSHOULD HAVE ANESTHESIA/RESP AND EMERGENCY TRACH TRAY AT BEDSIDE WHEN EXTUBATED\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-24 00:00:00.000",
"description": "Report",
"row_id": 1327481,
"text": "CCU NSG NOTE: ALT IN RESP/CV\nO: For complete VS see CCU flow sheet.\nID: T-max 100.8 R. Tylenol given. Vanco trough drawn and pt conts on flagyl and levo.\nRESP: Pt was extubated at 1245. Cook catheter inserted at time of extubation but removed at pt seemed to be doing well. She is non cool neb at 80% with gas after 2 hours 7.33/ 33/ 92/ -7/ 18. RR 22-24. Her cough is weak but she does seem to get mucus up. She is assisted with oral suctioning. SHe has decreased breath sound with some crackles and bronchial sounds on the L.\nCV: Off the esmolol her heart rate has been increasing to 100-120s a-fib. Lopressor was increased from 75mg to 75mg tid with second dose given at 1400. BP has been 130-150/60s. She continues on po amiodarone. SHe will be started on iv heparin at 1100u with no bolus.\nRENAL: Pt is 9 liters positive and started receiving lasix today, with 20mg given at 10am and 20 at 1420. She is 400cc neg for the day. Foley was leaking, so catheter was changed from 20 to 18f catheter.\nGI: tube feeds stopped at 7am for extubation. If pt remains table they can be restarted. No bm today.\nENDO: FInger sticks in 12-130s and no ss reg insuin required.\nSKIN: Pt is anasarcic. Both hand edematous. She has Skin tear on R forarm and eccymosis of L hand. Buttocks reddened, but no breakdown.\nMS: Pt alert, following commands, but very weak. She can move all limbs on the bed, but has difficulty lifting off the bed. SHe has no gotten OOB today and is very tired with extubation. Family and physician are planning to talk to pt about her desires per further care-ie does she agree to re-intubation if required and code status.\nA: Tolerating extubation/conts abx/starting diuresis\nP: Continue diuresis. Assist pt with position changes. Start heparin. Monitor I & O closely. Restart tube feedings.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-24 00:00:00.000",
"description": "Report",
"row_id": 1327480,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. BLBS are coarse. Sxn for thick tan secretions. Pt biting down on ETT throughout noc, anxious. Will do RSBI in AM. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 1327463,
"text": "NPN\nCCU\n11 PM - 7 AM\nORALLY INTUBATED AND UNRESPONSIVE\nRECEIVED THIS YR OLD FEMALE ON FULL VENT SUPPORT AND POSTURING TO MINIMAL TACTILE STIMULATION..\nCV HR 90-100'S AFIB ..WITH UNIFOCAL PVCS/BIGEM.. .. K AND MG REPLETED ..SBP 90-120'S/60'S..VIA RIGHT RADIAL ALINE ...CONTINUES ON AMIODARONE AT 1 MG/MIN ..EPISODE OF HYPOTENTION AT 0645 ..WITH SBP DROPPING FROM 90'S TO MID 70'S.9 ( IN THE SETTING OF SLOW PROPOFOL INFUSION AT 10MCGS/KG ) .SLOW RESPONSE TO 500 CC NS BOLUS ...\nRESP AC MODE AT A RATE OF 20 ..TV OF 500 ..FI02 OF 70% ..WITH ACCEPTABLE ABGS ..PLS SEE FLOWSHEET ...FOUND PT OVERBREATHING AT 0615 IN THE 30-40'S..PT APPEARED AWAKE AND TURNING HEAD TOWARD SPEAKER ...UNSUCCESSFUL TRIAL OF PS UP TO 18..PT REMAINED TACHYPNEIC ..THUS SLOW PROPOFOL INFUSION BEGUN AND SBP DROPPING TO THE 70'S..\nGI ..SURGERY TEAM ATTEMPTED NG/OG TUBE PLACEMENT WITHOUT SUCCESS..ABD DISTENDED AND SOFT ..DILATED COLON PER ABD KUB..PASSING FLATUS ..NO STOOL\nHEME HCT 42..INR 2..GIVEN 10 MG OF VIT K ...CONTINUES WITH BLDY ETT/ORAL/NASAL BLDG ..\nNEURO ..INITIALLY POSTURING TO MINIMAL TACTILE STIMULATION..NO MOVEMENT TO PAINFUL STIMULI..PUPILS REMAINED PINPOINT TO 2 MM AND CONSTRICTED ...UNTIL 0615 ..WHEN PT NOTED TO OPEN EYES TO NAME WHEN CALLED AND TURNED HEAD TOWARD SPEAKER...WITHDRAWING TO PLANTAR STIMULATION BY DRAWING KNEES UPWARD ..NO MOVEMENT TO UPPER EXTREMITIES TO COMMAND OR PAINFUL STIMULATION\nGU URINE OUTPUT 30-40 CC Q1 ..\n COLLAR PLACED AT 0200 FOR CHEST CT REPORT OF C3 SUBLUXED ON C4..WITH WIDENING OF THE C3-C4 INTERSPACE..AND C5 POST SUBLUXED ON C6..NO INCREASE IN SQ EMPHYSEMA NOTED\nSLIGHTLY IMPROVED NEURO EXAM RESULTING IN PATIENT'S RESP DISTRESS..DROPPING SBP TO SMALL DOSE OF SEDATION ..RESPONDING TO FLUID RESUSCITATION\nP MONITOR NEURO EXAM CLOSELY...GENTLE SEDATION AS NEEDED ...KEEP FAMILY CURRENT OF PATIENT'S STATUS AND PROCEED PER PATIENT/PROXY WISHES\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 1327464,
"text": "CCU NPN 7a-7p\nADDENDUM: PT MENTAL STATUS IMPROVED AFTER 6PM AND SHE IS NOW LIFTING BOTH ARMS OFF THE BED AND ACTIVELY LOOKING AROUND. CV: PT HAD 250NS BOLUS IN AFTERNOON WITH BP AND URINE OUTPUT DOWN.\nVALUABLES: WITH SON AND PRESENT YELLOW BAND AND YELLOW RING WITH 3 CLEAR STONES WAS REMOVED FROM LEFT HAND. THE FAMILY TOOK RINGS HOME.\nENT: PT CONTS TO HAVE BLEEDING FROM BOTH NOSTRILS WITH SOME BLOOD IN THE BACK OF THE THROAT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 1327465,
"text": "CCU NPN 7a-7p\nS: intubated\nO: see carevue for VS trends/event data\nNEURO: Initially eye opening to voice/tactile stim only, progressing to spontaneous arousal and tracking movement w/ eyes. PERRLA, 2mm w/ brisk reaction. Following commands consistently, moving all extremities on bed to command and spontaneously, R>L, equal strength. EOM and corneal reflex intact, gag impaired, coughs to deep sxn. Communicating via blinking and nodding. Bilat SWR d/t difficult intubation. 0.5mg versed given for anxiety @ 0800, no further sedation. Per family subluxation injury to c-spine is old injury, request removal of J upon arrival of foam collar, team ok'd. Head CT tomorrow for r/o stroke.\n\nCV: Recieved pt. hypotensive 80's/40's, slow response to 1L NS bolus, BP 90-110's/50's, additional 250cc bolus given @ 1400. AF 90's-120's, no ectopy noted. Amio gtt decreased 0.5mg/min. Started 5mg IV lopressor for tachycardia, tol well. Hct stable 41.4, K+4.5 after 20meq K+ IV. Lactic acid 2.6\n\nRESP: intubated, ventilated on AC 500x16/., LS clear, initially rhonchrous, most recent ABG 7.36/34/111/20. Cont to sxn ?gastric aspirate from lungs q2-4hr, blood oozing from nares L>R. Overbreathing vent ~4breaths. RR decresed to 16, ABG @ 1800 Pending. CT showed marked SQ air, laryngeal edema, and multiple fx'd tracheal rings. Bilat pleural effustions R>L\n\nGI: Abd soft/distended/hypoactive BS, no BM today. Not currently recieving enteral or parenteral nutrition, or bowel regime. PPI for GI prophylaxis.\n\nGU: foley draining minimal amounts amber yellow urine. Fluid balance + 1700 cc for 24hr. BUN/Cr 41/1.6 (36/1.4). No diuresis today, lasix ordered but held d/t marginal BP.\n\nENDO: BG 81 @ 0800, insulin gtt d/c'd. No RISS ordered, resume insulin gtt if necessary. BG range 81-109.\n\nID: WBC 13.7, tmax 101.8 PR. Given 650mg tylenol q4-6hr PRN. Cont flaggyl and levaquin for ? aspiration pneumonitis. Blood cultures x2, urine and sputum pending.\n\nSKIN: W/D/I, L leg mildly edematous, per family, pt. had lymphoma years ago w/ lymph node dissection and this is pt. baseline.\n\nSOCIAL: family @ bedside t/o day.\n\nA/P: Pt. DNR s/p ? VF arrest, anoxic brain injury/stroke, ? ATN. Neuro sts cont to improve. Transiently hypotensive, responsive to fluid boluses. Cont to monitor neuro signs q2hr, hold sedation. Cont to wean vent settings as tol, monitor ABG. Monitor u/o, BUN/Cr, fluid balance. Cont to support pt. and family, plan for extubation once laryngeal edema improved.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 1327466,
"text": "Patient continues to be mechanically ventilated with good ABG. Awake following commands.Plan to wean to extubate soon\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-21 00:00:00.000",
"description": "Report",
"row_id": 1327467,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Minimal changes made overnoc. Less blood noted in oropharynx, from ETT. BS's coarse. See flowsheet for further pt data.\nPlan: Will follow, maintain support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-22 00:00:00.000",
"description": "Report",
"row_id": 1327473,
"text": "Resp Care: Pt remains intubated via #6 ETT secured 24cm at lip. Lg audible cuff leak noted when PT coughs. Pilot balloon adequately inflated. Pt was a very difficult intubation. BS sl coarse t/o w/ rales LLL. Sx'd reg for mod to lg amts thick tan, yellow and brown sputum. RSBI this AM on 5cm IPS/ 0 PEEP and on Versed was 142. 2 hours after sedation off, and while on 7cm IPS/ 0 PEEP RSBI= 220 (Pt awake and following commands. C/o SOB. Automatic Tube Compensation turned on to 60%, sensitivity increased, and placed on CPAP w/ IPS 18cm. ABG reveals Resp Alkalosis w/ normoxia. MD is to cont w/ slow IPS wean as tol. Cxray today reveals \"ETT satisfactory position (5.9cm above carina), persist CHF\". Please see carevue for further vent inquiries.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-22 00:00:00.000",
"description": "Report",
"row_id": 1327474,
"text": "CCU NPN 7A-7P\nS: Pt orally intubated and mechanically ventilated.\n\nO: Please see flowsheet for additional data. Pt admitted on after syncopal episode at home, pt in WCT defib x1 to ST, pt to EW with traumatic intubation, laryngeal edema, please see admission note and chart for additional data.\n\nCV: Pt afib HR 96-113 (observed 86-120), Pt with DDI perm pacemaker. Pt continued today on amiodarone 0.5 mg/min and started esmolol gtt for rate control, esmolol titrated up to 150/mcg/kg/min with BP tol. Pt had rare PVCs and frequent pacer spikes noted on monitor( please see strip in chart), EP interagated pacer, pacer decreased to rate 40 (was at a rate of 60). ABP 101-132/46-85 MAPs 58-95. K 3.9, with 10 MeQ KCL.\n\nResp: Pt mechanically vent, this am on AC .40 RR 14 TV 500, pt was overbreathing at a RR 19-21. Pt vent changed to PS 18 .40 Vt 430's-600's, RR 14-30's. PS weaned down to 14, pt did not tol, RR increased up to 38. Pt put back on AC .40 5 PEEP RR 14 Vt 500, pt own RR 19-24. Pt sxn'd multiple times for thick yellow-tan sputum. LS clear to coarse at apices, coarse to bronchial at bases, crackles noted this am in LLL. O2 sats 95-99.\n\nID: Pt febrile, T max 101.6, acetaminophen given x 2, pt continues on levofloxacin, metronidazole, and vancomycin. Cx pending. Additional bld and sputum cx ordered with temp increase this eve.\n\nNeuro: Pt following commands this am, pt nodded head yes or no appropriately to questions, opened eyes to voice, held up arms and moves legs on bed, pupils 3mm, briskly reactive. Pt had no c/o pain, but nodded head yes to discomfort with ETT, RR increasing to 30's. Pt put back on versed gtt for comfort, presently versed 2mg/hr.\n\nGI/GU: Pt + BS x 4, scant amts of stool this shift, guiac positive. Pt NPO, started on amioacid 35 g/d dextrose 50 g/d (PN) @ 41/hr this eve. Pt with minimal u/o, HO notified, fluid bolus 250 cc given without affect.\n\nSocial: Pt son and daughter-in-law at bedside for most of shift. MD spoke with family regarding code status, pt status was changed to full code.\n\nA: Pt pacer interagated and pt started on esmolol gtt. IV nutrition was started and abx continues. Pt restarted on versed gtt.\n\nP: As discussed per interdisciplinary rounds, continue to monitor hemodynamics. Continue to follow temps and cx's. Continue to monitor u/o. Continue with hydration and IV nutrition. IP to continue to follow pt for possible extubation, ? next few days.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-23 00:00:00.000",
"description": "Report",
"row_id": 1327475,
"text": "Respiratory Care\nPt remains intubated with 6.0 et tube taped at 24cm. She had been placed on pressure support for several hours yesterday but tired by evening and was placed back on assist/control to rest. RSBI = 180. RSBI done with tubing compensation on due to small diameter of et tube.She does not appear extubatable at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-23 00:00:00.000",
"description": "Report",
"row_id": 1327476,
"text": "CCU Progress Note:\n\nS- intubated\n\nO- see flowsheet for all objective data.\n\ncv- Tele: Afib no ectopy- HR 92-103- Pt has DDD pacemaker- interagated yesterday -rate decreased to 40(was 60)- R radial Aline- ABP 101-115/53-60- amiodarone gtt @ .5mg/min -esmolol gtt @ 150mcq/kg/min (started yesterday for rate control)- Hct 33.6- K 4.9- Mg 2.2\n\nresp- con't on vent AC 500/12/40%/5- ABG 7.37-33-93- versed gtt D/C'd @ 4am- RSBI 180- lung sounds with scattered rhonchi- unable to obtain sputum specimen for C&S- SpO2 97-99%.\n\nneuro- sedation D/C'd @ 4am- opens eyes to verbal stimuli- nods head appropriately to simple questions- follows command- moving all extremities- PERRL\n\ngi- abd soft (+) bowel sounds- on PPN @ 41cc/hr - no BM this shift.\n\ngu- foley draining small amts conc amber colored urine- U/O 15cc/hr- BUN 48 Crea 1.3- hydrating IV NS @ 75cc/hr- urine lytes pending- I&O overall (+).\n\nID- T max 100.3 PO- WBC 16.6 (was 17.7)- blood cultures X2 done- unable to obtain sputum C&S- con't on levo, flagyl & vanco.\n\ndispo- Pt now full code per family.\n\nA- versed gtt D/C'd @ 4am- RSBI 180- unlikely Pt will be extubated today.\n\nP- repeat RSBI if Pt more awake later this am- attempt weaning to CPAP- monitor temp- pan culture with temp spikes- monitor vs, I&O, lung sounds & labs- offer emotional support to Pt & family- keep them updated on plan of care.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-23 00:00:00.000",
"description": "Report",
"row_id": 1327477,
"text": "Respiratory Care Note:\n Patient remains intubated and on vent support today. Weaning attempts earlier today failed possibly due to sedation and thick secretions. A heated vent circuit was placed. A bronchoscopy was done in the afternoon nasally to assess airway and place a nasogastric tube. Tracheal perforations not seen during bronch. ET tube with good cuff leak. Patient placed on ATC during wean due to size 6 ET tube. Plan to attempt wean again tomorrow morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-23 00:00:00.000",
"description": "Report",
"row_id": 1327478,
"text": "CCU NPN 7a-7p\nS: orally intubated\nO: see carevue for VS trends/event data\nNEURO: lethargic, awakes to loud voice, tactile stim. Following commands inconsistently, MAE, equal strength. PERRLA, cough/gag intact. OOB->chair x 2.5hr w/ heavy 3 person assist, tol well, minimal weight bearing. Midazolam gtt d/c'd @ 0400, given total 3mg midazolam IVP prior to and during bronchoscopy.\n\nCV: AF, 80's-100's no ectopy on 175mcg/kg/min Esmolol gtt. BP 100's-120's/50's-60's. To start meds per NGT, first dose metoprolol 50mg given @ 1800, to start Esmolol wean @ 1900. Amio cont @ 0.5mg/min, off @ 1800, to start 200mg PO in am. H/H stable, K+ 4.9.\n\nRESP: orally intubated AC 500x14/. overbreathing 4-6 breaths, maintaining Sp02 95-99%. Deep sxn'd for mod amounts thick tan secreations, culture specimen sent. Last ABG in am 7.37/33/93/20. + cuff , pulmonology minimal edema noted during bronch.\n\nGI: BS hypoactive, no stool, bronchoscopy assisted NGT placement, aspirated bilious secrestions, no frank or coffee ground blood noted. Placement verified by CXR, promote w/ fiber started @ 20cc/hr, all meds changed to per NGT. 1L NS @ 75cc/hr w/ 400cc remaining, no further hydration ordered.\n\nGU: foley draining 400cc out for 24hr. Drainage bag noted, bag changed, ? urine around foley, advanced and balloon reinflated, no further noted. BUN/Cr 48/1.3\n\nENDO: BG range 144-154, covered w/ 2U RISS.\n\nID: Tmax 101.2 PR. 650 tylenol PR x 2. WBC 16.6 (17.2), femoral TLC tip growing gram + cocci. Cont vanco, flaggyl, levo PO.\n\nSKIN: W/D, R wrist laceration 4cm/.5cm. steri-strips and tegaderm intact. R radial a-line sharp, WNL, R posterior forarm, L wrist, L hand PIV patent and intact.\n\nA/P: s/p VF arrest, traumanic intubation. As discussed in multidiciplinary rounds started on enteral nutrition, continue to eval need for hydration. Cont to eval mental sts, hold sedation for RSBI/vent wean in am, plan for extubation early, per family, pt. would not wish to be trached. Cont to monitor u/o, renal sts. Titrate down esmolol. Continue to monitor temp, abx, vanco trough ordered after next dose (noon). F/u cultures. Check BG, tol of TF, titrate up to goal rate 50cc/hr. Cont to support pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-24 00:00:00.000",
"description": "Report",
"row_id": 1327479,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT TITRATED OFF AMIODRONE 6PM AND ESMOLOL BY 2AM. SWITCHED OVER TO PO AMIO 200 QD AND PO LOPRESSOR 50 MG .\nWITH AGITATION, PT INCREASED HR AS HIGH AS 120'S AFIB- SO RECEIVED 1X EXTRA DOSE 25 MG LOPRESSOR AND TO INCREASE DOSE TO 75MG THIS AM. SEDATE AND SLEEPING- HR AT 90'S AFIB. HOLDING OFF ANTICOAG D/T HIGH NORMAL COAGS- PNEUMOBOOTS ORDERED- AWAIT MACHINE FROM CENTRAL SUPPLY, NONE CURRENTLY.\nBP STABLE- 120/80'S THIS NITE WITH RT RADIAL ALINE IN PLACE.\nNO CAPTOPRIL CURRENTLY- REMAINS ON ASA.\n\n PT VENTILATED ON 40/500/14 A/C - BREATHING ABOVE RATE 5-7 BREATH PER MINUTE. SUCTIONED FOR THICK TANNISH SPUTUM- COARSE BREATH SOUNDS- COVERED FOR PROBABLE ASP PNA WITH IV FLAGYL/VANCO/LEVO.\nABG WNL- 7.37-33-93.\n\nID- LOW GRADE- SEE ABOVE, ON ANTIBX- T MAX 100 RECTAL\n\nGU- FAIR UO- 10-25CC/HOUR- NO LASIX- GIVEN 1 L NS FOR HYDRATION- CURRENTLY KVO.\nFOLEY IN PLACE - VERY SMALL AMOUNT LEAKING THIS SHIFT.\n\nGI- TOLERATING TUBE FEEDS= STARTED 6P PROMOTE 20/HOUR- UP TO 30/HOUR WITH MINIMAL RESIDUALS.\n(+) BS, NO STOOL.\nBS QID- 130-140'S.\n\n PT SEDATE AND SLEEPING WELL- BUT AWAKENED, AGITATED AND NOT VENTILATING( BITING TUBE) AND REQUIRING 1 MG VERSED 3AM\nCURRENTLY COMFORTABLE, MOVING ALL EXTREMITIES AND FOLLOW COMMANDS WHEN AWAKE.\nTO CHECK RSBI THIS AM\nNO FAMILY CALLS CURRENTLY\n\nA/P - PT S/P LARGE MI/ARREST REMAINS INTUBATED WITH PROBABLY ASP PNA.\nAFEBRILE ON ANTIBX AND TOLERATING CV MED REGIMEN AND TRANSITION FROM IV TO PO MEDS.\n\n - AGITATION ON VENTILATOR REPSONDING TO VERSED\n\nCONTINUE TO KEEP PT SAFE/VENTILATED- CHECK AM LABS AND ABG\nRSBI - CHECK ? EXTUBATION THIS AM, IF SECRETIONS ALLOW\nCONTINUE TO RAMP UP B BLOCKER TO CONTROL HR. INCREASE TUBE FEEDS TO GOAL WHILE NG TUBE IN/REQUIRED AS TOLERATED\nCHECK WITH TEAM BASED ON AM LABS ? RESTART ANTICOAGULANTS FOR AFIB\nKEEP PT COMFORTABLE AND AWARE OF PLAN OF CARE.\nETHICS MEETING ? TODAY TO HELP DIRECT OVERALL PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 1327461,
"text": "CCU Nursing Adm/progress note\n yr old admitted after becoming suddenly unresponsive, witnessed, at home with family CPR initialted, EMS notified, defibrilated in field. Unable to be intubatyed, traumatic, trachia perforated, difficult intubation in EW, HEad CT neg for bleed. See FHA for details.\n\nNeuro: arrived, posturing, no withdrawal to pain, no responce to verbal stimuli, no spon movement, PERL, corneal reponce weak, abnormal responce to cold calorics during exam by neuro. Propofol has been dc'd to assess neuro status.\n\nCV: BP 140-160/50, HR 80-90's A.fib, intermittent bigeminy, K+ 4.2, Mg 1.8, given 2 gms mag sulfate IV. 1st CK 55. Dig level 1.0\n\nResp: Vented, initially on 100%, weaned to 70%, VT 450, rate 20, not overbreating vent. Suctioned x1 for sm amt thick bloody secretions. Ls clear. Surgery called for perfortated trachia. Will follow for now given neuro changes, pt ventilating.\n\nID: afebrile, WBC 19.5, vomitted in EW, BCx2, Urine C&S sent, needs sputum, to start flagyl and levoquin.\n\nSkin: intact, bleeding from oral pharynx. Sq emphysema of neck, upper chest.\n\nGI: unable to pass NGT in EW, abd distended, soft, (+)BS, passing flatus, KUB done.\n\nEndo: no diagnosis of DM, place on reg ins gtt to get tight control of BS in critically ill pt, gtt currently at 1mg/hr with BS 155\n\nSoc; son is health care proxy, here with wife visiting, decision made to make pt DNR in the event of another arrest. Pt has clearly stated in the past that she would not want heroics and does not want to live if she is unable to care for herself. PT previously active, drives, plays bridge, recently had to stop playing golf.\n\nA/P: hemodynamically stable, cont support with mechanical ventilation, DNR, cont neuro assessment, family to return tomorrow, another son from out of state to arrive tomorrow afternoon. Support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 1327462,
"text": "Respiratory Care\nPt remains intubated with 6.0 et tube taped at 23cm. Breath sounds are diminished,clear. Vent settings- a/c 500 x 20 70%+5, no spontaneous breaths. ABGs are within normal limits with adequated oxygenation. Suctioned for small amounts of frank blood from ett.\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846527,
"text": " 9:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement - just advanced ETT\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n\n REASON FOR THIS EXAMINATION:\n eval for tube placement - just advanced ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated status post perforation of trachea. ETT advanced.\n\n COMPARISON: .\n\n AP PORTABLE SUPINE CHEST: The ET tube now projects 5.5 cm above the carina.\n Previously, it projected 4.6 cm above the carina. The tip abuts the right\n lateral tracheal wall. Bilateral perihilar hazy opacities persist, and there\n is persistent cardiomegaly as well. Small pleural effusions are also present,\n and there is a dual-lead cardiac pacer, unchanged in position.\n\n IMPRESSION: ET tube with tip abutting right lateral tracheal wall 5.5 cm from\n the carina. Persistent CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846481,
"text": " 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated.\n REASON FOR THIS EXAMINATION:\n evaluate for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A -year-old female status post arrest and intubation.\n Evaluate tube placement.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: \n\n FINDINGS: Endotracheal tube terminates approximately 4.8 cm above the level of\n the carina. Dual chamber pacemaker leads are in stable position. The heart\n appears larger than on the prior study and has a saccular configuration. A\n pericardial effusion cannot be excluded. There is interstitial edema. A\n pleural effusion is noted on the right. The left costophrenic angle was\n excluded from the image. Subdiaphragmatic structures are notable for a marked\n gasseous distention. There is subcutaneous emphysema of the soft tissues of\n the neck.\n\n IMPRESSION:\n\n 1. Termination of endotracheal tube of approximately 4.8 cm above the level of\n the carina.\n 2. Cardiomegaly and interstitial edema. A pericardial effusion cannot be\n excluded as above.\n 3. Gasseous distention of the stomach.\n 4. Subcutanous emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-19 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 846489,
"text": " 4:28 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate source of subcutaneous emphysema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with traumatic intubation, with right subcut emphysema.\n REASON FOR THIS EXAMINATION:\n evaluate source of subcutaneous emphysema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A -year-old female with traumatic intubation and\n subcutaneous emphysema.\n\n TECHNIQUE: Non-contrast enhanced multidetector CT images of the chest were\n obtained.\n\n COMPARISON: None available.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Pacemaker wires and an endotracheal tube\n are noted. There is extensive subcutaneous emphysema, predominantly tracking\n along the right neck and right anterior chest wall. There is\n pneumomediastinum as well. There is evidence of discontinuity of the\n posterior trachea (7 o'clock position) at the level of the upper\n sternoclavicular joints with adjacent extraluminal air, consistent with\n traumatic break-through. A large amount of secretions are noted within the\n trachea. There is bronchomalacia. Numerous enlarged precarinal and\n prevascular lymph nodes are identified. There are extensive calcifications of\n the aorta. A small amount of pericardial fluid is present. The lung fields\n are notable for mild interstitial edema and moderate-sized bilateral pleural\n effusions. The osseous structures are notable for extensive degenerative\n change.\n\n IMPRESSION: Findings consistent with traumatic tracheal injury, with evidence\n of tear and associated pneumomediastinum and subcutaneous emphysema. These\n findings were communicated to Dr. at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 846490,
"text": " 4:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial head\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with reported vfib arresst on coumadin - ?head \n REASON FOR THIS EXAMINATION:\n r/o intracranial head\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa FRI 4:56 PM\n No acute intracranial hemorrhage or shift of midline structures.\n Fullness of nasopharyngeal soft tissues which may be related to intubation.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: -year-old woman with reported ventricular fibrillation arrest\n on Coumadin. Possible head trauma, evaluate for intracranial bleed.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage or mass\n effect. There is no shift of normally midline structures. The ventricles and\n cisterns are normal. The density values of the brain parenchyma are normal.\n There is fullness of the nasal pharyngeal soft tissues, which may be related\n to intubation. There is fluid within the maxillary sinuses bilaterally. The\n osseous structures of the head appear unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage. Nasopharyngeal fullness may be\n related to intubation. Fluid within the maxillary sinuses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 846491,
"text": " 4:29 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: would like to r/o c-spine pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with reported vfib arresst on coumadin - ?head trauma\n REASON FOR THIS EXAMINATION:\n would like to r/o c-spine pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa FRI 5:50 PM\n PRELIM ** Without coronal and sagital recons.\n Marked subcutaneous air in neck and edema of the larynx. Hyoid fracture is\n seen on the right. The age of this fracture is not clear. The endotracheal\n tube may not be intraluminal within the larynx. Air is seen within the airway\n not adjacent to the ET tube and there is soft tissue density material\n surrounding the ET tube in the larynx. More inferiorly, the ET tube re-enters\n the air filled tracheal lumen. Multiple images with motion artifact suggest\n multiple possible fractures of calcified tracheal rings. An urgent ENT\n evaluation is recommended to assess the course of the endotracheal tube. This\n was discussed with Dr. .\n\n Recons now available. C3 anteriorly subluxed on C4. Anterior C3/4 interspace\n widened. C5 posteriorly subluxed on C6. These findings could be due to pt\n motion, however, C spine cannot be cleared until patient is re-imaged.\n WET READ VERSION #1 KKXa FRI 5:38 PM\n PRELIM ** Without coronal and sagital recons.\n Marked subcutaneous air in neck and edema of the larynx. Hyoid fracture is\n seen on the right. The age of this fracture is not clear. The endotracheal\n tube may not be intraluminal within the larynx. Air is seen within the airway\n not adjacent to the ET tube and there is soft tissue density material\n surrounding the ET tube in the larynx. More inferiorly, the ET tube re-enters\n the air filled tracheal lumen. Multiple images with motion artifact suggest\n multiple possible fractures of calcified tracheal rings. An urgent ENT\n evaluation is recommended to assess the course of the endotracheal tube. This\n was discussed with Dr. .\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: -year-old woman with reported ventricular fibrillation arrest\n at home, on Coumadin. Possible head trauma. Evaluate for cervical spine\n pathology.\n\n TECHNIQUE: Axial images through the cervical spine were obtained without\n contrast. At the time of this preliminary report, coronal and sagittal\n reconstructions were available.\n\n FINDINGS: There is marked subcutaneous air within the neck. There is a\n significant amount of edema within the larynx. There is a fracture of the\n right hyoid bone, and the age of this fracture is not clear. There is an\n additional smaller calcified fragment, adjacent to the hyoid bone on the left,\n anteriorly. This could possibly represent an additional fracture fragment.\n This fragment is only seen on one slice, and its margins appear smooth. The\n age of this possible fracture is also indeterminant.\n (Over)\n\n 4:29 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: would like to r/o c-spine pathology\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n (Cont)\n\n The course of the endotracheal tube through the larynx is not clearly\n intraluminal. In particular, the air within the larynx is not seen adjacent\n to the endotracheal tube. There is soft tissue density material seen adjacent\n to the endotracheal tube, which may suggest that this endotracheal tube is not\n intraluminal within the larynx, but rather tunnelled through the posterior\n wall of the larynx. An urgent ENT evaluation to accertain the course of the\n endotracheal tube is recommended.\n\n More inferiorly, the endotracheal tube is seen within the trachea. The\n examination is limited due to patient motion, however, it is possible that\n multiple calcified tracheal rings have been fractured.\n\n On the axial images available at the time of this interpretation, no fracture\n of the cervical spine is identified. However, patient motion limits the\n sensitivity of this exam.\n There are bilateral pleural effusions, on the right side greater than on the\n left. The pulmonary vessels are prominent within the lung apices, greater on\n the left than on the right.\n\n IMPRESSION\n\n 1. Multiple injuries including hyaloid fracture of indeterminate age,\n laryngeal edema, and subcutaneous air. Some of these images suggest\n significant laryngeal injury. It is not clear that the endotracheal tube\n is intraluminal within the larynx. Urgent ENT evaluation of the course of\n the endotracheal tube is recommended.\n\n 2. In addition, multiple calcified tracheal rings may be fractured.\n\n The findings were discussed with Dr. at approximately 5:15 and 5:30 PM\n on .\n\n ADDENDUM #1: On the sagittal images, the C3 vertebral body appears to be\n subluxed anteriorly on C4. There is widening of the anterior C3-4 interspace.\n In addition, the C5 vertebral body is posteriorly subluxed on C6. No cervical\n spine fractures are identified. This exam is limited due to significant\n patient motion during the scan. The alignment abnormalities could be related\n to patient motion. However, the cervical spine cannot be cleared until the\n patient can be re- imaged.\n\n ADDENDUM #2: The coronal and sagittal reconstructions are now available.\n\n As described in the cross-sectional exam, there is extensive subcutaneous\n emphysema, as well as pneumomediastinum. There is no evidence of acute\n fracture or malalignment. However, there are multilevel degenerative changes,\n with osteophyte formation and intervertebral disc space narrowing. These\n (Over)\n\n 4:29 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: would like to r/o c-spine pathology\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n (Cont)\n changes are most severe at C4-5 and C5-6. There is grade-1 anterolisthesis of\n C6 on C7, as well as grade-1 retrolisthesis on C5 on C6. In addition, there is\n evidence of spinal stenosis at C5-6, moderate in degree. The spinal canal\n otherwise appears patent. The prevertebral soft tissues appear edematous,\n likely relating to known traumatic intubation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 846501,
"text": " 9:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o perforation or obstruction\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with presumed vfib arrest now w/ marked abdominal distention\n - would like to r/o perforation\n REASON FOR THIS EXAMINATION:\n r/o perforation or obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman with presumed ventricular fibrillation arrest, now\n with marked abdominal distension. Rule/out perforation or obstruction.\n\n PORTABLE AP SUPINE ABDOMEN, , at 10:26 PM: The most inferior portion\n of the pelvis is cut off of the films. There is marked gasseous distension of\n the stomach, duodenum, and small bowel. Cannot rule/out obstruction. Cannot\n assess perforation on this supine film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 846505,
"text": " 12:11 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess for ileus\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p vfib arrest\n REASON FOR THIS EXAMINATION:\n assess for ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: y/o woman. Please assess for ileus.\n\n SUPINE ABDOMEN, 00:40: No change from prior study to hours earlier. As\n before, there is marked gaseous distension of the stomach, duodenum and small\n bowel of the abdomen. There is gas seen in the rectum and ascending colon.\n This may represent ileus, but obstruction can't be excluded. Recommend\n auscultation.\n\n IMPRESSION: Marked gaseous distension of the stomach and small bowel. Cannot\n rule out obstruction or exclude ileus. Recommend auscultation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846506,
"text": " 12:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: re-assess placement of ett\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n\n REASON FOR THIS EXAMINATION:\n re-assess placement of ett\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman status-post cardiac arrest, status-post intubation\n complicated by tracheal perforation. Please re-assess placement of ET tube.\n\n PORTABLE SUPINE CHEST, at 12:25 AM: Comparison is made to a prior\n portable chest on . No significant change. The tip of the\n endotracheal tube still appears to be at the level of the medial ends of the\n clavicles. The patient is in failure with perihilar patchy densities\n indicative of pulmonary edema. Subcutaneous emphysema is seen overlying the\n right shoulder.\n\n IMPRESSION: No change in the apparent position of the endotracheal tube.\n Pulmonary edema. Subcutaneous emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846592,
"text": " 9:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? consolidate ? Failure ?ETT placement\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation and\n apparent aspiration.\n REASON FOR THIS EXAMINATION:\n ? consolidate ? Failure ?ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: year old woman status post arrest, intubation complicated by\n tracheal perforation and apparent aspiration. Question interval change.\n\n AP PORTABLE CHEST AT 10 AM: No change from prior study one day\n earlier. Patient is still in pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846649,
"text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? failure ? ETT\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n and apparent aspiration.\n REASON FOR THIS EXAMINATION:\n ? failure ? ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post arrest. Intubated complicated by tracheal performation.\n Question failure. Question ETT position.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST: The endotracheal tube is in good position 5.9 cm\n above the carina. There is a dual-lead pacer unchanged in position. The\n heart remains enlarged and there are hazy diffuse bilateral opacities\n persisting. There is some blunting of the costophrenic angles suggesting\n small effusions. There is indistinctness of the central pulmonary\n vasculature. There is no pneumothorax or persistent pneumomediastinum.\n\n IMPRESSION: Satisfactory ETT position. Persistent CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847171,
"text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for changes in pneumonia/CHF\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal\n perforation/aspiration.\n REASON FOR THIS EXAMINATION:\n Eval for changes in pneumonia/CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post arrest with complicated intubation.\n\n COMPARISON: Radiograph dated .\n\n AP PORTABLE SUPINE VIEW OF THE CHEST: There is marked interval improvement in\n the previously demonstrated bilateral pleural effusions with improved aeration\n of both lungs. The lines and tubes are unchanged. There is no evidence of\n pneumothorax.\n\n IMPRESSION: Marked interval improvement in bilateral pleural effusion with\n improved aeration of the lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-21 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 846600,
"text": " 11:33 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: re-eval c-spine\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with ?VF arrest found down, previous CT for C-spine sub-opt.\n REASON FOR THIS EXAMINATION:\n re-eval c-spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ventricular fibrillation arrest, found down; previous CT for\n cervical spine suboptimal due to patient motion, please re-evaluate cervical\n spine.\n\n TECHNIQUE: Noncontrast CT of the cervical spine was performed. Additional\n sagittal and coronal reformatted images are provided.\n\n CT CERVICAL SPINE: No fracture of the cervical spine is identified. There is\n extensive multilevel degenerative change of the cervical spine, with\n intervertebral disc space narrowing and endplate sclerosis, most prominent at\n C4-5, C5-6, and C6-7. There is grade-1 anterolisthesis of C4 on C5. There is\n grade-1 retrolisthesis of C5 on C6, with grade-1 anterolisthesis of C6 on C7.\n\n In comparison to the previous examination, there is interval increase in fluid\n and soft tissue stranding within the soft tissues of the neck, originating in\n the laryngeal and paratracheal area, consistent with the patient's known\n traumatic intubation. There is marked interval decrease in the amount of sub-\n cutaneous emphysema tracking within the soft tissue planes of the neck, with\n tiny foci of gas located in the right lateral neck soft tissues, as well as\n adjacent to the trachea. The endotracheal tube is located within the trachea.\n Consolidation noted in the left lung apex.\n\n IMPRESSION\n\n 1. No fracture of the cervical spine.\n\n 2. Extensive degenerative change of the cervical spine, most prominent at C4\n thru C7, with multilevel intervertebral disc space narrowing, and grade-1\n anterolisthesis of C4 on C5, and C6 on C7, and grade-1 retrolisthesis of\n C5 on C6.\n\n 3. Interval improvement in subcutaneous emphysema, but interval increase in\n stranding and fluid within the subcutaneous soft tissues, a finding likely\n related to the patient's known traumatic intubation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 846601,
"text": " 11:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? CVA\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with ?VF arrest found down, previous CT for C-spine sub-opt.\n REASON FOR THIS EXAMINATION:\n ? CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question ventricular fibrillation arrest, found down, please\n evaluate for CVA.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n CT HEAD W/O IV CONTRAST: No acute intracranial hemorrhage is identified.\n There is no mass effect or shift of normally midline structures. In\n comparison with the head CT dated , there is no change. The lateral\n ventricles are symmetric and unchanged in size. There is diffuse prominence\n of the ventricles and sulci, consistent with age-related involutional change.\n There is no loss of /white differentiation to suggest an acute minor or\n major vascular territorial infarct. A tiny dot of calcification seen adjacent\n to the right occipital lobe (series 2, image 14). This is located along the\n tentorium, and may represent vascular calcification. There is diffuse fluid\n opacification of the ethmoid, sphenoid and the visualized portions of the\n maxillary sinuses, bilaterally. The opacifying fluid is low density (\n Hounsfield units). In addition, there is partial fluid opacification of the\n mastoid air cells bilaterally. These findings appear progressed since the\n previous examination. No fractures are identified. The patient is intubated.\n\n IMPRESSION\n\n 1. No acute intracranial hemorrhage. Stable CT appearance of the brain\n since .\n\n 2. No CT evidence of acute minor or major vascular territorial infarct. CT\n is limited for the detection of infarct and, if clinically indicated, MR\n of the brain could be performed.\n\n 3. Interval progression of fluid opacification of the paranasal sinuses and\n mastoid air cells.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-21 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 846602,
"text": " 11:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval subcut empysema secondary to trach. perf.\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with traumatic intubation, with right subcut emphysema.\n\n REASON FOR THIS EXAMINATION:\n eval subcut empysema secondary to trach. perf.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Traumatic intubation, with right subcutaneous emphysema.\n Follow/up.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained through the chest without\n intravenous contrast.\n\n CONTRAST: None.\n\n CT CHEST W/O IV CONTRAST: In comparison with the previous examination of two\n days prior, there is marked interval decrease in the extent of subcutaneous\n emphysema along the right anterior chest wall and neck. In addition, there is\n marked interval decrease in the extent of mediastinal emphysema. There is\n interval increase in soft tissue stranding and fluid surrounding the larynx\n and proximal trachea, consistent with edema and subcutaneous hemorrhage. The\n endotracheal tube tip is located within the trachea.\n\n Multiple prominent prevascular and pretracheal lymph nodes are again seen,\n measuring up to 1.3 cm in diameter, unchanged from the previous examination.\n There are calcifications of the thoracic aorta consistent with atheromatous\n disease, unchanged from the previous examination. Cardiac pacer with dual\n electrodes. Coronary artery calcifications. There is a minimal amount of\n pericardial fluid, unchanged. No pneumothorax. Bilateral pleural effusions,\n right slightly greater than left, appear approximately unchanged in size since\n the previous examination. There is continued compressive atelectasis within\n the lower lobes bilaterally, posteriorly. In addition, there is interval\n development of patchy air space opacity within the posterior segments of the\n upper lobes bilaterally. The osseous structures appear unchanged.\n\n IMPRESSION\n\n 1. Interval marked improvement in subcutaneous emphysema following traumatic\n endotracheal intubation. Persistent small amount of mediastinal air\n adjacent to the right lateral wall of the trachea.\n\n 2. Interval increase in hemorrhage and edema surrounding the low cervical\n trachea just above the thoracic inlet.\n\n 3. Interval development of air space opacity within the upper lobes\n (Over)\n\n 11:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval subcut empysema secondary to trach. perf.\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bilaterally, and stable compressive atelectasis within the lower lobes\n bilaterally. Stable bilateral pleural effusions.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846835,
"text": " 4:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n and apparent aspiration.\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Complicated tracheal intubation.\n\n COMPARISON: Radiograph dated .\n\n AP VIEW OF THE CHEST: There is an ET tube in satisfactory position. There is\n an NG tube terminating in the stomach. The cardiac and mediastinal contours\n are stable. No interval change in patchy bibasilar opacities with left-sided\n pleural effusion. No evidence of pneumothorax.\n\n IMPRESSION: No interval change in patchy bibasilar opacities and left-sided\n effusion, compared to the study of seven hours prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847065,
"text": " 11:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Central line/Swan placement\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal\n perforation/aspiration.\n REASON FOR THIS EXAMINATION:\n Central line/Swan placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: y/o status post arrest, intubated, complicated by tracheal\n perforation.\n\n AP portable study of the chest was obtained.\n\n Comparison is made to prior study of earlier the same day. There has been\n placement of an endotracheal tube; the tip is 7.4 cm above the carina. A left\n subclavian vein pacemaker and NG tube remain in place. There is no evidence\n of pneumothorax. Bilateral pleural effusions and bilateral pulmonary vascular\n congestion are again noted with no significant changes. Cardiomegaly is again\n noted.\n\n IMPRESSION: Interval placement of an endotracheal tube. No other significant\n changes are noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-25 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 847103,
"text": " 3:54 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: GROSSLY DILATED RV CONCERNING FOR PE\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with recent VF arrest now with hypoxic respiratory failure\n intubated with fever and grossly dilated RV concerning for PE.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Bilateral lower extremity venous ultrasound.\n\n INDICATION: Hypoxia with respiratory failure and fever, recent V-fib arrest\n with grossly dilated right ventricle concerning for PE.\n\n FINDINGS:\n\n Grayscale and Doppler color/waveform images of the right and left common\n femoral, superficial femoral, popliteal, deep femoral, and greater saphenous\n veins was performed. Normal augmentation, waveforms, flow, and\n compressibility were identified. No intraluminal thrombus was seen.\n\n IMPRESSION:\n\n No DVT of either lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 846767,
"text": " 9:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change retrocardiac density, effusions\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n and apparent aspiration.\n REASON FOR THIS EXAMINATION:\n eval for interval change retrocardiac density, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac arrest. Intubated. Possible tracheal\n perforation and aspiration. Check for current status.\n\n FINDINGS: A single AP upright image. Comparison study dated .\n The endotracheal tube is in good position below the thoracic inlet. There has\n been significant partial resolution of the patchy infiltrate demonstrated\n throughout both lungs on the previous examination. Residual changes are noted\n mainly in the left base and left upper zone. The heart again shows moderate\n left ventricular enlargement. The aorta is calcified and unfolded. A\n pacemaker electrodes are in satisfactory position.\n\n IMPRESSION: Substantial resolution of bilateral pulmonary infiltrates\n demonstrated. Minor residual infiltrates in the left lung and right base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847018,
"text": " 6:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated complicated by tracheal perforation\n and apparent aspiration.\n REASON FOR THIS EXAMINATION:\n CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: y/o s/p arrest, intubated complicated by tracheal perforation and\n aspiration.\n\n Comparison is made to the prior study of . Since the previous\n study, there has been development of bilateral pulmonary edema, bilateral\n pleural effusions and compression atelectasis of the lower lobes. An NG tube\n in place the tip is in the mid gastric body. There is continued application of\n IV pacemaker. Cardiomegaly and arteriosclerotic changes involving thoracic\n aorta are noted. No evidence of pneumothoraces.\n\n IMPRESSION: Bilateral pulmonary edema associated with bilateral pleural\n effusion most likely due to congestive heart failure.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 154928,
"text": "Irregular ventricular pacing. Background rhythm is difficult to discern but\nagain is probably atrial fibrillation. There may have been a change in pacer\nmode to DDD and intermittent atrial sensing. Clinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 154929,
"text": "Baseline artifact. Narrow complex rhythm which is slower and more regular.\nAtrial mechanism is difficult to discern. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-25 00:00:00.000",
"description": "Report",
"row_id": 154924,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of a single wide complex beat, probably ventricular, is seen.\nThe rate has increased. Other features are as previously seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-22 00:00:00.000",
"description": "Report",
"row_id": 154925,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of the ST-T wave pattern may be somewhat different. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-21 00:00:00.000",
"description": "Report",
"row_id": 154926,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-20 00:00:00.000",
"description": "Report",
"row_id": 154927,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of ventricular pacing is no longer seen. ST-T wave\nabnormalities persist.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 155168,
"text": "Since the previous tracing of the rate has increased. The rhythm\nremains irregular. However, there is more organized atrial activity whicih can\nbe seen in atrial fibrillation.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2179-11-19 00:00:00.000",
"description": "Report",
"row_id": 155169,
"text": "Atrial fibrillation with conducted complexes showing low limb lead voltage and\nST-T wave abnormalities. There is considerable baseline artifact. Since the\nprevious tracing of the ventricular pacing is no longer seen. Conducted\ncomplexes are similar to those seen on .\nTRACING #1\n\n"
}
] |
67,284 | 118,525 | The patient was admitted to the plastic surgery service on and had a Left forearm fasciocutaneous flap to palate. The patient tolerated the procedure well. He was maintained in the ICU directly postoperatively and POD#1 so that flap checks could be done every one hour. He was transferred to the floor on POD#2 in stable condition and with a stable flap. His left forearm was maintained in a splint. . Neuro: Post-operatively, the patient received Dilaudid and fentanyl IV while in the ICU. He was transitioned to Morphine PCA later the same day with good effect and adequate pain control. On POD#1, the morphine PCA was discontinued and patient was transitioned to morphine 2mg IV PRN but patient did not require any pain meds once he was taken off of the PCA. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids. His diet was advanced to clear liquids on POD#2 which were tolerated well. On POD#4, his diet was advanced to full liquids which were, again, tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO Augmentin for discharge home x 7 days. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. He was started on daily aspirin therapy to maintain integrity of the flap and will continue for 30 days after discharge home. . At the time of discharge on POD#4, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. | FINDINGS: No endotracheal tube apparent. IMPRESSION: No endotracheal tube seen. No pleural effusion or pneumothorax. No acute cardiopulmonary process. No acute cardiopulmonary process. No acute cardiopulmonary process. Mediastinal, hilar and cardiac contours are normal. , CC1A 7:19 AM CHEST (PORTABLE AP) Clip # Reason: intubated check ETT position per standard ICU protocol Admitting Diagnosis: MALIGNANT NEOPLASM HARD PALATE/SDA MEDICAL CONDITION: 54 year old man s/p free flap to palate, intubated check ETT position per standard ICU protocol REASON FOR THIS EXAMINATION: intubated check ETT position per standard ICU protocol PFI REPORT PFI: No endotracheal tube seen. 7:19 AM CHEST (PORTABLE AP) Clip # Reason: intubated check ETT position per standard ICU protocol Admitting Diagnosis: MALIGNANT NEOPLASM HARD PALATE/SDA MEDICAL CONDITION: 54 year old man s/p free flap to palate, intubated check ETT position per standard ICU protocol REASON FOR THIS EXAMINATION: intubated check ETT position per standard ICU protocol PROVISIONAL FINDINGS IMPRESSION (PFI): PBec FRI 1:33 PM PFI: No endotracheal tube seen. Minimal linear opacity is seen in the bases right greater than left likely representing atelectasis. Otherwise lungs are clear. | 2 | [
{
"category": "Radiology",
"chartdate": "2146-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156123,
"text": ", CC1A 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated check ETT position per standard ICU protocol\n Admitting Diagnosis: MALIGNANT NEOPLASM HARD PALATE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p free flap to palate, intubated check ETT position per\n standard ICU protocol\n REASON FOR THIS EXAMINATION:\n intubated check ETT position per standard ICU protocol\n ______________________________________________________________________________\n PFI REPORT\n PFI: No endotracheal tube seen. No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156122,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated check ETT position per standard ICU protocol\n Admitting Diagnosis: MALIGNANT NEOPLASM HARD PALATE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p free flap to palate, intubated check ETT position per\n standard ICU protocol\n REASON FOR THIS EXAMINATION:\n intubated check ETT position per standard ICU protocol\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec FRI 1:33 PM\n PFI: No endotracheal tube seen. No acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old status post free flap to palate, intubated; please\n check ET tube position.\n\n FINDINGS: No endotracheal tube apparent. Minimal linear opacity is seen in\n the bases right greater than left likely representing atelectasis. Otherwise\n lungs are clear. Mediastinal, hilar and cardiac contours are normal. No\n pleural effusion or pneumothorax.\n\n IMPRESSION: No endotracheal tube seen. No acute cardiopulmonary process.\n\n"
}
] |
82,217 | 163,753 | This pt was admitted through the emergency department for acute left sdh / on coumadin. INR was reversed on admission - She was taken to the OR emergently for evacuation of the collection. Post operative day # 1 she had focal sz activity that was described as twitching movements of angle of mouth on the right side. This was followed by twitching movement of her Right upper limb upto hand after few seconds. The entire episode lasted for less than 1 minute. She was seen by the neurology service and their recommendations were followed. Cardiology consult was obtained for guidance in anticoagulation for her mechanical heart valves. She started on ASA on day #2. On day # 4 a heparin drip was started / wt based, for her mechanical heart valves. Surface echo was performed. She is due to start coumadin on monday the while in rehab. Her goal PTT is 50 at which time she should have a CT scan of the brain. Her diet and sctivity were advanced and she was seen by PT. She did have a 24 hour EEG which did not show any sz activity. Her home med of dilantin was discontinued and only keppra remains. Her exam steadily improved and she was transferred to the step down unit. PT/OT/ST evals deem pt a rehab candidtate. She is to be d/c's to rehab and agrees with plan. | Chief complaint: SDH PMHx: PMH: - Aortic valve replacement x2: originally porcine , now ? Chief complaint: SDH PMHx: PMH: - Aortic valve replacement x2: originally porcine , now ? - Consult cards re artificial valve w reversal of anticoag. - Consult cards re artificial valve w reversal of anticoag. Pt weaned and extubated MD. Chief complaint: PMHx: PMH: - Aortic valve replacement x2: originally porcine , now Mechanical aortic valve prosthesis ? Subdural hemorrhage (SDH) Assessment: Action: Response: Plan: Hypertension, benign Assessment: Action: Response: Plan: Subdural hemorrhage (SDH) Assessment: Action: Response: Plan: Response: Off sedation pt MAE. Mitral valve replacement.Weight (lb): 182BP (mm Hg): 121/55HR (bpm): 95Status: InpatientDate/Time: at 13:34Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%decrease during respiration (estimated RA pressure (0-5mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Pt to OR for left craniotomy to evacuate hematoma. Assessment and Plan SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN Assessment and Plan: 64F on coumadin for artificial valve presents with a SDH, s/p evacuation in OR, w slowly improving mental status. Moderate pulmonary artery systolic hypertension.Preserved global biventricular systolic function.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis IS recommended. Subdural hemorrhage (SDH) Assessment: s/p crani and evacuation of bleed, pt seized yesterday. Neurologic: - CT in AM - Vit K x 3 w goal INR < 1.5 - Dilantin 100mg TID - HOB flat - Dilantin level Neuro checks Q2hr Pain: fentanyl Cardiovascular: Pt has hx MI with aortic valve replacement. Action: Propofol turned off fore neuro exams, neuro exam unchanged, pt unresponsive but exam improving from triple flexion/posturing (see metavision). LABORATORY DATA: 138 105 8 11.2 ----|-------|------< 168 19.4 >------< 177 3.6 24 0.4 33.0 INR 1.5 ASSESSMENT AND PLAN: 64 yo F w/ h/o presumed aortic and mitral mechanical valves, s/p fall resulting in SDH, now clinically stabilized s/p SDH evacuation yesterday. Subdural hemorrhage (SDH) Assessment: Pt was sedated on Propofol and continued to have hourly neuro checks, , but not to commands, impaired gag/intact cough, pain assessed vital signs; Remained intubated on CMV, 40%, 5 PEEP, 10 PS, lung sounds clear thoughout Action: Weaned sedation to off, weaned ventilator to extubate Response: Pt extubated at 1100, lethargic, opens R eye to voice (unable to open L eye due to periorbital edema), followed commands , , , c/o headache , given IV Dilaudid with good results; OOB to chair for 1 hour and at 1530 with MD present Pt became unresponsive to verbal/tactile stimuli and had seizure activity of less than 1 minute on R corner of her mouth and R arm; Repeat head CT done and shows no acute changes, started on IV Keppra in addition to IV Dilantin; Currently back to baseline for most of shift, lethargic, oriented x2 at best, follows commands, tolerating PO intake; Neurology consulted after seizure Plan: Continue with every hour neuro checks, check Dilantin level in the AM, ?transfer to floor tomorrow Hypertension, benign Assessment: Pts SBP in 160-170s Action: Given 20mg IV Labetalol x1 and IV Dilaudid for presumed pain Response: SBP <140 after intervention Plan: Continue to monitor BP There is a foci of hyperdensity (2:16) anterior to the left lateral ventricle, unchanged, which may represent or hemorrhagic contusion. There is a focus of hyperdensity anterior to the left lateral ventricle, 2:17, unchanged. There is unchanged appearance to intraparenchymal hemorrhage and hypodensity in the right temporoparietal lobe (2A:17). Unchanged appearance to left temporoparietal intraparenchymal hemorrhage with hypodensity and small left subdural hematoma. Unchanged appearance to left temporoparietal intraparenchymal hemorrhage with hypodensity and small left subdural hematoma. Unchanged appearance to left temporoparietal intraparenchymal hemorrhage with internal hypodensity, now with small layering blood/flood levels, and small extra-axial hematoma over the left convexity. The left temporoparietal lobe, 2:18, shows a region of hypodensity which appears unchanged with hyperdense blood tracking through, with similar appearance compared to prior study. The subdural hematoma that was present at this site has been largely evacuated with minimal residual hyperdense blood layering along the left temporoparietal convexity (2:13). Hypodensity left frontoparietal lobe indicating encephalomalacia. FINDINGS: Patient is status post left frontal temporoparietal craniotomy. FINDINGS: Patient is status post left frontotemporoparietal craniotomy. There is a mild anterior wedge compression deformity of the T8 vertebral body of unknown chronicity. There is minimal pneumocephalus adjacent to the left subdural hematoma. change in bleed No contraindications for IV contrast PFI REPORT IMPRESSION: 1. CT ABDOMEN WITH CONTRAST: An orogastric tube terminates in the stomach which is otherwise unremarkable. Stable hyperdense foci anterior to the left lateral ventricular may represent area of contusion injury or . Stable hyperdense foci anterior to the left lateral ventricular may represent area of contusion injury or . Additional subarachnoid blood is seen over the left convexity, with unchanged small amount of blood within the occipital of the left lateral ventricle, as well as an intraparenchymal focus adjacent to the frontal of left lateral ventricle. | 45 | [
{
"category": "Echo",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Report",
"row_id": 89271,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve replacement. Mitral valve replacement.\nWeight (lb): 182\nBP (mm Hg): 121/55\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%\ndecrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Increased AVR\ngradient. No AR.\n\nMITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal MVR leaflet\nmotion. Increased MVR gradient. No MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%). Right ventricular cavity size and systolic function are normal. A\nmechanical aortic valve prosthesis is present. The transaortic gradient is\nhigher than expected for this type of prosthesis. No aortic regurgitation is\nseen. A bileaflet mitral valve prosthesis is present. The motion of the mitral\nvalve prosthetic discs appeas normal. The gradients are higher than expected\nfor this type of prosthesis. No mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is moderate pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mechanical aortic valve prosthesis with\nincreased gradient. Bileaflet mitral valve prosthesis with good disc motion,\nbut increased gradient. Moderate pulmonary artery systolic hypertension.\nPreserved global biventricular systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis IS recommended. Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 470387,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Airway\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 470454,
"text": "Chief Complaint: SDH\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n Post operative day:\n POD#1 - left craniotomy for evacuation of SDH\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 04:26 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Labetalol - 06:30 PM\n Hydralazine - 04:00 AM\n Hydromorphone (Dilaudid) - 05:06 AM\n Other medications:\n Past medical history:\n Family / Social history:\n - Aortic valve replacement x2: originally porcine , now ? St. ?\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n NKDA\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.6\n HR: 96 (52 - 100) bpm\n BP: 130/51(77) {104/51(74) - 163/69(99)} mmHg\n RR: 19 (10 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 82.5 kg\n Total In:\n 2,287 mL\n 772 mL\n PO:\n TF:\n IVF:\n 2,287 mL\n 772 mL\n Blood products:\n Total out:\n 2,090 mL\n 430 mL\n Urine:\n 1,040 mL\n 310 mL\n NG:\n 130 mL\n 120 mL\n Stool:\n Drains:\n Balance:\n 197 mL\n 342 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 396 (352 - 440) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 13 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.44/38/155/24/2\n Ve: 7.1 L/min\n PaO2 / FiO2: 388\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 177 K/uL\n 11.2 g/dL\n 168 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 138 mEq/L\n 33.0 %\n 19.4 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n WBC\n 13.3\n 19.4\n Hct\n 31.7\n 33.0\n Plt\n 208\n 177\n Cr\n 0.4\n 0.4\n TCO2\n 25\n 27\n Glucose\n 145\n 168\n Other labs: PT / PTT / INR:16.4/28.2/1.5, Lactic Acid:1.1 mmol/L,\n Ca++:8.0 mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n HYPERTENSION, BENIGN\n Assessment And Plan: 64F on coumadin for artificial valve presents with\n a SDH, s/p evacuation in OR, w slowly improving mental status.\n Neurologic: - CT in AM \n - Vit K x 3 w goal INR < 1.5\n - Dilantin 100mg TID\n - HOB flat\n - Dilantin level\n Neuro checks Q2hr\n Pain: fentanyl\n Cardiovascular: Pt has hx MI with aortic valve replacement.\n - BP goal per NSurg < 140. Tolerating SBPs < 170.\n - Consult cards re artificial valve w reversal of anticoag. Possible\n 2D echocardiogram\n - Discuss when to restart anticoag (ASA?) w NSurg\n Pulmonary: Intubated post-op. Wean as tolerated. Extubate if possible\n today.\n Gastrointestinal: Start pt on TFs if not extubated . Will\n discontinue OGT and place Dobhoff or NGT if requires enteral TF\n Renal: Keep pt on maintenance IVF while NPO\n Hematology: Hct 33, stable\n Infectious Disease: No signs of infection\n Endocrine: RISS\n Fluids: NS @ 75\n Electrolytes: WNL, observe\n Nutrition: NPO for now\n General:\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 470433,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Airway\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n ------ Protected Section ------\n Traveled to CT at 0600. Uneventful.\n ------ Protected Section Addendum Entered By: , SRT\n on: 06:49 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470434,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n 66yo female s/p left SDH with herniation and midline shift. Pt to OR\n for left craniotomy to evacuate hematoma. Now POD 1.\n Action:\n Sedation on/off as needed during the night, Q1hr neuro checks. Head Ct\n done 6am. Dilantin level sent.\n Response:\n Off sedation pt MAE. Purposeful with UE attempting to pull at ETT when\n coughing. Opens eyes briefly to voice but does not follow commands.\n PERL + corneals, + cough, + gag.\n Plan:\n ? if pt is able to extubate this am due to inability to wake up and\n follow commands.\n Hypertension, benign\n Assessment:\n Sbp to be < 140 per neuro . b/p 120-150\n Action:\n Hydralazine given prn when SBP >140. pain med given when pt\n hypertensive and tachycardic.\n Response:\n Pt responded well to hydralazine and pain med.\n Plan:\n Cont to asses pain and treat b/p as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 470562,
"text": "TSICU\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n Chief complaint:\n SDH\n PMHx:\n PMH:\n - Aortic valve replacement x2: originally porcine , now ? St. ?\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n Soc:\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 11:05 AM\n INVASIVE VENTILATION - STOP 11:05 AM\n comes from OR intubated\n ARTERIAL LINE - STOP 04:30 PM\n Post operative day:\n POD#2 - left craniotomy for evacuation of SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:00 PM\n Infusions:\n Other ICU medications:\n Labetalol - 10:52 AM\n Hydromorphone (Dilaudid) - 11:30 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 97 (78 - 102) bpm\n BP: 120/59(63) {103/41(56) - 140/74(89)} mmHg\n RR: 30 (5 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 81.8 kg (admission): 82.5 kg\n Total In:\n 2,523 mL\n 717 mL\n PO:\n 150 mL\n Tube feeding:\n IV Fluid:\n 2,313 mL\n 717 mL\n Blood products:\n Total out:\n 1,070 mL\n 170 mL\n Urine:\n 950 mL\n 170 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 427 (427 - 427) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.49/31/160//-1\n Ve: 6.3 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), click from artificial valve\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somnolent and difficult to rouse\n Labs / Radiology\n 177 K/uL\n 11.2 g/dL\n 168 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 105 mEq/L\n 138 mEq/L\n 31.7 %\n 19.4 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n 10:46 AM\n 03:55 PM\n WBC\n 13.3\n 19.4\n Hct\n 31.7\n 33.0\n 31.7\n Plt\n 208\n 177\n Creatinine\n 0.4\n 0.4\n TCO2\n 25\n 27\n 22\n Glucose\n 145\n 168\n Other labs: PT / PTT / INR:13.5/28.6/1.2, Lactic Acid:1.1 mmol/L,\n Albumin:3.4 g/dL, Ca:8.0 mg/dL, Mg:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN\n Assessment and Plan: 64F on coumadin for artificial valve presents\n with a SDH, s/p evacuation in OR, w slowly improving mental status, now\n s/p seizure\n Neurologic: Neuro checks Q: 2 hr, (1) Seizure: seized afternoon of \n dilantin and keppra for prophylaxis INR not elevated, no new changes on\n head CT (2) SDH: no sx of increased ICP continue to hold\n anticoagulation for now, heparin gtt with goal PTT of 50 when cleared\n by NSG (3) Pain: dilaudid PRN\n Cardiovascular: (1) BP: SBP goal of < 170 (2) artificial\n valve/thrombotic risk: per cardiology high risk of thrombosis, should\n not use vitamin K, start aspirin ASAP with heparin to follow\n Pulmonary: extubated, no issues\n Gastrointestinal / Abdomen: regular diet\n Nutrition: Regular diet\n Renal: Foley, maintenance IVF, urine output as low as 15/hr overnight,\n bolused 500 mL x 1\n Hematology: Hct 33, stable\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, infiltrated peripheral IV w/ edema to L\n hand, no sx of compartment syndrome, will attempt peripheral IV,\n possible PICC\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 470427,
"text": "Chief Complaint: SDH\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n Post operative day:\n POD#1 - left craniotomy for evacuation of SDH\n Allergies:\n Last dose of Antibiotics:\n Cefazolin - 04:26 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 PM\n Labetalol - 06:30 PM\n Hydralazine - 04:00 AM\n Hydromorphone (Dilaudid) - 05:06 AM\n Other medications:\n Past medical history:\n Family / Social history:\n - Aortic valve replacement x2: originally porcine , now ? St. ?\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n NKDA\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.6\n HR: 96 (52 - 100) bpm\n BP: 130/51(77) {104/51(74) - 163/69(99)} mmHg\n RR: 19 (10 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 82.5 kg\n Total In:\n 2,287 mL\n 772 mL\n PO:\n TF:\n IVF:\n 2,287 mL\n 772 mL\n Blood products:\n Total out:\n 2,090 mL\n 430 mL\n Urine:\n 1,040 mL\n 310 mL\n NG:\n 130 mL\n 120 mL\n Stool:\n Drains:\n Balance:\n 197 mL\n 342 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 396 (352 - 440) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 13 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.44/38/155/24/2\n Ve: 7.1 L/min\n PaO2 / FiO2: 388\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 177 K/uL\n 11.2 g/dL\n 168 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 138 mEq/L\n 33.0 %\n 19.4 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n WBC\n 13.3\n 19.4\n Hct\n 31.7\n 33.0\n Plt\n 208\n 177\n Cr\n 0.4\n 0.4\n TCO2\n 25\n 27\n Glucose\n 145\n 168\n Other labs: PT / PTT / INR:16.4/28.2/1.5, Lactic Acid:1.1 mmol/L,\n Ca++:8.0 mg/dL, Mg++:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n HYPERTENSION, BENIGN\n Assessment And Plan: 64F on coumadin for artificial valve presents with\n a SDH, s/p evacuation in OR, w slowly improving mental status.\n Neurologic: - CT in AM \n - Vit K x3 w goal INR < 1.5\n - Dilantin 100mg TID\n - HOB flat\n - Dilantin level\n Neuro checks Q2hr\n Pain: fentanyl\n Cardiovascular: Pt has hx MI with aortic valve replacement.\n - BP goal per NSurg < 140. Tolerating SBPs < 170.\n - Consult cards re artificial valve w reversal of anticoag.\n - Discuss when to restart anticoag (ASA?) w NSurg\n Pulmonary: Intubated post-op. Wean as tolerated.\n Gastrointestinal: Start pt on TFs if not extubated .\n Renal: Keep pt on maintenance IVF while NPO\n Hematology: Hct 33, stable\n Infectious Disease: No signs of infection\n Endocrine: RISS\n Fluids: NS @ 75\n Electrolytes:\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470428,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Generic Note",
"row_id": 470517,
"text": "TITLE:\n Resp Care: Pt received intubated via #7 ETT secured 18cm at lip. BS\n clear bilat. Sx\nd for small amt thick beige sputum. Pt weaned and\n extubated MD. Plan: will cont to monitor closely. Please see Resp\n flowsheet for further vent inquiries.\n 18:02\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470672,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. Pt has limited IV access and\n one IV infiltrated last night and the IV nurse could only get a 20g in\n his right arm. No seizure activity noted. Pt on 2L NC and sats are\n >95%. pt in NSR and SBP 100-120\n Action:\n -Changed to q4hr neuro checks\n -Dilantin discontinued and Keppra started last evening and dose\n increased today\n -Pt started on SQ heparin and aspirin per Cardiology for heart valves.\n -Echo performed\n -24hr EEG placed\n -double lumen PICC line placed at bedside\n Response:\n Pt neuro exam unchanged. No seizures noted.\n Plan:\n Change to Heparin gtt tmr per NeuroSurg and Cardiology. ?Transfer to\n stepdown tmr.\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470723,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam unchanged. Pt lethargic, arousable to voice, a&o x1-2 w/\n prompting, follows commands consistently, MAE but weaker on the right\n side (baseline), PERRLA, left eye droop, speech garbled. Weak\n cough/gag. Continuous EEG on, no seizure activity noted. VSS. Urine\n output borderline. L brachial PICC line & PIV 1 for access.\n Action:\n Neuro exams q4hrs\n Keppra administered as ordered for seizure prophylaxis\n SQ Heparin & ASA administered as ordered d/t heart valves\n 250ml LR bolus given x1 for low UO\n Response:\n Pt neuro exam unchanged. No seizures noted.\n Plan:\n Change to Heparin gtt tmr per NeuroSurg and Cardiology. ?Transfer to\n stepdown tmr.\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 470766,
"text": "TSICU\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n .\n Chief complaint:\n PMHx:\n PMH:\n - Aortic valve replacement x2: originally porcine , now Mechanical\n aortic valve prosthesis ? \n -Bileaflet mitral valve prosthesis (MVR)\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n Soc:\n Current medications:\n 24 Hour Events:\n - PICC placed, Echo done, started ASA\n EEG - At 08:51 AM\n TRANSTHORACIC ECHO - At 10:24 AM\n PICC LINE - START 01:38 PM\n Post operative day:\n POD#3 - left craniotomy for evacuation of SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.9\nC (98.4\n HR: 89 (79 - 100) bpm\n BP: 108/37(54) {95/34(52) - 127/62(75)} mmHg\n RR: 20 (16 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.8 kg (admission): 82.5 kg\n Total In:\n 2,718 mL\n 701 mL\n PO:\n 320 mL\n Tube feeding:\n IV Fluid:\n 2,398 mL\n 701 mL\n Blood products:\n Total out:\n 845 mL\n 240 mL\n Urine:\n 845 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n 461 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, appears groggy\n HEENT: PERRL, slight left eyelid droop\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic, No(t) Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (RLE:\n Weakness)\n Labs / Radiology\n 155 K/uL\n 10.1 g/dL\n 87 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 5 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.1 %\n 13.1 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n 10:46 AM\n 03:55 PM\n 05:00 AM\n 02:21 AM\n WBC\n 13.3\n 19.4\n 17.0\n 13.1\n Hct\n 31.7\n 33.0\n 31.7\n 30.4\n 30.1\n Plt\n 55\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 25\n 27\n 22\n Glucose\n 145\n 168\n 114\n 87\n Other labs: PT / PTT / INR:11.9/28.5/1.0, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, Ca:7.9 mg/dL, Mg:1.5 mg/dL, PO4:1.8 mg/dL\n Imaging: ECHO: Mechanical aortic valve prosthesis with increased\n gradient. Bileaflet mitral valve prosthesis with good disc motion, but\n increased gradient. Moderate pulmonary artery systolic hypertension.\n Preserved global biventricular systolic function.\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN\n Assessment and Plan: 64F on coumadin for artificial valve presents with\n a SDH, s/p evacuation in OR, w slowly improving mental status.\n Neurologic: Neuro checks Q: 2 hr, (1) Seizure: seized afternoon of\n min EEG neg, 24EEG in progress\n - off Dilantin, increaseed Keppra for prophylaxis\n (2) SDH: no sx of increased ICP, started SC Heparin\n (3) Pain: dilaudid PRN\n Cardiovascular: Aspirin, (1) BP: SBP goal of < 170 (2) artificial\n valve/thrombotic risk:\n - high risk of thrombosis, started ASA, and will start Heparin gtt\n tomorrow \n Pulmonary: PULM: extubated, no issues, but high risk for aspiration\n Gastrointestinal / Abdomen:\n Nutrition: regular diet- minimal po intake\n -passed speech and swallow, although per nursing report, patient\n choking on food\n -maintenance IVF as decreased po intake\n Renal: Foley, Somewhat decreased UOP, responding to fluid boluses\n Hematology: Serial Hct, stable anemia at 30\n Endocrine: RISS\n Infectious Disease: No signs of infection\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:27 AM\n PICC Line - 01:38 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470552,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470555,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n s/p crani and evacuation of bleed, pt seized yesterday.\n Action:\n Q1hr neuro checks, VS monitored, u/o low IVF re-started 500cc LR bolus\n given. c/o nausea/ and pain. zofran ordered and given. Dilantin and\n Keppra ordered for sz activity.\n Response:\n Pt lethargic but increasingly alert this am, follows commands, MAE but\n weaker on the right side, PERL 2-3mm, left eye swollen, speech garbled,\n oriented X2. responded well to zofran, states stomach feels better.\n Left hand IV infiltrated with LR bolus. Approx 390cc infused. LLE taut\n and white, finger tips . + pulses radial and finger tips. Dr.\n in to eval. IV removed. Arm elevated and warm packs applied.\n Swelling has gone down. No further seizure activity.\n Plan:\n ? Q 2hr neuro checks, ? SDU. Cont to monitor infiltrate site.\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 470613,
"text": "TSICU\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n Chief complaint:\n SDH\n PMHx:\n PMH:\n - Aortic valve replacement x2: originally porcine , now ? St. ?\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n Soc:\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 11:05 AM\n INVASIVE VENTILATION - STOP 11:05 AM\n comes from OR intubated\n ARTERIAL LINE - STOP 04:30 PM\n Post operative day:\n POD#2 - left craniotomy for evacuation of SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:00 PM\n Infusions:\n Other ICU medications:\n Labetalol - 10:52 AM\n Hydromorphone (Dilaudid) - 11:30 AM\n Other medications:\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 97 (78 - 102) bpm\n BP: 120/59(63) {103/41(56) - 140/74(89)} mmHg\n RR: 30 (5 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 81.8 kg (admission): 82.5 kg\n Total In:\n 2,523 mL\n 717 mL\n PO:\n 150 mL\n Tube feeding:\n IV Fluid:\n 2,313 mL\n 717 mL\n Blood products:\n Total out:\n 1,070 mL\n 170 mL\n Urine:\n 950 mL\n 170 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 427 (427 - 427) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.49/31/160//-1\n Ve: 6.3 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), click from artificial valve\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somnolent and difficult to rouse\n Labs / Radiology\n 177 K/uL\n 11.2 g/dL\n 168 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 105 mEq/L\n 138 mEq/L\n 31.7 %\n 19.4 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n 10:46 AM\n 03:55 PM\n WBC\n 13.3\n 19.4\n Hct\n 31.7\n 33.0\n 31.7\n Plt\n 208\n 177\n Creatinine\n 0.4\n 0.4\n TCO2\n 25\n 27\n 22\n Glucose\n 145\n 168\n Other labs: PT / PTT / INR:13.5/28.6/1.2, Lactic Acid:1.1 mmol/L,\n Albumin:3.4 g/dL, Ca:8.0 mg/dL, Mg:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN\n Assessment and Plan: 64F on coumadin for artificial valve presents\n with a SDH, s/p evacuation in OR, w slowly improving mental status, now\n s/p seizure\n Neurologic: Neuro checks Q: 4 hr, (1) Seizure: seized afternoon of \n despite dilantin. keppra added for prophylaxis INR not elevated, no new\n changes on head CT (2) SDH: no sx of increased ICP continue to hold\n anticoagulation for now, heparin gtt with goal PTT of 50 when cleared\n by NSG (3) Pain: dilaudid PRN (4) Will discontinue dilantin and\n increase keppra per neurology recommendations.\n Cardiovascular: (1) BP: SBP goal of < 170 (2) artificial\n valve/thrombotic risk: per cardiology high risk of thrombosis, should\n not use vitamin K, start aspirin ASAP with heparin gtt to follow\n Pulmonary: extubated, no issues\n Gastrointestinal / Abdomen: regular diet\n Nutrition: Regular diet\n Renal: Foley, maintenance IVF, urine output as low as 15/hr overnight,\n bolused 500 mL x 1 now adequate UO.\n Hematology: Hct 33, stable\n Endocrine: RISS (little requirements).\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, infiltrated peripheral IV w/ edema to L\n hand, no sx of compartment syndrome, will attempt peripheral IV,\n possible PICC.\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: floor\n Total time spent: 25 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470695,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. Pt has limited IV access and\n one IV infiltrated last night and the IV nurse could only get a 20g in\n his right arm. No seizure activity noted. Pt on 2L NC and sats are\n >95%. pt in NSR and SBP 100-120\n Action:\n -Changed to q4hr neuro checks\n -Dilantin discontinued and Keppra started last evening and dose\n increased today\n -Pt started on SQ heparin and aspirin per Cardiology for heart valves.\n -Echo performed\n -24hr EEG placed\n -double lumen PICC line placed at bedside\n Response:\n Pt neuro exam unchanged. No seizures noted.\n Plan:\n Change to Heparin gtt tmr per NeuroSurg and Cardiology. ?Transfer to\n stepdown tmr.\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470864,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated Sunday and then had seizure later Sunday. Pt has PMH of\n seizure disorder\n Pt was on Dilantin and level was therapeutic. Pt\n changed to Keppra IV.\n PMH: valve replacement ', cerebral hemorrhage '-> decreased\n sensation on the right side (pt can walk on level surfaces but often\n trips/falls); seizure disorder\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. No seizure activity noted. Pt\n on 2L NC and sats are >95%. pt in NSR and SBP 100-120\n Action:\n -q2hr neuro checks\n -Keppra IV\n -Pt started on SQ heparin and aspirin per Cardiology for mechanical\n heart valves.\n -24 hr EEG in place\n Response:\n Pt neuro exam unchanged. No seizures noted. Awaiting Neurology\n attending to decide to discontinue EEG monitoring. Cardiology would\n like to start Heparin gtt until goal PTT and then transfer to coumadin\n for heart valves. Neurosurgery agreed to heparin gtt once Head CT\n done. Awaiting discontinuation of EEG to go do head CT.\n Plan:\n Plan for Head CT after EEG ceases and then start pt on Heparin gtt.\n Transfer to Step Down for q2hr neuro exams and monitoring.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 82.5 kg\n Daily weight:\n 81.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Seizures\n CV-PMH: MI\n Additional history: valve replacement ', cerebral hemorrhage '->\n decreased sensation on the right side (pt can walk on level surfaces\n but often trips/falls); seizure disorder\n Surgery / Procedure and date: : Left craniotomy for evacuation\n of hematoma\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:54\n Temperature:\n 98.5\n Arterial BP:\n S:144\n D:59\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,838 mL\n 24h total out:\n 670 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:21 AM\n Potassium:\n 3.5 mEq/L\n 02:21 AM\n Chloride:\n 105 mEq/L\n 02:21 AM\n CO2:\n 25 mEq/L\n 02:21 AM\n BUN:\n 5 mg/dL\n 02:21 AM\n Creatinine:\n 0.3 mg/dL\n 02:21 AM\n Glucose:\n 87 mg/dL\n 02:21 AM\n Hematocrit:\n 30.1 %\n 02:21 AM\n Finger Stick Glucose:\n 105\n 08:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: husband\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470865,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated Sunday and then had seizure later Sunday. Pt has PMH of\n seizure disorder\n Pt was on Dilantin and level was therapeutic. Pt\n changed to Keppra IV.\n PMH: valve replacement ', cerebral hemorrhage '-> decreased\n sensation on the right side (pt can walk on level surfaces but often\n trips/falls); seizure disorder\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. No seizure activity noted. Pt\n on 2L NC and sats are >95%. pt in NSR and SBP 100-120\n Action:\n -q2hr neuro checks\n -Keppra IV\n -Pt started on SQ heparin and aspirin per Cardiology for mechanical\n heart valves.\n -24 hr EEG in place\n -speech and swallow consult- nectar thick liquids and pureed food\n Response:\n Pt neuro exam unchanged. No seizures noted. Awaiting Neurology\n attending to decide to discontinue EEG monitoring. Cardiology would\n like to start Heparin gtt until goal PTT and then transfer to coumadin\n for heart valves. Neurosurgery agreed to heparin gtt once Head CT\n done. Awaiting discontinuation of EEG to go do head CT.\n Plan:\n Plan for Head CT after EEG ceases and then start pt on Heparin gtt.\n Transfer to Step Down for q2hr neuro exams and monitoring.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 82.5 kg\n Daily weight:\n 81.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Seizures\n CV-PMH: MI\n Additional history: valve replacement ', cerebral hemorrhage '->\n decreased sensation on the right side (pt can walk on level surfaces\n but often trips/falls); seizure disorder\n Surgery / Procedure and date: : Left craniotomy for evacuation\n of hematoma\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:54\n Temperature:\n 98.5\n Arterial BP:\n S:144\n D:59\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,838 mL\n 24h total out:\n 670 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:21 AM\n Potassium:\n 3.5 mEq/L\n 02:21 AM\n Chloride:\n 105 mEq/L\n 02:21 AM\n CO2:\n 25 mEq/L\n 02:21 AM\n BUN:\n 5 mg/dL\n 02:21 AM\n Creatinine:\n 0.3 mg/dL\n 02:21 AM\n Glucose:\n 87 mg/dL\n 02:21 AM\n Hematocrit:\n 30.1 %\n 02:21 AM\n Finger Stick Glucose:\n 105\n 08:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: husband\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470532,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt was sedated on Propofol and continued to have hourly neuro checks,\n , but not to commands, impaired gag/intact cough, pain\n assessed vital signs; Remained intubated on CMV, 40%, 5 PEEP, 10 PS,\n lung sounds clear thoughout\n Action:\n Weaned sedation to off, weaned ventilator to extubate\n Response:\n Pt extubated at 1100, lethargic, opens R eye to voice (unable to open\n L eye due to periorbital edema), followed commands , , ,\n c/o headache , given IV Dilaudid with good results; OOB to chair\n for 1 hour and at 1530 with MD present Pt became unresponsive to\n verbal/tactile stimuli and had seizure activity of less than 1 minute\n on R corner of her mouth and R arm; Repeat head CT done and shows no\n acute changes, started on IV Keppra in addition to IV Dilantin;\n Currently back to baseline for most of shift, lethargic, oriented x2 at\n best, follows commands, tolerating PO intake; Neurology consulted after\n seizure\n Plan:\n Continue with every hour neuro checks, check Dilantin level in the AM,\n ?transfer to floor tomorrow\n Hypertension, benign\n Assessment:\n Pt\ns SBP in 160-170s\n Action:\n Given 20mg IV Labetalol x1 and IV Dilaudid for presumed pain\n Response:\n SBP <140 after intervention\n Plan:\n Continue to monitor BP\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470528,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt was sedated on Propofol and continued to have hourly neuro checks,\n , but not to commands, impaired gag/intact cough, pain\n assessed vital signs; Remained intubated on CMV, 40%, 5 PEEP, 10 PS,\n lung sounds clear thoughout\n Action:\n Weaned sedation to off, weaned ventilator to extubate\n Response:\n Pt extubated at 1100, lethargic, opens R eye to voice (unable to open\n L eye due to periorbital edema), followed commands , , ,\n c/o headache , given IV Dilaudid with good results; OOB to chair\n for 1 hour and at 1530 with MD present Pt became unresponsive to\n verbal/tactile stimuli and had seizure activity of less than 1 minute\n on R corner of her mouth and R arm; Repeat head CT done and shows no\n acute changes, started on IV Keppra in addition to IV Dilantin;\n Currently back to baseline for most of shift, lethargic, oriented x2 at\n best, follows commands, tolerating PO intake; Neurology consulted after\n seizure\n Plan:\n Continue with every hour neuro checks, check Dilantin level in the AM,\n ?transfer to floor\n Hypertension, benign\n Assessment:\n Pt\ns SBP in 160-170s\n Action:\n Given 20mg IV Labetalol x1 and IV Dilaudid for presumed pain\n Response:\n SBP <140 after intervention\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470863,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated Sunday and then had seizure later Sunday. Pt has PMH of\n seizure disorder\n Pt was on Dilantin and level was therapeutic. Pt\n changed to Keppra IV.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. No seizure activity noted. Pt\n on 2L NC and sats are >95%. pt in NSR and SBP 100-120\n Action:\n -q2hr neuro checks\n -Keppra IV\n -Pt started on SQ heparin and aspirin per Cardiology for mechanical\n heart valves.\n -24 hr EEG in place\n Response:\n Pt neuro exam unchanged. No seizures noted. Awaiting Neurology\n attending to decide to discontinue EEG monitoring. Cardiology would\n like to start Heparin gtt until goal PTT and then transfer to coumadin\n for heart valves. Neurosurgery agreed to heparin gtt once Head CT\n done. Awaiting discontinuation of EEG to go do head CT.\n Plan:\n Plan for Head CT after EEG ceases and then start pt on Heparin gtt.\n Transfer to Step Down for q2hr neuro exams and monitoring.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 82.5 kg\n Daily weight:\n 81.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Seizures\n CV-PMH: MI\n Additional history: valve replacement ', cerebral hemorrhage '->\n decreased sensation on the right side (pt can walk on level surfaces\n but often trips/falls); seizure disorder\n Surgery / Procedure and date: : Left craniotomy for evacuation\n of hematoma\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:54\n Temperature:\n 98.5\n Arterial BP:\n S:144\n D:59\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,838 mL\n 24h total out:\n 670 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:21 AM\n Potassium:\n 3.5 mEq/L\n 02:21 AM\n Chloride:\n 105 mEq/L\n 02:21 AM\n CO2:\n 25 mEq/L\n 02:21 AM\n BUN:\n 5 mg/dL\n 02:21 AM\n Creatinine:\n 0.3 mg/dL\n 02:21 AM\n Glucose:\n 87 mg/dL\n 02:21 AM\n Hematocrit:\n 30.1 %\n 02:21 AM\n Finger Stick Glucose:\n 105\n 08:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: husband\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470383,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt sedated on propofol gtt 50mcg/kg/min upon arrival to TSICU (13:00\n ), remained on sedation d/t not reversed from OR procedure.\n Sedation weaned d/t labile BP, pt tolerated propofol wean well,\n remained safe. Off propofol, pt unresponsive, does not follow\n commands, does not open eyes, does not attempt to communicate. See\n metavision for neuro exam specifics, most recent exam: pt withdraws to\n all extremities, +corneals (3mm/3mm, briskly reactive), +cough,\n impaired gag. Pt appears comfortable. Pt\ns BP 140-170 systolic at\n rest with propofol and off sedation/with activity. Hr 50-70\ns, SB/NSR,\n no ectopy.\n Action:\n Propofol turned off fore neuro exams, neuro exam unchanged, pt\n unresponsive but exam improving from triple flexion/posturing (see\n metavision). Head CT done at 17:45 to assess post-surgical\n intervention. Q1 hr neuro checks done. Lytes repleted. Most recently,\n propofol turned off completely d/t pt calm, safe, remains off.\n Labetalol IVP 10mg given for BP control since goal per is <140\n systolic. Hydralazine IVP given for BP control. EKG done d/t\n Bradycardia. Family supported, talked to RN, HO, MD and had\n questions answered.\n Response:\n Labetalol did not decrease pt\ns BP, hydralizine more effective. Neuro\n exam slightly improving but pt still unresponsive, remains off of\n propofol.\n Plan:\n Continue to wean sedation (leave off) as tolerated. Wean vent settings\n as tolerated. Extubate in the AM? Continue Q1 hr neuro exams, repeat\n head CT at 6AM per . Dilantin level in the AM? Continue to treat\n BP to goal <140 systolic as needed, consider nicardipine or labetalol\n gtt if BP not well controlled. Continue to support pt and family.\n"
},
{
"category": "Rehab Services",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Bedside Swallowing Evaluation",
"row_id": 470846,
"text": "TITLE:\n BEDSIDE SWALLOWING EVALUATION:\n HISTORY:\n Thank you for referring this 64 year-old admitted s/p\n mechanical fall, found to have large primarily subdural L extra-axial\n hemorrhage with R deviation of midline anatomy, hypodensity on L\n frontal parietal lobe indicating encephalomalacia, hyperdensity\n anterior to the left anterior due to axonal injury or contusion\n and a large amount of retained secretions in the nasopharynx. She was\n taken to OR on for evacuation. On was extubated, but then\n had seizure activity. Of note, the patient began having seizures 26\n years ago following a hemorrhagic stroke.\n MD notes indicate pt passed a swallowing evaluation on \n following extubation and was tolerating PO, however our department was\n not in the hospital on and we have never met the patient. She has\n been ordered for regular diet, but per RNs, has not been taking much\n more than a small amount of pureed solids and ice cream. We were\n consulted today to evaluate oral and pharyngeal swallow function to\n determine the safest diet.\n PMH includes:\n RHD s/p bivalvular replacement with repair\n ?Hemorrhagic stroke with evacuation\n Seizures in the past\n HTN\n Caesarean section\n EVALUATION:\n The examination was performed while the patient was seated at\n approximately 45 degrees, as pt was on EEG monitoring and needed to\n stay in view of camera; in TSICU.\n Cognition, language, speech, voice:\n Awake but lethargic with eyes closed throughout evaluation. Oriented\n to self, place, year, and month, but not date (states today is\n ). Follows simple commands. Answers y/n questions reliably\n regarding factual info, but may not be accurate re: more abstract\n info. Language grossly fluent. Speech and voice WNL.\n Teeth: many molars missing, pt reports she wears dentures, but they do\n not appear to be present in the room\n Secretions: small amount of thin clear and thicker white secretions in\n oral cavity, cleared with brief oral care.\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Labial seal reduced with poor strength.\n Tongue protrudes midline with reduced strength and ROM. Palatal\n elevation symmetrical. Gag present.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquid (tspn, straw), nectar thick liquids\n (tspn, straw, drop straw), puree, and bites of ground solids. Oral\n phase prolonged with ground solids and remarkable for mild oral cavity\n residue, requiring liquid wash down to clear. Pt also with poor\n extraction of nectar via straw, requires significant encouragement and\n cues. Laryngeal elevation reduced but timely to palpation. Pt had\n overt coughing with thin liquids, stating \"I'm choking!\" No other\n throat clearing, coughing, choking, or O2 desat during other PO\n consistencies. Pt denied sensation of aspiration or pharyngeal residue\n during the eval.\n Following today's evaluation, I left the room to get pt a blanket,\n which she had requested. On return to the room (3-5 minutes following\n my eval), pt was coughing. When I asked what she coughed on, she said\n \"I'm choking on the food!\" Suction of oropharynx via Yankauer was\n without return.\n SUMMARY / IMPRESSION:\n Pt presents with overt s/sx of aspiration of thin liquids and poor\n chewing/management of ground solids as well as lethargy which will\n likely limit her ability to participate in feeding. In addition, pt\n had coughing 3-5 minutes after PO intake for unclear reasons. After\n discussion with RN and MD, we support cautiously initiating a PO diet\n of pureed solids and nectar thick liquids over night. Strict 1:1\n assist/supervision and please hold tray if pt has s/sx of aspiration.\n We will return tomorrow to re-assess and ensure diet tolerance. Pt\n will also benefit from Nutrition f/u.\n This swallowing pattern correlates to a Dysphagia Outcome\n Severity Scale (DOSS) rating of 2, moderate-severe dysphagia.\n RECOMMENDATIONS:\n 1. PO diet: pureed solids, nectar thick liquids\n 2. PO meds crushed in puree\n 3. Q4 oral care\n 4. 1:1 supervision with all PO intake. Please hold tray if pt too\n lethargic. Please keep pt NPO if there are s/sx of aspiration.\n 5. Nutrition f/u\n 6. We will return tomorrow to re-assess and ensure diet tolerance.\n These recommendations were shared with the patient, nurse and medical\n team.\n M.S., CCC-SLP\n Pager #\n Face time: 11:45-12:00\n Total time: 60 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2112-07-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 470380,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 18 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1700\n 07:27 PM\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-17 00:00:00.000",
"description": "Cardiology Consultation",
"row_id": 470477,
"text": "TITLE: DIVISION OF CARDIOLOGY\n COMPREHENSIVE CONSULTATION NOTE\n Chief complaint: Patient is seen for consultation today at the request\n of Dr. . We are asked to give consultative advice\n regarding evaluation and management of stroke risk off of\n anticoagulation, in setting of mechanical valve replacements.\n EVENTS/EXTENDED HISTORY OF PRESENT ILLNESS:\n 64 yo F w/ h/o mechanical aortic and mitral valve replacements, CVA and\n MI in , residual right sided weakness/numbness, who presented with\n a SDH after a mechanical fall on . Per pt's sister, pt had been\n at a shooting range and was cooking in the parking lot, when she\n tripped over a cord and fell on her left side, hitting the left side of\n her head. Several minutes later, she lost consciousness. She was\n intubated and med-flighted to , where an initial head CT showed L\n sided SDH with associated right deviation (~10 mm). She was given 2U\n FFP and Vitamin K 10 mg IV to reverse her INR of 2.2. Yesterday evening\n she was taken to emergent neurosurgery, where her SDH was evacuated\n through a L craniotomy.\n Cardiology service was asked today to comment upon risk of stroke off\n of anticoagulation. Notably, although details not clear (no records),\n per pt's family, pt had two (presumed aortic and mitral) valve\n replacements in for ?rheumatic heart disease. Initially one each\n bioprosthetic and mechanical, then the bioprosthetic valve was replaced\n with a mechanical valve in . These surgeries were done at \n Medical Center. Also in , prior to her 2nd valve replacement\n surgery, pt's son reports she had a CVA in , then was taken off\n coumadin x 2 wks, then had a MI in that setting. She recovered with\n residual right sided numbness and weakness, but has been independent in\n her ADLs. Since that time, she has been on coumadin and doing well.\n ALLERGIES: NKDA\n CURRENT MEDICATIONS: Labetalol IV prn, dilaudid prn, Ancef x 3 doses,\n Protonix 40 IV daily, colace, dilantin 100 iv q8h, SSI\n Medications at home: Dilantin, lisinopril ?dose, coumadin, fosamax,\n amoxicillin, zetia\n PAST MEDICAL HISTORY: As above, +seizures post CVA, dyslipidemia,\n hypertension\n Social history is significant for the absence of current tobacco use.\n There is no history of alcohol abuse. There is no family history of\n premature coronary artery disease or sudden death.\n On review of symptoms, limited due to pt's sedation and ETT in place,\n but denies pain.\n Cardiac review of systems per family members is notable for absence of\n chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,\n orthopnea, ankle edema, palpitations, syncope or presyncope prior to\n the event.\n PHYSICAL EXAMINATION\n The blood pressure was 152/70 mmHg supine. The pulse was 95 bpm. The\n respiratory rate was 16. The patient was afebrile. Intubated, arouses\n to voice and tactile stimulation. Left head bandage in place. Left\n eyelid edematous. There was no xanthalesma and conjunctiva were pink\n with no pallor or cyanosis of the oral mucosa. A hard neck brace was\n present. The were no chest wall deformities, scoliosis or kyphosis.\n The respirations were not labored on the ventilator. The lungs were\n clear to ascultation bilaterally with normal breath sounds and no\n adventitial sounds or rubs.\n On cardiovascular examination, there were no thrills, lifts or palpable\n S3 or S4. The heart sounds revealed a crisp mechanical S1 and S2 with\n a II/VI early systolic murmur at the left sternal border and a short\n I/VI systolic murmur at the apex. There were no clicks or gallops.\n The abdominal aorta was not enlarged by palpation. There was no\n organomegaly or tenderness. The extremities had no pallor, cyanosis,\n clubbing or edema. Inspection and/or palpation of skin and\n subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or\n xanthomas.\n Pulses:\n Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+\n EKG demonstrated SR at 58 bpm with some baseline artifact, nl\n axis and intervals, no notable ST elevations or depressions. No prior\n in OMR for evaluation.\n LABORATORY DATA:\n 138 105 8 11.2\n ----|-------|------< 168 19.4 >------< 177\n 3.6 24 0.4 33.0\n INR 1.5\n ASSESSMENT AND PLAN: 64 yo F w/ h/o presumed aortic and mitral\n mechanical valves, s/p fall resulting in SDH, now clinically stabilized\n s/p SDH evacuation yesterday.\n Given mechanical both aortic and mitral valves, HTN, and prior CVA, pt\n is at high risk for thrombosis/ CVA off of all anticoagulation,\n ~>4%/year. her exact valve type is unclear, but likely bileaflet given\n the examination findings and year of replacement. The stroke risk for\n older type of prosthetic valve could be even higher. As I explained to\n the family and primary ICU team, clearly her SDH takes precedence at\n this point, and any risk of CVA would be outweighed by the risk of\n bleeding from the SDH/craniotomy. We will have to accept the risk of\n thrombosis of the valves, and begin anticoagulation as soon as safe\n from a neurosurgical perspective.\n Recommendations:\n 1. Aspirin 325 mg daily as soon as possible if unable to start full\n anticoagulation.\n 2. Begin heparin and coumadin, to goal INR 2.5-3.5 as soon as safe from\n neurosurgical perspective.\n 3. Obtain records from her cardiologist/ regarding her exact\n cardiac history/ valve replacement history.\n 4. Obtain 2D echo tomorrow for LV function, evalution of valves.\n 5. Continue beta blocker; consider restarting ACE-I if still\n hypertensive and if evidence of LV dysfunction on echo.\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470729,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam unchanged. Pt lethargic, arousable to voice, a&o x1-2 w/\n prompting, follows commands consistently, MAE but weaker on the right\n side (baseline), PERRLA, left eye droop, speech garbled. Weak\n cough/gag. Continuous EEG on, no seizure activity noted. Pt w/ occ c/o\n HA. VSS. Urine output borderline. L brachial PICC line & PIV 1 for\n access.\n Action:\n Neuro exams q4hrs\n Keppra administered as ordered for seizure prophylaxis\n SQ Heparin & ASA administered as ordered d/t heart valves\n 250ml LR bolus given x1 for low UO\n Lytes repleted\n Dilaudid PRN for pain\n Response:\n Neuro exam unchanged.\n Plan:\n Cont to monitor neuro status, hemodynamics, resp status,\n urine output\n Tx to SDU when bed available\n ?Change anticoagulation therapy to Heparin gtt tmr per\n NeuroSurg and Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 470816,
"text": "TSICU\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n .\n Chief complaint:\n PMHx:\n PMH:\n - Aortic valve replacement x2: originally porcine , now Mechanical\n aortic valve prosthesis ? \n -Bileaflet mitral valve prosthesis (MVR)\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n Soc:\n Current medications:\n 24 Hour Events:\n - PICC placed, Echo done, started ASA\n EEG - At 08:51 AM\n TRANSTHORACIC ECHO - At 10:24 AM\n PICC LINE - START 01:38 PM\n Post operative day:\n POD#3 - left craniotomy for evacuation of SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 04:15 PM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Hydromorphone (Dilaudid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 36.9\nC (98.4\n HR: 89 (79 - 100) bpm\n BP: 108/37(54) {95/34(52) - 127/62(75)} mmHg\n RR: 20 (16 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.8 kg (admission): 82.5 kg\n Total In:\n 2,718 mL\n 701 mL\n PO:\n 320 mL\n Tube feeding:\n IV Fluid:\n 2,398 mL\n 701 mL\n Blood products:\n Total out:\n 845 mL\n 240 mL\n Urine:\n 845 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n 461 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, appears groggy\n HEENT: PERRL, slight left eyelid droop\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic, No(t) Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (RLE:\n Weakness)\n Labs / Radiology\n 155 K/uL\n 10.1 g/dL\n 87 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 5 mg/dL\n 105 mEq/L\n 138 mEq/L\n 30.1 %\n 13.1 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n 10:46 AM\n 03:55 PM\n 05:00 AM\n 02:21 AM\n WBC\n 13.3\n 19.4\n 17.0\n 13.1\n Hct\n 31.7\n 33.0\n 31.7\n 30.4\n 30.1\n Plt\n 55\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 25\n 27\n 22\n Glucose\n 145\n 168\n 114\n 87\n Other labs: PT / PTT / INR:11.9/28.5/1.0, Lactic Acid:1.1 mmol/L,\n Albumin:3.1 g/dL, Ca:7.9 mg/dL, Mg:1.5 mg/dL, PO4:1.8 mg/dL\n Imaging: ECHO: Mechanical aortic valve prosthesis with increased\n gradient. Bileaflet mitral valve prosthesis with good disc motion, but\n increased gradient. Moderate pulmonary artery systolic hypertension.\n Preserved global biventricular systolic function.\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN\n Assessment and Plan: 64F on coumadin for artificial valve presents with\n a SDH, s/p evacuation in OR, w slowly improving mental status.\n Neurologic: Neuro checks Q: 4 hr, (1) Seizure: seized afternoon of\n min EEG neg, 24 hour EEG in progress\n - off Dilantin, increaseed Keppra for prophylaxis\n (2) SDH: no sx of increased ICP, started SC Heparin and ASA\n (3) Pain: dilaudid PRN\n Cardiovascular: Aspirin, (1) BP: SBP goal of < 170 (2) artificial\n valve/thrombotic risk:\n - high risk of thrombosis, started ASA, and will start Heparin gtt goal\n PTT 50. (3) Coumadin per NS\n Pulmonary: PULM: extubated, no issues, but high risk for aspiration\n Gastrointestinal / Abdomen: Regular diet (though she is taking\n little). Speech and Swallow eval. With increasing neuro status\n Nutrition: regular diet- minimal po intake\n -passed speech and swallow, although per nursing report, patient\n choking on food\n -maintenance IVF as decreased po intake\n Renal: Foley, Somewhat decreased UOP, responding to fluid boluses\n Hematology: Serial Hct, stable anemia at 30\n Endocrine: RISS\n Infectious Disease: No signs of infection, WBC decreased to 13. If\n spikes, repeat CXR\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, Potassium Chloride\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:27 AM\n PICC Line - 01:38 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470674,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt lethargic but increasingly alert throughout the day, follows\n commands, MAE but weaker on the right side, PERL 2-3mm, left eye\n swollen, speech garbled, oriented X2/3. Pt has limited IV access and\n one IV infiltrated last night and the IV nurse could only get a 20g in\n his right arm. No seizure activity noted. Pt on 2L NC and sats are\n >95%. pt in NSR and SBP 100-120\n Action:\n -Changed to q4hr neuro checks\n -Dilantin discontinued and Keppra started last evening and dose\n increased today\n -Pt started on SQ heparin and aspirin per Cardiology for heart valves.\n -Echo performed\n -24hr EEG placed\n -double lumen PICC line placed at bedside\n Response:\n Pt neuro exam unchanged. No seizures noted.\n Plan:\n Change to Heparin gtt tmr per NeuroSurg and Cardiology. ?Transfer to\n stepdown tmr.\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470725,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam unchanged. Pt lethargic, arousable to voice, a&o x1-2 w/\n prompting, follows commands consistently, MAE but weaker on the right\n side (baseline), PERRLA, left eye droop, speech garbled. Weak\n cough/gag. Continuous EEG on, no seizure activity noted. VSS. Urine\n output borderline. L brachial PICC line & PIV 1 for access.\n Action:\n Neuro exams q4hrs\n Keppra administered as ordered for seizure prophylaxis\n SQ Heparin & ASA administered as ordered d/t heart valves\n 250ml LR bolus given x1 for low UO\n Lytes repleted\n Response:\n Neuro exam unchanged.\n Plan:\n Cont to monitor neuro status, hemodynamics, resp status,\n urine output\n Tx to SDU when bed available\n ?Change anticoagulation therapy to Heparin gtt tmr per\n NeuroSurg and Cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2112-07-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470776,
"text": "66yo female s/p trip and fall over hoses on asphalt parking lot,\n witnessed, fell on left side. +LOC with breathing, then pt awoke but\n soon lost consciousness again (per husband). Pt vomited and was\n intubated for GCS 4 and medflighted to ED where head CT showed\n left SDH with herniation and midline shift. Pt to OR for left\n craniotomy to evacuate hematoma and sent to TSICU for further care. Pt\n extubated yesterday.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro exam unchanged. Pt lethargic, arousable to voice, a&o x1-2 w/\n prompting, follows commands consistently, MAE but weaker on the right\n side (baseline), PERRLA, left eye droop, speech garbled. Weak\n cough/gag. Continuous EEG on, no seizure activity noted. Pt w/ occ c/o\n HA. VSS. Urine output borderline. L brachial PICC line & PIV 1 for\n access.\n Action:\n Neuro exams q4hrs\n Keppra administered as ordered for seizure prophylaxis\n SQ Heparin & ASA administered as ordered d/t heart valves\n 250ml LR bolus given x1 for low UO\n Lytes repleted\n Dilaudid PRN for pain\n Response:\n Neuro exam primarily unchanged. Pt having some difficulty swallowing\n crushed pills in apple sauce. Keppra changed to IV.\n Plan:\n Cont to monitor neuro status, hemodynamics, resp status,\n urine output\n Tx to SDU when bed available\n ?Change anticoagulation therapy to Heparin gtt tmr per\n NeuroSurg and Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2112-07-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 470624,
"text": "TSICU\n HPI:\n 64F on coumadin for artificial valve presents with a SDH. The pt had a\n mechanical fall from standing onto her left side. She lost\n consciousness for 2 minutes, was lucid for 2 minutes, then lost\n consciousness again. She vomited and had a clenched jaw. The pt was\n airlifted to the , where she was found to have a large left,\n primarily subdural, extra-axial hemorrhage with associated right\n sub-falcine herniation of ~10mm. The SDH was evacuated in the OR.\n Chief complaint:\n SDH\n PMHx:\n PMH:\n - Aortic valve replacement x2: originally porcine , now ? St. ?\n - Cerebral hemorrhage . Residual R-sided weakness at baseline.\n - MI \n - Seizures - last 15 yr ago\n - HTN\n PSH: Valve replacement\n : Lisinopril, Fosamax, Dilantin, Coumadin\n Soc:\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 11:05 AM\n INVASIVE VENTILATION - STOP 11:05 AM\n comes from OR intubated\n ARTERIAL LINE - STOP 04:30 PM\n Post operative day:\n POD#2 - left craniotomy for evacuation of SDH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:00 PM\n Infusions:\n Other ICU medications:\n Labetalol - 10:52 AM\n Hydromorphone (Dilaudid) - 11:30 AM\n Flowsheet Data as of 05:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 97 (78 - 102) bpm\n BP: 120/59(63) {103/41(56) - 140/74(89)} mmHg\n RR: 30 (5 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 81.8 kg (admission): 82.5 kg\n Total In:\n 2,523 mL\n 717 mL\n PO:\n 150 mL\n Tube feeding:\n IV Fluid:\n 2,313 mL\n 717 mL\n Blood products:\n Total out:\n 1,070 mL\n 170 mL\n Urine:\n 950 mL\n 170 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,453 mL\n 547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 427 (427 - 427) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.49/31/160//-1\n Ve: 6.3 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), click from artificial valve\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, somnolent and difficult to rouse\n Labs / Radiology\n 177 K/uL\n 11.2 g/dL\n 168 mg/dL\n 0.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 105 mEq/L\n 138 mEq/L\n 31.7 %\n 19.4 K/uL\n [image002.jpg]\n 01:45 PM\n 11:07 PM\n 03:21 AM\n 03:29 AM\n 10:46 AM\n 03:55 PM\n WBC\n 13.3\n 19.4\n Hct\n 31.7\n 33.0\n 31.7\n Plt\n 208\n 177\n Creatinine\n 0.4\n 0.4\n TCO2\n 25\n 27\n 22\n Glucose\n 145\n 168\n Other labs: PT / PTT / INR:13.5/28.6/1.2, Lactic Acid:1.1 mmol/L,\n Albumin:3.4 g/dL, Ca:8.0 mg/dL, Mg:1.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), HYPERTENSION, BENIGN\n Assessment and Plan: 64F on coumadin for artificial valve presents\n with a SDH, s/p evacuation in OR, w slowly improving mental status, now\n s/p seizure\n Neurologic: Neuro checks Q: 4 hr, (1) Seizure: seized afternoon of \n despite dilantin. keppra added for prophylaxis INR not elevated, no new\n changes on head CT (2) SDH: no sx of increased ICP continue to hold\n anticoagulation for now, heparin gtt with goal PTT of 50 when cleared\n by NSG (3) Pain: dilaudid PRN (4) Will discontinue dilantin and\n increase keppra per neurology recommendations.\n Cardiovascular: (1) BP: SBP goal of < 170 (2) artificial\n valve/thrombotic risk: per cardiology high risk of thrombosis, should\n not use vitamin K, start aspirin ASAP with heparin gtt to follow\n Pulmonary: extubated, no issues\n Gastrointestinal / Abdomen: regular diet\n Nutrition: Regular diet\n Renal: Foley, maintenance IVF, urine output as low as 15/hr overnight,\n bolused 500 mL x 1 now adequate UO.\n Hematology: Hct 33, stable\n Endocrine: RISS (little requirements).\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, infiltrated peripheral IV w/ edema to L\n hand, no sx of compartment syndrome, will attempt peripheral IV,\n possible PICC.\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Communication: ICU consent signed\n Code status: Full code\n Disposition: floor\n Total time spent: 32 minutes\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088524,
"text": " 6:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change in bleed\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p SDH w evacuation, seizure\n REASON FOR THIS EXAMINATION:\n ? change in bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE 8:05 PM\n IMPRESSION:\n 1. Unchanged appearance to left temporoparietal intraparenchymal hemorrhage\n with hypodensity and small left subdural hematoma. No new areas of\n hemorrhage. No midline shift.\n 2. Stable hyperdense foci anterior to the left lateral ventricular may\n represent area of contusion injury or .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old woman status post subdural hematoma with evacuation and\n seizure. Evaluate for change in bleed\n\n HEAD CT: Axial imaging was performed through the brain without IV contrast.\n\n COMPARISON: CT head . There is unchanged appearance to small\n left frontoparietal subdural hematoma measuring approximately 4 mm in\n thickness.\n\n FINDINGS: There is no shift of normally midline structures. There is\n unchanged appearance to intraparenchymal hemorrhage and hypodensity in the\n right temporoparietal lobe (2A:17). The ventricles appear stable in size\n without evidence for hydrocephalus. There are no new areas of hemorrhage.\n -white matter differentiation appears well preserved. There are\n persistent hyperdense foci anterior to the anterior of the left lateral\n ventricle (2A:16). There is no evidence for herniation, ambient and basilar\n cisterns are widely patent. Patient is status post left craniotomy. There is\n mucosal thickening of ethmoid air cells and maxillary sinuses. There is\n decreased hematoma with decreased subcutaneous gas along the left frontal\n scalp. There is minimal pneumocephalus adjacent to the left subdural\n hematoma.\n\n IMPRESSION:\n 1. Unchanged appearance to left temporoparietal intraparenchymal hemorrhage\n with internal hypodensity, now with small layering blood/flood levels, and\n small extra-axial hematoma over the left convexity.\n 2. No new foci of hemorrhage or shift of midline structures.\n 3. Stable more punctate hyperdense focus anterior to the left lateral\n ventricular frontal may represent additional contusion, or .\n (Over)\n\n 6:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change in bleed\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088525,
"text": ", NSURG FA11 6:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? change in bleed\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p SDH w evacuation, seizure\n REASON FOR THIS EXAMINATION:\n ? change in bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n 1. Unchanged appearance to left temporoparietal intraparenchymal hemorrhage\n with hypodensity and small left subdural hematoma. No new areas of\n hemorrhage. No midline shift.\n 2. Stable hyperdense foci anterior to the left lateral ventricular may\n represent area of contusion injury or .\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088033,
"text": " 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 64 year old woman with L SDH s/p evacuation, evaluate for hy\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with L SDH s/p evacuation, evaluate for hydro\n REASON FOR THIS EXAMINATION:\n 64 year old woman with L SDH s/p evacuation, evaluate for hydro\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy SUN 9:41 AM\n PFI: Expected changes status post craniotomy for evacuation of subdural\n hematoma. There is no new hemorrhage. There is no significant mass effect,\n including no shift of midline structures or evidence of herniation. The\n ventricles are unchanged in size, with no evidence for hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female status post left subdural hematoma evacuation.\n Evaluate for hydrocephalus.\n\n COMPARISON: at 17:50 hours and 10:15 hours.\n\n NON-CONTRAST HEAD CT: The patient is status post left frontal craniotomy for\n evacuation of underlying subdural hematoma. Pneumocephalus has decreased\n compared to prior study. There is no evidence for new hemorrhage. There is\n no shift of midline structures. There is no evidence for herniation.\n Ventricles are unchanged in size, with no evidence for development of\n hydrocephalus.\n\n Persistent small amount of hyperdense subdural blood is seen tracking along\n the left temporoparietal region, with a small amount tracking along the\n tentorium. Additional subarachnoid blood is seen over the left convexity,\n with unchanged small amount of blood within the occipital of the left\n lateral ventricle, as well as an intraparenchymal focus adjacent to the\n frontal of left lateral ventricle. Hypodensity in the left\n temporoparietal region may reflect a contusion versus edema. Focal thickening\n is identified in the ethmoid air cells and maxillary sinuses. The mastoids\n are clear. Extensive superficial soft tissue air is seen overlying the\n craniotomy site, extending over the left zygoma.\n\n IMPRESSION: Expected evolution of postoperative changes status post left\n frontal craniotomy for evacuation of subdural hematoma. There is no new\n hemorrhage, no midline shift or herniation, and no evidence for development of\n hydrocephalus. Persistent small amount of subdural blood, intraparenchymal\n blood, and subarachnoid blood is again noted, with also a small amount of\n blood layering in the lateral ventricle.\n\n (Over)\n\n 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 64 year old woman with L SDH s/p evacuation, evaluate for hy\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088034,
"text": ", NSURG TSICU 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 64 year old woman with L SDH s/p evacuation, evaluate for hy\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with L SDH s/p evacuation, evaluate for hydro\n REASON FOR THIS EXAMINATION:\n 64 year old woman with L SDH s/p evacuation, evaluate for hydro\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Expected changes status post craniotomy for evacuation of subdural\n hematoma. There is no new hemorrhage. There is no significant mass effect,\n including no shift of midline structures or evidence of herniation. The\n ventricles are unchanged in size, with no evidence for hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1087916,
"text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? cp process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ? cp process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old woman status post fall.\n\n PORTABLE CHEST RADIOGRAPH.\n\n COMPARISON: None.\n\n FINDINGS: Evaluation is limited by presence of trauma backboard underlying\n the patient. There are sternal wires as well as surgical clips in the upper\n mediastinum. There is an endotracheal tube whose tip abuts the carina and\n should be withdrawn approximately 3 to 4 cm. A nasogastric tube courses\n through the esophagus and into the stomach. The cardiomediastinal silhouette\n appears abnormal with abnormal widening of the upper mediastinum and an\n indistinct aortic knob. There is opacification which obscures the\n retrocardiac silhouette as well as the left heart border. Additional\n opacity noted in right upper hemithorax. There is no pneumothorax. There are\n no obvious rib fractures.\n\n IMPRESSION:\n 1. Endotracheal tube abutting the carina and should be re-positioned.\n 2. Abnormal widening of the mediastinum, in the setting of trauma cannot\n exclude possible aortic injury and recommend chest CT for further evaluation.\n 3. Increased density in the retrocardiac region as well as abutting the left\n heart border and in right upper lung. Aspiration and/or contusion are\n principal diagnostic considerations.\n 4. No displaced rib fracture or pneumothorax.\n\n Findings were communicated via telephone to Dr. at 10:15\n a.m. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1087917,
"text": " 9:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL, ? BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 10:32 AM\n Large left, primarily subdural, extra-axial hemorrhage with associate right\n sub-falcine herniation of ~10mm. D/w Trauma surgery service.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Axial CT images were acquired through the head in the absence of\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS:\n A large area of subdural blood extends over the entire left cerebral\n hemisphere, including parafalcine extension. At maximal depth, this subdural\n collection appears to measure approximately 21 mm (2:23). There is associated\n effacement of the ipsilateral sulci and lateral ventricle as well as\n subfalcine herniation measuring approximately 10 mm at greatest deviation\n (2:18). Small areas of hyperdensity extending along the gyral surface\n overlying the right parietal lobe (2:23) may represent foci of parenchymal\n contusion or small amount of subarachnoid blood. There is no evidence of\n entrapment of the contralateral lateral ventricle. The third ventricle\n appears partially effaced as well as displaced secondary to the subdural\n blood. The posterior fossa appears unremarkable. There are no other foci of\n hemorrhage. Extracranial soft tissue structures reveal a mild amount of soft\n tissue prominence overlying a surgical defect in the left parietal bone,\n possibly related to the recent fall or remote surgery. Visualized osseous\n structures reveal the surgical defect, overlying the subdural blood as\n previously depicted. There is no other evidence of fracture. The included\n paranasal sinuses reveal a hypoplastic left frontal sinus as well as\n circumferential mucosal thickening in the ethmoidal air cells, bilaterally, as\n well as in the maxillary sinuses bilaterally. A large amount of fluid and\n secretions is seen in the included portion of the nasopharynx and should be\n clinically correlated for possibility of aspiration.\n\n IMPRESSION:\n 1. Large primarily subdural extra-axial hemorrhage, with associated right\n deviation of normal midline anatomy of approximately 10 mm.\n 2. Hypodensity left frontoparietal lobe indicating encephalomalacia.\n 3. S,all hyperdensity adjacent to left anterior due to axonal injury or\n contusion.\n 4. Large amount of retained secretions in the nasopharynx which should be\n (Over)\n\n 9:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL, ? BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n correlated for concern of possible aspiration. These findings were discussed\n with Dr. from the trauma surgery service at 10:30 a.m. on , .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1087918,
"text": " 10:00 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P FALL, ? C SPINE FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ? fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 10:50 AM\n no fracture or traumatic malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall.\n\n COMPARISON: Comparison is made to concurrent CT of the head as well as torso.\n\n TECHNIQUE: Axial CT images were acquired through the cervical spine in the\n absence of intravenous contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n FINDINGS: There is no fracture or traumatic malalignment. There is no\n prevertebral soft tissue swelling. Intracranial contents are better\n characterized on a concurrent CT head dictated separately. Vertebral body\n heights are well preserved. The regional soft tissue and vascular structures\n appear unremarkable. The portions of the lung apices included are better\n characterized on the concurrent CT of the torso.\n\n Moderate amount of retained secretions in the hypo- and -pharynx are\n redemonstrated.\n\n IMPRESSION: No fracture or traumatic malalignment. Findings were discussed\n in person by Dr. with Dr. from the trauma surgery service at\n approximately 10:50 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1087919,
"text": " 10:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P FALL, ? INJURY\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ? thoracic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 10:59 AM\n ETT is only 12-15mm above the carina and should be retracted. Bilateral\n pulmonary opacities are some combination of atelectasis and aspiration. Note\n is made of cholelithiasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall.\n\n COMPARISON: Comparison is made to concurrent CT of the cervical spine.\n\n TECHNIQUE: Axial CT images were acquired through the torso following\n administration of 130 cc of intravenous Optiray contrast. Coronal and\n sagittal reformatted images were also reviewed.\n\n CT CHEST WITH CONTRAST: The patient is intubated with the tip of the\n endotracheal tube terminating approximately 12 mm above the carina (301B:41).\n This tip could be retracted slightly. Otherwise, airways are patent to\n segmental levels bilaterally. Consolidative opacities are noted in the upper\n lobes bilaterally as well as dependently in the lower lobes, likely reflecting\n some combination of atelectasis and aspiration. The heart and great vessels\n are notable for postoperative change, following an apparent mitral valve\n replacement. Atherosclerotic calcification is visualized along the aortic\n annulus as well as at the aortic arch. There is no axillary or mediastinal\n lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: An orogastric tube terminates in the stomach which\n is otherwise unremarkable. The duodenum, spleen, fatty pancreas, adrenal\n glands, liver, kidneys are unremarkable. The gallbladder contains numerous\n hyperattenuating foci consistent with layering gallstones. There is no free\n gas or fluid in the abdomen. There is no retroperitoneal or mesenteric\n lymphadenopathy.\n\n CT PELVIS WITH CONTRAST: The rectum, colon, uterus, adnexa are unremarkable.\n The urinary bladder contains a Foley catheter. There is no free gas or fluid\n in the abdomen. There is no pelvic sidewall or inguinal lymphadenopathy.\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n Note is made of multiple sternotomy wires. There is a mild anterior wedge\n compression deformity of the T8 vertebral body of unknown chronicity.\n\n IMPRESSION:\n (Over)\n\n 10:02 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: S/P FALL, ? INJURY\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Bilateral pulmonary opacities are consistent with some combination of\n atelectasis and aspiration.\n 2. Endotracheal tube is approximately 12 mm above the carina and could be\n retracted slightly.\n 3. Cholelithiasis.\n\n These findings were discussed in person by Dr. with Dr. from\n trauma surgery at approximately 10:50 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088115,
"text": " 4:01 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: SEIZURE, EVALUATE FOR NEW BLEED\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with seizure, SDH\n REASON FOR THIS EXAMINATION:\n evaluate for new bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf SUN 5:15 PM\n Expected changes status post craniotomy for evacuation of subdural hematoma.\n There is no new hemorrhage. There is no significant mass effect, including no\n shift of midline structures or evidence of herniation. The ventricles are\n unchanged in size with no evidence of hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old woman with seizure and subdural hemorrhage, evaluate for\n new bleed.\n\n TECHNIQUE: CT head without contrast.\n\n COMPARISON: Compared to , at 6:10 a.m.\n\n FINDINGS: Patient is status post left frontotemporoparietal craniotomy. There\n are expected post-surgical changes at the craniotomy site, with no interval\n change compared to the study done earlier in the morning.\n\n Subdural hematoma on the left is unchanged. There is no shift of midline\n structures. There is a focus of hyperdensity anterior to the left lateral\n ventricle, 2:17, unchanged. The left temporoparietal lobe, 2:18, shows a\n region of hypodensity which appears unchanged with hyperdense blood tracking\n through, with similar appearance compared to prior study. There is a\n persistent trace of subarachnoid hemorrhage, 2:23, on the left vertex. Right-\n sided sulci and gyri appear normal.\n\n Minimal mucosal thickening in the ethmoid air cells. There is mild mucosal\n thickening in both maxillary sinuses. There is subcutaneous emphysema at the\n left soft tissue post-surgical. The mastoid air cells appear normal.\n\n IMPRESSION:\n\n Post-surgical changes status post craniotomy for evacuation of subdural\n hematoma. There is no new hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088116,
"text": ", NSURG TSICU 4:01 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: SEIZURE, EVALUATE FOR NEW BLEED\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with seizure, SDH\n REASON FOR THIS EXAMINATION:\n evaluate for new bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Expected changes status post craniotomy for evacuation of subdural hematoma.\n There is no new hemorrhage. There is no significant mass effect, including no\n shift of midline structures or evidence of herniation. The ventricles are\n unchanged in size with no evidence of hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1088258,
"text": " 1:34 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 46 cm Picc placed in left basilic vein, need Picc tip placem\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 46 cm Picc placed in left basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj MON 3:37 PM\n PFI: Left PICC tip projecting near cavoatrial junction. Improving lung\n aeration.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old female with left PICC placement.\n\n COMPARISONS: .\n\n A portable chest radiograph demonstrates a left PICC tip projecting near the\n cavoatrial junction. Bilateral scattered opacities are markedly improved\n compared to the radiograph from two days prior, most consistent with history\n of pulmonary contusion. Bibasilar opacities, left greater than right,\n persist. There is no pneumothorax. Median sternotomy wires are intact.\n\n IMPRESSION: Left PICC tip projecting near the cavoatrial junction. Improving\n pulmonary opacities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1088259,
"text": ", NSURG TSICU 1:34 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 46 cm Picc placed in left basilic vein, need Picc tip placem\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 46 cm Picc placed in left basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left PICC tip projecting near cavoatrial junction. Improving lung\n aeration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1087960,
"text": " 3:02 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: 66 y/o female on coumadin s/p fall, acute SDH, emergent \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o female on coumadin s/p fall, acute SDH, emergent Cranni for evacuation,\n pleae evaluate for residual. please perform w/ in 4 hrs.\n REASON FOR THIS EXAMINATION:\n 66 y/o female on coumadin s/p fall, acute SDH, emergent Cranni for evacuation,\n pleae evaluate for residual. please perform w/ in 4 hrs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw SAT 9:54 PM\n 1. Marked improvement in midline shift with residual 4 mm rightward shift\n post-evacuation of left-sided subdural hematoma.\n\n 2. Hypodensity in the left temporoparietal lobe with new hyperdense blood\n seen within and new hyperdense blood within the left lateral ventricle. No\n hydrocephalus.\n\n 3. There is no sign of herniation.\n\n 4. Persistent hyperdensity adjacent to the left anterior may be due to\n axonal injury or contusion injury, stable.\n\n 5. Post left craniectomy or craniotomy with underlying pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old female on Coumadin status post fall with acute subdural\n hemorrhage with emergent craniotomy for evacuation. Please evaluate for\n residual blood.\n\n HEAD CT: Axial imaging was performed through the brain without IV contrast\n administration. Coronal and sagittal reformations were prepared.\n\n FINDINGS: Patient is status post left frontal temporoparietal craniotomy.\n There is pneumocephalus underlying the site of craniotomy. The subdural\n hematoma that was present at this site has been largely evacuated with minimal\n residual hyperdense blood layering along the left temporoparietal convexity\n (2:13). There has been significant improvement in midline shift with now only\n 3 mm of rightward shift of the normally midline structures. There is a foci\n of hyperdensity (2:16) anterior to the left lateral ventricle, unchanged,\n which may represent or hemorrhagic contusion. The left temporoparietal\n lobe (2:17) has a region of hypodensity which appears unchanged; however,\n there is new hyperdense blood tracking through (2:17) and there is no blood\n layering dependently in the posterior of the left lateral ventricle which\n was not well seen on prior study. There is persistent trace subarachnoid\n hemorrhage at the left vertex (2:23). The right-sided sulci and gyri appear\n normal. There is mucosal thickening throughout the ethmoid sinuses and\n maxillary sinuses. Sphenoid sinuses are clear. Mastoid air cells remain well\n aerated. There is air in the subcutaneous tissue at the vertex and at the site\n of craniotomy. The ambient cistern and basilar cisterns are not effaced. No\n (Over)\n\n 3:02 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: 66 y/o female on coumadin s/p fall, acute SDH, emergent \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sign of herniation.\n\n IMPRESSION:\n\n 1. Marked improvement in midline shift with residual 4 mm rightward shift\n post-evacuation of left-sided subdural hematoma.\n\n 2. Hypodensity in the left temporoparietal lobe with new hyperdense blood\n seen within and new hyperdense blood within the left lateral ventricle. No\n hydrocephalus.\n\n 3. There is no sign of herniation.\n\n 4. Persistent hyperdensity adjacent to the left anterior may be due to\n axonal injury or contusion injury, stable.\n\n 5. Post left craniectomy or craniotomy with underlying pneumocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1087961,
"text": ", NSURG TSICU 3:02 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: 66 y/o female on coumadin s/p fall, acute SDH, emergent \n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 y/o female on coumadin s/p fall, acute SDH, emergent Cranni for evacuation,\n pleae evaluate for residual. please perform w/ in 4 hrs.\n REASON FOR THIS EXAMINATION:\n 66 y/o female on coumadin s/p fall, acute SDH, emergent Cranni for evacuation,\n pleae evaluate for residual. please perform w/ in 4 hrs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Marked improvement in midline shift with residual 4 mm rightward shift\n post-evacuation of left-sided subdural hematoma.\n\n 2. Hypodensity in the left temporoparietal lobe with new hyperdense blood\n seen within and new hyperdense blood within the left lateral ventricle. No\n hydrocephalus.\n\n 3. There is no sign of herniation.\n\n 4. Persistent hyperdensity adjacent to the left anterior may be due to\n axonal injury or contusion injury, stable.\n\n 5. Post left craniectomy or craniotomy with underlying pneumocephalus.\n\n"
}
] |
16,789 | 126,298 | The patient was admitted on and underwent L common carotid bypass to inominate artery/CABGx1(SVG->PDA)/inominate to ascending aorta bypass, aortic valve resuspension, asc. aorta repalcement/endovascular stent of arch and descending aorta on . She tolerated the procedure well and was transferred to the CSRU on Milrinone and NTG. She received multiple blood products. On POD#1 she was having seizures and neurology was consulted. She was started on Dilantin and the seizures resolved. She was unresponsive and unable to move her left side, and was found to have watershed emboli on MRI. She was started on tube feeds on POD#3, and was more alert on POD#5. She was weaned off her cardiac drips and was progressing. She has a progressively ischemic LUE and underwnet R carotid subclavian transposition on . Her arm improved immediately. She was unable to wean from the vent quickly and underwent trach and open G tube on . She was followed by for DM and was on Lantus insulin. ON she becan moving her L side to command. She had temps and was started on Vanco and Cefipime on . Her lines were changed and she was fully cultured. She eventually grew out MSSA from a line tip and was treated with Vanco. Her BUN and creat. began to rise on and renal was consulted. She became progressively lethargic and eventually unresponsive. She had another head CT and MRI which was unchanged. She was started on hemodialysis and eventually became more responsive. She was on hemodialysis for 4 weeks and remained anuric. She and her family were very discouraged with the pt's prognosis as she never wanted to live on dialysis. There were many discussions with the patient, the family, and Dr. of the ethics service, and the decision was made by the patient that she wanted to go home with hospice and discontinue dialysis. | Right ventricular systolicfunction is normal.4.The aortic valve is not well seen. Normal ascending aorta diameter.AORTIC VALVE: Aortic valve not well seen. Moderate cardiomegaly and the postoperative appearance of the mediastinum and aortic graft are unchanged. IMPRESSION: Stable chest radiographic appearance with left basilar atelectasis and small pleural effusion. Normal RVsystolic function.AORTA: Normal aortic root diameter. Unchanged left lung collapse and secondary left pleural effusion. The chronic left parietal and cerebellar infarcts are unchanged in appearance. There is persistent left retrocardiac opacity and a small left pleural effusion. An endotracheal tube remains in place, terminating just above the thoracic inlet level, and could be advanced 1-2 cm from optimal placement. Note is again made of a tracheostomy tube in standard position. Status post median sternotomy. Total opacification of left hemithorax. Encephalomalacia of the left temporo- parietal junction with associated ex vacuo dilatation of the occipital is consistent with remote infarction. Partial comparison is made to CT from . RECHECK DILANTIN LEVEL. The scout view shows that the patient has been extubated. dilantin and vanco levels done. SVO2 thermo swan , recal and fick co, svo2 61 fick ci >2.0, dressing changed. BS fine crackles L>R. csru updatecvs stable, tolerating lopressor dose. DP/PT pulses dopplerable bilaterally. pt on scheduled dilantin.C/V: NSR rare PVCs. Diamox to be started.GU: Lasix IV w/ good output. PPP, weakly.Resp: Pt on Vent support, SIMV+PS mode. Recheck K+ given diuresis. CATH TIP CULTURED STAPH AUREUS. Elevated RR w/ attempts at weaning. K+ repleted as protocol.Plan for peg and trach, possibly today. + doppler pulses.Resp: LS coarse. + FLATUS.GU: FOLEY CATH, SCANT U/O (SEE CAREVUE). SQ HEPARIN FOR DVT PROPHYLAXIS. BLE cool/ cyanotic. GROSSLY EDEMATOUSRESP: PT WEANED TO CPAP 8/5 WITH ACCEPTABLE ABG. strips CDI. LUNGS ARE CLEAR AND DECREASED > ON L SIDE BASE. PS weaned along with IMV according to ABG's. ETT ROTATED.GI--TOL. HAD HD YESTERDAY.SKIN: MODERATE AMOUNTS OF SEROUS DRAINAGE FROM PEG SITE. LYTES REPLEATED AS DOCUMENTED.RESP: TRACHED, ON CMV OVERNOC FOR REST. THEY HAVE BEEN UPDATED REGARDING RESP STATUS AND PT BEING PLACED ON CPAP VENTILLATION.A--RESP STATUS IMPROVING. peripheral pulses as charted, afebrile. Pt had episodes of dscrony taht were self resolved. recheck dilantin level. Placed on CMV with rate back to ''s. care note - Pt. REPLETE LYTES PRN-? Placed on Cpap/PS in am. See carvue for skin assess.GI/GU: Abd softly distended. R femerol aline with sharp waveform.CV: NSR without ectopy. See carevue for further assess.Resp: Pt remains with trach intact-vent weaning. Dopplered pulses to ext. vent and pressor weaning as tolerated. LOW K 2.9 REPLETED. HO notified cont'd lasix regimen. NGT PLACED POST PYLORIC-ABD XRAY CONFIRMED. LASIX GIVEN AS SCHEDULED GOOD DIURESIS. K+ repleated as protocol.Endo: BS covered per SSRI + sched long acting dose.Continue with pressent plan. ulnar, radial and brachial pulses all confirmed by doppler. SBP 120-150's, given scheduled lopressor with fair effect. DIAMOX STARTED FOR ALK. TITRATE NEO PER PARAMETERS AS ABOVE. GIVEN DILANTIN LOAD. ON NEO TITRATING-> ^ SBP CONVERTED TO SR. NEO TO MAINTAN SBP 120-140.RESP~REMAINS ON SIMV RR~12, BREATHING 2 OVER VENT. ABG adequate after trach placed. Wean Milrinone.Keep sbp <110.Replete lytes and follow HCT. Duoderm on coccyx intact.Access: R fem a-line, R fem TLC.ID: afebrileLabs: WBC down to 9.9 from 13.3; INR down to 2.2 from 2.9; Bun/Cr 112/4.1. Remains on A/C ventilation w/ PIP/Pplat = 26/19. informed,pm dose given.RESP- Trach dressing done,inner cannula changed. ABG on vent settings= 7.39/31/123/19. Resp CarePt. Lungs clear in upper fields, diminished in lower fields.GI/GU: Abd soft/distended, +BS, FS Respalor at 45cc/hr (goal) via PEG w/ no resids. Lytes treated prn.ID: Abx cont. Coumadin given. Resp CarePt. Resp CarePt. New G-tube was placed yest. trach care done.gi/gu: remains npo. Spont resp noted. Updated on POC. turned & repositioned q2h. Cynanosis to LLE and LUE. CPAP wean again . Gen edema noted.GU/GI: Foley to bsd with adequate huo. PASSIVE ROM ALL EXT Q2H. Weaned to CPAP w/ 18 IPS. resp. Updated on POC/supported. t&r q2hrs. Max temp 101. CONTINUE PASSIVE ROM/PT. +rp/pp bilat. 1 unit prbc's given. dampened.CV: HR is NSR 70-80's with SBP 120-150. Foley to bsd with adequate u/o.Skin: Sternal dressing and medialstinal dressing cdi. Abgs still alkalotic despite lasix d/c'd yest. radial pulses palp.Resp: Remains on vent. DOPP PP AND RADIAL PULSES. MDI's given. Gen edema noted. HD when ordered. CORDIS TIP CULTERED. PP via doppler. resp. Resp. Pt placed on A/c on return from OR. dopplerable pulses. Resp CarePt remains trached on A/C. 1HR GTT STARTED WITH RAPID DROP.PLAN: CONTINUE TO ASSESS CV/RESP STATUS. R subcl tunneled dialysis cath placed - CXR done - ok to use. WBC 16.2, afebrile.CV: SR -> ST, no ectopy. ABG's remain alkalotic - started on IV Diamox x4 dosesGU: foley to gravity. Minimal whitish secretions sx'd.CV: Hemodynamics stable. support.No vent.changes this shift.Abg's reveal a metabolic alkalemia,with excellent oxygenation.Suctioned for moderate amounts of thick white/clear secretions.Plan:continue support as indicated. continue PT/OT, passive rom. Foley to bsd with fair u/o.Endo. BP labile, NTG drip titrated to maintain SBP 120-140. Minimal secretions.CV: HR is 1st degree avb, rate 70-80's with SBP 100-150's. No objective s/sx pain noted.ASSESS: Ventilator dependent, elevated WBC count. +palp rp & +dopp pp bilat. Resp Care,Pt. MDI's given. pp by doppler. Resp. REMAINS IN 1 ST DEGREE AVB. Initiated trach care. TF as tol. tolerating tf well. cont tf. Breaths sound CTA w/diminished @ bases. t&r q2hr. DNRROS:Neuro: A+O. Minimal-trace movement of LUE noted. Care: Pt. hct stable. Pulses via doppler, peripheral edema noted, esp to LUE. coumadin remains on hold d/t elvated INR. NSR-ST, pac's and pvc's clears with lyte replacements. remains on A/C overnoc. t&r q2hrs. ABD SOFT WITH NORMOACTIVE BS'S. WEAN VENT AGAIN IN AM AS TOLERATED. GT patent and draining moderate amts of serous fluid. CONT VENT WEAN AS TOL. MDI's given. CREATININE 3.0. DISTAL PULSES DOPPLERABLE. Dopplerable pulses.Resp: Trach #8 Portex, weaned to Cpap 5/5. hct stable. DOPPLER PULSES BLE'S. CXR WAS DONE TO R/O EFFUSIONS. RXN TO DILANTIN. PS was weaned, plan to keep on current settings as tol. Dopplerable pulses. ?REHAB SCREEN. Ok to give despite AV MD . CONTINUE CPAPING VIA TRACH. | 240 | [
{
"category": "Echo",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 63775,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O Thrombus.\nWeight (lb): 183\nBP (mm Hg): 70/36\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nEffusion echo dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF>55%).\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve is not well seen. No aortic regurgitation is seen.\n5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n6.There is mild pulmonary artery systolic hypertension.\n7.There is a small to moderate sized pericardial effusion. The effusion\nappears circumferential. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. There are no echocardiographic signs\nof tamponade.\n8. No thrombus seen in the LV or RV.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-10-05 00:00:00.000",
"description": "Report",
"row_id": 125593,
"text": "Sinus rhythm\nGeneralized low voltage\nConsider prior inferior myocardial infarction\nConsider prior anterior myocardial infarction\nSince previous tracing of , QRS voltage lower and ST-T wave changes\nappear less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2187-09-25 00:00:00.000",
"description": "Report",
"row_id": 125594,
"text": "Atrial fibrillation with ventricular response rate approximately 120.\nBorderline low voltage. Inferior myocardial infarction of indeterminate age,\npossibly acute. Probable old anterior myocardial infarction. Minor non-specific\nlateral repolarization changes. Compared to the previous tracing of \nchanges suggesting inferior myocardial infarction of indeterminate age\n(possibly acute) are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2187-09-23 00:00:00.000",
"description": "Report",
"row_id": 125595,
"text": "Sinus rhythm\nLow limb lead QRS voltages - is nonspecific\nSince previous tracing of , atrial fibrillation not present\n\n"
},
{
"category": "ECG",
"chartdate": "2187-09-19 00:00:00.000",
"description": "Report",
"row_id": 125596,
"text": "Atrial fibrillation with a ventricular response rate approximately 90.\nGeneralized low voltage. Occasional aberrant A-V conduction. Compared to the\nprevious tracing of Sinus bradycardia with first degree A-V block has\ngiven way to atrial fibrillation and the ventricular rate has increased.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888775,
"text": " 8:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? left pneumothorax\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n ? left pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:01 P.M., \n\n HISTORY: Cardiac surgery. Left subclavian carotid transposition.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are clear. Postoperative mediastinal widening is stable. Cardiac\n silhouette may be slightly larger. Small left pleural effusion is new. No\n pneumothorax. ET tube, right jugular line in standard placement and the\n nasogastric feeding tube passes into the stomach and out of view. Aortic\n prosthesis unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 888451,
"text": " 5:14 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line placement\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery w/hypotension, decr SVO2\n\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac surgery, check line placement.\n\n COMPARISON: Radiograph dated .\n\n AP SEMI-UPRIGHT VIEW OF THE CHEST: Endotracheal tube terminates at the\n thoracic inlet. Two apparent nasal/orogastric tubes are in place and\n terminate below the diaphragm. There is interval exchange of the pulmonary\n artery catheter. A right IJ line terminating in the SVC. Median sternotomy\n wires and aortic stent material are again demonstrated. There is persistent\n left retrocardiac opacity not significantly changed. Right lung appears\n clear. No definite pneumothorax is present.\n\n IMPRESSION:\n 1. Status post exchange of pulmonary artery catheter for right IJ central\n venous line in satisfactory position.\n 2. Persistent left retrocardiac opacity possibly secondary to a small\n effusion with atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888525,
"text": " 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery w/hypotension, decr SVO2\n ^wbc\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Decreased oxygen saturation and elevated white blood cell count.\n\n Patient is status post median sternotomy and aortic graft placement. Lines\n and tubes remain in satisfactory position. Cardiac and mediastinal contours\n are stable. There is persistent left retrocardiac opacity and a small left\n pleural effusion. The right lung is grossly clear.\n\n IMPRESSION: Stable chest radiographic appearance with left basilar\n atelectasis and small pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 893571,
"text": " 6:33 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o pts\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, new right IJ Quinton line\n placement\n REASON FOR THIS EXAMINATION:\n r/o pts\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Port line placement status post cardiac surgery.\n\n CHEST: A single portable supine view at 1830 hours is compared to previous\n examination of . Again, seen complete opacification of left\n hemithorax likely secondary to a combination of pleural effusion and\n atelectasis. There is no significant shift of the mediastinal structures.\n There is a small right pleural effusion. The right lung is clear.\n\n There is a new a right IJ central venous catheter with the tip in SVC. There\n is no evidence of pneumothorax. The tracheostomy tube is in place. The\n patient is status post median sternotomy and aortic stenting.\n\n IMPRESSION: No significant change since the previous examination of , .\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2187-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893728,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess infiltrates/effusions\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, new right IJ Quinton line\n placement\n REASON FOR THIS EXAMINATION:\n assess infiltrates/effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old status post cardiac surgery, assess for effusions and\n infiltrates.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT CHEST RADIOGRAPH: Right internal jugular central venous\n catheter and tracheostomy tube are in unchanged position. Note is again made\n of an aortic stent and median sternotomy wires.\n\n Again seen is complete opacification of the left hemithorax with associated\n leftward mediastinal shift. This has not changed appreciably from the prior\n study and likely represents left lung atelectasis with some component of left\n pleural effusion. The right lung is clear. Osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n 1. Unchanged left lung collapse and secondary left pleural effusion.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-04 00:00:00.000",
"description": "CHEST FLUORO WITHOUT RADIOLOGIST",
"row_id": 893569,
"text": " 4:55 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: PERMACATH\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n FINAL REPORT\n Chest fluoro was performed without radiologist present. One minute of fluoro\n time was used. No films submitted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-19 00:00:00.000",
"description": "T ENDO, STENT GRAFT THORACIC ANYSM W/O SUBCLVN",
"row_id": 887679,
"text": " 5:04 PM\n 0039T ENDO, STENT GRAFT THORACIC ANYSM W/O SUBCLVN Clip # \n Reason: ASCENDING AORTIC AND TRANSVERSE AND DESCENDING ARCH ANEURYSM\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n FINAL REPORT\n Please see CareWeb Notes for the complete operative report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 887921,
"text": " 10:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o CVA\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with s/p aortic surgery\n REASON FOR THIS EXAMINATION:\n r/o CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post aortic surgery. Assess for stroke.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: Head CT from .\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,\n hydrocephalus, or change from . The chronic left parietal and\n cerebellar infarcts are unchanged in appearance. No new areas of -white\n matter differentiation are seen.\n\n IMPRESSION: Unchanged appearance of the brain since .\n Specifically, no new intracranial hemorrhage or major vascular territorial\n infarction is seen. MRI is more sensitive in the assessment of acute brain\n ischemia if the patient is an MRI candidate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887699,
"text": " 8:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, tamponade, pneumothorax, pulmonary edema\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery\n REASON FOR THIS EXAMINATION:\n pleural effusion, tamponade, pneumothorax, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracic aortic aneurysm repair.\n\n COMPARISON: .\n\n FINDINGS: AP supine portable view of the chest. The endotracheal tube\n terminates in satisfactory position just below the thoracic inlet. The\n nasogastric tube extends below the left hemidiaphragm, terminating below the\n inferior margin of the image. The right internal jugular Swan-Ganz catheter\n terminates in the right main pulmonary artery. Multiple mediastinal drains\n are present. There is post-surgical widening of the mediastinum. A graft is\n present in the ascending aorta, aortic arch, and descending thoracic aorta.\n There is mild pulmonary vascular congestion. There is no pleural effusion and\n no evidence of a pneumothorax in supine position. There are new mediastinum\n sternotomy wires, as well as new surgical clips in the right axilla. There is\n a new fracture of the right second rib, which may be related to preceding\n surgery.\n\n IMPRESSION:\n 1. Satisfactory position of lines and tubes. No evidence of pneumothorax.\n 2. Post-surgical changes in the mediastinum, right axilla, and right second\n rib.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888200,
"text": " 10:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval cardiopulm process\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery w/hypotension, decr SVO2\n\n REASON FOR THIS EXAMINATION:\n eval cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n COMPARISON: .\n\n INDICATION: Hypotension and decreased oxygen saturation.\n\n There has been interval change in position of a Swan-Ganz catheter, which\n makes an abrupt downward turn in the region of the main pulmonary artery. It\n is uncertain whether this is coursing back within the right ventricular\n outflow tract or if it has coursed into the descending left pulmonary artery\n branch. An endotracheal tube, nasogastric tube, mediastinal drains, and\n left-sided chest tube remain in place. There is no evidence of pneumothorax.\n There has been interval resolution of perihilar haziness. Atelectatic changes\n are noted in the left retrocardiac region and there is also a small left\n pleural effusion. There is stable postoperative widening, and an aortic graft\n remains in place with stable widening of the adjacent left mediastinal\n contour.\n\n IMPRESSION: Possible malpositioning of Swan-Ganz catheter, as described\n above. Correlation with pressure measurements may be helpful. Otherwise,\n satisfactory postoperative appearance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 887806,
"text": " 1:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed, CVA\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with s/p aortic surgery\n REASON FOR THIS EXAMINATION:\n r/o bleed, CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n HISTORY: Rule out infarction or hemorrhage after aortic surgery.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. No prior brain imaging studies are available for comparison.\n\n FINDINGS: There is no evidence of hemorrhage. There are multiple areas of\n hypodensity in the cerebellar hemispheres bilaterally. These appear\n relatively well defined, and thus are not likely to represent acute\n infarction. However, the larger area in the left cerebellar hemisphere may\n represent a subacute infarction. There is encephalomalacia and atrophy in the\n left parietal lobe, suggesting old infarction.\n\n There is fluid in the sphenoid and ethmoid sinuses with mucosal thickening in\n the maxillary sinuses bilaterally.\n\n CONCLUSION: No evidence of acute infarction or of hemorrhage. There is an\n area of old infarction in the left parietal lobe. There are bilateral\n cerebellar hemispheric infarctions. These appear old on the right and chronic\n or perhaps subacute on the left. Incidentally noted are drusen bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-20 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 891652,
"text": " 12:03 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: r/o cva, pls. do DWI\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o cva, pls. do DWI\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with CVA, for further evaluation.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\n images of the brain were acquired. Comparison was made with the previous MRI\n examination of .\n\n FINDINGS: The diffusion images demonstrate an area of increased signal\n adjacent to the anterior portion of the left lateral ventricle. Accounting\n for differences in slice selection, this is unchanged from the previous MRI\n study. There is chronic watershed infarct in the left parietooccipital region\n as before. The previously detected multiple infarcts in both cerebral\n hemispheres are also noted as T2 hyperintense changes. There is no evidence\n of a new area of slow diffusion visualized. Again noted is absence of flow\n within the left vertebral artery. Increased signal is seen in the right basal\n ganglia region on the T1-weighted images, which is more pronounced since the\n previous study and could be secondary to petechial hemorrhage and/or\n mineralization in the areas of ischemia. Soft tissue changes are seen in the\n mastoid air cells and sphenoid sinus.\n\n IMPRESSION: No evidence of definite new acute infarct. Area of\n hyperintensity on diffusion images adjacent to the anterior portion of the\n left lateral ventricle was present on the previous study when accounting for\n differences in slice selection and indicate subacute infarct. No mass effect\n or hydrocephalus. Other changes as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891540,
"text": " 7:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n assess for effusions\n ______________________________________________________________________________\n FINAL REPORT\n Portable AP chest.\n\n Comparison to .\n\n INDICATION: Assess for effusion. Recent left subclavian carotid\n transposition.\n\n A small pleural effusion slightly larger than 2 days prior. Left lower lobe\n atelectasis is unchanged. The exam is otherwise unchanged. Moderate\n cardiomegaly and postoperative mediastinum are stable. Aortic graft is\n unchanged. Tracheostomy tube is in standard position. The right lung is\n clear.\n\n IMPRESSION: Stable left lower lobe atelectasis with slightly larger small\n left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-19 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 891595,
"text": " 12:35 PM\n RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: r/o obstruction\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with s/p aortic surgery\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE RENAL ULTRASOUND AND DOPPLER\n\n CLINICAL INDICATION: Status post aortic surgery, to assess for possible\n hydronephrosis or vascular abnormality.\n\n Both kidneys are normal in size, measuring 11.6 cm in length on the right and\n 11.2 cm on the left. There is no evidence of hydronephrosis or renal stones.\n There is a small bulge in the upper pole of the left kidney compatible with a\n simple cyst as seen on CT of . No other renal masses or cysts are\n identified. Color flow and pulse Doppler evaluation shows a relatively\n normal-appearing blood flow in the left kidney with normal acceleration time.\n Color flow and Doppler of the right kidney also appeared normal but pulse\n tracings could not be obtained due to respiratory motion.\n\n CONCLUSION: No evidence of renal obstruction, calculi, or obvious vascular\n abnormalities in this limited portable study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891277,
"text": " 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: patient with wbc and intermittent fever please eval for infe\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n patient with wbc and intermittent fever please eval for infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery, aortic graft. Intermittent fever.\n\n IMPRESSION: AP chest compared to and 21st:\n\n Opacification in the left lower lobe is more severe, most commonly due to\n atelectasis. There is also a new small left pleural effusion. Moderate\n cardiomegaly and the postoperative appearance of the mediastinum and aortic\n graft are unchanged. Right lung is essentially clear. Tracheostomy tube is\n in standard placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893195,
"text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS FOR INFILTRATES/EFFUSIONS\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left\n subclavian-carotid transposition\n REASON FOR THIS EXAMINATION:\n ASSESS FOR INFILTRATES/EFFUSIONS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old female status post cardiac surgery for recent left\n subclavian-carotid transposition, now evaluate for infiltrates and effusions.\n\n COMPARISON: .\n\n AP SUPINE CHEST RADIOGRAPH: There is total opacification of the left\n hemithorax which is new compared to the prior examination. There is slight\n mediastinal shift. Likely a small right pleural effusion. Note is again made\n of a tracheostomy tube in standard position. Aortic graft is unchanged.\n\n IMPRESSION:\n 1. Total opacification of left hemithorax. Slight mediastinal shift. This\n likely represents atelectasis and less likely effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 891441,
"text": " 10:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for cva\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p L carotid->inominate bypass/CABGx1/Asc Ao replacement\n REASON FOR THIS EXAMINATION:\n assess for cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 83-year-old woman status post left carotid to innominate artery\n bypass surgery, aortic valve replacement, and coronary artery bypass.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intra- or extraaxial hemorrhage. There is no mass\n effect, hydrocephalus or shift of the normally midline structures. The sulci\n and ventricles are again noted to be prominent, consistent with age-related\n involutional changes. The -white matter differentiation is preserved,\n without evidence of acute territorial infarction.\n\n The appearance of a chronic infarct in the left parietal lobe is unchanged, as\n well as multiple hypodense areas in the cerebellum. Vascular calcifications\n of the carotid and vertebral arteries are again seen. There is perhaps\n minimally increased sphenoid sinus mucosal thickening compared to the prior\n study, as well as minimal right-sided maxillary sinus thickening. The osseous\n and soft tissue structures are unremarkable.\n\n The scout view shows that the patient has been extubated. There is persistent\n swelling of the oropharyngeal soft tissues, which could be related to recent\n intubation.\n\n IMPRESSION: No significant interval change. No evidence of intracranial\n hemorrhage or other acute process. Persistent soft tissue swelling in the\n oropharynx and neck.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888265,
"text": " 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check DHT placement, cts d/c'd\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery w/hypotension, decr SVO2\n\n REASON FOR THIS EXAMINATION:\n check DHT placement, cts d/c'd\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 11:20 A.M.\n\n COMPARISON: at 22:51 p.m.\n\n INDICATION: Dobbhoff tube placement and chest tube removal.\n\n A feeding tube is in place, and courses below the diaphragm, with the tip not\n included on the radiograph. A pre-existing nasogastric tube remains in place\n also coursing below the diaphragm. There remains an unusual appearance of the\n Swan-Ganz catheter, which is either coiled in the main pulmonary artery and\n directed inferiorly in the right ventricular outflow tract or coursing within\n the descending portion of the left pulmonary artery. Following removal of a\n left-sided chest tube, there has been development of a tiny left apical\n pneumothorax. Cardiac and mediastinal contours are stable. An endotracheal\n tube remains in place, terminating just above the thoracic inlet level, and\n could be advanced 1-2 cm from optimal placement. There is otherwise no\n significant change since the recent chest radiograph.\n\n Findings communicated to on the date of the study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889537,
"text": " 4:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o sub q emphysema\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n r/o sub q emphysema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postop cardiac surgery.\n\n AP bedside chest. There is a poorly assessed large stent extending from the\n mid ascending aorta across the arch and into the mid descending thoracic\n aorta. There is a 17 mm separation between this stent and the superior\n portion of the visualized aortic knob. Sternal wire sutures and\n satisfactorily positioned multiple tubes and catheters. There is probably a\n small layering left pleural effusion with atelectasis behind the heart. Right\n lung is clear. Skin staples overlie the left lower neck and supraclavicular\n region. Incidentally noted is a laterally subluxed left humeral head and\n surgical clips in the right axilla (with right breast silhouette poorly\n identified). Allowing for slight differences in positioning, there is little\n change from exam with probable diminution in the postop left\n cervical subcutaneous emphysema.\n\n IMPRESSION: No significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-26 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 888516,
"text": " 8:56 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please use DWI, r/o CVA\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with s/p aortic surgery\n REASON FOR THIS EXAMINATION:\n please use DWI, r/o CVA\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN\n\n INDICATION: Status post aortic surgery with suspicion of cerebral infarction.\n\n Correlation is made to head CT of .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the brain without contrast\n was performed. In addition, MR angiography of the brain with 3D time-of-\n flight images of the circle of and its major tributaries was performed.\n\n MRI OF THE BRAIN WITHOUT CONTRAST: Several foci of restricted diffusion are\n found within the left frontal lobe, left caudate head, bilaterally within the\n cerebellum, and within the right occipital lobe. This is indicative of\n infarction that is subacute - days to up to two weeks old. Encephalomalacia of\n the left temporo- parietal junction with associated ex vacuo dilatation of the\n occipital is consistent with remote infarction.\n\n The ventricles are appropriate in size for the patient's age and mostly\n symmetric. There is no shift of the normally midline structures. Some\n evidence of old hemorrhagic by-products in the location of left\n temporoparietal encephalomalacia is noted. No other susceptibility foci are\n found. The brainstem is normal in appearance.\n\n MRA OF THE BRAIN: There is absence of flow within the left vertebral artery.\n The other major arterial vessels of the circle of and its tributaries\n show normal flow signal without occlusion, aneurysm formation, or stenosis.\n\n IMPRESSION:\n 1. Multiple bilateral foci of recent infarction consistent with embolic\n etiology.\n 2. Old left temporoparietal junction infarction.\n 3. Absence of flow within the left vertebral artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890130,
"text": " 1:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of left subclavian carotid transposition and tracheostomy.\n\n Status post median sternotomy. Tracheostomy tube is 7 cm above carina.\n Endograft is present in the aortic arch and proximal descending thoracic\n aorta. No pneumothorax. There is cardiomegaly and opacity at the left base\n obscuring the left hemidiaphragm consistent with consolidation/atelectasis in\n the left lower lobe. Cannot rule out an associated small left pleural\n effusion. Surgical clips are present in the right axilla.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-09-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 888270,
"text": " 12:21 PM\n PORTABLE ABDOMEN Clip # \n Reason: check DHT placement\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with\n REASON FOR THIS EXAMINATION:\n check DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placement.\n\n COMPARISONS: No comparisons are available. Partial comparison is made to CT\n from .\n\n TECHNIQUE: AP supine single view of the abdomen.\n\n FINDINGS: There is a Dobbhoff feeding tube placed with the tip in the third\n portion of the duodenum. The NG tube tip is located probably in the first\n portion of the duodenum. There are multiple thin wires overlying the patient.\n There is atherosclerotic calcification of the aorta and of the splenic artery\n in this patient with a known small infrarenal AAA. There are also\n calcifications in the splenic artery. There is a stent in the right iliac\n artery. There are degenerative changes of the lumbar spine. There are\n pacemaker wires.\n\n IMPRESSION:\n 1. Dobhoff feeding tube tip is in the third portion of the duodenum.\n 2. NG tube tip is probably in the pyloric region. If the desired position is\n yet to be in the stomach, recommend withdrawing approximately 10 cm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889206,
"text": " 3:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ASCENDING & DESCENDING AORTA\\ ASCENDING AORTIC ARCH W/CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman s/p Cardiac surgery, recent left subclavian-carotid\n transposition\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Coronary artery disease status post cardiac surgery.\n\n CHEST: There has been increased opacification in the basal regions suggesting\n bilateral effusions which were not present on the prior chest x-ray of\n . The position of the various other lines, tubes and stents is\n unchanged.\n\n IMPRESSION: New bilateral effusions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-04 00:00:00.000",
"description": "Report",
"row_id": 1482016,
"text": "Respiratory Care\nRemains intubated and ventilated on simv/psv. No vent changes made overnight. Still tachypneic with resp rate 25-35. Failed rsbi (113).\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-04 00:00:00.000",
"description": "Report",
"row_id": 1482017,
"text": "NEURO: ALERT, ANIMATED. NODDING AND SHAKING HEAD APPROPRIATELY TO QUESTIONS. FOLLOWING COMMANDS CONSISTENTLY. SEE CAREVUE FOR Q4H NEURO ASSESSMENTS. NO PAIN MEDS OR SEDATIVES GIVEN.\n\nPULM: ORALLY INTUBATED TO SIMV MODE RATE 10, FIO2 0.4, VT 550, PEEP 5, PS 14. CONTINUES TO TACHYPNEIC WITH RR > 30. LUNGS FAIRLY CLEAR, SX'D FOR TENACIOUS YELLOW-TAN SECRETIONS.\n\nCV: NSR-ST WITH RARE ECTOPIC BEATS. SEE CAREVUE FOR Q1H VS. TOLERATING LOPRESSOR 25MG VIA FEEDING TUBE. LYTES REPLETED PER LABS. PEDAL PULSES VERY WEAKLY PALPATED BY 4. RADIAL PULSES EASILY PALPATED. LE WARM AND PINK, BOTH FEET COLD WITH SLIGHTLY CYANOTIC TOES. R HAND COLD, L HAND COLD WITH BLACK TIPS OF DIGITS.\n\nENDO: Q6H FSBS, BS > 200 RX WITH 8 UNITS REGULAR INSULIN SC X 2.\n\nGI: ABD SOFT. TOLERATING PROMOTE WITH FIBER AT GOAL RATE 65CC/HR, NO RESIDUALS. SCANT AMT BROWN FECAL SMEARING ON CHUX.\n\nGU: FOELY TO CD DRAINING QS AMTS URINE. GOOD RESPONSE TO LASIX. DIAMOX AT 0600.\n\nSOCIAL: SON VISITED LAST EVE.\n\nPLAN: TO OR FOR TRACH AND PEG THIS AM. CONTINUE CURRENT RX. RECHECK DILANTIN LEVEL. REPLETE LYTES PER LAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-04 00:00:00.000",
"description": "Report",
"row_id": 1482018,
"text": "Resp Care\nPt remains intubated on SIMV. Possible trach tomorrow. Pt continues hyperventilate, due to neuro status. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-04 00:00:00.000",
"description": "Report",
"row_id": 1482019,
"text": " A\ncv: Bilat. toes duskier throughout day. Feet cool to mid calf, ped/pst tib pulses w/ doppler only. Left fingertips cyanotic unchanged from . Strong radial pulses\nneuro: able to move left toes and fingers on command this am - new. follows commands, answers appropriately w/ nod/head shake.\nresp: rr continues to be >30 suctioned x2 for thick white sputum. bilat bases dim.\nGU: lasix increased to TID w/ good outputs\nGI: tube feed at goal, sm. stool, pos. BOS\nactivity: OOB to chair x3hrs. PT and OT for ROM tolerated well\nsocial: son, daughter, son-in-law, grandchildren to visit much more positive outlook from family today.\nassessment:edema increasing, peripheral circ decreasing, left side improving. pt denies pain but bp and rr up w/ movement med x2 for pain darvocet this am, motrin 4pm.\nplan: NPO after midnoc for PEG/trach . lasix increased, continue to increase activity as tol. vanco trough tonight\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-04 00:00:00.000",
"description": "Report",
"row_id": 1482020,
"text": "endo: visit today Lantus increased , sliding scale changed sugars 150's\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-20 00:00:00.000",
"description": "Report",
"row_id": 1482085,
"text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex on PSV. Currently +15PSV/+5PEEP maintaining Ve ~14L sometimes > when agitated. No vent changes made. BLBS slightly coarse, suctioned for small amounts of thick white sputum. SpO2 remained 90s. ABG shows compensated metabolic acidosis w/ PaCO2 = 27/HCO3 = 18. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; wean per pulmonary plan (rest on A/C overnoc)...\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-21 00:00:00.000",
"description": "Report",
"row_id": 1482086,
"text": "Respiratory Care:\n\nPatient trached # 8.0 Portex. Cuff presssure 15cm H20. Pt. weaned to Psv 15 yesterday and rested on A/c for the noc. Vent settings Vt 500, A/c 10, Fio2 40% and Peep 5. RR mid to high 20's. Bs coarse with scattered rhonchi bilaterally. Sx'd for sm amount of thick white secretions. No further changes made. Plan: Will do RSBI later this morning. Continue with Psv wean during day/resting on A/c at noc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-21 00:00:00.000",
"description": "Report",
"row_id": 1482087,
"text": "Neuro: pt rsponds to verbal and tactile stimuli, is not or will not follow commands, ? angry... depressed... effects of stroke.\nResp: see flow sheet and resp note\nCardiac: 1 degree AVB, ABP per flow sheet\nSkin: light red rash over most of pt's body, Gt site draining serous fluid per flow sheet\nGI/GU: + BS, formed stool at the rim of rectum, digital disimpaction done, ? need suppository or enema, foley to gravity draining clear yellow urine, quantity borderline10 to 20 cc/hr\nPlan: continue to minitor labs and vitals and treat as indicated and as ordered, frequent repositioning\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-21 00:00:00.000",
"description": "Report",
"row_id": 1482088,
"text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex trach on PSV. Currently on +15PSV/+5PEEP w/ Vt ~500 RR ~26 maintaining Ve ~14L, becomes tachypneic at times w/ RR ^40s. SpO2 remained 90s. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; continue to wean per pulmonary plan...\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-21 00:00:00.000",
"description": "Report",
"row_id": 1482089,
"text": "NPH-0700-1900\nNEURO-no acute neuro changes,no movement-left arm,open ayes to stimuli\n\nCV-hr-70's,no ectopy,sbp-90-130's,inc lasix to 80mg iv bid am dose given -no respond\n\nGI-bs + x4,bm x 1,tf-45 cc/hr tolerating well ,\n\nRENAL- uo-10-20cc/hr,? -start-HD-MD-FAMILY meeting -monday\n\n pt on c-pap tolerating well\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-22 00:00:00.000",
"description": "Report",
"row_id": 1482090,
"text": "Neuro: slightly more /awake this shift vs 24 hours ago, PERRL, no S/S of pain or discomfort\nCardiac: SR, no ectopy, ABP down to upper 70's low 80's a couple of times when pt was sleeping, stimulated pt and BP WNL\nResp: see flow sheet\nGI/GU: + BS, + flatus, XXL soft formed brown stool, pt slightly impacted, digital disimpaction done with close monitoring of vitals, no vagal response, noted, foley to gravity, minimal increase in UO after lasix, zero residuals from GT\nPlan: monitor vitals and labs and treat as indicated and as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-22 00:00:00.000",
"description": "Report",
"row_id": 1482091,
"text": "Resp: pt on psv 15/+5/40%. Pt is trached with #8 portex. CP 18 cmh20. BS are clear bilaterally with diminished bases. Suctioned for small amounts of thick white secretions. Pt rested on a/c 10/500/+5/40% noc. AM ABG 7.36/31/143/18. RSBI=126. Plan to continue to wean to psv when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-23 00:00:00.000",
"description": "Report",
"row_id": 1481964,
"text": "Neuro Nursing Note\nAccuracy of exam is significantly blood pressure dependant. With higher systolic BP patient opens eyes and focuses on RN, purposefully moves right hand to attempt to extubate self. Requiring re-restraint of the RUE. Moves right upper and lower extremities on the bed, minimal withdraw/posture of left upper extremity. Intact gag, cough and corneals. No command following, but significantly better exam then with lower SBP, as follows. Eyes disconjugate with pupils 3 with rebound sluggish hippus on right and brisk 3 on left. No movement of left upper or lower ext with triple flex on right upper and lower. Will attempt to maintain SBP toward higher end of 120-140 parameter with neo, currently at 0.25 mcg/kg.\nPLAN: Continue q 8 hour dilantin will recheck level in AM, periodic neuro exams, if deteriorates report to MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-23 00:00:00.000",
"description": "Report",
"row_id": 1481965,
"text": "Respiratory Care\nPt.remains on PSV and tolerated well abg's adequate.No vent.changes this shift.Plan:maintain minimal vent.support till neuro status improves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-23 00:00:00.000",
"description": "Report",
"row_id": 1481966,
"text": "Nursing Progress Note:\nCVS: hr 70's sinus with rare pvc. SVO2 thermo swan , recal and fick co, svo2 61 fick ci >2.0, dressing changed. Currently on neo at 0.3 on and off overnight for sbp goal 120-140. Pulses by doppler x 4 ext, right hand pink and warm. Left middle three fingers cold and purplish, bilat feet/toes cool and cyanotic. Skin on back and buttocks pink and intact. See carevue flowsheet for further info on dressings and incisions. 2 a and 2 v wires not in use, improper sensing secured and capped. r ulnar art line patent, blood return hand boarded due to initial posturing then attempt to grab at ett lead to restraining.\n\nResp: LS clear in uppers to dim in lower lobes, sxn for scant thin tan to white secretions. sats >98 on 40 percent oxygen.\n\nNeuro: see previous note.\n\nGI: abd large round slightly distended. OGT clamped when hooked to suction returned only drops of bright green bile. Meds given via gt, no feedings ordered at this time. BS hypoactive no BM.\n\nGU: UOP slowing, SBP fluctuates low to 80's after lasix dosing, changed from tid dosing to lasix drip at 5 mg per hour. uop has maintanied >75 cc hour since drip started.\n\nEndo: fs bs checked q 6 hours, note requiring coverage at this time.\n\nPlan: control SBP within parameters, follow dilantin levels and neuro exams with neuro team. FOllow cardiac needs with CSURG, ? start OGT feedings? monitor labs and I $ O 's. possibly wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-22 00:00:00.000",
"description": "Report",
"row_id": 1481962,
"text": "NURSING PROGRESS NOTE 11P-7A\nS: INTUBATED\n\nO: NEURO: PT. OFF ALL SEDATION. WILL OPEN EYES TO COMMAND, DOES NOT FOLLOW ANY OTHER COMMANDS. WILL NOT SQUEEZE HANDS. MOVING ARMS ON BED, ABLE TO LIFT RIGHT ARM OFF BED. NO MOVEMENT OF LOWER EXTREMITIES NOTED. CONT ON DILANTIN 100 MG TID, NO SEIZURE ACTIVITY NOTED.\n\nCV: NEO NOW OFF BP AS HIGH AS 170'S SYS WHEN AWAKE. NTG GTT STARTED AT 0.5 MCG/KG/MIN TO KEEP SBP ~140. TITRATED FREQUENTLY AS SBP DRIFTS DOWN TO 90-100 WHEN SLEEPING. SEE FLOWSHEET FOR HEMODYNAMIC DATA. CT SITE C&D, CT DRAINING MINIMAL AMT OF SERO/SANG FLUID. STERNAL INCISIONS INTACT, DSD INTACT. NO DRAINAGE NOTED. DOPPLERABLE PULSES ONLY. FEET COOL TO TOUCH. RIGHT GROIN C&D. K+ 3.6 REPLETED WITH 20 MEQ THIS AM.\n\nRESP: INTUBATED, SEE RESP FLOWSHEETT FOR VENT SETTINGS. SUCTIONING FOR TAN SECRETIONS. ABG ADEQUATE THIS AM. DIMINSHED BREATH SOUND AT BASES, CLEAR IN UPPER AIRWAYS.\n\nGI: OGT IN PLACE, VERIFIED WITH AIR AUSCULTATION. OGT AT LOW INTERMITTENT SUCTION. DRAINING BILIOUS GASTRIC CONTENTS. OB -\n\nGU: CONT TO RECEIVE LASIX 40 MG TID, RESPONDS WELL TO LASIX. URINE CLEAR YELLOW.\n\nENDO: SSRI COVERAGE FOR ELEVATED BLOOD GLUCOSE.\n\nA/P: S/P CABG, AVR POD #2. ? CVA POST SURGERY, MINIMAL NEURO REPONSE, NO SEIZURE ACTIVITY NOTED. MONITOR LYTES AND REPLETE AS NEEDED. MONITOR FOR ANY SEIZURE ACTIVITY, FOLLOW DILANTIN LEVELS. UPDATE FAMILY ON PLAN OF CARE PER CSRU TEAM\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-08 00:00:00.000",
"description": "Report",
"row_id": 1482037,
"text": "PROB: S/P TRACH, RESP FAILURE\n\nCV: SR WITH OCC PVC NOTED, VSS. L HAND FINGERTIPS CYANOTIC. R AND L TOES WARM AND DUSKY. K REPLACED AT 16:00.\n\nRESP: CONT ALKALOSIS. SUCTION FOR THICK YELLOW. SUCTION CATH CHANGED THEN SPUTUM CULTURED. O2 SATS ADEQUATE.\n\nGU: FOLEY CATHETER AND DRAINAGE SYSTEM CHANGED D/T HX OF YEAST IN URINE. URINE WITH MORE SEDIMENT AFTER CATH CHANGED. URINE CULTURE SENT.\n\nGI: TOLERATING TUBE FEED. SMALL AMOUNT OF SOFT STOOL OOZING.\n\nID: VANCO CHANGED TO OXACILLIN. CATH TIP CULTURED STAPH AUREUS. RECULTURED SPUTUM, URINE, AND BLOOD. PICC CONSULT CALLED, UP TO EVALUATE PT. DID NOT RECOMMEND PICC D/T POS LINE TIP CULTURE, AND DILANTIN DOSES WHICH WOULD PRECIPITATE IN LINE.\n\nENDO: LANTIS DOSE INCREASED D/T HIGH S/S COVERAGE. SEE FLOW SHEET.\n\nNEURO: CONT TO MOVE L FINGERS SLIGHTLY TO COMMAND. DID NOT SEE PT L LEG. PERL. FOLLOWS COMMANDS. NODS APPROPRIATELY. CASE MANAGER IN TO SPEAK WITH FAILY REGARDING REHAB. OOB TO CHAIR VIA LIFT. SEEN BY PT AND OT TODAY.\n\nSOCIAL: SOCIAL WORKER- CALLED TO VISIT WITH DAUGHTER. DAUGHTER APPEARED ANGRY THIS AM UPON ARRIVAL, STATING THAT THE FAMILY WAS NOT GIVEN ANY INFORMATION REGARDING THEIR MOTHER OVER THE WEEKEND. IT HAD BEEN REPORTED THAT THE RESIDENT ON CALL HAD UPDATED THEM. DAUGHTER REPORTED THAT THE FAMILY HAD TO \"FORCE\" HIM TO TALK TO THEM. SPENT MANY HOURS WITH DAUGHTER TODAY, HOPING TO IMPROVE COMMUNICATION. DAUGHTER ALSO UPDATED BY TODAY.\n\nASSESSMENT: , NODDING APPROPRIATELY.\n\nPLAN: RECHECK BS/LYTES.\nCPAP AS TOLERTED.\nPULM HYGIENE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-08 00:00:00.000",
"description": "Report",
"row_id": 1482038,
"text": "Respiratory Care Note:\n\n Pt received confortably on ventilatory support. No changes done until NP to try PSV as tol. After ~less than 1/2 hr we had to put back on CMV. Plan: Will coninue to monitor VS closely and daily wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-09 00:00:00.000",
"description": "Report",
"row_id": 1482039,
"text": "csru update\ncvs stable, tolerating lopressor dose. NSR, no ectopy. tmax F, continued antibiotics. distal pulses weak, audible by doppler. vent settings unchanged overnight, secretions yellow, thick. pt moves slightly left arm and fingers (except ring and small finger) to command. nods appropriately, uses symbols chart and mouth words to communicate. tolerating tf, insulin covered per sliding scale, fixed dose of lantus given during the day. coccyx red, small broken area about 1/2 cm in diameter slightly oozing with serous drainage, barrier cream applied. rest of pressure areas unmarked.\n\nplan: continue plan of care. ?pressure relieving mattress, ?allevyn dressing for coccyx area, position changes\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-09 00:00:00.000",
"description": "Report",
"row_id": 1482040,
"text": "Resp Care NOTE\n\nPt attempted wean on 20/5 PSV yesterday but tolerated only half hour. SHe has been on AC 14 x 550, +5, 50%. attempt short wean of hour or less today\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-09 00:00:00.000",
"description": "Report",
"row_id": 1482041,
"text": "NPN: Review of Systems\nNeuro: Pt sleeping intermittenly. Rouses easily to voice. Nodding to \"yes, no\" questions and mouthing words. Asked in pain and Pt nodded \"no\". Stuck tongue out, grasped w/ right hand and attempting to bend right leg to command. No movement elicited from LLE and Pt moved center three fingers on left hand to command. (+) cough reflex. PERRL. No seizure activity observed.\n\nResp: pt placed on PS 20 per respiratory, but rr up to 30s so Pt placed back on CMV. Breathing approx 2-5 breaths over the vent. Sao2=100% on 50% Fio2. Sxned small amt of thick pale yellow secretions. BS are CTA bilaterally.\n\nCV: SR. Hr in the 80s. No ectopy. K+=3.9->40meq KCl given. BP has been stable. Please see flowsheet for data and assessment. DP/PT pulses dopplerable bilaterally. Radial pulses palpable bilaterally. Left great toe tip cyanotic as well as left 2nd, 3rd and 4th fingers. Pt continues on heparin at 1400 units/hour.\n\nGI: Tubefeedings at goal rate of 65cc/hr. Abdomen is soft. (+) bowel sounds. Small amts of soft brown stool. Colace held. Blood sugar=197-> 8 units regular insulin per sliding scale.\n\nGU: Lasix as ordered. Brisk clear yellow urine.\n\nID: Continues on vancomycin and cefepime. Sputum sent for culture as requested by ID. Tmax=99.6 orally.\n\nSkin: Small, approx 1cm skin abrasion present on coccyx. Wound assessed by skin care specialist and duoderm applied to site. Perineal and perianal are red. Miconazole powder applied to perineal area and aloe vesta cream applied to perianal area. Plan to apply fungal ointment , followed by aloe vesta cream once it arrives. Red splotchy rash present on back and arms. NP aware and plan is to continue to follow. ? rxn to oxacillin.\n\nSocial: Dtr. called twice this shift and updated on Pt's plan of care.\n\nA: Hemodynamically stable. Elevated RR w/ attempts at weaning. Open wound present on backside.\n\nP: Continue to monitor per plan. PICC line to be placed in interventional radiology in future once blood culture results are finalized. Awaiting g-tube placement.Pt to be transferred onto therapeutic airmattress once it arrives. Recheck K+ given diuresis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-09 00:00:00.000",
"description": "Report",
"row_id": 1482042,
"text": "BS fine crackles L>R. Attempted CPAP x 2 with patient becoming agitated and tachypneic. Most likely will need further diuresis before weaning will be successful.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-22 00:00:00.000",
"description": "Report",
"row_id": 1481963,
"text": "Neuro: pt opens eyes to voice. does not follow commands. moves rt arm freely. moves rt leg to stimuli. moves left leg to noxious stimuli. moves left arm inward to noxious stimuli no spontanious movement noted on left. PERL .\n\nPain: unable to assess due to altered neuro status .\n\nCV: pt is NSR dopplerable DP/PT pulses. and dopplerable left arm radial/ulner and brachial.Left hand cold with cyonotic finger tips. Lt hand +4 edema as is rt hand; elevated hand on pillow and placed in warm blankets . hand is warm but fingers tips still cyonotic. vascular into evaluate pt B/P rt 114/75, L 103/56. SBP to be between 120-140. NTG and neo used to maintain desird SBP. pt SBP dropped after lasix needing neo on intermittently. pt SBP elevates with care but usually returns to base no NTG need since am.neo currently at .14mcg/kg/MIn Pa cath in place. see care view. SVO@ > 60 most of day dropped to high 50's while bathing and turning pt returned to 60 after am care given. K 2.9 currenly repleating.\n\nLungs: vent CPAP 40/5/15. lungs coarse to clear upper coarse to edecreases in bases suction for small amt of white sputum. CT to wall minimal drainage.\n\nGI: abd soft BS present. slightly hypoactive. NG LWS bilious drainage. no stool\n\nGU foley to gravity . yellow to amber clear urine. lasix given with effect. pt is running negative for today.\n\nSkin: incisions clean and dry dsg done see care view. no redness or break down noted .\n\nA unstable. cause of altered neuro status unclear.\nP continue frequent monitoring notify service of changes monitor left arm closley notify team and vascular service of significant changes. sent K after repleation. monior SVO2 closley when providing stage activity if needed . maintain SBP betwwen 120-140 as able.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-07 00:00:00.000",
"description": "Report",
"row_id": 1482032,
"text": "BS coarse crackles. Despite temp of 101.4 overnight, Tmax today 99. Failed wean to CPAP this AM - f.40 despite PSV 20. Also attempted on trach collar with f>50. Late morning PSV tried again - f>40. This afternoon, pt apparently more comfortable and for the moment doing well on PSV 20 - rate in mid ''s, Vt's 500. Does not tolerate lowering of PSV however.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-07 00:00:00.000",
"description": "Report",
"row_id": 1482033,
"text": "Addendum: PSV terminated due to tachypnea and increased BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-07 00:00:00.000",
"description": "Report",
"row_id": 1482034,
"text": "Nursing note: Neuro: , nods head appropriately to questions, denies pain. Moves right arm and head spontaneously, no other movement noted. Perrl.\n\nCV: SR, sbp stable. Heparin gtt infusing at 1200units/hr with last PTT 61.3, theraputic per Dr. .\n\nPulm: See RT notes, cpap , Lungs coarse/clear bilaterally.\n\nGU: Uo >50cc/hr, good response to diuresis.\n\nGI: Tube feed at goal rate, frequent soft/formed stool\n\nSkin: Surfaces grossly intact, finger and toe tips cyanotic, pulses by doppler. Temp 99 this am\n\nSoc: Several children in, express interest in all aspects of care and desire to be more updated by MD on a daily basis as possible.\n\n\nP: Continue vent wean as tolerated/indicated, monitor for further temps spikes. Facilitate communication between family/MD and clarify questions as appropriate. Ptt in am with daily labs.\n\n\nR: Pt back on CMV for tachypnea/hypertension with return to baseline vital signs. Temp at 1600 98.9. Dr. in to see family for update this pm. All else per careview data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-25 00:00:00.000",
"description": "Report",
"row_id": 1482105,
"text": "neuro: more easily arousable since yesterday to voice, moves rt upper & lower extrs, but not on command. slight twitching in left upper extr with prom. moves foot with tactile stimulation. stuck out tongue on command! perrl. grimaces with nailbed stimulus.\n\ncv: hr 70s-80s, sbp low 70s-110s while resting- 120 to 170s with turning side to side. dopplerable pulses. lopressor decreased to 25mg. 2mg coumadin given\n\nresp: bilat upper lscta, diminished at bases. sx sm amt thick white sputum. rr high 20s to 30s. Psupp weaned from 15 to 10. abgs good-see flowsheet.\n\ngi/gu: bs present. sm bm. tf @ 35cc/hr. foley patent, uo scant. hemodialysis out 2000cc, hemodialysis to continue on Saturday.\n\nendo: blood sugars monitored per ss protocol. lantus increased to 30 units.\n\nskin: red rash over torso, upper extrs, back and abd. redness on lower extrs not as severe as upper body.\n\nsocial: daughter visited.\n\nplan: continue to monitor respiratory status and wean Psupp. monitor hemodynamics. ? whether ac is needed overnight or continue cpap.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-26 00:00:00.000",
"description": "Report",
"row_id": 1482106,
"text": "Neuro: Pt arouses to voice. PERRLA. Able to track shortly then loses focus. Inconsistent w/movement to command, did blink to command x1, hold RUE to command, and wiggle toes to commandx1. L arm remain flaccid-but moved L fingertips when asked to squeeze hand. pt on scheduled dilantin.\nC/V: NSR rare PVCs. Lytes repleated. SBP 80s-120, short period of 160s when turning. Pt aroused when SBP 80s-->increased to >90. Goal SBP >90 per team. Edema in L/R thigh, LUE. Skin W&D, fingertips & toes cool to touch-see carevue. Continues on coumadin per daily order.\nResp: Continues on CPAP, tachy RR 30-40s. PS increased by RT-->RR improved. ABG compensated met acidosis MD made aware, no tx ordered. LS: clear R lobe, crackles L lobe.\nGI/GU: +BSx4, TF at goal rate 35cc/hr. +loose stool x2. Abd soft & NT. Minimal UO, plan for HD on per team.\nSkin: Body rash,pink slightly raised, cont. Ordered non-bleached linen. See carevue for incisions.\nID: Afebrile. Plan to inform team in Am regarding previous pan culture results. No antibx tx right now.\nEndo: Blood sugars tx per pt's sliding scale.\nComfort: No c/o pain. No call/visit from family.\nA/P: continue hemodynamic/resp/neuro monitoring. Plan for HD on sat.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-03 00:00:00.000",
"description": "Report",
"row_id": 1482013,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt has no neuro changes. Still no movement on left side of body. Random movement of rt leg and arm. Able to trach with eyes and attempts to mouth words. Able to perform weak hand grasps with rt hand.\nCV: HR is NSR 90-100's, rare ectopy. SBP 90-160's. Goal sbp 130.\nBP is very labile at times. Off all gtt's, except heparin. Goal 50-70. Tharaputic at this time. Skin warm and diaphoretic at times. RT hand is warm with cool and cyanotic finger tips. Pulses palable. CVP runs . PPP, weakly.\nResp: Pt on Vent support, SIMV+PS mode. Rate 10/PS 14/peep 5/40%\nPt over-breathes by 10-20 bpm. Pt has failed earlier wean trials.\nABG somewaht alkalotic.\nGU/GI: TF at goal, 65 ml/hr. BS x4, small smear of brown liq stool only. Abd soft. Foley to bsd with adequate u/o with Lasix 20 mg .\nEndo: BS have been running high 100-200's. Coverage per SSRI, awaiting consult. K+ repleted as protocol.\nPlan for peg and trach, possibly today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-03 00:00:00.000",
"description": "Report",
"row_id": 1482014,
"text": "CV: BP stable. Feet warm, pedal pulses palpable w/ 8am assessment, cool, dusky and pulses by doppler only at 4pm. Left finger tips remain dark and cool.\nResp: lungs coarse. sxn for thick yellow sputum. culture sent. ABG alkalotic. Diamox to be started.\nGU: Lasix IV w/ good output. Diflucan started for + yeast in urine.\nGI: Tolerating tube feed at current rate. No residuals. Small stool x 1.\nNeuro: Dilantin low - extra doses x2. some movement of left hand during PT consult - previously flaccid. OOB to chair via w/ left femoral a-line. OK'd by .\nEndo: consult today. Lantus and new sliding scale started. Glucoses 150's covered w/ sliding scale.\nSocial: Daughters updated many times by nsg, PT, , Dr. . Social worker and priest in to talk to daughter . she felt more optimistic leaving today.\nAssessment: change in pedal pulses. neuro improving - movement left hand.\nPlan: Diamox for alkalosis, cont. pulmonary hygiene, new insulin regimen, increased activity as tolerated, trach and PEG insertion pending.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-08 00:00:00.000",
"description": "Report",
"row_id": 1482035,
"text": "csru update\nNSR without ectopy, lytes all repleated, bp stable. tmax 100.6, cooling measures done. dilantin and vanco levels done. heparin ^1300, rpt ptt at 1000hrs. pedal pulses very weak, present by doppler. dozing off intermittently, denies any pain. attempts to mouth words, nods appropriately when asked. able to move left hand forefinger and thumb to command, no movement noticed to left foot. left hand (+)sensation but not to light touch.tolerating tf well, bs covered per sliding scale, involve with glucose control. diuresing excessively with lasix, pt complains of thirst all the time and dryness of mouth. sacrum red but intact, skin barrier applied, precaution to avoid skin breakdown taken related to bowel movements+++.\n\nplan: ptt at 1000hrs, resp wean as tolerated, vascular assessments, maintain skin integrity intact, continue plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-08 00:00:00.000",
"description": "Report",
"row_id": 1482036,
"text": "Resp Care Note\n\nPt remaining on AC x 14 x 550, 50% . Weaning has been attempted several times over past few days but she becomes tachypneic to 40's. Plan is to try again today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-24 00:00:00.000",
"description": "Report",
"row_id": 1482099,
"text": "Respiratory Care Note\nPt received on PSV as noted. PS weaned to 8cm - pt tolerating well with VT 400-450 and RR 26-33. Pt started on Dialysis. Pt seems to be tiring with increased WOB and sats of 89% during dialysis and placed on AC with improvement. Pt's breathing seems more comfortable with sats of 100%. BS are clear bilaterally. Plan to continue with PSV trials as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-24 00:00:00.000",
"description": "Report",
"row_id": 1482100,
"text": "NEURO: PT MORE AWAKE AFTER HD, SMALL HAND SQUUEZE TO COMMAND BUT MORE READILY OPENING EYES. SPONT MVMT RT ARM (RESTRAINED FOR KNOCKING OFF VENT) , WITHDRAWS TO PAIN IN RT LEG, LT LEG. NO MVMT LT ARM. NO SZ\nCV: STABLE. HR 60-70'S NSR, BP DROPS TO 80-90'S WHEN ASLEEP BUT U TO 120-150 W/ STIMULUS. ALL PULSES DOPPLERABLE. TIPS OF EXTREM DUSKY, BUT OTHERWISE WARM. GROSSLY EDEMATOUS\nRESP: PT WEANED TO CPAP 8/5 WITH ACCEPTABLE ABG. PT APPEARED LABORED WITH SLIGHT INCREASE RR, AND DROP IN O2 SATS WHILE ON HD. ABG WAS WNL AT THAT TIME BUT PO2 IN 70'S. ATTEMPTED TO INCREASE PS TO 15 WITH NO CHANGE. PT PLACED ON AC TO REST, RETRY CPAP WEAN IN AM. O2 SATS BACK UP TO 97-100% ON AC. SX SM THICK WHITISH/YELLOW\nGI: TF CHANGED TO FS NEPRO AT 35CC/HR (=GOAL- FROM RESPALOR FOR RENAL PROTECTION) TOLERATED WELL. NO RESDIUAL. LG BM WITH TURNS--FORMED. FOUL SMELLING, TARRY--GUAIAC + ( AWARE) HCT STABLE. CDIFF SPEC SENT. ABD SOFT. COPIOUS AMT SEROUS FLUID FROM GT INSERTION SITE.\nGU: MINIMAL UOP APPROX 20CC Q4HR. FIRST HD THIS PM. 2HOUR RUN, REMOVED APPROX 500CC. PT TOLERATED WELL EXCEPT RESP STATUS AS ABOVE. PLAN HD IN AM. QUINTON CATH FLUSHED BY HD NURSE\nPLAN: CONT AS ABOVE. CONT ASSESS CARDIO/RESP STATUS. RE WEAN TO CPAP IN AM. PLAN HD TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-24 00:00:00.000",
"description": "Report",
"row_id": 1482101,
"text": "ADDENDUM: RASH UNCHANGED ON BODY, COUMADIN RESTARTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-20 00:00:00.000",
"description": "Report",
"row_id": 1482083,
"text": "Neuro: pt arousable to name when called at times. Opens eyes but does not follow commands. Continues to move right arm all around and right leg on bed. Slight movement of left leg seen but no movement of left arm. Pupils equal and reactive. Pt went for head MRI tonight, no obvious changes seen awaking radioloigist report.\nResp: attempted to place pt back on cpap with ips last evening but pt dropped sats to 85% which correlated with ABG. REsted overnight on AC. Suctioned for small amounts of thick white to yellow secretions. THis am pt placed on cpap with ips 15 RR immediately 40 wtih sats of 95%. pt initially hypertensive but bp settling down.\nC/V: blood pressure labile depending on level of consciousness. When asleep bp drops to 90's when awake as high as 170's. Heart rate in the 70's 1st degee AV Block with a PR interval of .22 pulses present by doppler in both feet but difficult to find in left foot.\nGI: tolerating tube feeds well Respalor at 45cc/hr with no residiual via PEG tube.\nEndo: pt treated with lantus and sliding scale at beditime.\nGU: urine outputs 10-20cc/hr Ho aware will follow per renal. No further lasix order. Cr repeat last evening 2.6. Pt started on Prednisone 40mg po per Renal request.\nSkin: pt continues to have bright pink rash on torso upper legs and arms. Antibiotics have been stopped for now. Sternal incision healed, left neck incision steristripes following off no drainage.\nAbdominal incision with staples PEG tube right bedside it dsg over both saturated with serous drainage. 1st and 2nd toes on both feet cyanotic feet cool to touch with good cap refill. left had with necrotic finger tips hand swollen\nPLan: Coninue to wean pt, Follow neuro status\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-20 00:00:00.000",
"description": "Report",
"row_id": 1482084,
"text": "Neuro: arousal to voice does node head and move eyes to command and questions, denies pain, does lift and hold right arm, no movement out of left arm, does move both legs on bed, does not move extremities to command.\n\nCardiac: 1st degree av block, no ectopy noted, sbps running wnls, faint dopplerable pedial pulses, both legs are cool and cyanotic, left hand has 2 finger tips that are blue no color in fingers are improving, +3 edema in extremities.\n\nResp: put to cpap during day shift has good abg though does have bicab of 18 and pco2 of 27, at 10pm to 6am will rest back on a rate, lungs are dim in bases, sxned for scant tan secretions.\n\nSkin: chest is healed, moderate amount of serous drainage from around abd incision site, duoderm to coccyx that is intact.\n\nGi/Gu: tf at goal small loose bm, good bowel sounds, on riss, abd soft round and nontender, did get lasix doses per renal team, making around 10-15/hr of u/o-bun and creat are up-abx were d/c'd yesterday and started on prdnisone per renal.\n\nPlan: back to rate at night, monitor pulses, monitor blood sugars, monitor abgs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-25 00:00:00.000",
"description": "Report",
"row_id": 1482102,
"text": "CSRU NPN\nNEURO: MOSTLY SLEEPING, AROUSES TO LOUD VOICE/NOISE. DOES NOT FOLLOW COMMANDS. PERRLA. NONPURPOSEFUL MOVEMENTS OF RIGHT ARM - RESTRAINED WITH SOFT WRIST RESTRAINT AS PT WILL INADVERTENTLY DISCONNECT THE VENT FROM THE TRACH, LEFT ARM FLACCID. OCCASIONALLY MOVES BLE ON BED. AFEBRILE. NO SZ ACTIVITY NOTED.\n\nCV: SEE CAREVUE. SR NO ECTOPY. B/P LABILE - SBP AS LOW AS 70S WHEN ASLEEP, AS HIGH AS 150S WITH SXN. SQ HEPARIN FOR DVT PROPHYLAXIS. ALL PULSES DOPPLERABLE. LYTES REPLEATED AS DOCUMENTED.\n\nRESP: TRACHED, ON CMV OVERNOC FOR REST. SXN FOR THICK WHITE SECRETIONS VIA TRACH. L/S COARSE WITH DIM BASES.\n\nGI: NEPRO @ 35CC/HR VIA PEG. 2 SMALL BM'S. + FLATUS.\n\nGU: FOLEY CATH, SCANT U/O (SEE CAREVUE). HAD HD YESTERDAY.\n\nSKIN: MODERATE AMOUNTS OF SEROUS DRAINAGE FROM PEG SITE. ABRASION ON LEFT BUTTOCK, COVERED WITH DUODERM. ON KINAIR BED WITH MULTIPODUS BOOTS.\n\nENDO: CSRU SSRI.\n\nPLAN: ATTEMPT WEAN TO CPAP TODAY AS TOLERATED. MONITOR LABS, TREAT AS ORDERED. ? IF PT WILL CONTINUE WITH HD ON SHORT TERM VS. LONG TERM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-25 00:00:00.000",
"description": "Report",
"row_id": 1482103,
"text": "Respiratory Care\nPt.switched to PSV this AM,see carevue for specifics,Abg adequate this am.Suctioned for small to moderate amounts of thick white secretions.Plan:Decrease ps as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-25 00:00:00.000",
"description": "Report",
"row_id": 1482104,
"text": "after dialysis we began to wean the ps from 15 to 10cmh2o.she has been\ngenerating vt=400 cc with rr20's.moderate amt white thin secretion,\nexcept once a small amt of yellow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482008,
"text": "addendum: pt on cpap with ips of 18 resp rate in the 30's but not labored np ordered to decrese ips to 16. pt became tachypneic in the 40's and labored.. pt also with temp at this time so pt placed on simv. Early this am while team rounding pt placed back on cpap with ips 18\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482009,
"text": " am:\nNeuro: opens eyes to command and moves head and right hand to command, does move left leg but not to command, no left side movement, pupils equal and reactive to light, denies pain.\n\nCardiac: nsr with no ectopy, sbps wnls, dopplerable pedial pulses and radial ulnar pulses, skin warm dry and intact, +3 edema in extremities, low grade temps, continues hep gtt did increase gtt are awaiting new ptt.\n\nResp: lungs are clear, failed cpap back on imv, abg wnls, sxned for scant thick tan.\n\nSkin: chest with dsd that is cdi, old ct dsd is cdi, lef tleg app[roximated and is cdi, left neck with staples and is cdi, righ neck with strips and is cdi with transparent dsd.\n\nGi/Gu: tf at goal with no residuals, abd is soft and obese with good bowel sounds, on riss blood sugars running high, good u/o.\n\nPlan: ? peg and trach this week, ? consult, monitor for any left sided movement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482010,
"text": "Respiratory Care Note\nPt received on PSV as noted. BS clear bilaterally. Pt suctioned for small amts thick, tan secretions. Pt placed on SIMV + PS due to increased RR to 40's. PS weaned along with IMV according to ABG's. Attempted to wean PS to 10, but RR increase to 35-38. Plan to remain on current settings at this time. Plan to possibly trach sometime this week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482011,
"text": "NSG update\nNeuro:Pt alert to verbal stimuli, able to follow simple commands example: squeeze right hand and wiggle right toes. Unable to move left side. Perrla. Denies pain by nodding no when asked. 1 episode of bilat eye twitching, seeming less responsive, though able to follow commands during this period, NP at bedside during episode, no interventions.\n\nCV: HR 80-105 SR/ST No ectopy. BP labile SBP 90-140s. CVP 13-15. Lasix dose increased. BLE cool/ cyanotic. Left nailbeds dusky. + doppler pulses.\n\nResp: LS coarse. On SIMV rate 10, PS 16, Peep 5, FiO2 40%, Abgs 7.50/32/147/2/26/98%. NP aware. PS decreased to 14. RR high 20s-30s. Sats greater than 94%.\n\nGI/GU: Abd soft obese, +BS, smearing of stool x1. Foley draining adequate amts clear yellow urine.\n\nSkin: Sternal dsg intact. strips CDI. Sutures to left neck D+I.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamics. Monitor pulmonary status. consult for FS. Monitor for neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-03 00:00:00.000",
"description": "Report",
"row_id": 1482012,
"text": "Respiratory Care\nRemains intubated and ventilated on simv 550 x 10 40% 14psv/5 of peep. Resp rate generally high 20s. ABGs with good oxygenation, slight alkalosis. No plans to extubate this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482078,
"text": "Resp Care\nPt remains on vent. Pt rested on AC overnight and was returned to cpap in am. Suctioned mod amt of thcik white secretions. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482079,
"text": "Respiratory Therapy\n\nPt remains trached and mechanically ventilated. Pulmonary consult, plan is to wean PSV slowly starting at +15/+5PEEP, resting overnoc on A/C settings per resp flowsheet. If pt tired during the day, rest 2-4 hrs at a time on A/C. VD/VT calculated this shift --- PaCO2=30 PeCO2=10 for a deadspace measurement of 67%. Dr. aware. BLBS slightly coarse, suctioned for small amounts of thick white sputum. SpO2 remained 90s. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; wean per pulmonary plan...\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482080,
"text": "PATIENT'S NEURO STAUS APPEARS TO DECREASEING IN LOC, NONRESPONSIVE TO VERBAL STIMULI THIS PM, EYES ONLY OPEN TO PAINFUL STIMULI, IE TURNING, SUNCTIONING. NOT EVEN RESPONSIVE AT TIMES TO HER DAUGHTERS, DID OPEN EYES TO BROTHER'S VOICE THIS AM, DOES NOT FOLLOW COMMANDS, MOVES RSIDE/LEFT LE SPONTANEOUSLY, NO MOVEMENT TO LEFT ARM.. PUPILS EQUAL/REACTIVE, NO SEIZURE ACTIVITY, BUT DID RECEIVE 300MG DILANTIN IV PER NEURO, DILANTIN LEVEL WAS 8.. NEURO AWARE, PLAN TO MRI IN NEAR FUTURE... CARDIAC SR IN THE 80'S WITH NO ECTOPY, SBP 110-130'S WHEN RESTING DROPPED TO 85, DID TOLERATE LOPRESSOR 75 MG TH IS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-01 00:00:00.000",
"description": "Report",
"row_id": 1482004,
"text": "CSRU NURSING PROGRESS NOTE 0700-1900\nCARDIAC--RARE PVC'S WHICH CLEARED WITH K+REPLETMENT. BP REMAINS LABILE WITH ANY STIMULATION AS WELL AS HAPPENING SPONTANEOUSLY. IT IS SELF LIMITING AND HAS NOT NEEDED ANY INTERVENTION. HR SR/ST. REMAINS ON HEPARIN GTT AT 1400 U HR WITH NO CHANGES DONE TODAY AS PT IS WITH THERAPEUTIC LEVELS.\n\nRESP--PLACED ON IPS 18 AND PEEP 5. ATTEMPTED IPS OF 16 BUT RESP RATE INCREASED AND TV FELL. SX Q2 HRS FOR SCANT AMTS OF THICK WHITE SPUTUM. SAO2 >96%. LUNGS ARE CLEAR AND DECREASED > ON L SIDE BASE. ETT ROTATED.\n\nGI--TOL. TUBE FEEDS AT GOAL THROUGH PEDITUBE. SOFT FORMED STOOL X2.\n\nGU--GOOD RESPONSE TO 20 MG IV LASIX. UO NOW AT >30CC HR VIA FOLEY CATH.\n\nENDO--SSRI COVERAGE EARLIER TODAY AND WILL RECHECK LATER THIS EVENING.\n\nSKIN--INTACT ON BUTTOCKS AND BACK. NECK INCISIONS ARE DRY WITH -STRIPS AND STAPLES. MIDLINE CHEST INCISION IS WITH DSD. NO OOZING. EARLIER THIS AM, L NECK INCISION WAS OOZING BUT THIS HAS SUBSIDED. L FINGERTIPS REMAIN BLUE. BILAT. FEET ARE MOTTLED AND COOL. ALL PULSES VIA DOPPLER.\n\nNEURO--ALERT AT TIMES. OPENS EYES TO NAME. NODS HEAD TO SIMPLE QUESTIONS INCONSISTENTLY. NO MOVEMENT ON L SIDE. R SIDE MOVES ON BED WITH RUE LIFT AND HOLDING. PEARL AT 3-4MM.\n\nID--FEBRILE TO 100.3. ON ABX. NEED TO SEND VANCO LEVEL TONIGHT.\n\nPAIN--NO PAIN MED GIVEN. NODS HEAD NO WHEN ASKED IF IN PAIN.\n\nCOPING--FAMILY IN ALL DAY. THEY HAVE BEEN UPDATED REGARDING RESP STATUS AND PT BEING PLACED ON CPAP VENTILLATION.\n\nA--RESP STATUS IMPROVING. REMAINS WITH LABILE BP ALTHOUGH LESS LABILE THAN PREVIOUS DAYS.\n\nP--CON'T PULM TOILET. OFFER SUPPORT TO PT AND FAMILY. ? WHEN TO START PT. CON'T TO WEAN VENT. MONITOR LYTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-01 00:00:00.000",
"description": "Report",
"row_id": 1482005,
"text": "Respiratory Care Note:\n\nPt received on ventilatory support and was able to tolerate daily spont support. We started on PSV ~0900 AM of 16 and incrteased a few hrs up to 18cmH20. Plan: daily wean as tol with resting on vent support O/N and try to keep more stable BP. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482006,
"text": "Resp. Care:\n Pt, remains intubated and on vent.support. Attempted to wean PS slightly, but pt. with rr 40 and labored respirations--Back to SIMV/PS mode with good results. RSBI =168.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-02 00:00:00.000",
"description": "Report",
"row_id": 1482007,
"text": "cv: sbp decreased to 84/ briefly ~ 1 minute, but returned to baseline without intervention. hr sr to st 90's to 106 st no ectopy.\n\nid: temp to 101.6 po. blood cultures times one via peripheral, unable to get set number 2 peripherally\n so drawn via multilumen. tylenol 650 mg per feeding tube.temp decrease to 100.8 po.\n\ngi: tolerating tube feed at goal ..promote with fiber at 65 cc/hr.. residual 5 cc. abd soft, positive bowel sounds, 2 large soft bms\n\ngu: foley draining clear yellow urine.Diuresed after lasix 20 mg iv .\n\nneuro: pt opens eyes to stimulus. moves R arm and R leg on bed. No movement of left leg, no movemnt left arm.tips of fingers of left hand are blue.left radial pulse present by doppler. feet are cool bilaterally. toes are mottled, dp and pt pulses present by doppler. obeys simple commands such as open your mouth.\n\nendo: blood sugas elevated on current sliding scale dr pt received a one time increased dose o 14 units reg sc to cover 8 pm blood sugar of bs=165 tx with 8 units regular. pt to have consult today fo ? long acting insulin in addition to coverage with regular.\n\nlytes: mag, ca , K repleted\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482081,
"text": "PATIENT RESP STAUS CONTINUES ON CPAP WITH IPS 15, PLAN TO WEAN BY 2 EACH DAY IF TOLERATES,REST IN 3-4HR INTERVALS ON AC IF NEEDED, THEN PLACE BACK ON CPAP, REST OVERNIGHT ON AC. MINIMAL THICK WHITE SECRETIONS, TRACH CLEAN, CARE DONE.. GU CREATININE RISING UP TO 2.3, U/O DRIFTING DOWN TO 10-15CC/HR LASIX DECREASED TO 20 MG WILL FOLLOW CLOSELY, RENAL US COMPLETED. FAMILY AWARE OF REANL ISSUES.. GI TUBE FEEDS NOW RESPALOR AT 45CC/HR VIA JTUBE, DRAININED LOTS OF SEROUS FLUID NEW DSD PLACED.. SKIN RASH RED RAISED TO ABDOMEN/LEGS AWARE. ?? ANTIBIOTIC THERAPY. DUODERM CHANGED TO COCCYX AREA, X2 AREA OF STAGE 2 WILL FOLLOW CLOSELY... ENDOCRINE BS ELEVATED TO 162 THIS PM, 4U REGULAR INSULIN SC GIVEN LANTUS TO BE GIVEN THIS AM. COUMADIN 4MG VIS JTUBE THIS PM WILL FOLLOW PT/DILANTIN LEVELS. FAMILY AT BEDSIDE ALL AFTERNOON, ASKING APPROPRIATE QUESTIONS.. PLAN FOR MRI THIS EVENING...\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-20 00:00:00.000",
"description": "Report",
"row_id": 1482082,
"text": "Resp Care\nPt remains on vent. Trached with # 8 portex. Suctioned mod amt of thick white secretions. Went to mri without incident. Placed on Cpap/PS in am. Plan to wean as tolersted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-21 00:00:00.000",
"description": "Report",
"row_id": 1481957,
"text": "Nursing Plan\nPlan: monitor neuro status, pain, blood pressure and sugar control. vent and pressor weaning as tolerated. Wake up per team deceision in am. recheck dilantin level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-21 00:00:00.000",
"description": "Report",
"row_id": 1481958,
"text": "resp care\npt remained on imv 550x12 40% 5peep and 10psv with peak/plat 27/24. BS bil and clear. spont breaths with volumes of 200-300cc.Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-21 00:00:00.000",
"description": "Report",
"row_id": 1481959,
"text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to CSRU without incident, weaned to PSV tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-21 00:00:00.000",
"description": "Report",
"row_id": 1481960,
"text": "NPN:\n\nNEURO: PROP OFF THIS AM. OPENS EYES TO PAIN AND THIS AFTERNOON TO VOICE WHEN FAMILY VISITED. NOTED TO MOVE R ARM AND MIN R LEG ON BED. L LEG WITH OCC SL KNEE JERK TYPE MOVEMENT. NO MVT OF L ARM SEEN. PUPILS SL IRREG PER NEURO-REACT TO LIGHT. HAD REPEAT HEAD CT AND EEG. REMAINS ON DILANTIN 100MG TID- LEVEL CHECKED PRIOR TO 16PM DOSE -12.9.\nCV: APACED AT 90 INITIALLY-NOW IN SR 70-80 WITH RARE APC'S SEEN. LOW K 2.9 REPLETED. MAG AND CA REPLETED. BP SOMEWHAT LABILE AT TIMES-ON/OFF NEO TO .3 TO KEEP SBP 120-140/. CO> BY FICK WITH MVO2 SATS 74-66. PAD 22-15 WITH CVP 16-10. PEDAL PULSES BY DOPPLER EXCEPT UNABLE TO GET L DP. FEET WARM. HCT SATBLE AT 35.\nRESP: VENTILATED ON SIMV MOST OF DAY WITH STABLE ABG'S. PLACED ON CPAP WITH 15 PS THIS AFTERNOON WITH GOOD ABG'S. SXN FOR SMALL THICK YELLOW SECRETIONS. CT TO SXN-NO AIRLEAK-MOD SEROSANG DNG. SATS 97-98%.\nGU: FOLEYN TO GD. CR 1.1. UO GOOD RESPONDING TO LASIX 40 IV TID.\nGI: ABD OBESE, SOFTLY DISTENDED WITH HYPO BS. OGT TO LWS-BILIOUS OUTPUT.\nENDO: ON/OFF INSULIN GTT PER CTS PROTOCOL FOR 6 GLUCOSES TO 197.\nINCISIONS: STERNUM AND CT WITH DSD-D/I. R UPPER CHEST/NECK-DSD. L LEG WITH ACE WRAP. L FEM CORDIS REMOVED DSD.\nACTIVITY: BEDREST-TURNED SIDE TO SIDE WITH MAX ASSIST 2.\nA: CONT MINIMALLY RESPONSIVE WITH NO MVT L ARM.\nP: NEURO FOLLOWING-AWAITING CT AND EEG RESULT-CONT DILANTIN. NEO TO KEEP SBP 120-140. REPLETE LYTES PRN-? REST OVERNIGHT ON IMV?.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-18 00:00:00.000",
"description": "Report",
"row_id": 1482074,
"text": "1900-0700\n\nNeuro: No acute neuro changes noted. Pt remains with eye opening to verbal stimuli. Tracking at times. Intermit follows simple commands. Moves RUE off bed, RLE on bed, no movement to LExt. Severe vascular compromise see carevue for further details. Pupils equal and reactive, Irregular resp patterns noted, HO aware.\n\nResp: Pt with trach intact, A/C, 500, 40%, 10 +5. Irregular patterns noted. O2 sat stable. No abg this am. Suctions for minimal thick white secretions. Lungs coarse bilaterally. L femeral aline intact without ability to draw blood.\n\nCV: NSR without ectopy. HR 70-90, SBP 100-140. Tolerating lopressor well. Remains on Heparin drip lowered to 1000u/hr per HO after PTT >90. Repeat PTT 60.9. Coumadin dose given in PM. Vanco level lower than 20.0 dose given. Remains on cefapime. ^WBC. Torso rash noted. See carvue for skin assess.\n\nGI/GU: Abd softly distended. No BM. Peg intact draining copious amounts of serous fluid. Surgery evaluated-no new orders at this time. Promote with fiber @ 65cc/hr tolerated. Foley to gravity draining gold urine, pt receiving lasix IV. BUN:53, CR:1.9.\n\nEndo: RISS\n\nPlan: Supportive care, ?CT scan of head.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-18 00:00:00.000",
"description": "Report",
"row_id": 1482075,
"text": "Resp Care\nPt remains on vent, trached with # 8 portex. Bs course. Suctioned mod amt of thick white secretions. Pt had episodes of dscrony taht were self resolved. plan to Psv trials.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-18 00:00:00.000",
"description": "Report",
"row_id": 1482076,
"text": "csru update\nNSR, no ectopy. sbp drops to 80s when asleep, goes up immediately when stimulated, np informed. uop drops with low bp, lasix increased to tid, still uop dropped to 10cc/hr, team aware, may require volume. ct scan today, result pending. obeys commands, inconsistently at times. pt moved both left upper and lower extremities when asked, right arm moves all the time when awake. left fingers black, noticed slight bleed under fingernails, team aware. tf at goal, insulin increased. peg site very with serous fluids, redressed x3 during shift, a-line resited to right fem, site bleeding, redressed x2. pressure areas unchanged, duoderm to sacrum intact, pt positioned to sides, on kinair bed. family in, updated.\n\nplan: volume (1uprbc) to improve urine output\n continue plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482077,
"text": "1900-0700\n\nNeuro: Pt remains with + eye opening to verbal stimuli. No acute changes noted in neuro status. No movement noted to L side. No seizure acitivity. See carevue for further assess.\n\nResp: Pt remains with trach intact-vent weaning. Pt tolerated CPAP/PS-rested through the night. Remains with Irregular resp pattern. Tachypnic at time. Lungs coarse bilaterally. Suctions for minimal amounts of thick white secretions. O2sat stable. AM ABG: 7.44/27/101/19. R femerol aline with sharp waveform.\n\nCV: NSR without ectopy. HR 60-70, SBP labile 70-140. Remains on Heparin drip @ 1000u/hr. PTT: 81.2, INR:2.4. Received 1 unit PRBCs. Increased lasix to 40mg IV TID with minimal effect. Dopplered pulses to ext. Vascular compromise to ext-see carevue for details. air bed in use/multipodis boots in use.\n\nGI/GU: Abd round softly distended. No BM. Peg intact draining serous fluid at site. Promote with fiber @ 65 cc/hr tolerating well. Foley to BSD draining clear yellow urine. UO poor-15-60cc/hr. HO notified cont'd lasix regimen. BUN:64, CR:2.3.\n\nEndo: RISS\n\nPlan: Supportive care, vent weaning as tolerated, Renal management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-22 00:00:00.000",
"description": "Report",
"row_id": 1481961,
"text": "Respiratory Care\nStable t/o night.Abg's adequate.Suctioned one medium size brown mucous plug earlier in shift.RSBI-93 this am.Plan:awating plan from team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-06 00:00:00.000",
"description": "Report",
"row_id": 1482026,
"text": "Neuro: lifts RUE off of bed RLE moves on bed LLE LUE no movement does withdraw to pian to LLE. Pt mouths words appropriately, follows commands. Denies pain. no sedation.\n\nCV: Sr no ectopy bp to 80's when deep asleep returns to 100-140's with stimulation. doppler pulses in feet. R fingers and bilat toes cold purple-black in color.\n\nPULM: simv 14/5 50% sats 96-100% tachypneic at times. lungs clear to coarse suction thick brown secretions. new #8 per-fit trach site with scant blood drain.\n\ngi: dobhoff in place clamped + bs. 2 small loose brown stools abd soft. plan for peg in the future when inr down. riss. lantis on hold while npo\n\ngu: adequate clear yellow uop. good response to lasix -530 for the day.\n\nskin: sternal incision approximated no drainage, mediastinal sites no drainage open healing, L neck with staples ota, R neck healing approxamated incision. nystatin powder to vaginal area for yeast.\n\nplan: restart tf, plan for peg when inr down, wean ps.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-06 00:00:00.000",
"description": "Report",
"row_id": 1482027,
"text": "BS coarse crackles. Pt weaned to CPAP but still mod tachypnea with f 30-40 requiring PSV 20. Rate higher during Nursing Care and when family present. Back on SIMV now; will attempt PSV again in AM. Pt will eventually need PEG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-06 00:00:00.000",
"description": "Report",
"row_id": 1482028,
"text": "Addendum: with family present, pt becoming tachypneic to 40 while on SIMV. Placed on CMV with rate back to ''s. After she settles in, will discuss AC v CMV with team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-06 00:00:00.000",
"description": "Report",
"row_id": 1482029,
"text": "csru update\ncvs stable, map >60, occassionally sbp drops to 90s when, asleep, still maintaining map >60. NSR, isolated pvc's rare, kcl repleated x1. peripheral pulses as charted, afebrile. CPAP today, went tachypneic, abg resp alkalosis. no movements noted on left side, although noticed slight twitching of left thumb once only. attempts to mouth words, nods appropriately. insulin given per sliding scale and fixed dose of lantus. bowels moved x5 all shift, med to large amount, brown, from formed to loose (appears constipated at first then loose). pressure areas unmarked, pls refer to carevue\n\nplan: vascular assessments. cont vent wean as tolerated. continue plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-07 00:00:00.000",
"description": "Report",
"row_id": 1482030,
"text": "ASSESSMENT AS NOTED\n\nRES: RES ALKALOSIS WITH CO2 <32 PERSISTS, STILL ON A/C, PO2>100.\nLS COARSE, SM AMNT OF THICK YELLOW SPUTUM IN TRACH,\n\nNEURO: L.SIDE PARESIS, MOVES R.ARM WELL, WEAK, FOLLOWS SIMPLE COMMANDS\n\nHEME: ON HEP GTT DOWN TO 1200(PTT>80 TWICE), NO OBVIOUS BLEEDING NOTED\n\nCV: DIPS SBP TO 90S WHEN ASLEEP, KEEPS MAP>60, GENERALIZED EDEMA, L.ARM/FOOT ARE COOL/CYANOTIC TOES/FINGERS, POOR PULSE \n\nID: SPIKED TEMP >101, TREATED WITH TYLENOL, H/O AWARE, CULTURES WERE DRAWN LAST, CONT ON VANCO\n\nGU: ON LASIX WITH BRISK U/O ,\n\nGI: TOL TF WELL AT GOAL, CONSTANT BM -SOFT PASTY DARK YELLOW, + BS,\n\nENDO: RISS IN USE-SEE CHART\n\nFAMILY WAS IN LAST NIGHT AND TALKED TO RN , UPDATED\n\nPLAN: MONITOR VASCULAR,HEME, BS/ENDO ? PUT PT ON CONTACT PRECAUTIONS,\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-07 00:00:00.000",
"description": "Report",
"row_id": 1482031,
"text": "Resp Care note\n\nPt has elevated temp, UTI, central line culture + as well as sputum for staph. She has a respiratory alkalosis combine with mild metabolic alkalosis. Attempted to place pt on PSV 20/5 peep again but rr increases to > 40 BPM each time. Rested overnight on AC 14 x 550, 50% +5. ABG remain similar on both PSV and AC. Plan to attempt wean again today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-23 00:00:00.000",
"description": "Report",
"row_id": 1482094,
"text": "Resp: pt on psv 15/4/40%. Bs are diminished with some coarsness noted. Suctioned for small amounts of thick white secretions. Pt had episodes of ^ wob with ^ rr, then placed back on a/c 10/500/+5/40% to rest noc. Will wean to psv today as tolerated. RSBI=122, AM ABG 7.39/31/123/19\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-23 00:00:00.000",
"description": "Report",
"row_id": 1482095,
"text": "Respiratory Care Note\nPt. received on PS 15/5 FiO2 .40 over course of the day pt. tol gradual decreasing of pressure support. Currently tol. settings of PS 10/5 with vol. of 350-450 and RR 26-35 FiO2 .40. Diminished with occasional coarse rales. ABG's within acceptable limits. Plan to remain on PS as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-23 00:00:00.000",
"description": "Report",
"row_id": 1482096,
"text": "neuro: arouses to speech, moves rt upper extr spontaneously; r/l lower extrs move slightly with tactile stimulation; slight twitching in left upper extr with tactile stimulus and prom. oob to stretchair with 4-5 assist. perrl.\n\ncv: hr 70s, bp labile with coughing and turning-at rest sbp 80s to low 110s. afebrile.\n\nresp: bilat upper lung sounds clear; diminished lower lobes. weaned Psupp to 10 with sats maintained >96%. frequent coughing with repositioning-suctioned sm amts thick white sputum.\n\ngi/gu: bs present, bm x2; foley patent-uo clear yellow; tf @ 45cc/hr, no residuals. latest bun 119, creatinine 4.2.\n\nendo: blood sugar monitored per ss protocol.\n\nsocial: family visited, conferred with MD re: dialysis. after consideration, family has consented to time limited dialysis.\n\nplan: needs dialysis catheter placement for dialysis to start tomorrow. withhold lantus tonight. continue monitoring hemodynamic & respiratory status and blood sugars.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-24 00:00:00.000",
"description": "Report",
"row_id": 1482097,
"text": "7p-7a\nneuro: pt remains arousable to loud voice. Lifts and hold RUE, moves bilat lower extremities on the bed, withdraws RUE, LLE, RLE from painful stimuli. No movement of LUE. Remains +PERRL. No seizures.\n\ncv: Remains sr 60-70 without ectopy. sbp 90-140, increases with stimuli, decreases when sleeping. Remains dopplerable pulses.\n\nresp: CPAP over night, peep5/pressure supp. 10/ tv 300-400's/rr 20's. See careview for abg. LS clear bilat with diminished bases.\n\ngi/gu: Continues tube feedings respalor at goal, no residuals. Abd soft, +bowel sounds. Indwelling catheter draining minimal amts clear yellow urine. Family decided to have dialysis, quintin catheter inserted to L groin by pa, renal to eval in am what type of dialysis. Lasix dc'd.\n\nskin: red rash over torso, abd, back, all extremities. rash more pronounced, brighter in color and has moved down to legs since as noted by another rn. Team aware. Plan to stop lasix, bleach free linens, monitor rash.\n\nendo: Blood sugars monitored per protocol, pm lantus insulin held .\n\nplan: continue to monitor neuro/hemodynamics/resp/skin. Start dialysis. Continue current meds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-24 00:00:00.000",
"description": "Report",
"row_id": 1482098,
"text": "Resp: pt on psv 10/5/40%. Bs are clear with diminished bases. Minimal suctioned required for small amounts of white secretions. Pt remained on psv noc and tolerated well. AM ABG 7.35/32/83/18 RSBI=122. Will continue to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-23 00:00:00.000",
"description": "Report",
"row_id": 1481967,
"text": "update\nD: pt more awake today- opens eyes to name, blinking when asked, grasp right hand, movement noted right leg, no movment noted of left side during my shift. left hand appears more mottled, ulnar and radial pulses dopplerable--vascular team in to see pt today- sc heparin started. dr asked to re-eval left hand- appears more mottled--yet warmer to touch-blanching noted.\nneuro:pupils equal and rx to light, as noted above moves right side, no movement of left side noted--pt responding more to family today. neuro in to see pt- request MRI when pt able to ...ie: removal of swan.\ncardiac; pt in nsr rare pvc noted, sbp 90-160/60--goal obtain sbp <140/--may have occas bumps but goal is to be <140/, as noted left hand appears more mottled yet warmed- sc heparin started. co/ci adeq- svo2 >68%. dopplerable pedal pulses, toes remain mottled.\nresp: no changes on vent- pao2 good- pt remains on cpap with ips 15- tv >400cc. bs clear dim in bases, left base tubular bs.sx for tan secretions.\ngi: pt with ogt draining green bilious material-pt cont on h2 blocker, bs present. no bm today.\ngu: foley intact, pt cont on lasix drip at 5--u/o .100cc/hr.\ninc: intact-drsg D+I, no skin break down noted.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-24 00:00:00.000",
"description": "Report",
"row_id": 1481968,
"text": "Nursing progress Note\nCVS: temp spike to 38.7 at , miv venous drop to 57 then svo2 to 50, with fick CI only 1.5. MD to bedside, orders for fluid bolus to hold lasix and start antibiotics, CXR, EKG, and pan culture. Svo2 rising to mid 60's with fick index >2.0. CVP 14, lasix drip on hold. Neo at 0.25 to keep sbp 120-140, labile bp ranging for 80 to 180 systolic. temp currently down to 37.9 after tylenol, vanco and levoflox. pulses by doppler x 4 ext. a and v wires secured, meds ct draining scant mahogany serosang. RIJ dressing cdi.\n\n vasc: L hand fingers cool, cyanotic, blanch to white with prolonged cap refill > 6 seconds. ulnar, radial and brachial pulses all confirmed by doppler. Appears purple coloring moving up fingers towat palm of hand, Dr made vascular team aware. BLE's warm, remain cyanotic purple turning flushed erythematous extending up toward medial maleolous. MP boots on/off. R hand warm and pink.\n\nResp: remains intubated no sedation, on cpap with PS with stable abgs. sats on 0.4 oxygen are 100 %. Sxn for scant thick tan secretions, ls clear in uppers and dim at bases.\n\nNeuro: Exam varies widely, very blood pressure dependant. Best exam with systolic > 140 which only occurs with care and turning. At that time slight movement of left leg laterally on bed, no movement of LUE, r arm purposeful to ETT, Right leg lifts and holds. tracks and follows min commands of blink and squeeze my hand. gag cough and corneals remain intact. ? seizure activity fine eyelid twitching noted when pt febrile with low svo2's (MD aware). With lower SBP exam inconsistent sometimes no movement, some posturing, very little eye opening and discongujate gaze.\n\nGI: abd soft round lcs ogt with green bilious secretions. No BM. BS hypo x 4 quads. CSurg does not want to start tube feeds or water bolus as suggested by vascular.\n\nGU: Foley cath patent draining clear yellow urine. Lasix drip currently on hold.\n\nPain: not apparent not medicated.\n\nEndo: FS BS covered with csru protocol sliding scale.\n\nSocial: no family contact this shift.\n\nPlan: continue to hold lasix drip, hold heparin for falling platelet count. monitor co/ci, lfts, abgs. Control bs, pulmo toilet. Probable need for special airbed to protect skin. Attempt to maintain sbp 120-140with min neo.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-24 00:00:00.000",
"description": "Report",
"row_id": 1481969,
"text": "Respiratory Care\nPt.remains on PSV and tolerating well.Abg's wnl.no vent.changes made this shift.Suctioned for moderate amounts of yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-20 00:00:00.000",
"description": "Report",
"row_id": 1481955,
"text": "NUERO~EPISODES OF SZ ACTIVITY WHERE PT WOULD BEND R ARM @ ELBOW & EYE LIDS WOULD TWITCH, LASTING A FEW SECONDS. 3-4 EPISODES FROM 1500-1900. 1500 EEG DONE. NO ACTIVE SX ACTIVITY NOTED DURING TEST. NEURO TEAM F/U DID NOTE SZ ACTIVITY ON EEG. DILANTIN BOLUS GIVEN PRIOR TO EEG. TO BE GIVEN Q 8 HRS. STARTED ON PROPOFOL GTT @ 10 MCG/KG/MIN PER NEURO & CARDIAC . TO REST PT OVER NIGHT UNTIL DILANTIN TAKES EFFECT. SEE FLOW SHEET FOR NEURO ASSESSMENT.\n\nCARDIAC~VPACED UNEVENTFULLY @ 90 UNTIL 1830. PROPOFOL STARTED AT THAT TIME @ 10 MCGS, BECAME HYPOTENSIVE BEGAN OVERRIDING PACER UNDERLYING RHYTHM AFIB 70'S. ON NEO TITRATING-> ^ SBP CONVERTED TO SR. NEO TO MAINTAN SBP 120-140.\n\nRESP~REMAINS ON SIMV RR~12, BREATHING 2 OVER VENT. MAINTAINING SATS 98%. DIAMOX STARTED FOR ALK. SEE FLOW SHEET SETTINGS.\n\nA/P~LABILE BP. NEO TO MAINTIAN SBP 120~140. ALTERED NEURO STATUS. GIVEN DILANTIN LOAD. DILANTIN Q8 HRS. DILANTIN LEVEL PENDING. KEEP PT SEDATED OVERNIGHT TEAM TO REASSESS IN AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-21 00:00:00.000",
"description": "Report",
"row_id": 1481956,
"text": "Nursing Note\nNeuro: awoke x 1, unable to move l side even to deep nailbed pain, grimaces. intact gag cough and corneals. pupils 3 brisk equal, gaze occasionally disconjugate. NO SEIZURE activity noted this entire shift. right side moves spont on bed, does not appear to be purposeful. Eyes open to verbal stim, no tracking or focus. Questionable left side facial droop difficult to assess with ett in place, and patient not able to follow commands.\n\nCVS: 2 a and 2 v wires, a sense and pace at max gain, set rate 90 to help prevent atrial ectopy. runs of pacs when not paced drop sbp to 90's. Currently on neo at 1 to keep sbp between 120-140. propofol for sedation/comfort on vent. CI >2.0 by thermo dilutional swan svo2 >66. Pulses by doppler BLEs generalized edema, l leg ace wrap. r ulnar a line good waveform with notch, dampens when wakes. Dressing to sternal incision stained through with clot developing on gauze, dressing changed steri strips now appear to be clean dry and intact. mediastinal chest tubes with small amounts of dark old blood drainage, dressing changed. unable to assess pain level due to sedation and neuro defecits. other drips include milrinone at 0.125\nResp: remains intubated and sedated on vent. No wean attempts until after am rounds. ls clear to dim at bases, sxn for scant yellow, sats 100 on 0.5 %.\n\nGI: abd soft round obese. bs hypo, ogt pos placement by air bolus ausc. tylenol and potassium via ogt. npo excpet meds, until extubated.\n\nGU: foley cath draining large amounts of conc to dark amber color urine. increased diuresis after diamox and lasix.\n\nEndo: insulin gtt off at 0400.\n\nSocial: no calls or contact from family.\n\nSkin: reddened, ruddy, intact except for mentioned surgical wounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-24 00:00:00.000",
"description": "Report",
"row_id": 1481970,
"text": "NEURO: PT IS OPENS EYES TO SPEECH. RESPONDS TO PAINFUL STIMULI ON RT SIDE ONLY. MOVING RIGHT ARM AND LEG FREELY. MOVED SLIGHTLY X1 L LEG SPONTANEOUSLY WITHOUT STIMULATION. NO MOVEMENT OF L UPPER EXTREMITY. DILANTIN GIVEN. PUPILS ARE EQUAL ROUND AND REACTIVE TO LIGHT. SQUEEZES RT HAND AND WIGGLES RT TOES ON COMMAND INTERMITTENTLY.\n\nCV: BP LABILE. 30 PT DIFF BETWEEN LEFT AND RIGHT ARM-PER VASCULAR CHECK Q4H. ALL PULSES AUSCULTATED BY DOPPLER. HR 80S-90S NSR WITH PACs & PVCs. LOPRESSOR ONLY 6.25 GIVEN DUE TO LABILE BP. NEO RESTARTED TO MAINTAIN BPs >120-140s. SVO2 57-63, . FICKS CORRELATING. RECALED X2. D5W 500CC BOLUS FOR LOW CO. HIT SCREEN DONE. PLATELETS DOWN TO 74. LEPIRUBIN STARTED. TEMP INCREASED TO 38.6C, 650 TYLENOL GIVEN. LEFT HAND AND BILATERAL TOES CYANOTIC. TEAM AWARE, VASCULAR AND FOLLOWING.\n\nRESP: LSCTA, SUCTIONED SM AMT BLOOD TINGED SPUTUM. CHEST TUBES DC'D-LARGE AMT SEROSANGUIOUS DRAINAGE ON DSG POST PULL. DRESSING CHANGED. ABGs GOOD. PRESSURE SUPPORT WEANED TO 13 WITH ABGS WNL. ETT ADVANCED 2CM AND TUBE ROTATED.\n\nGI/GU: FOLEY TO GD-CLEAR YELLOW UO. HYPOACTIVE BS. NGT PLACED POST PYLORIC-ABD XRAY CONFIRMED. TUBE FEEDINGS PROMOTE WITH FIBER STARTED AT 10cc/hr TO BE ADVANCED Q4H SEE ORDER TO A GOAL OF 50cc/hr. OGT OUTPUT COFFEE GROUND/BILIOUS APPEARANCE, HEME +, AWARE.\n\nENDO: BS TREATED PER CSRU SLIDING SCALE PROTOCOL\n\nSOCIAL: FAMILY VISITING; DAUGHTER CONSULTED WITH TEAM; CONTINUE TO PROVIDE EMOTIONAL SUPPORT\n\nPLAN: CONTINUE MONITORING NEURO STATUS. MONITOR HEMODYNAMIC STATUS AND COAGS. TITRATE NEO PER PARAMETERS AS ABOVE. CONTINUE TO MONITOR COAGS WHILE ON LEPIRUDIN AND SIGNS OF BLEEDING. ADVANCE TUBE FEES AS ORDERED. FOLLOW CULTURES.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-10 00:00:00.000",
"description": "Report",
"row_id": 1482043,
"text": "CSRU NPN 7p-7a\nNeuro: , attempting to talk and mouth words. Denies pain. Able to move right upper extrem. on command, can wiggle right toes. Does move left UE on bed with spastic movements, LLE with no movement. PERRL.\n\nCV: HR SR 80's, no ectopy noted. SBP 120-150's, given scheduled lopressor with fair effect. K 3.7 this am, pt receiving KCl 40meq iv. LE pulses are dopplerable, radial pulses palpable. LUE with cyanotic 2nd, 3rd, and 4th fingers, cool to touch. BLE with dusky toes, skin is warm. Heparin gtt at 1400u/hr, AM PTT pending. HCT 27.3 this am, clot sent off for type and cross.\n\nPulm: No vent changes made overnight. Current settings AC 550x14 50% +5, am abg 7.47/44/127/33. Sxned for thick yellow secretions. Pt does overbreath vent up to 5 breaths per minute. O2 sat 98-100%. LS CTA.\n\nGI: Abd obese, soft, +hypoactive BS. TF at goal rate of 65cc/hr, no residuals. Stooled x2, soft brown. BS <160, no coverage given per RISS.\n\nGU: F/C draining clear yellow urine 50-300cc/hr. Pt getting lasix 40mg tid.\n\nID: Tmax 99.7, remains on antibx coverage. Awaiting pancx results from . When bcul come back neg pt will have PICC and Gtube placed.\n\nSkin: Duoderm to coccyx. Pt placed on kinair bed last night. Peri area reddened, miconazole placed to area. Backside with non-raised blotchy rash.\n\nSocial: Wife visited last pm, updated on plan of care.\n\nPlan: ?transfuse today. Recheck lytes this afternoon. Wean vent settings as pt tolerates. F/U on cultures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-05 00:00:00.000",
"description": "Report",
"row_id": 1482021,
"text": "Nurses Progress Note for 7p-7a:\nNeuro: Pt is , able to follow commands consistantly by performing hand grasps on rt and trace movement of the fingers on the left. Able to communicate by mouthing words and nodding.\nResp: Oral intubation to vent. support. Pt continues to have slight alkalosos per abg, Simv-rate 10, PS 14, peep4. O@ at 40%. Attempted to try CPAP mode. Pt was briefly trialed on the CPAP mode, which she failed. Now back on SIMV. Plan for trach today.\nCV: HR is 80-90's, rare ectopy. SBP 100-140's with goal 130. Skin mostly warm and dry. LLE is warm with cyanoti fingers. BLE are cool and dusky.\nGU/GI: Good BSx4, abd soft. TF off since 1011. Foley with goog u/o after lasix. K+ repleated as protocol.\nEndo: BS covered per SSRI + sched long acting dose.\nContinue with pressent plan. Pt sched for peg and trach today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-05 00:00:00.000",
"description": "Report",
"row_id": 1482022,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Attempted weaning overnoc, pt did poorly, now continues on SIMV. BS's w/ some coarseness, sxing thick white secretions. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-05 00:00:00.000",
"description": "Report",
"row_id": 1482023,
"text": "Resp Care\nPt trached w/o incident. Pt on SIMV. Increased IMV rate due to procedure. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-05 00:00:00.000",
"description": "Report",
"row_id": 1482024,
"text": "See carevue for objective data.\n\nAssessment remains essentially unchanged. Follows commands-slight movement of left fingers to grasp when asked. No movement noted of left leg.\n#8 portex trach placed at bedside this afternoon. Received vec/fentanyl/proprofol/neo for procedure and proprofol continued until pt was no longer chemically paralyzed. ABG adequate after trach placed. Minimal bloody secretions.\nRight subclavian noted to be red with green drainage from insertion site upon assessment this AM. Team notified. Right groin TLC placed.\nR SC line tip sent for CX.\nTemp 100.8PO-(2) sets of BC off of new line sent. WBC 11.9.\nHeparin to be re-started in AM. Glargine insulin to be held tonight related to pt's NPO status. Will resume TF when + bowel sounds.\nYeast in peri-area. Nystatin powder prn.\nPEG to be inserted at a later date per Dr. .\nFamily called and updated on status. To visit this PM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-06 00:00:00.000",
"description": "Report",
"row_id": 1482025,
"text": "Respiratory Care Note:\n patient is trached and on ventilatory support. Alarms are functioning and have been tested. For specific settings please see carevue. BS clear. SX'd a small amount of blood tinged thick secretions. Lavaged several times for a moderate amount of secretions as well. RSBI this am is 73.1. Will continue to monitor and wean when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-10 00:00:00.000",
"description": "Report",
"row_id": 1482044,
"text": "Respiratory Care\nPt.remains on A/C,no vent.changes this shift.Abg's adequate.Suctioned for moderate amounts of thick yellow secretions.RSBI-165.Plan:continue support as indicated,wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-10 00:00:00.000",
"description": "Report",
"row_id": 1482045,
"text": "Correction:\nSocial part of note from nights incorrect. No contact from family overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-10 00:00:00.000",
"description": "Report",
"row_id": 1482046,
"text": "BS fine crackles. No weaning today; morning RSBI 165. Continue to consider weaning when appropriate. Pt is over 1 liter negative today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-10 00:00:00.000",
"description": "Report",
"row_id": 1482047,
"text": "NURSING NOTE 7A-7P REIVEW OF SYSTEMS:\nNEURO: AWAKE OPENS EYES SPONTANEOUSLY, PERRLA, ATTEMPTING TO MOUTH WORDS. FOLLOWS COMMANDS AND DENIES PAIN. ABLE TO MOVE RIGHT ARM PURPOSEFULLY. UNABLE TO MOVE LEFT ARM TO COMMAND ONLY VERY SLIGHTLY ON BED. ABLE TO WIGGLE TOES TO COMMAND.\nC/V: HR NSR IN THE 80-90'S, BO 130-150'S/ 60-70'S, LOPRESSOR INCREASED TO 50MG PO BID. LEFT HAND WITH CYANOTIC 2ND, 3RD AND 4TH FINGERS POSITIVE PULSES. CONTINUES ON HEPARIN DRIP AT 1400 UNITS/HR.\nRESP: VENT SETTING UNCHANGED CURRENTLY AT AC 550X 14X 50%X 5 PEEP. SUCTIONED THICK WHITE/ YELLOW SECRETIONS. O2 SAT CONTINUES AT 96-98%.\nLUNG SOUNDS CLEAR. PATIENT NEEDS SPUTUM SPEC SENT.\nGI: NGT FEEDING TUBE PRESENT. TUBE FEEDINGS INFUSING AT 65CC/HR TOL WELL. ABD. SOFT POSITIVE BOWEL SOUNDS. INC SMALL SOFT BROWN STOOLS.\nGU: FOLEY PATENT DRAINING CLEAR YELLOW URINE. LASIX GIVEN AS SCHEDULED GOOD DIURESIS. PLEASE SEE CAREVUE.\nID: TMAX 100.4 CONTINUES ON CEFEPINE, FLUCONAZOLE AND VANCO. PAN CULTURED ON RESULTS PENDING.\nENDO: FS 172 AND 170 TODAY TREATED WITH SSI.\nSOCIAL: PATIENTS DAUGHTER AND SON INTO VISIT FAMILY MEETING TODAY WITH DR. , SOCIAL SERVICE AND NURSING PRESENT. FAMILY MEMBERS UPDATED ON PLAN OF CARE.\nPLAN: ? BRONCH IN AM HOLD TUBE FEEDINGS AFTER MN, PLAN FEEDING TUBE PLACEMENT IN OR ON FRIDAY. FAMILY TO EVALUATE REHABS FOR PATIENT TRANSFER WITHIN NEXT FEW WEEKS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-26 00:00:00.000",
"description": "Report",
"row_id": 1482107,
"text": "Respiratory Care\nPt.remains on PSV,IPS increased to 15 last evening d/t tacypnea.Abg's reveal a fully compensated metabolic acidemia,with very good oxygenation.Suctioned for small,to moderate amounts of mucoid seceretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-26 00:00:00.000",
"description": "Report",
"row_id": 1482108,
"text": "respiratory care\npatient on cpap 5 peep and 10 of pressure support well tolerated is doing 368 to 400 and is breathing a rate of 33 breaths per minutes .plan to continue weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-26 00:00:00.000",
"description": "Report",
"row_id": 1482109,
"text": "7a-7p\nNeuro: Pt to verbal stimuli, nods appropriately at times. Follows commands inconsistently. See carevue for details of moving extremeties. Perrla. No seizure activity.\n\nCV: HR 70-80 SR occasional PVCs. Repleted w/ 2 doses of 10meq of KCL secondary to renal insufficiency. SBP 90s-140s as high as 160s w/ stimulation only, SBP goes down on w/out intervention. Doppler pulses. Cyanotic left fingers, no change from previously documented.\n\nResp: At present on CPAP 40%, PEEP 5, PS 10 via trach. See carevue for details of abgs. Sats 99-100% LS coarse, diminished at bases. Suctioned for small amts of thick white via trach.\n\nGI/GU: Abd soft +BS, multi soft stool throughout day. U/O 0-15cc/hr. HD today for three hours and took off 2L of fluid dialysis RN.\n\nEndo: FS checked every 6 hours, following pt's own scale.\n\nSkin: See carevue for details.\n\nSocial: Daughter in most of day at bedside.\n\nPlan: Monitor hemodynamics. Monitor neuro status.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-20 00:00:00.000",
"description": "Report",
"row_id": 1481951,
"text": "Pt.arrived from O.R. on Propofol, Milrinone, Ntg. Monitor shows NSR with many pac's. Ntg titrated to keep SBP <110. Coags remain elevated, therefore 2 more FFP given and Prbc's given x2 for Hct 25-27. HCT at 0200 stable at 29. No significant bleeding from CT's. Diuresing >200cc/30 minutes. Electrolytes repleted prn. Pulses by doppler in both feet. Warming blanket on until Temp ~36.5. EKG, PCXR done.\n trailing off to low 3's through the night although SVO2\nhas maintained >/=64% yielding Fick Co >6. TEE shows mod. TR so will follow Fick CO.\nPropofol off since 0400 but no response from pt. other than some mouth motions noted. Eyelids flickering but not open to command. No movements of extrem. to command or spont. Pupils remain pinpoint -2mm\nPlan: continue to try to wake pt. Wean Milrinone.Keep sbp <110.\nReplete lytes and follow HCT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-20 00:00:00.000",
"description": "Report",
"row_id": 1481952,
"text": "Resp Care note\n\nPt is s/p AAA respair, cabg, and avr, , She is not yet alert and likely will not wean from vent until later this evening or tomorrow. ABG show mld hyperoxemia and a metabolic alkalosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-20 00:00:00.000",
"description": "Report",
"row_id": 1481953,
"text": "NEURO: PT IS NOT SEDATED, BUT REMAINS UNRESPONSIVE. AROUSES TO SPEECH WITH EYE OPENING (EYE EQUAL BUT DO NOT TRACK), GRIMACES IN RESPONSE TO PAINFUL STIMULI (NAILBED). HAS BRIEF PERIODS OF TWITCHING OF LEFT HAND. NONPURPOSEFULLY MOVED RT ARM WHILE OPENING EYES AND PROTRUDING TONGUE. QUESTIONABLE SEIZURE ACTIVITY NOTED WITH EYE AND RT ARM TWITCHING. NEURO EVALUATED. CT SCAN DONE.(RESULTS PENDING) DILANTIN ORDERED. EEG AT BEDSIDE BEING PERFORMED. NO MOVEMENT NOTED AT ALL IN LOWER EXTREMITIES, TEAM AWARE.\n\nCV: BP LABILE, INCREASES WITH STIMULATION, MAINTAINING BP 120-140 WITH +/- NEO; HR 80s, DOPPLER PULSES, CO>4.0. EPICARDIAL WIRES DO NO SENSE APPROPRIATLEY. PT WITH ? AFIB/JUNCTIONAL WITH DILANTIN RUNNING, UNSTABLE HEMODYNAMICS WITH RHYTHM, AT BEDSIDE ABLE TO AV PACE AT 90 WITH RETURN OF GOOD HEMODYNAMICS. CT OUPUT MINMAL EXCEPT 1 HR OF 120CC. HCT STABLE.\n\nRESP: LSCTA, ABG COMPENSATED MET ALKALOSIS( DIAMOX STARTED) O2 SATS>97% ON FIO2 40%. SUCTIONED FOR NOTHING. OVERBREATHING VENT INTERMITTENTLY CURRENTLY ON IMV 550X12 PS 10 PEEP 5.\n\nGI/GU: OGT PLACEMENT CONFIRMED BY AUSCULTATION; HYPOACTIVE BS; FOLEY PATENT TO GD, URINE CONCENTRATED-OUTPUT <50CC/HR; LASIX INCREASED TO 40MG TID, DIAMOX ORDERED-IMPROVED UO >100 CLEAR LIGHT YELLOW\n\nENDO: INCREASED BLOOD SUGAR TREATED WITH SSR SEE FLOWSHEET ? RESTART GTT\n\nSOCIAL: DAUGHTER VISITED, THIS AM, UPDATED ON NEURO STATUS BY , DAUGHTER THIS PM.\n\nPLAN: CONT ASSESS HEMODYNAMIC STATUS, TITTATE NEO TO MAINTAIN BP 120-140. CONT ASSESS NEURO STATUS. DRAW DILANTIN LEVEL AT 1 HR AFTER COMPLETION OF LOAD. DECREASE MIL TO 0.125 MCG IF HEMODYNAMICALLY STABLE. PROVIDE EMOTIONAL SUPPORT FOR FAMILY\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-20 00:00:00.000",
"description": "Report",
"row_id": 1481954,
"text": "resp care\nno vent changes were made this shift see careview for current settings last abg 7.41/50/97/33/5/97% pt travels to CT for neuro status due to siezures results were negative pt also had eeg which also came back negative pt is slowly waking up and we will continue to wean as appropriate\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-03 00:00:00.000",
"description": "Report",
"row_id": 1482015,
"text": "Resp Care\nPt remains intubated on SIMV. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-22 00:00:00.000",
"description": "Report",
"row_id": 1482092,
"text": "neuro: arouses to voice, flexes & withdraws to nailbed stimulus on rt side only. able to lift and hold rt arm. slight twitching seen in left hand and left leg when touched.\n\ncv: hr 70s, sr, bp labile with coughing. dopplerable pulses. left extremeties cool, dusky. rt upper extr warm, normal color, rt lower extr cool, dusky. calcium repleted.\n\nresp: bilat lung sounds clr upper lobes, dim lower lobes. on CPAP with 15 Psupp. pt coughs frequently-sx'd thick white sputum. abgs- compensated metabolic acidosis\n\ngi/gu: bs present, stooling with turns. tube feeds at 45cc/hr. foley patent-uo clear yellow, no sediment-ua sent. BUN & creating continue to rise. uo low with no results from lasix\n\nendo: blood sugars monitored per sliding scale. lantus increased to 26 units\n\nsocial: children visited. ? family meeting tomorrow re: dialysis.\n\nplan: continue monitoring respiratory status, hemodynamics. rest on cmv overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-23 00:00:00.000",
"description": "Report",
"row_id": 1482093,
"text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: Responds to verbal stim - opens eyes, doesn't track, doesn't follow commands. Moves RUE freely about - non-purposeful, moves RLE/LLE on bed spont, moves L hand to stim. Pupils 33mm/brisk. On dilantin; no seizure activity noted.\n\nCV: HR=60-70s, NSR, no ectopy. BP=90-120/40-50s, SBP up to 170/ when coughing/agitated, but then returns to normal when she settles down. Pedal pulses +w/ doppler, radials weak, but palp. +generalized edema, extrems cool, except RUE warm. Skin pink - rash noted over torso.\n\nResp: Pt was on CPAP/PS 40% at beginning of shift, but was changed over to AC for the night when RR ^to 40s. ABG on vent settings= 7.39/31/123/19. On vent, RR=21-26. Suctioned for small amt thick yellow secretions via +8 trach. Lungs clear in upper fields, diminished in lower fields.\n\nGI/GU: Abd soft/distended, +BS, FS Respalor at 45cc/hr (goal) via PEG w/ no resids. BM - soft-formed brown BM. Foley cath w/ minimal urine output despite lasix 25-30cc/hr. BUN/Cr=112/4.1. Family meeting today discuss dialysis.\n\nPain: Does not appear to be uncomfortable.\n\nSkin: Torso/chest pink w/ rash. Extrems cool/pink as well. Fingernails L hand black. Duoderm on coccyx intact.\n\nAccess: R fem a-line, R fem TLC.\n\nID: afebrile\n\nLabs: WBC down to 9.9 from 13.3; INR down to 2.2 from 2.9; Bun/Cr 112/4.1. K=5.7.\n\nSocial: Family meeting today to discuss the need for dialysis.\n\nPlan: Continue current plan, monitor neuro/resp/cardiac status. Family meeting - ?dialysis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-27 00:00:00.000",
"description": "Report",
"row_id": 1482110,
"text": "NEURO- Patient is calm and responds to verbal commands ,moves all her limbs except her left arm. Left hand middle 3 fingers necrotic.Toes bilaterally mottled with good capillary refill.Generalised edema present. No complaints of pain .dilantin level 6.5,DR. informed,pm dose given.\n\nRESP- Trach dressing done,inner cannula changed. on cpap ps 10 ,peep 5, .40%,t.v>350,rr 20-35bpm, spo2>95%.Lungs sounds coarse,suctioned frequently minimal watery secretions,albuterol puffs given by resp tech. DR. into assess,no other interventions advised.\n\nCVS-NSR hr 70-95,sbp 95-140,lopressor given.5 meqs of kcl given as k-3.9->4.4. All pulses dopplerable.\n\nGI/GU-peg tube ->nepro @ 35 mls/hr,no residuals.+bs. small formed stools x 3- greenish black.\n\nENDO-BS treated as flow sheet.\n\nSKIN-2 open areas to coccyx,right buttocks 4 cm x 2.5cm through the dermis,see flow sheet.left side similar in size,shape and through dermis.\n\nA/P-Neurologically more responsive. Compromised lung status, Lungs coarse-inhalers given. chest physio.? hd today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-27 00:00:00.000",
"description": "Report",
"row_id": 1482111,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings: PS:10 peep: 5, fio2 40%. Spontaneous tidal volumes are around 300 with respiratory rates in the high 20's to low 30's. Abluterol mdi started this am. Breathsounds are coarse. ABG this am 7.41/34/115 22 -1. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-06 00:00:00.000",
"description": "Report",
"row_id": 1482155,
"text": "SHIFT UPDATE\nCODE STATUS: DNR\n\nPT A&O X 3. SPEAKING CLEARLY WITH PASSY-MUIR VALVE IN. MEETING HELD AT BS TODAY WITH FAMILY, CSRU TEAM, AND ETHICS. PROGNOSIS AND FUTURE CARE OPTIONS EXPLAINED TO PT. PT INITIALLY INDECISIVE REGARDING CARE OPTIONS PRESENTED: REHAB WITH DIALYSIS VS HOME WITHOUT DIALYSIS. PT STATES SHE UNDERSTANDS THAT SHE WILL DIE AT HOME WITHOUT DIALYSIS. PT ALLOWED TO REST AFTER FIRST DISCUSSION AND MET AGAIN IN THE AFTERNOON WITH DR. AND PT'S CHILDREN WHERE SHE THEN EXPRESSED CLEARLY HER DESIRE TO GO HOME WITHOUT HD. PALLIATIVE CARE NOTIFIED AND MET WITH FAMILY. PT NOW DNR STATUS HOSPICE EVAL TOMORROW AM.\n\nSPENT MAJORITY OF DAY ON TRACH MASK WITH VALVE IN. PLACED BACK ON VENT FOR REST AT 1700. LUNGS SOUNDS VERY DIMINISHED ON LEFT SIDE. CXR DONE, PER TEAM PT HAS LARGE PULM EFFUSION. PT MORE TACHYPNEIC THROUGHOUT THE DAY BUT SPO2 98-100% AND PT CONSISTENTLY DENIES DIFF BREATHING. PER PT AND FAMILY THEY UNDERSTAND THAT BREATHING WILL BECOME MORE LABORED WITHOUT DRAINING FLUID, PT AND FAMILY CHOOSE NOT TO DO ANY FURTHER INVASIVE PROCEDURES. RENAL TEAM NOTIFIED AS WELL REGARDING HD, RENAL RESIDENT SPOKE TO PT AND PT AGAIN STATED SHE DOES NOT WANT HD. RENAL IS NOW SIGNED OFF CASE.\n\nHOSPICE RN COMING TOMORROW 0930 TO ARRANGE FOR TRANSPORT HOME. SEE PALLIATIVE RN NOTES FOR HOME MED RX'S NEEDED. PT SEEN BY SPEECH THERAPY TODAY AND PASSED SWALLOW EVAL. DRINKING WATER WITHOUT DIFFICULTY.\n\nPLAN: PROVIDE COMFORT CARE. D/C HD CATHS AND TL CL. PT'S DAUGHTER WILL BE HERE TOMORROW AM AND NEEDS SOME TEACHING ON SUCTIONING, G-TUBE CARE/MEDS, AND TURNING. PLEASE CALL PT TO CONSULT FAMILY ON TRANSFERS AND TURNING. SEE CAREVIEW FOR COMPLETE ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-28 00:00:00.000",
"description": "Report",
"row_id": 1481992,
"text": "3-7pm\nneuro no changes awake and follows commands. no left sided movement noted.\ncv/resp vss bp sl. labile. remains on heparin gtt. intubated w no vent changes. remains on simv.\ngi/gu foley good uop no stools. tube feeds infusing well w no residuals. at goal rate of 65cc/hr.\nct. site w bag/ leaked. bag removed and dsd applied. large amt brown drainage noted. pt's daughters and son in to visit.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-29 00:00:00.000",
"description": "Report",
"row_id": 1481993,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results determined a normal acid-base balance with excellent oxygenation.\n\nRSBI = 129 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-27 00:00:00.000",
"description": "Report",
"row_id": 1481986,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Remains on A/C ventilation w/ PIP/Pplat = 26/19. BLBS slightly coarse anteriorly, clears w/ ETT suctioning; minimal amounts of white thick secretions. SpO2 remained 90s. ETT secure/patent & in good position.\n\nPlan: maintain support; to OR this PM for vascular procedure; assess readiness to wean when appropriate...\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-27 00:00:00.000",
"description": "Report",
"row_id": 1481987,
"text": "TO OR at 1740\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-28 00:00:00.000",
"description": "Report",
"row_id": 1481988,
"text": "Respiratory Care\nPt.from OR this shift s/p carotid to subclavian transposition.decreased vent. settings t/o noc.abg's adequate.suctioned for moderate amounts of thick tan secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-29 00:00:00.000",
"description": "Report",
"row_id": 1481994,
"text": "SEE CAREVUE FOR OBJECTIVE INFORMATION\n\nNEURO:PT RECIEVED MORPHINE 2MG X1 FOR PAIN CONTROL. PT NODS YES NO APPROPRIATELY BUT DELAYED. FOLLOWS COMMANDS. MOVES R EXT SPONT L UPPER EXT NO MOVEMENT L LOW EXT WITHDRAW TO PAIN. PERRL.\n\nCV:BP LABILE 80-170'S. NSR-ST WITH OCC. PAC. PULSES DOPPLER TO FEET, GOOD PULSES TO UPPER EXT. HEPARIN GTT 1300 UNITS/HR TO MAINTAIN PTT 50-70. NO S/S OF BLEEDING.\n\nPULM: LUNGS COARSE CLEAR WITH SUCTION MOD THICK TAN SPUTUM. SATS 96-98% ON CURRENT VENT SETTINGS. WEANED X 3HR YEST.\n\nGI/GU: UOP 25-240CC/HR (AFTER LASIX). TOTAL +260 FOR DAY. GENERALIZED EDEMA. PROMOTE WITH FIBER AT GOAL. TOL WELL. +BOWEL SOUNDS NO BM. ABD SOFT DISTENDED. BLOOD SUGARS ELEV 240/228 REQUIRING 14 UNITS REG EACH.\n\nSKIN: STERNAL DRSG -STRIPS COVERED WITH DSD. MEDIASTINAL WOUND WITH LARGE AMT BROWN DRAIN. DRSG COVERED WITH 4X4'S AND ABD PAD NEEDING REINFORCEMENT IN 2HRS.\n\nID: AFEBRILE WBC UP TO 13.4 ON VANCO AND LEVO.\n\nSOCIAL: DTR IN TO VISIT SUPPORTIVE.\n\nPLAN: NEED TIGHTER GLUCOSE CONTROL\n ATTEMPT WEAN\n MONITOR PTT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-29 00:00:00.000",
"description": "Report",
"row_id": 1481995,
"text": "Resp Care\n\nPt remains intubated and on full vent support. Pt weaned for 5 hrs on 15/5 with a mv on approx 16L and rr in the low 30's. At ended of wean pt was demonstrating an increase WOB and was hypertensive. BS are coarse and suctioning thick yellow in small amts\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-29 00:00:00.000",
"description": "Report",
"row_id": 1481996,
"text": "7a-7p\nneuro: lethargic, easily aroused, follows simple commands, pt very weak, no movement noted to L arm\n\ncv: hr nsr-st, no ectopy, sbp labile(96-159), iv ntg gtt to keep sbp 120-140, po lopressor, po amiodarone\n\nresp: wean to 50% cpap5/15 ips today x 5 hrs, tol well, now resting back on imv, bs+ all lobes & course, sux sm amt loose thick tan sputum, rr 24-32, sat 95-100\n\ngi: goal TF tol well, no stool, po prevacid, po colace\n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: mod amt brown serous drainaged from old ct sites, chest incision clean & dry, family in most of day & updated on pt's condition, L arm ulner/radial pulse by doppler, L finger tips cyanotic, heparin continues @ 1300u/hr, no c/o pain\n\nplan: contniue with ventilatory support, wean to cpap as tolerated, iv ntg as needed to keep sbp 120-140, support family\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-15 00:00:00.000",
"description": "Report",
"row_id": 1482064,
"text": "Resp Care\nPt. remains trached on ventilator with no changes overnight. Has episodes of anxiety coughing and setting of high pressure limit. BS: clear bilat. secreations minimal white thick.\nNo abgs at this time. Cuff pressure 20 cmH20 with good seal.\nPlan: continue support as pt. awaits rehab placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481980,
"text": "See carevue for objective data.\n\nNeuro status unchanged. Nods yes or no appropriately and follows commands. MRI of brain done this AM. Results pending.\nBP extremely labile requiring increase dosage of neo and (1) LR bolus of 500cc's. CVP transduced with CVP 9. Unchanged after bolus. NSR with PAC/PVC's occasionally. AMiodarone gtt at .5mg remains. Bedside echo completed this afternoon.\nTf at goal. SSRI per FSBS. If glucose continues to rise, will re-initiate insulin gtt.\nDressings to chest changed. Chest tube site on left draining brown liquid. Team in to evaluate. CXR ordered and done.\nAttempted to wean from AC with no success. Failed CPAP. ABG adeqaute on AC. See flowsheet for additional details.\nIVAB as ordered. Max temp 101. Motrin given with good effect. Pan cx yesterday and the day before. Cultures pending.\nPTT 40.1. Heparin increased at 1500 to 1000U/ PTT at 2100. Goal-60.\nFamily called several times throughout the day. Will be up later this PM to visit. Updated on POC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481981,
"text": "the pt remains on the sames vet settings CMV 550x12x50%x5.abg\n7.42/35/202.bs:coarse.sxn scan thin yellow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481982,
"text": "Addendum:\n\nLeft fingertips remain cyanotic and cold. Vascular in this afternoon to assess pt. ? OR tomorrow to try and re-vascularize hand.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-27 00:00:00.000",
"description": "Report",
"row_id": 1481983,
"text": "RESPIRATORY CARE\nNO VENT.CHANGES THIS SHIFT.PT.REMAINS ON A/C.ABG'S ADEQUATE ON CURRENT SETTINGS.SUCTIONED FOR SMALL AMOUNTS OF THICK YELLOW SECRETIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-27 00:00:00.000",
"description": "Report",
"row_id": 1481984,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt still does not move left side extremities. Able to move rt upper and lower extremities to commands, intermittently. Opens eyes to command, turns head away frequently. Nods appropriately most of the time.\nCV: SBP is Very labile 89-170's. Frequent titration of neo gtt. to keep sbp at goal of 120-130's. HR is NSR 80-90's. Skin is cool and diaphoretic with cold extremities. Cynanosis to LLE and LUE. All pulses are audible by doppler. Pt also on Amiodarone and Heparin gtt.\nResp: Pt remains intubated on CMV mode. ABG's are WNL. Minimal amt of secretions via ett. Sats > 92%.\nGU: Hypoactive BS, no bm. TF on hold since mn for OR today. Dobhoff clamped.\nGI: Foley to bsd with very low u/o. 500ml LR bolus given for fluid challenge.\nPlan for pt to have a carotid-subclavian bypass to hopefully increase the blood flow to the extremities.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-27 00:00:00.000",
"description": "Report",
"row_id": 1481985,
"text": "See carevue for objective data.\n\nMore alert today-following commands more interactive with family.\nBP less labile-off of neo X3 hours. NSR with rare PAC. AMiodarone gtt changed to po dosing.\nNo vent changes. Adequate ABG. Minimal secretions.\nHeparin dc'd at 1400 in preparation for OR. NPO throughout the day.\nLeft arm remains cool and edematous with cyanotic fingertips.\nSkin remains intact.\nMarginal urine output. (1)U PRBC's for HCT 29. No tx reaction noted.\nCVP higher today 14-16.\nSSRI per FSBS.\nFamily in all day. Support/updates provided.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-28 00:00:00.000",
"description": "Report",
"row_id": 1481989,
"text": "Nurses Progress Note for 7p-7a:\nNeuro: s/p carotid-subclavian bypass. Pt awakens and has returned to the same pre/op baseline neuro status. Opens eyes spontaneously. Moves\nrt hand and leg randomly. Able to perform hand grasps to command and nod head appropriately. No movement of the left side of the body, not even to pain.\nResp: Pt on vent support, AC mode with rate of 16/fio2 50%/peep 5.\nSats.92% Minimal amts of whitish secretions sx'd via ett. Pt is breathing over vent.\nCV: HR is sinus 80-110's with rare pvc and occ pac noted. SBP is VERY\nlabile. Pt has been on and off both neo and nitro with frequent titrations to keep SBP 120-130's and map 60-90's. Currently on nitro gtt only. Rec'd 1 unit of PRBC for HCT less than 30.(HCT 27)\nLR at 100 ml/hr. Skin is slightly warm-cool and dry. PPP and radial pulses are palpable. Gen and peripheral edema noted.\nGU: pt had no bs untill early this am, now bs are hypoactive. TF needs to be restarted. Pt had a small brown smear of stool this am.\nGI: foley to bsd with fair u/o\nENDO: blood sugar treated with SSRI as per protocol.\nPlan to restart heparin gtt at previous rate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-28 00:00:00.000",
"description": "Report",
"row_id": 1481990,
"text": "See carevue for objective data.\n\nRemains alert-following commands and nodding yes or no appropriately.\nRequiring intermittent infusion of IVNTG for BP control. No pressor requirement. CVP 6-10. NSR with PAC's/PVC's. Vent weaned to CPAP 15/5-tolerated for a few hours and then became hypertensive with increase RR requiring IVNTG. Settled back down approximately 15 minutes-returned to CPAP after rest period. See flowsheet for current vent settings and ABG's.\nTF re-initiated-currently at 40cc's with goal of 65cc's. SSRI per FSBS.\nHeparin restarted at 0800-PTT to be drawn at 1400. No bolus was given.\nK/MG repleted.\nReceived 20 mg lasix IV with approximately 600cc diuresis.\nReceived additional 300 mg dilantin for level 6.8.\n+ left radial pulse-tips of fingers remain cyanotic but less so than yesterday. No movement on left side.\nFamily in most of day. Updated on POC/supported.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-28 00:00:00.000",
"description": "Report",
"row_id": 1481991,
"text": "Resp Care\n\nPt remains intubated and on SImv/PSV. Pt weaned on 15/5 twice for a total of 4 hrs. ABG drawn 1.5 hrs into the first wean was 7.44/34/164/24. After a total 3hrs pt rested on simv due to hypertension increased rr and a dip in Spo2. The 2nd weaned lasted 1 hr and was terminated for the same reasons. On simv sats improved and rr decreased. Bs are diminished and pt has minimal secretions\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-15 00:00:00.000",
"description": "Report",
"row_id": 1482065,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt is most of the time, occ. dozes intermittantly. Able to perform hand grasps with rt hand most of the time. Occasionally does not follow commands. Randomly able to nod head yes or no. Not mouthing any words tonight. Occasional tremor of the left hand and arm noted, resovles within less than 1 min. No other movement on the left side. Minimal mlvement of rle.\nResp: Pt on AC-rate 14/fio2 40%/peep 5. Usually overbreaths the vent. Mod-small amt of thick whitish secrestions sx'd via trache. Unable to obtain any labs from fem a-line. Line flushes easily and show good wave form most of the time, occ. dampened.\nCV: HR is NSR 70-80's with SBP 120-150. Skin warm and dry, except for rue,rle and lle- which are cool to touch. Pedal pulses via doppler or weakly palp. Gen edema noted.\nGU/GI: Foley to bsd with adequate huo. New G-tube was placed yest. Now to drainage with approx. 50 ml of bile/green fluid noted. Pt had one episode of bleching and either coughing or gaging last night which was relieved by changing g-tube from clamped to low interm. sx. and reglan 10mg iv x1. Small amts of liq. brown bm smears noted.\nSkin: Very red and irritated under breasts and groin area. nystatin power applied as ordered. Mild rash/reddness noted over abd. Abraision healing noted over coccyx area. Pt on special skin care mattress and requires turn and re-position q2-3 hours.\nPlan to restart TF later today and re-start the vent weaning process.\nBS coverage with SSRI and sched. pm dose.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-15 00:00:00.000",
"description": "Report",
"row_id": 1482066,
"text": "Respiratory Care\nPt weaned to CPAP/PSV as noted on Carevue. Pt out of bed for significant portion of the time while weaning. Initial NIF as requested by Pulmonary: -28cm. Pts spontaneous Vt/RR varies frequently. RR=20-40 Vt=300-500cc. Suction for small amounts of thick white secreations. Pulmonary mentioned weaning on CPAP/PSV throughout the day, returning to AC mode at night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-13 00:00:00.000",
"description": "Report",
"row_id": 1482058,
"text": "NEURO: , NODDING HEAD APPROPRIATELY TO QUESTIONS. FOLLOWING COMMANDS. SMILING AT TIMES. DARVOCET X 1 FOR GENERALIZED DISCOMFORT.\n\nPULM: TRACHED TO VENTILATOR. SEE CAREVUE FOR SETTINGS. FI02 DECREASED TO 0.4 AT 0445 FOR PO 183. RSBI 173. SEE CAREVUE FOR ABG'S. LUNGS DIMINISHED BASES.\n\nCV: NSR WITHOUT ECTOPY. TOLERATING LOPRESSOR. SEE CAREVUE FOR VS. NO PRESSORS IV. PEDAL PULSES FAINTLY PALPATED.\n\nENDO: BS 236 AT HS, RX'D WITH 8 UNITS REGULAR INSULIN SC AT 2300. 1/2 DOSE OF PM LANTUS (18 UNITS) SC AT 2300 AS ORDERED. TF OFF AT 2400 FOR OR IN AM. AM BS 113, NO REGULAR COVERAGE.\n\nGI: ABDOMEN SOFTLY DISTENDED, + BS. SMALL AMTS SOFT BROWN STOOL.\n\nGU: FOLEY TO CD DRAINING QS AMTS AMBER COLORED URINE.\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: NPO FOR OR FOR PEG TUBE PLACEMENT. CONTINUE PASSIVE ROM/PT. WEAN FROM VENT AS ABLE. REPLETE LYTES PER LABS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-13 00:00:00.000",
"description": "Report",
"row_id": 1482059,
"text": "7a-7p\nneuro: lethargic, easily aroused, follows commands, slight movement noted to L arm & leg\n\ncv: hr nsr, no ectopy, sbp 88-141, po lopressor, po amiodarone\n\nresp: no vent changes today, remains on 40% fio2, AC 14, 5 peep. bs+ all lobes, clear, sux sm amt loose white sputum, sputum c&s sent per ID request, sat 98-100. rr 16-20, no resp distress noted\n\ngi: npo for PEG placement today in OR, OR cancelled & TF resumed @ 1700, pt to be NPO after MN for OR tomorrow, incont formed stool x 2, po colace, po prevacid\n\ngu: foley patent, clear yellow urine, good uo, iv diamox\n\nother: family in & updated on pt's condition, heparin gtt dc'd this am for OR, OR cancelled & heparin gtt resumed @ 1700 @ 1300u/hr, ivf started today @ 75cc/hr while TF off, ivf dc'd when tf resumed, no c/o pain\n\nplan: continue with ventilatory support, npo after MN for PEG placement in OR tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-13 00:00:00.000",
"description": "Report",
"row_id": 1482060,
"text": "resp. care\npt. remains intubated/vented. sx'd small amt. thick\nwhite sputum. no vent changes today. occ. breaths over\nset rate. o.r. canceled today. plan peg tomorrow.\nsee flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-14 00:00:00.000",
"description": "Report",
"row_id": 1482061,
"text": "Resp Care\nPt. remains trached on ventilator without change overnight. Bs; coarse bilat. sxn'd for sm-mod. white thick. Abgs: hyperoxygenated with mild resp. alkalosis (breathing 10-12 bpm over set rate). Plan: awaiting PEG placement today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-14 00:00:00.000",
"description": "Report",
"row_id": 1482062,
"text": "NEURO: TRACHED. OPENS EYES SPONTANEOUSLY, TRACKS, MAE TO COMMAND, NODDING/SHAKING HEAD APPROPRIATELY TO QUESTIONS. DILANTIN LEVEL 5.7 ON DILANTIN 100MG PO Q6H. NO SEIZURE ACTIVITY, + TREMORS.\n\nPULM: TRACHED TO CMV MODE, FIO2 0.4, VT 500, RATE 14, PEEP 5. NO VENT CHANGES THIS SHIFT. 02 SATS > 95%. SEE CAREVUE FOR ABG'S. LUNGS DIMINISHED BASES. SX'D FREQUENTLY FOR SCANT AMTS THIN TAN-WHITE SECRETIONS.\n\nCV: NSR WITHOUT ECTOPY. SEE CAREVUE FOR Q1H VS, Q4H ASSESSMENTS. BP LABILE WITH SBP DROPPING INTO 90'S AFTER LOPRESSOR DOSE, SBP AS HIGH AS 170 WITH COUGHING. EXTREMITIES COOL, LUE FINGERS CONTINUE TO BE CYANOTIC, RUE COOL AND PINK, LE COOL, TOES SLIGHTLY DUSKY. 1+ PALPABLE PEDAL PULSES BILATERALLY. HEPARIN GTT DC'D AT 2400 AS ORDERED IN PREPARATION FOR PEG PLACEMENT. CA AND K REPLETED PER LABS.\n\nENDO: SEE CAREVUE FOR BLD SUGARS. 15 UNITS LANTUS (HALF DOSE) SC AT 2300, NO REGULAR INSULIN COVERAGE. TF OFF AT 2400 AS ORDERED.\n\nGI: ABDOMEN OBESE, SOFT. + BS. + STAINING OF SOFT BROWN STOOL Q2H WHEN TURNED.\n\nGU: FOLEY TO CD DRAINING QS AMTS AMBER URINE. LAST DOSE OF DIAMOX UP AT 0600.\n\nSOCIAL: DAUGHTER VISITED UNTIL 2100.\n\nPLAN: TO OR FOR PEG TUBE PLACEMENT THIS AM. RESUME TUBE FEEDS WHEN PEG PLACED. CONTINUE VENT SUPPORT, WEAN AS ABLE. PASSIVE ROM ALL EXT Q2H. PT TO FOLLOW. WILL NEED REHAB.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-14 00:00:00.000",
"description": "Report",
"row_id": 1482063,
"text": "shift update: s/p peg placement.\n\nneuro: brief episodes of fine tremors of bilat upper & lower extremities with eye twitching noted. vvs at this time. pearl. team aware & into to eval. 500mg loading dose of dilantin given per neuro. neuro team to eval in am. darvocet 1 tab given x2 for abd pain after peg placement.\n\ncv/skin: nsr. hr 50-70's. sbp initially low post op->responded to fluid->stable since. a-line positional at times. ivf infusing d5 w/20meq kcl at 60/hr. lytes repleated. +rp/pp bilat. sternal & mediastinal incisions ota. abd incision staples intact, dsd changed d/t lg amt ss drainage. small abrasion to coccyx open to air. turned & repositioned q2h. heparin restarted.\n\nresp: lungs coarse to clear but diminished in lll. no vent changes made. suctioned for scant->small amt white thick secreations. trach care done.\n\ngi/gu: remains npo. peg patent. to start tf in am. uop adequate.\n\nendo: no ss insulin required.\n\nsocial: children into visit & daughter called from for update.\n\nplan: cont to monitor neuro status. pain management. cont heparin at 1300u/hr. t&r q2hrs. pulmonary care. npo. start tf in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-17 00:00:00.000",
"description": "Report",
"row_id": 1482070,
"text": "Resp Care\nPt. remains trached on vent. AC mode.\nBS: CEB, secreations sm-mod. white thick.\nPlaN: PSV trials again during days tommorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-17 00:00:00.000",
"description": "Report",
"row_id": 1482071,
"text": "1900-0700\n\nNeuro: Pt awake, to verbal stimuli with eye opening. Intermit following commands. Moves RUE/normally, RLE/on bed, /LLE no movement noted. LUE: pink with cyanotic finger beds with + radial pulse. LLE cool dusky with pulses by doppler. Pupils equal and reactive. Pt tracking. No seizure activity noted.\n\nResp: Pt trached on mech ventilation. A/C, 500, 40%, +5, 10. Spont resp noted. O2sat stable. Suctions for scant thick white secretions. L femerol aline with sharp waveform/cannot draw labs. No ABG for AM. Lungs coarse/diminished at the bases.\n\nCV: NSR without ectopy, HR 70-90, SBP 100-140. HCT:25.9. Heparin drip remains @ 1000 units/hr. Coumadin started in PM. PTT due at 8AM. See carevue for incision site/dsg info. Pedal edema noted.\n\nGI/GU:Abd round soft + BS, no BM. Peg inplace draining serous fluid. Promote with fiber @ 65cc/hr-tolerating. Foley to gravity draining yellow cloudy urine. ^BUN: 45, ^CR:1.5.\n\nEndo: RISS.\n\nPlan: Supportive care. Monitor PTT. Resp support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-17 00:00:00.000",
"description": "Report",
"row_id": 1482072,
"text": "CSRU NPN\n\nNeuro: Upon intial exam, pt opening eyes and tracking/focusing. Mouthed \"good morning\" back to RN and mouthed \"no\" and shook head no to answer of question of pain. Squeezed right hand and moved right foot to request. As day has progressed, pt has opened eyes to name but has not responded to questions/requests. Not moving extremities to request but right hand moving almost constantly throughout the day. Fidgeting in bed and pulling body towards right side frequently. Hand restrained to prevent trach from being pulled at. Dilantin trough calculated for albumin at ~ 25 per pharmacy. No change in dosing at this time.\n\nCV: NSR with no ectopy noted. BP stable until end of day when noted to have SBP's 150-170's w/ MAP's low 100's. Changed back to AC ventilation w/ decrease in BP. Heparin gtt increased to 1100->repeat PTT pnd, goal atleast 60 NP. Coumadin given. 1 unit prbc's given. Generalized edema.\n\nResp: BS coarse. Weaned to CPAP w/ 18 IPS. RR 30-40's, MV , O2 sats > 93%. On CPAP x ~ 8 hrs. Suctioned for scant amts yellow secretions. CXR w/ small left pleural effusion per report.\n\nGI: TF's increased to goal. No residuals. + BS. No stool. Copious amts serousang dng from around PEG tube. Dsg changed frequently.\n\nGU: u/o marginal at times. Lasix increased to TID. Lytes treated prn.\n\nID: Abx cont. Afebrile.\n\nEndo: Insulin dosing adjusted recommendations.\n\nSkin: Area of stage 2 breakdown noted on right coccyx area. Duoderm removed from left coccyx area and both areas cleansed and covered w/ new duoderm. Wound bases pink, scant serousang dng. Noted patchy, slightly raised pink rash from lower breasts to top of thighs. Area evaluated by NP.\n\nA: High MV on CPAP IPS 18. Pink rash on anterior trunk area. Fedgety\n\nP: Monitor neuro status. Monitor dilantin levels. Heparin gtt. Coumadin. CPAP wean again . Monitor rash. Assess response to lasix. Skin care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-17 00:00:00.000",
"description": "Report",
"row_id": 1482073,
"text": "resp. care\npt. remains trached/vented. on psv most of shift with resp.\nrate 20-45. changed back to a/c to rest overnight. see flowsheet\nfor more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1482131,
"text": "CSRU A NPN:\nPt's code status now \"FULL CODE\" and order written.\nNEURO: , mouthing words and following commands. Good strength to RUE and moving rest of extremities in bed. Denies pain. No sz activity. Dilantin level 7 this am.\nCV: Afeb. HR 1st degree AV block 70s-80s, no ectopy noted. BP stable. Skin warm with dusky extremities. Continues with cyanotic L finger tips and L great toe. Dopplerable pulses to feet and weak but palpable radial pulses bilaterally. INR 2.6 this am. To receive HD again this am.\nRESP: Put back on vent from TM at beginning of shift due to tachypenia and increased work of breathing. On vent overnight with current settings: CPAP with PS 10 Peep 5 FiO2 40% with O2 Sat >95%. LS coarse and diminished at bases. Sx'd for small amts thick pale tan secretions. Passy muir valve in room but not to be used until speech therapy by today.\nGI/GU: Abd. soft and distended with positive bowel sounds. Oozing small amts formed stool. Nepro at 35cc/hr with minimal residuals. Peg intact but continues to ooze serous drainage from insertion site- dsg changed x2. Foley draining scant amts amber urine.\nSKIN: Duoderm to coccyx intact. Excoriated perineum and rectum- barrier cream applied. Repositioned side to side.\nPLAN: OOB to chair as tolerated. Plan for HD today again.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1482132,
"text": "Respiratory Care Note:\n Patient on PSV overnight with increase to 10 for a few hours due to RR>35. Weaned back to PSV of this am and plan is for trach collar again today. She remains tachypneic with RSBI>150. Noted long trend of this breathing pattern and VD/VT ratio of 60% when checked. See Carevue flowsheet for specifics, no recent abgs available.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1482133,
"text": "SHIFT UPDATE\nPT , MOUTHS WORDS, FOLLOWS COMMANDS. RIGHT SIDED WEAKNESS > THAN LEFT.\nNO RESP DISTRESS FOR SHIFT. PLACED ON TRACH COLLAR @ 1730. SPO2 98% RR 24-28. PT AT 1600, NO COMPLICATIONS, SMALL AMT MUCUS WASHED LEFT LUNG. PT TOLERATED PROCEDURE WITHOUT SEDATION. SXN'ING THICK MUCUS FROM TRACH ON MODERATE AMTS. LEFT SIDED LUNG SOUNDS REMAIN DIMINISHED AS COMPARED TO RIGHT SIDE BUT PT SHOWING NO SIGNS OF RESP DISTRESS.\nECG SR, NO ECTOPY NOTED. BP STABLE, AFEBRILE. DOPPLER PULSES ONLY BLE'S. RIGHT FINGER TIPS NECROTIC, NO CHANGE. PT WITH RED RASH OVER ENTIRE BODY. ?RXN TO ANTIBX THERAPY. BENADRYL GIVEN X1 THIS AM. PT DENIES . RASH SEEMS TO BE IMPROVING SOME.\nTOLERATING TF AT 35 CC/HR. NO STOOL THIS SHIFT. PT HAD HD TODAY, 3L REMOVED, TOLERATED WELL.\nTX TO CHAIR AT 1720 VIA LIFT. ATTEMPTED WT BEARING FROM CHAIR BUT PT UNABLE TO EVEN SIT FORWARD IN CHAIR WITH ASSIST. CURRENTLY VISITING WITH CHILDREN IN NO ACUTE DISTRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1482134,
"text": "Resp Care\nHad Bronch today, not too prod for secretions, has been on Trach collar since 5pm. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-05 00:00:00.000",
"description": "Report",
"row_id": 1482148,
"text": "FULL CODE Unversal Precautions NKDA\n\n\nNeuro: Opens eyes, follows commands, mouthing words, nodding approp, moves RUE about, LE and LUE moves toes/fingers on command. Pupils 3mm/brisk. Weaning off Dilantin - no seizure activity noted.\n\nCV: HR=80-70s, NSR, no ectopy. BP=92-110s/40-50s. Pedal pulses +w/ doopler, +edema, extrems warm except for L hand - cool. On amiodarone and lopressor.\n\nResp: CPAP/PS 40% w/ 02sat 99-100%. Lungs coarse, diminshed in bases bilat. Sx min thick white secretions via ETT.\n\nGI/GU: Abd soft, +BS, BM smear each time she's turned. FS TF nepro restarted at 2100 at 35cc/hr w/ min resids. R subcl tunneled dialysis cath placed - CXR done - ok to use. Last HD on Sat - ?next rx - per renal. Foley cath w/ scant brown urine.\n\nPain: Denies discomfort.\n\nSkin: rash/flaking skin resolving. Duoderm to ccocyx intaxt. Abd PEG site draining serous fluid - small amt.\n\nLabs: FS=81 prior to starting TF - at 1400 upto 140 - no coverage needed. Lantus given abdominally. at 2200. Lytes ok. RBCs down to 27 from 31. ID: afebrile- on fluc.\n\nSocial: No calls during the night. Daughters at bedside at change of shift.\n\nPlan: Continue to wean vent as tol. HD when ordered. Monitor neuro/cardiac/resp status. Being screened for rehab.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-05 00:00:00.000",
"description": "Report",
"row_id": 1482149,
"text": "Respiratory Care Note:\n Patient awake and . PSV decreased to despite RSBI being 115. She has had chronically elevated RSBIs and done ok weaning to trach collar despite that. Plan to change to trach collar this am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-05 00:00:00.000",
"description": "Report",
"row_id": 1482150,
"text": "Resp Care\nPt remains trached. Pt on trach collar all day. Pt placed on PMV for about 15mins. No other changes made. PT working on transition tp PMV.\nPt placed back on vent for rest.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-05 00:00:00.000",
"description": "Report",
"row_id": 1482151,
"text": "SHIFT UPDATE 7-7P\nPT A&O X 3. OCCASIONAL MILD CONFUSION TO TIME/DATE. EASILY RE-ORIENTED. PLACED ON TRACH MASK @0930. NO RESP DISTRESS FOR MAJORITY OF DAY. PLACED BACK ON VENT @ 1815 AFTER PT \"THE MACHINE\" RR28, SPO2 98%, APPEARS TIRED, PLACED ON CPAP FOR WITH PS 5 FOR OVERNIGHT REST.\n\nEVALUATED BY SPEECH THERAPY TODAY. PLACED ON PASSIMIER VALVE X2. NO DIFFICULTY BREATHING, DEMONSTRATES STRONG PRODUCTIVE COUGH AND EASILY AUDIBLE VOICE. MOVES ALL EXT TO COMMAND WITH LEFT SIDED DEFICIT.\n\nSR FOR SHIFT, NO ECTOPY. V/S STABLE. DOPPLER PULSES X 4 EXTREMITIES. NECROTIC FINGERS LEFT UNCHANGED, APPEARS TO HAVE HEALTHY PINK TISSUE UNDER DEAD SKIN. DENIES PAIN. TL CL R GROIN, QUINTON CATH,LEFT GROIN, NEW VAS CATH RIGHT SCV. PER TEAM-LEAVE QUINTON CATH UNTIL VAS CATH USED FOR HD TOMORROW. SKIN RASH IMPROVING, DRY AND PEELING OVER ENTIRE BODY. DUODERM REMOVED @ COCCYX, SKIN INTACT.\n\nTF VIA G-TUBE AT GOAL OF 35CC/HR. SITE LEAKING CLEAR SEROUS FLUID AROUND INSERTION. PT FREQUENTLY SOFT, BROWN. TX TWICE TO CHAIR TODAY VIA LIFT.\n\nFAMILY MET WITH MULTI DISCIPLINES TODAY TO DISCUSS PROGNOSIS AND FUTURE CARE. TO MEET AGAIN WITH PT TOMORROW AT 1100 TO EXPLAIN PROGNOSIS TO PT AND DETERMINE PT'S WISHES FOR FUTURE CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-06 00:00:00.000",
"description": "Report",
"row_id": 1482152,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support throughout the night. No abg results at this time.\n\nRSBI = 101.5 0n 0-PEEP and 5 cm PSV.\n\nPlan is to continue trach collar trials today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-25 00:00:00.000",
"description": "Report",
"row_id": 1481976,
"text": "NEURO: PT. IS AROUSED TO SPEECH. RESPONDS INTERMITTENTLY TO COMMANDS TO MOVE EXTREMITIES ON RT SIDE ONLY. GRIMACES TO NAIL BED STIMULI ON LEFT SIDE. PT. NODS IN RESPONSE TO QUESTIONS. PUPILS ARE EQUAL ROUND AND REACTIVE TO LIGHT. EYES DO NOT TRACK. PT IS MORE RESPONSIVE TODAY THAN YESTERDAY.\n\nCV: BP IS EXTREMELY LABILE. TITRATING UP/DOWN WITH NEO TO MAINTAIN 120s-140s. VOLUME GIVEN 1 LITER LR TO A TOTAL OF 500CC 5% ALBUMIN WITH LITTLE HELP WITH BP CONTROL. HR 90-110 THIS AM, SR WITH PACs AND PVCs. PT WENT INTO RAF 120s-130s THIS PM WITH A DROP IN BP AND CO. AMIO BOLUS X2 WITH DRIP STARTED AND LYTES REPLETED. PT SPONTANEOUSLY CONVERTED BACK TO NSR WITH IMPROVEMENT IN HEMODYNAMICS-SEE FLOW SHEET. SWAN DC'D. CORDIS CHANGED TO CVL OVER WIRE. WIRES DC'D. HIT NEGATIVE. TO START HEPARIN THIS PM. LEFT HAND & BILATERAL FEET CONTINUE TO BE DUSKY UNCHANGED BUT STABLE. DOPPLERABLE PULSES IN ALL EXTREMITIES. CHEST TUBE SITE CONTINUED TO BE .\n\nRESP. PT PLACE ON AC DUE TO RAPID RR. ABGS WNL. LUNGS CLEAR. SATS >97% SX MIN TAN SECRETIONS.\n\nGI/GU: CONTINUE TUBE FEEDS, GOAL ADVANCE TO 65CC/HR. FREE WATER BOLUS ADDED. ABD SOFT. SMALL SMEARING OF STOOL. FOLEY PATENT, UO AMBER 20-70CC/HR.\n\nID: FEBRIBLE T MAX 102.1 PAN CULTURED. CORDIS TIP CULTERED. IBUPROFEN GIVEN. CURRENT TEMP 98.7. WBC 11\n\nENDO: BS RISING WITH SC INSULING. 1HR GTT STARTED WITH RAPID DROP.\n\nPLAN: CONTINUE TO ASSESS CV/RESP STATUS. TITRATE NEO ACCORDINGLY. ?MRI TONIGHT. FOLLOW COAGS AFTER START OF HEPARIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481977,
"text": "Respiratory Care Note;\n Patient remains intubated and on full vent support. She is not a candidate for a spontaneous breathing trial at this time as her RSBI was >130. Left on A/C at this time, awaiting rounds for further plans. See Carevue flowsheet for settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481978,
"text": "Respiratory Care Note;\nRSBI=124.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-04 00:00:00.000",
"description": "Report",
"row_id": 1482143,
"text": "neuro: a&o. able to follow commands, communicates by nodding and mouthing words. maes purposefully on bed; rt hand has normal strength. l hand with slight hand grasp. prom done. perrl. no sz activity noted.\n\ncv: hr 70s fluctuating between nsr and 1st avb. sbp 110s at rest, up to 130s with repositioning. dopplerable pulses. extrs are warm and dry. left fingertips continue to be blue. afebrile. cvl has only one lumen which will allow blood draw. calcium repleted. INR 2.5.\n\nresp: bilat upper lscta, dim at bases. pt rested on CPAP PS 5&5 0.40 fi02 overnight. sxd sm thick yellowish/white sputum. trach care done.\n\ngi/gu: tf shut off @ 12:30am d/t going to OR for tunneled dialysis cath insertion if family consents. bs present, sm bm x1. on hd, foley patent-occasional drng of amber uo <25cc/hr.\n\nendo: bs monitored per ss protocol. pt received ordered dose of pm reg ins and lantus. bs has decreased steadily since tf off. continue to monitor frequently. ? need for continuous iv fluid if pt remains npo.\n\nsocial: family has not called or .\n\nplan: continue monitoring cardiorespiratory, neuro status. monitor bs. need family consent for tunnel cath. resume tf if not going to OR. ? whether order in for heparin flush for cvl and coumadin. ? reverse coumadin if going to OR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-04 00:00:00.000",
"description": "Report",
"row_id": 1482144,
"text": "Resp. Care:\n No change in vent status. She appeared comfortable on PSV of overnight. See carevue flowsheet for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-04 00:00:00.000",
"description": "Report",
"row_id": 1482145,
"text": "Preop tunnel cath insertion\nS: \" HELP ME DECIDE WHAT TO DO, I THINK I WANT IT\"\nO: CARDIAC: SR 70-80'S WITHOUT VEA. SBP 100-120'S. EXTREMITIES WARM AND DRY. DOPP PP AND RADIAL PULSES. HCT 31. RECIEVED 3 UFFP PRIOR TO OR FOR PLACEMENT OF TUNNEL CATH.\n RESP: TRACHE COLLAR 1000 TO OR AT 1500. O2 SATS >99%. SX FOR SMALL AMOUNTS OF WHITE SPUTUM. RR 18-20'S. BS DIMINISHED BIBASILAR.\n NEURO: A+O X 3 . RIGHT GRASP STRONG LEFT LITTLE OR NO MOVEMENT. MOVING BOTH TOES AND MOVES LEGS SLIGHTLY ON BED. PUPILS BRISK UNEQUAL DUE TO CATARACT. CALM\n GI: NPO FOR OR, ABD SOFT NONTENDER, + BOWEL SOUNDS. SMALL AMOUNT OF BROWN STOOL.\n GU: SMALL AMOUNTS OF BROWN URINE.\n ENDO: GLUCOSE 84-79\n SKIN: DUODERM ON COCCYX INTACT\n PAIN: DENIES\n SOCIAL: DR. TO PT AND DAUGHTER AT LENGTH RE: IMPENDING PLACEMENT OF TUNNEL CATH FOR HD. PT CONSENTED, DAUGHTER SEEMED TO THINK PT SHOULD NOT HAVE IT DONE AND BEING HER HEALTH CARE PROXY WOULD NOT CONSENT FOR IT. PT'S DAUGHTER SPOKE TO THE ETHICS MD AND AGREED TO GO FORWARD AND HAVE CATH PLACED. ? FAMILY MEETING WITH DR. ON TUESDAY.\nA: TO OR AT 1530 FOR TUNNEL CATH PLACEMENT. ? WHETHER SHE IS DOING THE RIGHT THING PT FEELS SHE IS.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS- TRACHE CARE, TRACHE COLLAR, NEURO STATUS-OFFER REASSURANCE, I+O, LABS PENDING. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-04 00:00:00.000",
"description": "Report",
"row_id": 1482146,
"text": "Resp Care\nPt remains trached on A/C. Pt on trach collar for most of the day then transported to OR for procedure. Pt placed on A/c on return from OR. MDI's given. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-04 00:00:00.000",
"description": "Report",
"row_id": 1482147,
"text": "S/P TUNNEL CATH VIA RIGHT SC.\nO: ARRIVED SEDATED ON 20 MCQ OF PROPOFOL. RIGHT SC TUNNEL CATH INSERTED WITHOUT INCIDENT. 300 ML LR AND MIN EBL.\nPROPOFOL OFF BEGINNING TO WAKE AND MOVE.\nP: CHECK LABS PENDING, DC QUINTON IN LEFT FEM SITE. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-26 00:00:00.000",
"description": "Report",
"row_id": 1481979,
"text": "ekg nsr, rate 80s, rare pac. amiodarone continues at .5 mg. sbp labile, titrating neo to try to maintain between 120 and 140 with limited success. tmax 100.2 tonight. adequate uo, 35-60cc/hr, amber. heparin started at 600u with subtherapeutic ptt this am, increased to 800 at 0500 breath sounds coarse, clear some with suctioning, ett suctioned for mod to large amts thick tan secretions, lavaged several times to be able to get secretions out. no vent changes overnight, abgs acceptable, failed rsbi this am. sternal dressing dry, mediastinal ct site dressng saturated with old bloody drainage, changed. r neck dressing dry. abd soft, bowel sounds present, tolerating promote with fiber at goal, 65cc/hr. small smear of stool. skin moist and cool, feet and hands cold, l fingertips and bilat toes blue. dp,pt, radial, ulnar, and brachial pulses all present by doppler, though l foot pulses very difficult to find. skin on back and coccyx is intact. opens eyes spont and to voice, usually follows commands with r side, and moves r arm and leg restlessly often. no movement of any sort seen on l side. nods and shakes head approp to yes/no questions, denied pain. plan to have mri today hopefully. get oob with , continue tf, monitor peripheral circulation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-12 00:00:00.000",
"description": "Report",
"row_id": 1482052,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt is or awakens easily. Able to nod head and attempt to communicate by mouthing words. Able to move RUE to command. Moves RLE on the bed and LUE has very slight movement at times. No movement of LLE. No seizure activity.\nCV: HR is NSR 70-80's, SBP 100-150's. Skin warm and dry with ble cool and slightly dusky. LUE is warm with 3 cyanotic fingers. Gen edema noted. PP via doppler. radial pulses palp.\nResp: Remains on vent. AC mode, rate 14 with peep 5, fio2 50%. Pt does breath over the vent. Abgs still alkalotic despite lasix d/c'd yest. Minimal whitish-yellow secretion via Trach. Continue to wean vent as possible(Pt has failed RSBI Q day) Continue to T&R Q2-3 hours.\nGU/GI: Tolerates TF at goal of 65cc/hr. Passing flatus and small amts of liq. stool. Foley to bsd with adequate u/o.\nSkin: Sternal dressing and medialstinal dressing cdi. duoderm to coccyx. on kcl bed for skin care.\nPlan: Continue on Heparin gtt. Continue to monitor for any increase in secretions or temp spike->may need bronch at that time. Pt awaiting sche for picc line for antibiotics and g-tube for feeding. Pt will not be able to get oob until both fem lines d/c'd. benefit from an increased activity level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-12 00:00:00.000",
"description": "Report",
"row_id": 1482053,
"text": "Respiratory Care\nPt.continues on full vent. support.No vent.changes this shift.Abg's reveal a metabolic alkalemia,with excellent oxygenation.Suctioned for moderate amounts of thick white/clear secretions.Plan:continue support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-12 00:00:00.000",
"description": "Report",
"row_id": 1482054,
"text": "Nursing Note Addendum:\nTF off for probable G-tube placement today. Heparin off for high Ptth.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-12 00:00:00.000",
"description": "Report",
"row_id": 1482055,
"text": "Resp Care\nPt remains intubated on AC, with no changes, no psv trial. Plan to cont with current tx and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-08 00:00:00.000",
"description": "Report",
"row_id": 1482162,
"text": "Respiratory Care\nPlaced back on pressure support overnight to rest. Had been on trache collar with Passy-Muir valve all day, tolerated well. RSBI = 80. Pt to be discharged home for hospice care later this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-12 00:00:00.000",
"description": "Report",
"row_id": 1482056,
"text": " nursing progress note\nneuro: a/o x2 follows commands. right side weak but at baseline. left side wiggles fingers and toes on command. passive ROM w/ PT and family\nCV: vss, nsr - no ectopy. chest dsg D&I. Hep gtt therapeutic - ptt 60 @ 4pm\nResp: rate teens to 20's. suctioned for thick white sputum. strong cough and +gag. lungs clear dim bases. ABG's remain alkalotic - started on IV Diamox x4 doses\nGU: foley to gravity. clear yellow urine\nGI: tf at goal. sm stool today\nEndo: protocol changed today lantus increased - 1/2 dose of lantus to be given tonight due to NPO for PEG order. glu 157 4pm covered w/ ssri\nSocial: children x3 to visit most of day. very attentive and encouraging to pt.\nAssessment: denies pain. duoderm to coccyx in place, skin otherwise intact. multiboot on left foot. molded pillows for hands. mouths words to family, tries to write on board w/ family assist.\nPlan: NPO after midnoc for PEG placement, 1/2 dose lantus, resp hygeine. continue PT/OT, passive rom. ? begin weaning after PEG\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-13 00:00:00.000",
"description": "Report",
"row_id": 1482057,
"text": "RESP CARE: Pt remains trached/on vent on AC 500/14/breathing 10 breaths over set rate,FI02 decreased to .40/5 PEEP. ABGs acceptable. Sxd thick yellow/white. Pulling at vent tubing at times. RSBI-173\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 1482120,
"text": "CSRU NSG:\n\nNEURO: Awake & , follows commands, PERRL. Able to move LUE and LLL slightly on bed.\n\nCV: SR, 1st degree AVB. VSS. All peripheral pulses present per doppler. L digits necrotic, L great toe is dusky. Coumadin 4 mg given per Dr. . K 4.8.\n\nPULM: CPAP 5, PSV 5, 40%FiO2 all shift. No respiratory distress. Suctioned for scant respiratory secretions.\n\nGU: Scant urine output, approximately 5cc/hr. CR 4.2. No hemodialysis.\n\nGI: Abdomen soft, NT + BSX4Q. Small, soft stool X 1. Tolerating Tube feeds at goal with no residuals.\n\nINTEG: Duoderm to coccyx intact, clean. Red rash covers trunk and limbs, patient denies itching or other discomfort from the rash.\n\nASSESS: VSS, tolerating CPAP, elevated CR, no hemodialysis today.\n\nPLAN: Monitor renal function, urine output, mental status, K. Reposition to prevent further skin bteakdown.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-30 00:00:00.000",
"description": "Report",
"row_id": 1482121,
"text": "Nursing Progress Note for 7p-7a:\nPt has been made a DNR/DNI and family has decided to forego any further dialysis treatments per the pt's wishes.\nNeuro: Pt is and mouths words to communicate. Moves rt hand and arm-follows commands with this extremitiy. Minimal movement noted to RLE and LUE. No movemnet of LLE at this time. No neuro changes.\nResp: Pt is on trach to vent support. Cpap+ps 10 with peep of 5 and fio2 40%. PS was increased last night d/t pt increased resp rate and c/o difficulty breathing. Minimal secretions.\nCV: HR is 1st degree avb, rate 70-80's with SBP 100-150's. Off all gtts. Skin warm and dry. Afebrile. Pedal pulses via doppler. Generalized and peripheral edema. Left hand with 3 cyanotic finger tips. Rt foot with dusky toes.\nSkin has a red rash over entire trunk and extremities.\nGU/GI: foley to bsd with very low u/o at 0-5 ml per hour. TF via peg is Nepro at 35 ml /hr.\nPlan is to attempt to wean pt down to trach collar and contimue with comfort care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-30 00:00:00.000",
"description": "Report",
"row_id": 1482122,
"text": "Respiratory Care:\nPatient decreased to 5 cm PSV from 10 cm PSV in anticipation of switching to a trach collar this am. No abg's drawn at this time.\n\nRSBI = 95.2 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-30 00:00:00.000",
"description": "Report",
"row_id": 1482123,
"text": "Resp Care\nPt was placed back on PSV, after 4hr TM trial tol well. Plan to rest on PSV overnight, adn repeat TM trial in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482126,
"text": ",rrt\npt. remained on psv t/o shift, tolerating well sx'ing mod # thick white sputum, rates still in the >20's-< to mid 30's, vt >200's to high 300's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482127,
"text": "Neuro: pt and following commands this morning, was able to lift and hold right arm, was able to move RLE, LLE and LUE on the bed, was able to wiggle toes bilat, right hand grasp good, left grasp weaker than right but still strong, was able to answer questions appropriately by shaking her head \"yes\" and \"no\", ST in to evaluate and trial Paasey-Muir valve, pt's voice was strong initially then progressively became weaker, pt answered the following questions appropriately:\nWhat day is it: \" \"\nWhat year is it: \" 200 5\"\nWhere are you: \" In the hospital\"\n\n NP was in to evaluate, ST notified and present to reapply Passey-Muir valve, Pt again had a strong voice initially that became progessively weaker, explained current plan of care and her options concerniong HD and ventilation including going home with and without HD, ventilation options, pt saked several pointed questions, one question was concerning when dialysis could be started\npt also stated several times \"let's do it\", clarified to mean \"let's start dialysis\", This writer feels pt is totally and oriented and competent to make her own decisions\nPlan: start HD and have family team meeting when they arrive using the Passey-Muir valve\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482128,
"text": "Respiratory Care\n\n Pt placed on Trach collar at 1000 am and tolerating well. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482129,
"text": "Pt's daughter and son in to visit, Each one spoke individually with NP concerning progress and plan, placed Passey-Muir valve on during her visit for a short period, SPO2 > 94% throughout, pt following commands, speaking in one and two word answers and comments, slow deep breathes, no signs of respiratory distress, pt OOB in chair, dialysis currently being done, 2 liters taken off\nPlan: dialysis again in morning for @ 4 hours if tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482130,
"text": "Code status: this writer spoke with pt's daughter and son concerning code status, pt's son stated\" with the change in events we would like to take back the DNR and see how she does\" notified above discussion\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-03 00:00:00.000",
"description": "Report",
"row_id": 1482139,
"text": "Respiratory Care Note:\n patient rested most of this shift on CPAP 5/5 40%. Tolerated well. VT's ranging from 300cc to 400's cc. MDI's administered as ordered. BS diminished at the bases. RSBI this am is 101.8. Will continue to monitor closely and place on trach collar as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-30 00:00:00.000",
"description": "Report",
"row_id": 1481997,
"text": "CSRU NSG:\n\nNEURO: Rouses to voice, nods head appropriately to questions. +R side movement, no left side movement. WBC 16.2, afebrile.\n\nCV: SR -> ST, no ectopy. BP labile, NTG drip titrated to maintain SBP 120-140. L digits are necrotic, cold to touch, intact. All peripheral pulses are intact. HCT 31.9.\n\nPULM: Vent settings: SIMV 12, 50% FiO2, PEEP 5, PSV 10. LSCTAB. Small amount tan secretions suctioned prn.\n\nGU: Urine clr, yellow, output QS.\n\nGI: Abdomen soft, NT, +BSX4Q. Propmote with fiber infusing at 65cc/hr. No G-tune residuals. Small, brown, formed stool X1.\n\nINTEG: Skin intact, no breakdown noted.\n\nCOMFORT: Denies pain all shift. No objective s/sx pain noted.\n\nASSESS: Ventilator dependent, elevated WBC count. Requires NTG for BP control.\n\nPLAN: Wean vent as tolerates, administer IV antibiotics as ordered. Titrate NTG drip to maintain prescribed parameters. Vanco trough due before next dose.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-30 00:00:00.000",
"description": "Report",
"row_id": 1481998,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support all night long with no parametr changes made. Most recent abg results determined a mild metabolic alkalemia with good oxygenation on the current settings.\n\nRSBI = 115.9 on 0-PEEP and 5 cm PSV (failed RSBI).\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-30 00:00:00.000",
"description": "Report",
"row_id": 1481999,
"text": "Resp care\n\nPt weaned for a total of 7 hrs during the shift. Did have 1 hr rest after having been moved. MV remain high at aprox 14L with rr in the mid 30's. ABG with a respiratory alkalosis. BS are generally clear and suctioning thick yellow\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-16 00:00:00.000",
"description": "Report",
"row_id": 1482068,
"text": "nursing progress note for 7p-7a:\nNeuro: Occasional slight twitch of left shoulder noted for a few seconds, randomly. Stops withing a few seconds-less than 30 seconds. No other seizure activity noted. Pt is able to open eyes and trach speaker and able to move RUE with full ROM. Pt is not following any commands at this time. Strong withdrawal to pain on rue.\nPt is not moving any other extremity. Pt is not smiling or attempting to mouth words, does not nod head in response to questions, although she was mouthing words and following commands before G-tube placement on . ? lethargy, depression or result of anesthesia. Will continue to monitor. No other changes.\n\nResp: Pt continues on Vent support to trach via AC. ABG->metabotlic alkalosis, pt overbreaths vent. Minimal whitish secretions sx'd.\n\nCV: Hemodynamics stable. Pedal pulses via doppler, occasionally faintly palpable. Skin cool-warm and dry. Gen edema noted.\n\nGU/GI: Tolerating TF at 60 ml/hr with residual 0-20ml. Goal is 65 ml/hr. Small liq smear only. Foley to bsd with fair u/o.\nEndo. BS coverage with SSRI as ordered.\n\nPlan to continue to attempt to wean pt to CPAP+PS mode and increase TF to goal. Continue on Heparin gtt. Monitor hemodynamics and lab values with electrolyte replacement as protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-24 00:00:00.000",
"description": "Report",
"row_id": 1481971,
"text": "Resp Care\n\nPt remains intubated and currently vented on PSV 12/5 with Vt around 400cc and RR in the mid to upper 20s. BS clear to slightly course sxing for small amts of thick tan to white secretions. ETT advanced and retaped at 24 cm at the lip per CXR. ABG WNL on present vent settings. Will cont with vent support and reassess for daily weaning trials.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-24 00:00:00.000",
"description": "Report",
"row_id": 1481972,
"text": "ADDENDUM: PT FROM CT SITE, CORDIS, SPUTUM BLOOD TINGED, OGT DRNG HEME+ TEAM AWARE ( , AND DR. )AND CONTINUING LEPIRUDIN AT CURRENT DOSE. CONTINUE TO FOLLOW COAGS\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-25 00:00:00.000",
"description": "Report",
"row_id": 1481973,
"text": "Resp. Care:\n Pt. remains intubated and on vent. support-PS 15/ C-PAP 5 40%. ABG-normal. RSBI=127. She is febrile, 5 l fluid +. Sputum cult. shows yeast with pseudohyphae. CXR is unremarkable. Cont. present support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-03 00:00:00.000",
"description": "Report",
"row_id": 1482140,
"text": "7pm-7am update\npt , following commands. PERRL. left side remains weaker than right. pt remains in 1st degree AV block. hr 80-90's. SBP 90-140's. hct stable. pp by doppler. bil ulnar and bil radial pulses present by doppler. finger tip on left hand remain black. toes on bil feet remain dusky. coumadin remains on hold d/t elvated INR. LS clear with dim left side. pt on CPAP overnight with 5 peep and 5 PS. pt appear comfortable on the vent. o2 sats > 97%. bun/creatinine elvated from yesterday - ?? HD today. (last HD on ). foley draining scant amber cloudy urine. skin remains reddened (team aware - ??? dilatinin rash). pt denies pain. pt was recieving nepro TF at 35 cc/hr (goal rate) -> nepro TF held at 3 am -> ?? OR later today for tunneled catheter\n\nplan: ? HD today, monitor lytes/bs, ?? OR later today for tunneled line, monitor skin, ? begin rehab screening\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-03 00:00:00.000",
"description": "Report",
"row_id": 1482141,
"text": "Resp Care\nPt remains trached on PSV. Pt on trach collar for most of the day. MDI's given. Pt suctioned for mod amt of thick white. Initiated trach care. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-03 00:00:00.000",
"description": "Report",
"row_id": 1482142,
"text": "NEURO~. FC. COMMUNICATING EFFECTIVELY. LEFT SIDE WEAKER THAN RIGHT. SEE FLOW SHEET FOR CPMPLETE NEURO ASSESSMENT. NO C/O DISCOMFORT TODAY. HOYERED OOB TO CHAIR FOR 3 HRS TOL WELL. TRACH COLLAR FOR 10.5 HRS,TOL VERY WELL. PLACED BACK ON CPAP 5/5 @ 1830. PT NOT SEEN BY SPEECH THERAPY TODAY, PASSY MEUR VALVE NOT TRIALED.LUNGS COARSE/DIM BILAT SX FOR SM AMTS OF THICK WHITE SPUTUM. MAINTAINING SATS 90'S-100%. REMAINS IN 1 ST DEGREE AVB. RATE 80'S-90'S RUNNING TACHY DURING HEMO. SBP WNL FOR PT. TF NEPRO @ 35 CC/HR RESTARTED THIS AM. OFF @ 3 AM, ? -> OR TODAY FOR TUNNELED DIALYSIS CATH. OR POSPONED UNTIL MONDAY. HEMO DIALYSIS RUN UNEVENTFUL. 4 LITERS OFF. BODY RASH REMAINS UNCHANGED. TAPERING PT OFF DILANTIN STARTED ON LEVETIRACETAM (ANTICONVULSANT). EXTRA DOSE GIVEN POST HD.FAMILY IN VISITING TODAY. PT BEING SCREENED FOR REHAB PLACEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-07 00:00:00.000",
"description": "Report",
"row_id": 1482156,
"text": "DNR\n\nROS:\n\nNeuro: , O x's 3. MAEs x's 4, weakly. Mouthing words and nods head yes/no to questions asked. cooperative and friendly. seizure activity noted. Denies pain.\n\nCV: RSR w/o ectopy. VSS. On metoprolol. Central line and HD lines remain in place.\n\nResp: on CPAP over noc. Tachypnic when awake. Lungs clear/diminished. Sats 95% or >. No resp distress noted, = rise and fall of chest.\n\nGI: TF via gastric tube, minimal residuals. Taking sips of water. No stool or flatus noted.\n\nGU: Foley patent draining amber urine in minimal amt. No further hemodialysis to be done.\n\nEndo: FSG Standing + RSSI\n\nLabs: NONE\n\nSocial: no contact from family this shift\n\nPlan: Discharge to hospice on Thursday. Dc lines and meds not required. Hospice staff in this AM to make arrangements for transfer. Family to be comming in to needing teaching on G-tube mngt to include feedings and medication administration, trach sx, PT to work w/them on transfers and turning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-07 00:00:00.000",
"description": "Report",
"row_id": 1482157,
"text": "Resp Care: Pt continues trached and on ventilatory support with minimal psv maintaining spo2 100%; bs coarse, sxn thick yell secretions, rsbi 74, will cont trach collar trials as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-07 00:00:00.000",
"description": "Report",
"row_id": 1482158,
"text": "Respiratory Care\nPt. tol trach collar 40% with PMV all shift, BS wheezy at times Alb MDI administered with good effect. Scheduled to be DC'd with Hospice on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-30 00:00:00.000",
"description": "Report",
"row_id": 1482000,
"text": "csru update\nsbp elevated when stimulated (e.g. suction) settles down afterwards, occassional dipping down to 90s when in deep sleep, otherwise mostly 110-140 systolic. NSR-ST, pac's and pvc's clears with lyte replacements. vent setting per carevue, abg shows resp alkalosis on cpap-> back to simv. secretions, yellowish/thick, requires regular suction. obeying commands, no movement to left side noted, + response to painful stimuli, pt denied sensation to light touch, left fingertips still cyanotic but warm to touch. did not tolerate left side turning, pt became very hypertensive and desaturated to 70s (pt was having a bowel movement at the same time, ?pt may be doing valsalva). no same episode happened when turned the other side. tolerating tf well. family in, talked to md. pressure areas intact, though pt has still generalized edema. all procedures explained.\n\nplan: pulmonary toilet. keep sbp 120-140. ^ activity as tolerated. neuro assessments\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-15 00:00:00.000",
"description": "Report",
"row_id": 1482067,
"text": "FULL CODE Universal Precautions\n\n\nNeuro: According to neuro team - pt is a bit more sluggish than yesterday. She did eventually foolow some basic commands, turn her head, stick out her tongue, etc, but it took about 5 min of encouragement to do so. Since then, following any commands has been intermittent. She moves RUE well, moves toes to tactile stim, does not move LUE at all. Pupils 3mm/brisk. On Dilantin - no seizure activity noted.\n\nCV: HR=80-70s, NSR, no ectopy. BP=110-140s/50-70s. On lopressor. Doppler pedal pulses, feet cool/dusky bilat; RUE cool, LUE warm. On heparin gtt w/ last PTT=76.4 - gtt <to 1200units/hr from 1300 - next PTT due at 10pm.\n\nResp: Plan to wean in the day and rest on vent overnight. Placed on CPAP/PS 40% w/ 02sat 99%, RR=23-28; Vt=350-420. Coarse BS/diminished in bases bilat. Occ cough, but non-productive via trach. Sx for min thick yellow secretions. AC settings were 10 (dropped from 14 this am)x400/p=5/40%.\n\nGI/GU: Abd soft, hypo BS, GT in place. TF Promote w/ fiber started at 1600 at 20cc/hr. Smear of brown stool. Urine output marginal - 30-50cc/hr - clear yellow.\n\nAccess: L fem a-line - was able to draw from line this afternoon. R fem TLC\n\nSkin: Sl pink rash over torso - no change since am. Coccyx sl red - repositioned.\n\nID: T=98.8. On cefipime and vanco. Vanco level from am=58 - redrawn - result pending.\n\nLabs: FS=91 - no insulin coverage required. Pt is on Lantus, but had been held r/t PEG placement and NPO status. Will restart lantus tonight as TF have resumed.\n\nSocial: Daughter, , called this am for update.\n\nActivity: OOB to stretcher chair x4hours.\n\nPlan: Wean as tol. TF as tol. Assess neuro status. Monitor cardiac status - on lopressor and heparin gtt.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-25 00:00:00.000",
"description": "Report",
"row_id": 1481974,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt opens eyes to loud voice, randomly follows commands on rt side only. Very weak movements noted on rt. No movement of LUE, twitching noted to LLE. Pt has purposeful movement and withdrawal on the rt side. Nods appropriately at times. No seizure activity noted, occ. tensing of RUE.\nResp: Pt tolerating CPAP mode, but failed RSBI. Large amts of tan, blood tinged secretions suctioned via ETT. ABG are WNL.\nCV: HR is NSR 70-90's. SBP is VERY labile. SBP 85-170's while on neo, decreased down to 66 while neo is off. Pt was on and off neo all night. CO>3.5. Skin warm and diaphoretic. Pulses via doppler, peripheral edema noted, esp to LUE. Cyanosis of LUE fingers noted and\npartial cyanosis of LLE noted, RLU is dusky. Goal of SBP is 120's\nGU/GI: BS are hypoactive, no bm. Tolerating TF via dobhoff at 40ml/hr.(goal is 50ml)Oral GT for meds and to low continuous sx with 200 ml out of dark bile-brown. Foley to bsd with adequate u/o.\nPlan to hold Lepirudin(off at 0630am) and pull wires and swan in hours, then pt will go to MRI (not moving left side) If Lepirudin is re-started, it will be changed to Argatuban(after the bag of lepirudin is finished) Continue to monitor neuro status for improvement and/or seizures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-09-25 00:00:00.000",
"description": "Report",
"row_id": 1481975,
"text": "Resp Care\n\nPt remains intubated and currently vented on full ventilatory support. BS essentially clear sxing for scant amt of thick tan secretions. Pt received on PSV this morning but was placed on A/C to rest. WIll cont with vent support and reassess for readiness to wean in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-11 00:00:00.000",
"description": "Report",
"row_id": 1482048,
"text": "Resp Care,\nPt. remains on A/C overnoc. Overbreathing vent. ABG this am 7.54/38/118/34. VT decreased to 500. Suctioned yellow sputum. Attempted RSBI, VT 230. RR 50. Maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-11 00:00:00.000",
"description": "Report",
"row_id": 1482049,
"text": "Nurses Progress Note for 7p-7a:\nNeuro: No Neuro changes, no siezure activity. Pt is and attemptes to communicate by mouthing words. Able to follow some commands. Able to move RUE and wriggle toes of RLE on command. Minimal-trace movement of LUE noted. No movement of LLE.\nCV: HR is nsr 80-90's with SBP 120-150. Lopressor po was increased over last 24 hours.Skin mostly warm. BLE are cool and dusky. 3 fingers on LUE are cyanotic. Radial pulses palp. Pedal pulses via doppler.\nResp: Remains on vent to trach support. AC mode/Rate 14/fios 50%/Peep 5. Pt does overbreath the vent. Minimal yellowish-whitish sputum noted. ABG's still show alkalosis. TV decreased. Plan for a bronch in a couple of days, unless secretions increase or pt respikes fever.\nPlan also for a chest CT. Family requests to speak with MD scan.\nGU/GI: Foley to bsd with adequate u/o after lasix iv. TF at 65/cc per hour, minimal residuals.\n\nPlan to have MD talk to family regarding further tests. Pt will also need a G-tube and picc placement soon. ? Friday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-11 00:00:00.000",
"description": "Report",
"row_id": 1482050,
"text": "Respiratory Care Note\nPt received on AC as noted. BS clear bilaterally with good aeration. Pt suctioned for small amts thick secretions. No vent changes today. Plan to remain on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-07 00:00:00.000",
"description": "Report",
"row_id": 1482159,
"text": "Neuro: A&Ox3. Paralysis on left side follows commands.\n\nCV: NSR, NBP stable, R subcl. Quinton removed by MD. . Quinton cath removed by RN. R. triple lumen remains in until d/c.\n\nResp: Trached w/passmuir valve on x 7hrs tolerating well. Trach mask @ 40% sats 97 -99%. Lungs w/min. secretions. Breaths sound CTA w/diminished @ bases. No SOB trach care done and reviewed w/family.\n\nEndo: covered w/sc insulin\n\nskin: dry/flaking rash subsiding. duoderm on coccyx.\n\nGU/GI: sm. urine output, stool x 2. Con't on feeding tubes from g-tube. Serous fld drainage from g-tube site covered w/dsd.\n\nFamily teaching: trach care demonstrated and reviewed. use of g-tube demonstrated and irrigated for med. . and ? tube feeds. Turning and positioning reviewed w/family by PT. Hospice RN into evaluate home needs.\n\nPlan: D/c'd home w/hospice care for pallitive treatment around noon. Hospice RN arranged for home needs and transportation to home. D/c planning notes started.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-07 00:00:00.000",
"description": "Report",
"row_id": 1482160,
"text": "Respiratory Care\nPt. on trach collar w/cool mist @ 40% wearing PMV, tol well. BS w/ fine anterior upper lobe expiratory wheezes. Albuterol MDI administered x three with fair results. NAD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-08 00:00:00.000",
"description": "Report",
"row_id": 1482161,
"text": "DNR\n\n\nROS:\n\nNeuro: A+O. MAE x's 4 to command, weakly. Pleasant and cooperative. Verbalizes w/PM valve in. PEARRLA. Denies pain. Repositioning for comfort.\n\nCV: RSR w/o ectopy. VSS. Has femoral central line.\n\nResp: Trach mask and PM valve until on CPAP for the noc. Lungs clear/diminished. No resp distress noted, = rise and fall of chest. No dyspnea.\n\nGI: Taking sips water po. TF at 35 cc/hr via PEG. Smear stool.\n\nGU: Foley patent draining drk amber urine in marginal amt.\n\nEndo: FSG covered w/RSSI + standing\n\nLabs: None\n\nSocial: No contact from family/friends\n\nPlan: Dc to home w/hospice ~ noon today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-11 00:00:00.000",
"description": "Report",
"row_id": 1482051,
"text": "shift update:\n\nneuro: no neuro changes. no seizure activity. lifts/holds rue. movement of rle on bed. no movement noted of lue/lle. t&r q2hr. denies pain. attempting to communicate by mouthing words.\n\ncv/skin: nsr. no vea. sbp stable. cont on heparin at 1400u/hr. lytes repleated. +palp rp & +dopp pp bilat. duoderm intact to coccyx. sternal dsg changed.\n\nresp: lungs clear but diminished in bases. cont on ac. no vent changes made. trach care done. small amt yellow secreations. abg's=>akalotic. lasix d/c'd & free water bolus q4h started.\n\ngi/gu: +bs. abd soft. tf cont at 65cc/hr tolerating well. small amt of stool x3. uop adequate.\n\nendo: no insulin required per ss.\n\nsocial: daughters into visit. daughter from called to speak with md->message given to dr.\n\nplan: cont to monitor neuro status, hemodynamics, resp status. t&r q2hrs. i&o. free h2o bolus q4hrs. cont tf. monitor labs. insulin per ss.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-27 00:00:00.000",
"description": "Report",
"row_id": 1482112,
"text": "7a-7p\nNeuro: Pt to verbal stimuli, nodding appropriately and mouthing words appropriately. Following commands. See carevue for details of moving extremeties. Perrla. No seizure activity.\n\nCV: HR 70-80s SR -> new 1st degree AV Block w/ minor changes, MD aware. No interventions. SBP 90-150 (increase w/ stimulation). Dopplerable pulses.\n\nResp: #8 trach, Cpap 40%, Peep 5, PS 10. LS clear-> coarse at times. Suctioning for thin white small amts. Sats 98-100%.\n\nGI/GU: Abd soft, +BS, multi small soft formed stool. Foley intact draining scant amts of clear yellow urine. Pt's family spoke to team and Renal team, pt's family refusing dialysis.\n\nEndo: FS covered by scale.\n\nSkin: See carevue for details.\n\nPlan: Monitor hemodynamics. Monitor neuro status. ? Plan for family meeting w/ Dr. on Monday re: POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-28 00:00:00.000",
"description": "Report",
"row_id": 1482113,
"text": "NEURO: , TRACKING, FOLLOWING COMMANDS. INTERACTING WITH FAMILY. DAUGHTER ABLE TO READ PT'S LIPS.\n\nPULM: INITIALLY COMFORTABLE ON CPAP 40%, PEEP 5/PS 10 UNTIL ~ 2400 THEN INCREASINGLY MORE TACHYPNIEC (RR UP TO 47), INCREASED COUGHING, FORCING AIR AROUND TRACH, WHEEZING, HYPERTENSIVE, TACHYCARDIC. BENADRYL 25MG IV Q6H ORDERED BY MD WITH LITTLE EFFECT. PLACED BACK ON AC FOR THE NOC BUT NOT TOLERTED WELL UNTIL AFTER CETACAINE SPRAY DOWN TRACH. CUFF LEAK NOTED, AIR ADDED BY RESPIRATORY WITH SOME EFFECT PRIOR TO CETACAINE SPRAY. SX FOR SCANT-SMALL AMTS THIN WHITE SECRETIONS. NO XRAY PER MD. ABG ON AC MODE SHOWING RESP ALKALOSIS, VT DECREASED.\n\nCV: FIRST DEGREE AV BLOCK , HR 94-105, OCCASIONAL PAC'S. LOPRESSOR 25MG DUE AT 0200 GIVEN AT 2330 D/T TACHYCARDIA AND HYPERTENSION. HYDRALAZINE 10MG IV AT 2330 FOR SBP CONISTENTLY > 160'S WITH EFFECT.\nFEET AND HANDS COOL, TOES ON BOTH FEET DUSKY, L FINGER TIPS NECROTIC, R FINGERTIPS DUSKY. PULSES DOPPLED. ERYTHEMIC RASH PERSISTS OVER ENTIRE BODY.\n\nENDO: 28 UNITS LANTUS SC ABDOMEN AT 2200. Q6H SSRI COVERAGE PER ORDER. 2400 BS 139, NOT RX'D.\n\nGI: ABDOMEN SOFTLY DISTENDED. + BS. G TUBE SITE LEAKING, NO RESIDUALS ASPIRATED FROM TUBE. NEPRO FS AT GOAL RATE 35CC/HR. NO COLACE GIVEN D/T LIQUID BROWN STOOL.\n\nGU: FOLEY TO CD. OLIGURIC. CREATININE 3.0. NO HD X 48H.\n\nSOCIAL: DAUGHTER AND SON . BOTH INTERACTING WITH PATIENT, ABLE TO READ PT'S LIPS.\n\nPLAN: PLACE BACK ON CPAP MODE THIS AM. CETACAINE SPRAY DOWN TRACH PRN INCREASED COUGHING, FORCING AIR AROUND TRACH. BENADRYL IV PRN ANXIETY. ? INCREASE BETABLOCKERS TO CONTROL HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-28 00:00:00.000",
"description": "Report",
"row_id": 1482114,
"text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. Increased vent support to AC mode overnight to rest pt for increasing agitation and tachypnea. BS's coarse, administering prn Albuterol MDI's. See flowsheet for further data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-28 00:00:00.000",
"description": "Report",
"row_id": 1482115,
"text": "7a-7p\nNeuro:Pt , follows commands, see carevue for details of moving extremities. Perrla. Nodding appropriately. Able to mouth words ex: coffee, water etc.\n\nCV: HR 80-90s Sr w/ AV block SBP 110s-150s. Given hydralazine 10mg x1 IV for htn bringing SBP 110-130s. Lopressor 25mg po given as ordered. Ok to give despite AV MD . Dopplerable pulses.\n\nResp: Trach #8 Portex, weaned to Cpap 5/5. Tolerating CPAP 5/5, ABGs WNL. Sats 99-100: LS coarse to clear diminished at bases. Suctioned via trach for small amts of thin white.\n\nGI/GU: Abd soft +BS small multi soft stool, colace held secondary to loose stool. GT patent and draining moderate amts of serous fluid. Team aware. Foley draining scant amts of yellow to amber color urine. No dialysis per family's request.\n\nSkin: See carevue. Turned and repositioned frequently.\n\nSocial: Family updated. Son of pt to call Dr. re: POC per sisters.\n\nPlan: Monitor hemodynamics. Pulmonary toilet. ? family meeting this week.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-28 00:00:00.000",
"description": "Report",
"row_id": 1482116,
"text": "Resp Care\nPt remains on PSV, today tol well. PS was weaned, plan to keep on current settings as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 1482117,
"text": "NEURO: , TRACKING, INTERACTING WITH DAUGHTER. MOUTHING SENTENCES. WANTS TO GET OOB, WANTS COFFEE AND WATER. NODDING HEAD \"YES\" TO QUESTION OF ITCHING. BENADRYL 25MG IV X 1 AT 2300 WITH GOOD EFFECT. RESTFUL ALL NIGHT, SLEPT.\n\nPULM: TRACHED TO CPAP MODE, FI02 0.4, PS 5/PEEP 5. RR 30'S ALL SHIFT, RESTING COMVORTABLE. LUNGS CLEAR-COARSE UPPER AIRWAYS, DIMINISHED BASES. SX'D FOR SCANT-SMALL AMTS THIN WHITE SECRETIONS.\n\nCV: FIRST DEGREE AV BLOCK, RARE PAC. SEE CAREVUE FOR Q1-2H VS. LIFTS AND HOLDS RUE, MOVES OTHER EXTREMITIES ON BED, MINIMALLY IN LUE. PULSES DOPPLED. LUE FINGERS BLACK, UNCHANGED. LE TOES COOL/DUSKY, UNCHANGED. ERYTHEMIC RAISED RASH PERSISTS OVER ENTIRE BODY.\n\nENDO: 28 UNITS LANTUS SC IN ABDOMEN AT 2200 AS ORDERED. Q6H SSRI COVERAGE PER ORDER. SEE AND CAREVUE.\n\nGI: TOLERATING NEPRO FS TF AT GOAL OF 35CC/HR VIA GTUBE, NO RESIDUAL. ABDOMEN OBESE, SOFT + BS.\n\nSOCIAL: DAUGHTER, , UNTIL 2200. VERY INTERACTIVE WITH EACH OTHER.\n\nPLAN: ? FAMILY MEETING THIS AM TO DECIDE POC. CONTINUE CPAPING VIA TRACH. REPOSITION Q2H WITH SKIN CARE. BENADRYL PRN ITCHING/DISCOMFORT FROM RASH.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 1482118,
"text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. No vent changes made overnight. BS's coarse at times, sxing small amts thick white/tan secretions. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 1482119,
"text": "Resp Care\u0013\nPt remains on PSV, tol well, wit no changes. Plan to continue with current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-30 00:00:00.000",
"description": "Report",
"row_id": 1482124,
"text": "Comfort: No c/o pain. Pt DNR. Palliative care. Social work & palliative nurse discuss with pt/family/team about palliative care and home w hospice plan. No labs drawn on pt, no further HD per team. Plan for pt to tx to home w/ family & palliative care this thursday or friday.\n\nNeuro: A&Ox2, needs reorientation to time. PERRLA. Follows commands appropriately. Moves RUE spontaneously. L arm flaccid, moves e arm fingers for hand grasp. Wiggles toes to command.\n\nC/V: 1st degree AVB, no ectopy. Art SBP 170s-->IV hydralazine NP w/minimal results. Cuff SBP 130s/art pressure 160s. Following cuff pressures, A-line NP . Received scheduled dose of coumadin and no coags required np . On scheduled amiodarone/lopressor PO. see carevue for vascular issue (dusky fingers +toes)-dopplerable pulses.\n\nResp: Transitioned to trach collar 50% per team x4hrs. Sats remained >94%. Placed back on CPAP +PS for increased resp distress, labored breathing. Resting easily on CPAP/PS. Ls diminished both bases.\n\nGu/Gi: Scant UO, team aware no further dialysis tx per family/team. Tol TF at goal rate, 35cc/hr. Multiple loose stools. Abd soft & NT.\nendo: no bs check np\n\nSkin/ID: Evaluated by skin care RN today-coccyx improved by rn still stage II->changed duoderm, recommends zinc oxide skin protectant cream to excoriated perineum/rectumcontinue Total body rash cont, no tx at this time. See carevue. On scheduled fluconazole PO.\n\nA/P: Plan to continue palliative care. trach collar trial again +speaking valve. Provide comfort and support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-31 00:00:00.000",
"description": "Report",
"row_id": 1482125,
"text": "CSRU A NPN:\nNEURO: Pt. , mouthing words appropriately and follows commands. Able to move RUE well, minimal movement of RLE and no movement of LUE or LLE noted. Denies any pain. Pt. is DNR and plan is for pt. to be d/c home with palliative care. Also, to place passy-muir valve today, if tolerated, to assess pt's understanding and validate her wishes.\nCV: Afeb. HR 70s-90s 1st degree AVB, no ectopy noted. BP stable. Continues on amiodarone and lopressor. No labs to be drawn. L fingertips continue to be cyanotic. R foot with dusky toes. Skin warm and dry with +CSM. Dopplerable pulses. RESP: PS with CPAP 5 Peep 5 FiO2 40% with O2 Sat >95%. LS clear-coarse and diminished at bases. Sx'd for thick pale tan secretions in small amts. RR 20s-40. Trach intact.\nGI/GU: Abd. softly distended with positive bowel sounds. Loose BMs overnight. PEG intact with Nepro infusing at 35cc/hr with no residuals. Folely with scant u/o. No further HD to be done.\nSKIN: Excoriated perineum with barrier cream applied. Duoderm to coccyx intact. Total body rash continues but pt. asymptomatic.\nPLAN: Continue palliative care and trach collar trial again today with placement of speaking valve. Provide comfort and support to family. Palliative care nurse involved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1482135,
"text": "7pm-7am update\nneuro: pt , and able to follow commands. pt mouthing words. left side remains weaker than right. PERRL. no seizure activity. continues on dilantin tid\n\nCV: remains in 1st degree AV block, no ectopy noted. HR 70-90's. SBP 90-130's. hct stable. finger tips on left hand remain necrotic. toes on bil feet remain dusky. + doppler pulses in bil feet. + radial and ulnar pulse by doppler in left wrist.\n\nresp: LS clear, dim left side. pt intally on 40% trach collar. ~ 1 am pt placed back on 40% CPAP with 5 peep and 5 ips d/t tachypenia -> RR in low 30's. pt also s/o increased WOB. TV in the 400's. pt suctioned for thick yellow sputum\n\ngi/gu: pt with + bs. recieving nepro TF at 35 cc/hr (goal rate). no residual. foley draining scant amber cloudy urine. last HD . bun/creatinine pending\n\nendo: BS treated with reg ss insulin. pt continues to recieve lantus in the evening\n\nskin: red rash remains on torso. rash appears unchanged. duoderm intact on coccyx\n\nplan: trach collar during the day, oob to chair, continue TF, ?? screen for rehab, ?? HD\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1482136,
"text": "Respiratory Care Note:\n patient remains on ventilatory support at this time. For specific settings please see carevue flowsheet. patient on trach collar for 5-6 hours this shift. Patient placed back on CPAP about 1 a.m. due to tachypnean and increased wob. sx'd for a small amount of tan/yellowish secretions. VT's in the 400's. BS diminished at the bases. RSBI this am is 66.3 on 0/5. MDI's administered as ordered with good effect. Will continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1482137,
"text": "Resp Care\nPt remains trached on PSV. Pt on trach collar for 10hrs. MDI's given. No other changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-01 00:00:00.000",
"description": "Report",
"row_id": 1482001,
"text": "SHIFT UPDATE\nNEURO: OPENS EYES TO NAME. FOLLOWS SIMPLE COMMANDS. MOVES RIGHT SIDE. SQUEEZES WITH HAND AND MOVES LEG. NODS HEAD TO YES/NO QUESTIONS BUT INCONSISTANT. MUSCLE TWITCHING NOTED L ARM WHEN TO MOVE, NO MOVEMENT NOTED LLE, NODS YES TO SENSATION OF ALL EXT. LEFT TOES AND FINGERS CYANOTIC. POSITIVE PULSES PRESENT. RIGHT TOES COOL AND SLIGHTLY CYANOTIC. BILAT LE MULTIPODUS BOOTS ON. DILANTIN IV GIVEN AS ORDERED. NO SZ ACTIVITY OBSERVED.\n\nRESP: ON VENT, SEE CAREVIEW FOR SETTINGS. TACHYPNEIC AT TIMES, APPEARS TO BE MORE SO WITH CARE. LUNGS CLEAR. SX'ING SMALL AMT WHITE MUCUS. RESP APPEAR LABORED AFTER REPOSITIONING BUT PT DENIES DIFF BREATHING AND SPO2 99% WITH GOOD VOLUMES.\n\nCV: SKIN COOL AND DRY. DOPPLER PULSES BLE'S. ECG ST AT BEGINNING OF SHIFT, A-FIB WITH POORLY CONTROLLED RATE AT MIDNOC WITH LOWER SBP FLUCTUATING BETWEEN 70-120. TEAM NOTIFIED, PT GIVEN 150MG AMIODARONE BOLUS AND CONVERTED TO SR AT 0150 WITH SBP INCREASE 140-160. HEPARIN GTT AT 1400 UNITS/HR, WILL PTT WITH AML'S.\n\nGI/GU: DOBHOFF LEFT NARE WITH TF AT GOAL, NO RESIDUALS. ABD SOFT WITH NORMOACTIVE BS'S. INCONTINENT OF LARGE SOFT BM X2. F/C TO DD WITH CLEAR URINE, DIURESED WELL AFTER LASIX IV.\n\nENDO: 10 UNITS REG SC INSULIN GIVEN FOR BS 193.\n\nPAIN: PT GRIMACING WITH NURSING CARE, TACHYPNEIC AT TIMES WITH INCREASED BP, MEDICATED FOR COMFORT AND ETT TOLERANCE WITH MORPHINE PRN.\n\nPLAN: CONTINUE TO REPOSITION AND OFFER REASSURANCE. WEAN VENT AGAIN IN AM AS TOLERATED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-01 00:00:00.000",
"description": "Report",
"row_id": 1482002,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support, with no parameter changes made throughout the night. Morning abg results revealed a normal acid-base balance with excellent oxygenation.\n\nRSBI = 133.6 on 0-PEEP and 5 cm PSV (failed RSBI).\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-01 00:00:00.000",
"description": "Report",
"row_id": 1482003,
"text": "CSRU NURSING PROGRESS NOTE 0700-1900\nPT NEEDS 300MG IV DILANTIN X2 AND THEN TO START ON 100MG IV Q6HRS AS HER DILANTIN LEVEL IS 3.1.\n\nPT DOES NOT LIKE TURNING WITH L SIDE DOWN. SHE BECOMES EXTREMELY HTN, TACHYCARDIC AND TACHYPNIC. CXR WAS DONE TO R/O EFFUSIONS. SMALL EFFUSIONS NOTED PER TEAM .\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-16 00:00:00.000",
"description": "Report",
"row_id": 1482069,
"text": "UPDATE\nCV: NSR, NO ECTOPY. BP WNL. A-LINE W/ GD WAVEFORM BUT UNABLE TO DRAW BLOOD(OBTAIN ABG). FEET COOL, TOES DUSKY. DISTAL PULSES DOPPLERABLE. IV MAINTENANCE TURNED DOWN TO KVO NOW THAT TF @ GOAL RATE. HEPARIN GTT CONT'D.\n\nNEURO: OPENS EYES TO NAME AND FOCUSES BUT WILL INCONSISTENTLY FOLLOW COMMANDS. MOVING R ARM SPONT W/ FULL RANGE BUT WILL NOT SQUEEZE W/ HAND. NO MVMT NOTED ON L SIDE. LUE PLACED IN FOAM SPLINT. DOZES INTERMITTENTLY. OOB TO STRETCHAIR THIS AFTERNOON.\n\nRESP: LUNG SOUNDS COARSE. SUX FOR SM AMTS THICK, WHITE SECRETIONS. CPAP W/ IPS 18-20 ATTEMPTED. RR HIGH 30'S-42 WHEN AWAKE, LOW 30'S WHEN SLEEPING. SPO2 98%.\n\nG.I.: NO RESIDUALS ON GOAL RATE TF VIA PEG. MOD AMT SEROUS DRNG NOTED LEAKING FROM PEG SITE @ SKIN. \"SMUDGE\" STOOL ON LINEN ONLY.\n\nG.U.: ADEQ HUO. MOD DIURESIS TO LASIX DOSE(STARTED TODAY).\n\nSKIN: PINPOINT RASH NOTED ON FLANKS AND LOWER ABD. P.A. NOTIFIED. SM DUODERM INTACT TO COCCYX.\n\nENDO: GLUCOSES ELEVATED, TX W/ SSRI. M.D. IN AND INCREASED P.M. LANTUS DOSE.\n\nA/P: APPEARS COMFORTABLE AND OXYGENATES WELL BUT MAINTAINS MOD HIGH RR ON CPAP; CONT DIURESIS AND MONITOR FLUID BALANCE. CONT VENT WEAN AS TOL. CONT TO MONITOR LE CIRCULATION. GIVE LANTUS SAME TIME Q 24 HRS. ?REHAB SCREEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1482138,
"text": "SHIFT UPDATE 7A-7P\nPT , MOUTHS WORDS, MAE'S WITH RIGHT SIDED WEAKNESS. PLACED ON 40% TRACH COLLAR @ 0730. REMAINED ON TRACH COLLAR UNTIL 1700. RESP RATE 24-34 ON COLLAR, DENIES DIFF BREATHING. DEMONSTRATES EFFECTIVE COUGH. SXN'ING MODERATE AMT OF THIN TAN SECRETIONS.\n\nPLACED IN CHAIR AT 1130 VIA LIFT. ROM DONE ALL EXTREMITIES. HANDS AND FEET MASSAGED. LEFT FINGER TIPS WITH NECROTIC TISSUE PEELING OFF WITH MASSAGE, PINK HEALTHY LOOKING SKIN NOTED UNDERNEATH. PA AT BS AND AWARE. DOPPLER PULSES ALL EXTREMITIES. PT WITH RED RASH OVER ENTIRE BODY APPEARS WORSE TODAY. TEAM NOTIFIED, NEURO NOTIFIED, ? RXN TO DILANTIN. CHANGES MADE TO DILANTIN, PT TO BE WEANED OFF AND NEW ANTI-EPILEPTIC MED STARTED. DUODERM CHANGED COCCYX, SKIN INTACT, NEW DUODERM APPLIED FOR PREVENTIVE CARE.\n\nEVALUATED BY REHAB TODAY. PT WORKED WITH PT FOR 1 HR, STOOD FROM CHAIR WITH 3 ASSISTS, POOR WT BEARING BUT TOLERATED WELL. SPEECH THERAPY CONTACT REGARDING PASSIMIER VALVE- PER HOSPITAL DOES NOT HAVE COMPATIBLE VALVE FOR PTS TRACH SIZE. TEAM AWARE.\n\nFAMILY MET WITH ETHICS REGARDING PTS FUTURE CARE. MEETING TO BE SCHEDULED WITH ALL DISCIPLINES NEXT WEEK. PT NOW RESTING QUIETLY IN BED WITH EYES CLOSED. PLACED BACK ON VENT FOR REST. V/S'S STABLE FOR SHIFT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-06 00:00:00.000",
"description": "Report",
"row_id": 1482153,
"text": "RN shift note\nneuro: and cooperative. Slept in long naps. MAE, left UE weakly.\n\nCV: NSR, no ectopy, 70-80. SBP 90-110. +Doppler/palp pulses throughout.\n\nPulm: CPAP 5/5 @40%. Thick white secretions. Weak cough; strong gag.\nTrach stoma clean.\n\nGI: abd soft, non-tender. +BS. Incontinent soft brown stool. TF Nepro @ 35cc/hr, goal; no residual.\n\nGU: dark brown sludgy urine, min volume. RF labs: 74/3.9.\n\nskeletal: peeling dermis S/P drug rash, resolving. Coccyx pink, intact.\n\nEndo: RISS, none required. Tapering prednisone dose.\n\nP: trach collar, OOB. Cont w/ rehab efforts.\n\nHeme: 27.2/8.9/233\n\nID: afebrile; WBC 11.4 (up from 10). No antibx at present.\n\nP: OOB, trach collar trials. rehab/placemnet efforts.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-06 00:00:00.000",
"description": "Report",
"row_id": 1482154,
"text": "Resp Care\n\nPt remained on trach collar since 8AM. Hemodynamically stable with a Spo2 on 100%. Bs diminished L greater than R. Suctioning small thick tan\n"
}
] |
6,648 | 165,850 | 1. CAD s/p Lateral STEMI: By ECG V3-V6, III,F. Cardiac catheterization revealed disease in LAD and D1, and cypher stents were placed in these vessels. He was continued on ASA, Lisinopril 40 mg, and his bisoprolol was changed to Atenolol and titrated up as possible. He was started on Plavix (for 9 months). His lipids were checked, and he was continued on 80 mg Lipitor. He had no further anginal symptoms and was instructed to follow up with his cardiologist. He will start cardiac rehabilitation within 4-6 weeks of discharge. 2. EP: Post-catheterization, he had a new RBBB (not seen on prior EKG from ). This occurred intermittently on EKG's obtained post-procedure. His telemetry continuously showed what appeared to be dual atrial beating. EP stated that this was a benign rhythm, consistent with phase 4 block (block of repolarization of ventricles). In addition, he was found to be in atrial fibrillation prior to dishcarge (unclear if this was a new finding). Upon consult with his primary cardiologist, the decision was made to discharge on coumadin. He will have his PT/INR checked by his outpatient cardiologist in days. 3. Pump: TTE obtained post-catheterization revealed EF=50% with no significant valvular disease. He was continued on his Lisinopril, and euvolemia was maintained throughout. 4. Groin hematoma: He had a small superficial hematoma in right groin after procedure which resolved. He had significant superficial bruising, but hematocrit remained stable, and peripheral pulses were adequate. 5. Hypercholesterolemia: LFT's were checked and were within normal limits, and he was continued on his Lipitor 80 mg daily. 6. HTN: He required a nitroglycerin drip briefly after his procedure. This was weaned, and he was maintained on Lisinopril, Hydrochlorothiazide, Norvasc, and Atenolol. 7. ?glucose intolerance: His blood sugars were 100-150's while in-house, and HbA1C was sent and pending at time of discharge. As an outpatient, his blood sugars should be monitored to ensure that he is not persistently hyperglycemic/diabetic. Elevation in-house could have been secondary to stress s/p MI and UTI. - will ck FS, keep on SSI, ck HbA1C 8. ?Atrial fibrillation: unclear from his history, regular rhythm on EKG initially but with atrial fibrillation (rate 70-80) at time of discharge. As above, he was started on coumadin prior to discharge and will have coagulation parameters checked by his cardiologist as an outpatient. Atenolol was continued for rate control 9. UTI: He was febrile while in-house, and urine culture was positive for E. Coli and Pseudomonas (pseudomonas was pan-sensitive to all antibiotics tested). He was started on levofloxacin, continued for 7 day course. Dose was decreased to 250 mg daily given addition of coumading to his medication regimen. 10. Disposition: He was discharged in good condition, to complete a 7 day course of levofloxacin for his UTI. He will follow up with his Cardiologist 2 days after discharge and will have INR checked at that time. He was counselled on the importance of taking all his medications, especially ASA and Plavix for his new stents. | Trivial mitral regurgitation is seen. Mild (non-obstructive) focalhypertrophy of the basal septum. PA AND LATERAL VIEWS CHEST: The aorta is unfolded and mildly tortuous. Occasional atrial ectopy. Trace AR.MITRAL VALVE: Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Rule out myocardialinfarction. DENIES NAUSEA,DIAPHORESIS. There is a minimallyincreased gradient consistent with minimal aortic valve stenosis. Small hematoma inistu unchanged. Trace aorticregurgitation is seen. Left atrial abnormality. There is no pericardialeffusion.Impression: mild anteroseptal hypokinesis with preserved left ventricularejection fraction There is mild (non-obstructive)focal hypertrophy of the basal septum. Prior inferiormyocardial infarction. Prior anteroseptal myocardialinfarction. DENIES SOB.GU: U/O > 100CC/HRGI: TOL PO'S AND MEDS. ABD SOFT NON TENDER.SKIN: R GROIN HEMATOMA OUTLINED. Noresting LVOT gradient. Minimally increased gradient c/w minimal AS. Low normal LVEF. Suboptimal image quality - poor apicalviews.Conclusions:The left atrium is mildly dilated. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. HYPERTENSIVE WITH SBP 180-190. The left ventricular cavity size isnormal. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root. CPK/MB per . PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 70Weight (lb): 175BSA (m2): 1.97 m2BP (mm Hg): 110/78HR (bpm): 80Status: InpatientDate/Time: at 10:32Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Prior anteroseptal myocardial infarction. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Compared to the previous tracing atrial fibrillation hasappeared and ventricular ectopy is no longer recorded. Right ventricular chamber size and free wall motion are normal.The aortic root is moderately dilated. Right femoral groin site with slight oozing, no change in size of hematoma. The estimatedpulmonary artery systolic pressure is normal. PULSES + PALP BILATR FT WRM.NEURO: A/O X3 COOPERATIVE. EKG COMPLETED NO CHGS NOTED. Sinus rhythm. Sinus rhythm. Frequent atrial ectopy. AT 0145 PT C/ STERNAL CP NON RADIATING. Compared to the previous tracingof the ST segment elevation has abated. The right atrium is moderately dilated.Left ventricular wall thicknesses are normal. Atrial fibrillation with a controlled ventricular response. Compared to theprevious tracing of there is continued inferolateral ST segmentelevation consistent with acute ischemic process. + BS NO STOOL THIS SHIFT. Normal LV cavity size. Suboptimalimage quality - poor parasternal views. NO FURTHER C/O PAIN. Moderately thickened aortic valveleaflets. Evolution of inferior wall myocardialinfarction. ST segment elevation in leads I, II, III, aVF and V4-V6 consistentwith acute inferolateral ischemic process. Sinus bradycardia. Precordialvoltage for left ventricular hypertrophy. Leftatrial abnormality. Titrate ngt gtt to keep sbp <130 >100. + R GROIN HEMATOMA. AREA ECCYMOTIC. Otherwise, no diagnostic interim change. Pt did rule in for AWMI with new right BBB MD note. Rule out myocardial infarction.Followup and clinical correlation are suggested. REASON FOR THIS EXAMINATION: infiltrate, pulm edema FINAL REPORT INDICATION: Low grade temperature and leukocytosis. The heart size is within normal limits. PER NSG JUDGEMENT No LV mass/thrombus. Right bundle-branch block. Right bundle-branch block. Otherwise, no diagnosticinterim change. Sbp 120's-130's. S/P CATH WITH STENTS PLACED TO LAD,DIAG ON . The P-R interval is 0.20. The P-R interval is 0.20. NSG NOTECV: REMAINS IN SB WITH PAC'S NOTED. Rightbundle-branch block. Sinus bradycardia and frequent atrial ectopy. Sbp 130's/60's with ntg gtt currently at .9mcg/kg/min. Pulm: 02 at 2L via nc, respitory effort unlabored, 02 sats 99%, lungs clear bilaterally. Wandering baseline. R: As above, pt resting comfortably, call light in hand. Ntg gtt down to .25mcg/kg/min and pts cardiac meds resumed. Overall left ventricular systolic function is low normal (LVEF 50%)secondary to mild hypokinesis of the anterior septum and anterior free wall.No masses or thrombi are seen in the left ventricle. Compared to the previous tracingof right bundle-branch block has abated, ventricular ectopy has appearedand the rate has increased. No previous tracing availablefor comparison.TRACING #1 Adendum: No cp/sob or other distress noted or voiced. There is no ventricularseptal defect. ADVANCE ACT AS TOL. PLEASANT FOLLOWS COMMANDS. OBSERVE GROIN HEMATOMA. ATIVAN FOR SLEEP WITH GOOD EFFECT.ID: AFEBRILELABS: K+ 3.9 RECEIVED KCL 40 MEQ PO BS 143 HOUSE STAFF AWARE MG 2.1IVF: 1/2 NS @ 100CC/HR LITER #2 INFUSING.A/P; 86 YR OLD S/P AMI. IV NTG INCREASED TO 1.0 MCG/KG/MIN NTG X1 SL GIVEN WITH RELIEF OF PAIN. Notify MD of any recurring bleeding, incr hematoma , hemodynamic instablity, or recurring chest pain. Skin: Surfaces intact, pedal pulses palpable. Degenerative changes are noted in the spine. GI: Abd soft, bs+, heart health soft diet to be initiated (No dentures - was to pick them up today). Please see data, MD notes/orders. IMPRESSION: No radiographic evidence of pneumonia. Focal calcifications in aortic root.Focal calcifications in ascending aorta.AORTIC VALVE: Three aortic valve leaflets. Pt came from the cath lab with C clamp in place. Followup and clinicalcorrelation are suggested.TRACING #3 The lungs are clear. Post cath labs to include ck/mb as ordered. Followup and clinical correlation are suggested.TRACING #2 Hemostasis achieved after approx 90 minutes. There are three aortic valve leaflets.The aortic valve leaflets are moderately thickened. Recieved alert and oriented 89 yr old male to s/p stents to his lad/diaganol arteries. There is no pleural effusion or pneumothorax identified. HOUSE STAFF NOTIFED. NEED ADDITIONAL ANTI-HTN MEDS. GU: #14 foley catheter placed without difficulty for urinary retention with return of >200cc clear yellow urine. REPEAT CK 912,MB 80RESP: O2 SATS 98%. CV: SB with occ to frequent pac's. COMPARISON: No studies available for comparison. P: Monitor for recurring chest pain or other distress. 8:42 AM CHEST (PA & LAT) Clip # Reason: infiltrate, pulm edema Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\CATH MEDICAL CONDITION: 86 year old man with low grade temperature and leukocytosis. | 10 | [
{
"category": "Echo",
"chartdate": "2182-03-25 00:00:00.000",
"description": "Report",
"row_id": 78989,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 175\nBSA (m2): 1.97 m2\nBP (mm Hg): 110/78\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:32\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mild (non-obstructive) focal\nhypertrophy of the basal septum. Normal LV cavity size. Low normal LVEF. No\nresting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nFocal calcifications in ascending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Minimally increased gradient c/w minimal AS. Trace AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. There is mild (non-obstructive)\nfocal hypertrophy of the basal septum. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is low normal (LVEF 50%)\nsecondary to mild hypokinesis of the anterior septum and anterior free wall.\nNo masses or thrombi are seen in the left ventricle. There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic root is moderately dilated. There are three aortic valve leaflets.\nThe aortic valve leaflets are moderately thickened. There is a minimally\nincreased gradient consistent with minimal aortic valve stenosis. Trace aortic\nregurgitation is seen. Trivial mitral regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nImpression: mild anteroseptal hypokinesis with preserved left ventricular\nejection fraction\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1349895,
"text": "Adendum: No cp/sob or other distress noted or voiced. Right femoral groin site with slight oozing, no change in size of hematoma. CPK/MB per . Pt did rule in for AWMI with new right BBB MD note. Sbp 120's-130's. Ntg gtt down to .25mcg/kg/min and pts cardiac meds resumed. Will continue to monitor in ICU over night with probable transfer to floor in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 1349896,
"text": "NSG NOTE\n\nCV: REMAINS IN SB WITH PAC'S NOTED. AT 0145 PT C/ STERNAL CP NON RADIATING. DENIES NAUSEA,DIAPHORESIS. HYPERTENSIVE WITH SBP 180-190. EKG COMPLETED NO CHGS NOTED. HOUSE STAFF NOTIFED. IV NTG INCREASED TO 1.0 MCG/KG/MIN NTG X1 SL GIVEN WITH RELIEF OF PAIN. NO FURTHER C/O PAIN. REPEAT CK 912,MB 80\n\nRESP: O2 SATS 98%. DENIES SOB.\n\nGU: U/O > 100CC/HR\n\nGI: TOL PO'S AND MEDS. + BS NO STOOL THIS SHIFT. ABD SOFT NON TENDER.\n\nSKIN: R GROIN HEMATOMA OUTLINED. AREA ECCYMOTIC. PULSES + PALP BILATR FT WRM.\n\nNEURO: A/O X3 COOPERATIVE. PLEASANT FOLLOWS COMMANDS. ATIVAN FOR SLEEP WITH GOOD EFFECT.\n\nID: AFEBRILE\n\nLABS: K+ 3.9 RECEIVED KCL 40 MEQ PO\n BS 143 HOUSE STAFF AWARE\n MG 2.1\n\n\nIVF: 1/2 NS @ 100CC/HR LITER #2 INFUSING.\n\nA/P; 86 YR OLD S/P AMI. S/P CATH WITH STENTS PLACED TO LAD,DIAG ON . + R GROIN HEMATOMA. NEED ADDITIONAL ANTI-HTN MEDS. OBSERVE GROIN HEMATOMA. ADVANCE ACT AS TOL. PER NSG JUDGEMENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1349894,
"text": "Recieved alert and oriented 89 yr old male to s/p stents to his lad/diaganol arteries. Please see data, MD notes/orders. CV: SB with occ to frequent pac's. Sbp 130's/60's with ntg gtt currently at .9mcg/kg/min. Pulm: 02 at 2L via nc, respitory effort unlabored, 02 sats 99%, lungs clear bilaterally. GU: #14 foley catheter placed without difficulty for urinary retention with return of >200cc clear yellow urine. GI: Abd soft, bs+, heart health soft diet to be initiated (No dentures - was to pick them up today). Skin: Surfaces intact, pedal pulses palpable. Pt came from the cath lab with C clamp in place. Hemostasis achieved after approx 90 minutes. Small hematoma inistu unchanged. Soc: Message left for pts former wife per his request. He states he has no children but does have a niece and also his former wife who would speak for him if he could not. No health care proxy listed, pt states \"I never did any of that\". P: Monitor for recurring chest pain or other distress. Post cath labs to include ck/mb as ordered. Titrate ngt gtt to keep sbp <130 >100. Bedrest with right leg flat for six hours post cath. Notify MD of any recurring bleeding, incr hematoma , hemodynamic instablity, or recurring chest pain. R: As above, pt resting comfortably, call light in hand.\n"
},
{
"category": "Radiology",
"chartdate": "2182-03-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 862284,
"text": " 8:42 AM\n CHEST (PA & LAT) Clip # \n Reason: infiltrate, pulm edema\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with low grade temperature and leukocytosis.\n REASON FOR THIS EXAMINATION:\n infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low grade temperature and leukocytosis.\n\n COMPARISON: No studies available for comparison.\n\n PA AND LATERAL VIEWS CHEST: The aorta is unfolded and mildly tortuous. The\n heart size is within normal limits. The lungs are clear. There is no pleural\n effusion or pneumothorax identified. Degenerative changes are noted in the\n spine.\n\n IMPRESSION: No radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-27 00:00:00.000",
"description": "Report",
"row_id": 191667,
"text": "Atrial fibrillation with a controlled ventricular response. Prior inferior\nmyocardial infarction. Compared to the previous tracing atrial fibrillation has\nappeared and ventricular ectopy is no longer recorded. Otherwise, no diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-26 00:00:00.000",
"description": "Report",
"row_id": 191668,
"text": "Sinus rhythm. Left atrial abnormality. Occasional atrial ectopy. Precordial\nvoltage for left ventricular hypertrophy. Compared to the previous tracing\nof right bundle-branch block has abated, ventricular ectopy has appeared\nand the rate has increased. Otherwise, no diagnostic interim change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 191669,
"text": "Sinus rhythm. Wandering baseline. Evolution of inferior wall myocardial\ninfarction. Right bundle-branch block. Compared to the previous tracing\nof the ST segment elevation has abated. Followup and clinical\ncorrelation are suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 191670,
"text": "Sinus bradycardia and frequent atrial ectopy. The P-R interval is 0.20. Right\nbundle-branch block. Prior anteroseptal myocardial infarction. Compared to the\nprevious tracing of there is continued inferolateral ST segment\nelevation consistent with acute ischemic process. Rule out myocardial\ninfarction. Followup and clinical correlation are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 191671,
"text": "Sinus bradycardia. The P-R interval is 0.20. Frequent atrial ectopy. Left\natrial abnormality. Right bundle-branch block. Prior anteroseptal myocardial\ninfarction. ST segment elevation in leads I, II, III, aVF and V4-V6 consistent\nwith acute inferolateral ischemic process. Rule out myocardial infarction.\nFollowup and clinical correlation are suggested. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
}
] |
30,464 | 124,436 | A/P: Mr. is a 46 yo male with cryptogenic cirrhosis, awaiting liver transplant, who presents with hypotension and mental status changes. | Remains NPO for U/S Abd and gallbladder. Denies coughG/I- abd soft and distended, +BS. Abd distended, but soft, +BS. Sinus bradycardia with baseline artifact. Scattered areas of non-enhancement are identified within the spleen. npnpt is 46 yo M with cryptogenic cirrhosis, ,gerd, OSA, awiting liver translplant, , orig. denies nausea Pt given lactulose in ER and Unit, No BM. Comparison is made with the previous CT from . Mpderate ascites. Peripheral pulses palpable. Splenomegaly, splenic varices and splenorenal shunt. Abdomen with + ascites.GU: Pt voiding with each BM in commode, unable to quantify. Rightward transition point.Diffuse non-diagnostic T wave flattening. Note is made of moderate ascites. Comparison to , newly placed central venous access, right, in standard position. Patent IVC and hepatic veins. Pt is currently on trransplant list. admitted on for hypostension and mental status changes, US done this am showing thrombis in portal vein, ? On admisssion to ED, B/P were low in the 80's and pt was given 3L IVF and 1gm IV ceftriaxone. Patent hepatic arterial and venous vasculature. Able to uses call light appropriately.C/ Pt is pale, grey and dusky looking. FINAL REPORT AP UPRIGHT CHEST RADIOGRAPH: Follow up. HR 60-70's, NSR w/ no ectopy noted. Shrunken and cirrhotic liver with siderotic nodules but no focal arterial enhancing lesions. TLC was placed in ER. The liver is small and shrunken with a prominent caudate lobe consistent with the patient's known diagnosis of cirrhosis. Splenomegaly. s/p placement of RIJ with tip at cavo-atrial junction. The bowel wherever visualized is normal. Note is made of multiple splenic varices and a splenorenal shunt. A focal area inferiorly and posteriorly in relation to the spleen does not fill in with contrast. Pt has cryptogenic cirrohsis with resulting liver failure. The main portal vein is patent. Small, cirrhotic liver. Afebrile. The left portal vein is patent. Evaluate portal vein. Pt OOB to commode and chair with one assist. The right portal vein is diminutive but patent. The main portal vein does not demonstrate normal flow. Compared to previous tracingof no diagnostic change. MICU Nursing Progress Note 0700-1900Code: FullAllergies: NKDANeuro: Pt A&O x 3, lethargic at times but able to participate in appropriate conversation. IMPRESSION: 1. IMPRESSION: 1. Speech clear and able to use call light appropriatly.C/V- Admitted to unit SBP <80 and pt was given 500cc N/S bolus. The hepatic veins and IVC however are patent. Remains Fall risk. The gallbladder is visualized and is normal. There is normal arterial anatomy. MR : Note is made of a large right pleural effusion and associated atelectasis. Most of these fill in on the delayed images. (Over) 8:53 PM MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please evaluate portal vein (no flow seen on doppler ultraso Admitting Diagnosis: LIVER FAILURE;TELEMETRY Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) The osseous structures where visualized are normal. pt scheduled for MRI to evaluate. Planned U/S @ 8:30a and transport called.G/U- voiding small amounts of concentrated urine.Skin- IntactPlan----U/S of abd and gallbladder in am( to be done in ultrsound dept) Monitor B/P, goal keep SBP >80?C/O to floorMonitor for mental status changes The gallbladder is normal without gallstones. K= 3.2 and was replaced w/ 40Meq KCL. HCT stable 34. PLEASE OBTAIN STUDY WITH DOPPLERS. PLEASE OBTAIN STUDY WITH DOPPLERS. INDICATION: End-stage liver disease. COMPARISON: Comparison is made with previous CTA from and the previous Doppler ultrasound from . Pt NPO for am. Gait unsteady and legs appear to be generally weakened. old or new. Commode at bedside. Pt was also hemachromatosis negative. AAB COMPARISON: Abdominal ultrasound . The pancreas is visualized and is normal. Gait slightly unsteady, stand-by assist. Portal vein thrombosis, with no flow in the portal vein. C/O in amparacentesis in ammonitor B/Pcontinue lactulose and monitor mental status Within the liver, note is made of multiple siderotic nodules. Pt states he still has some confusion at times and his memory isn't at baseline. should have lactulose on return from MRIgu: voiding amber color urine.id: afebrileplan: pt is call out to 10 for continuation of care as trasplant pt. Skin jaundice, dusky. COMPARISON: . No edema noted. No edema noted. In ED B/P was low in the 80's and patient given 3L IVF and TLC placed. Pt was admitted to MICU for close monitoring of B/P. Large right pleural effusion with associated atelectasis. Lactate 2.0, INR 2.3Resp- Lungs clear, no SOB Sat's 94-98% on RA. Pt aware of the confusion and states " his thoughts gets mixed up". Post- administration of contrast, no evidence of any arterially enhancing lesions. The tip of the catheter projects over the right atrium. There is splenomegaly with the spleen measuring approximately 18.5 cm in the sagittal dimension. This is unchanged. Pt voiding small amounts of clear dark urine. paracentesis.G/ Pt has refused foley placement, voiding via urinal. Pt requested sleeping med, ativan 0.5mg given. Otherwise unchanged. Otherwise unchanged. evaluation of thromsis by MRI scheduled for today. ABDOMINAL SON: ultrasound evaluation of the abdomen reveals the liver to be small and cirrhotic without evidence of a focal lesion. Large amount of ascites. Due to slightly decreased inspiration, the transparency of the lung parenchyma is slightly decreased, and the size of the cardiac size has slightly increased. Pt has cryptogenic cirrhosis with resulting liver failure. A large amount of ascites is identified. Pt was discharged from hospital recently with same complaint. Pt is alert and oriented but vague at times. FINDINGS: Newly placed central venous access over the right internal jugular vein. | 8 | [
{
"category": "Radiology",
"chartdate": "2174-12-02 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 990933,
"text": " 8:47 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: 46 year old man with cirrhosis, please eval for and MARK asc\n Admitting Diagnosis: LIVER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis, please eval for and MARK ascites. PLEASE OBTAIN\n STUDY WITH DOPPLERS.\n REASON FOR THIS EXAMINATION:\n 46 year old man with cirrhosis, please eval for and MARK ascites. PLEASE OBTAIN\n STUDY WITH DOPPLERS.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male with cirrhosis.\n\n COMPARISON: Abdominal ultrasound .\n\n ABDOMINAL SON: ultrasound evaluation of the abdomen reveals\n the liver to be small and cirrhotic without evidence of a focal lesion. The\n gallbladder is normal without gallstones. There is no intrahepatic biliary\n ductal dilatation and the common bile duct measures 2 mm. The main portal\n vein does not demonstrate normal flow. The hepatic veins and IVC however are\n patent.\n\n There is splenomegaly with the spleen measuring approximately 18.5 cm in the\n sagittal dimension. A large amount of ascites is identified.\n\n IMPRESSION:\n 1. Portal vein thrombosis, with no flow in the portal vein. Patent IVC and\n hepatic veins.\n 2. Splenomegaly.\n 3. Large amount of ascites.\n 4. Small, cirrhotic liver.\n 5. No focal liver lesion.\n\n These findings were discussed with Dr. at approximately 11:00 am on the\n day of the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-11-30 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 990741,
"text": " 5:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval line placement\n Admitting Diagnosis: LIVER FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with liver cirrhosis and hypotension,r ight ij placede\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n WET READ: JWK WED 6:04 PM\n Low lung volumes and vascular crowding particularly on the right. s/p\n placement of RIJ with tip at cavo-atrial junction. No pneumothorax. Otherwise\n unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n AP UPRIGHT CHEST RADIOGRAPH:\n\n Follow up.\n\n COMPARISON: .\n\n FINDINGS: Newly placed central venous access over the right internal jugular\n vein. The tip of the catheter projects over the right atrium. Due to\n slightly decreased inspiration, the transparency of the lung parenchyma is\n slightly decreased, and the size of the cardiac size has slightly increased.\n No focal abnormalities in the lung parenchyma; no pleural effusions.\n\n Comparison to , newly placed central venous access, right, in\n standard position. No pneumothorax. Otherwise unchanged.\n\n AAB\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-12-02 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 991042,
"text": " 8:53 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate portal vein (no flow seen on doppler ultraso\n Admitting Diagnosis: LIVER FAILURE;TELEMETRY\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD, awaiting liver transplant\n REASON FOR THIS EXAMINATION:\n Please evaluate portal vein (no flow seen on doppler ultrasound), extent of\n portal venous thrombosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI abdomen.\n\n INDICATION: End-stage liver disease. Awaiting liver transplant. Evaluate\n portal vein.\n\n COMPARISON: Comparison is made with previous CTA from and the\n previous Doppler ultrasound from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic high-resolution 3D imaging, obtained prior to,\n during, and after the uneventful intravenous administration of 0.1 mmol/kg of\n gadolinium-DTPA. 2D and 3D reformations and subtraction images were generated\n on an independent workstation.\n\n MR :\n Note is made of a large right pleural effusion and associated atelectasis.\n\n The liver is small and shrunken with a prominent caudate lobe consistent with\n the patient's known diagnosis of cirrhosis. Within the liver, note is made of\n multiple siderotic nodules. Post- administration of contrast, no evidence of\n any arterially enhancing lesions. No focal liver lesions are identified. There\n is normal arterial anatomy. The main portal vein is patent. The left portal\n vein is patent. The right portal vein is diminutive but patent. The\n gallbladder is visualized and is normal. No evidence of any intra or extra-\n hepatic bile duct dilatation.\n\n The spleen is enlarged at 15.4 cm. Note is made of multiple splenic varices\n and a splenorenal shunt. Scattered areas of non-enhancement are identified\n within the spleen. Most of these fill in on the delayed images. Comparison is\n made with the previous CT from . A focal area inferiorly and\n posteriorly in relation to the spleen does not fill in with contrast. This is\n unchanged.\n\n Note is made of moderate ascites.\n\n The pancreas is visualized and is normal. No evidence of any significant\n lymphadenopathy. The bowel wherever visualized is normal.\n\n 2D and 3D reformations provided multiple perspectives for the dynamic series.\n (Over)\n\n 8:53 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate portal vein (no flow seen on doppler ultraso\n Admitting Diagnosis: LIVER FAILURE;TELEMETRY\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The osseous structures where visualized are normal.\n\n\n IMPRESSION:\n 1. Shrunken and cirrhotic liver with siderotic nodules but no focal arterial\n enhancing lesions.\n\n 2. Splenomegaly, splenic varices and splenorenal shunt. Mpderate ascites.\n\n 3. Patent hepatic arterial and venous vasculature.\n\n 4. Large right pleural effusion with associated atelectasis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-12-01 00:00:00.000",
"description": "Report",
"row_id": 1654644,
"text": "1900-0700 MICU ADmission note\n\n\n46 yo male admitted from ED after complaining of increased confusion at home. Pt was discharged from hospital on for similar complaints. Pt has cryptogenic cirrhosis with resulting liver failure. Pt is on transplant list, pt had donor liver but donor liver was diseased and could not be transplanted. Pt also has GERD and OSA. Pt is HIV, Hep A, B, and C negative. Pt was also hemachromatosis negative. Pt lives at home w/ wife and 2 children and has no ETOH or drug history. After last admission Lactulose was increased, to help decrease encephalopathy, while awaiting liver transplant. On admisssion to ED, B/P were low in the 80's and pt was given 3L IVF and 1gm IV ceftriaxone. TLC was placed in ER. Pt was admitted to MICU for close monitoring of B/P.\n\n Pt is alert and oriented but forgetful at times. Pt also seems to having trouble word finding at times and appears a little confused. Pt aware of the confusion and states \" his thoughts gets mixed up\". Pt states he is dizzy at times, even while lying flat in bed. Gait unsteady and legs appear to be generally weakened. Fall Risk. Speech clear and able to use call light appropriatly.\n\nC/V- Admitted to unit SBP <80 and pt was given 500cc N/S bolus. B/P 76-96/30-50 w/ MAPS 44-60. Pt has no edema. Pt looks greyish/dusky in color. Extremities warm to touch. HR 60-70's, NSR w/ no ectopy noted. K= 3.2 and was replaced w/ 40Meq KCL. HCT stable 34. Lactate 2.0, INR 2.3\n\nResp- Lungs clear, no SOB Sat's 94-98% on RA. Denies cough\n\nG/I- abd soft and distended, +BS. denies nausea Pt given lactulose in ER and Unit, No BM. Commode at bedside. Pt NPO for am. paracentesis.\n\nG/ Pt has refused foley placement, voiding via urinal. Pt voiding small amounts of clear dark urine. U/A sent in ED neg for UTI.\n\nSkin -Intact\n\nPsych/ Pt very anxious and restless, states he can't sleep because his mind is racing. Pt requested sleeping med, ativan 0.5mg given. Pt spoke to wife via his cell phone\n\nPlan-\n? C/O in am\nparacentesis in am\nmonitor B/P\ncontinue lactulose and monitor mental status\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-12-01 00:00:00.000",
"description": "Report",
"row_id": 1654645,
"text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nNeuro: Pt A&O x 3, lethargic at times but able to participate in appropriate conversation. Follows commands consistently, able to reposition self in bed. Pt OOB to commode and chair with one assist. Pt denies pain.\n\nCV: HR 60-80 NSR with no ectopy noted, NBP 90-110s/50-60, team will tolerate SBP in mid 80s as this is likely pt's baseline. CVP 6-14. Peripheral pulses palpable. Skin jaundice, dusky. Access includes PIV x 1 and right IJ, all ports patent, site WNL. No edema noted. Afebrile. Coags trending downward.\n\nResp: RR teens with sats >90% on RA. Lung sounds clear in all fields.\n\nGI: BS x 4, 2 loose, brown BM's this shift, pt receiving lactulose TID. Tolerating regular diet well. Abdomen with + ascites.\n\nGU: Pt voiding with each BM in commode, unable to quantify. Urine clear and .\n\nSkin: Intact.\n\nSocial: Wife and mother in to see pt, updated by ICU team on pt's condition and plan of care.\n\nPlan:\nmonitor BP, goal SBP >80\nmonitor mental status\nlactulose as ordered\ncalled out to floor, awaiting bed\nroutine ICU care and monitoring\nsupport to pt and family\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-12-02 00:00:00.000",
"description": "Report",
"row_id": 1654646,
"text": "1900-0700a MICU PROGRESS NOTE\n\n\n46 yo male admitted on from PCP's office, with c/o of increasing confusion and weakness. Pt was discharged from hospital recently with same complaint. Pt has cryptogenic cirrohsis with resulting liver failure. Pt is currently on trransplant list. Pt also has GERD and OSA.. Pt lives at home w/ wife and two children. No history of ETOH or drug abuse. In ED B/P was low in the 80's and patient given 3L IVF and TLC placed.\n\n Pt is alert and oriented but vague at times. Pt states he gets anxious at times, especially when he's trying to sleep. Pt states he's worried about his diagnosis and what it is doing to his family. Pt allowed to verbalize his feeling and social work following pt. Pt requested ativan to help him sleep, 0.5mg given with desired effect. Gait slightly unsteady, stand-by assist. Remains Fall risk. Pt states he still has some confusion at times and his memory isn't at baseline. Speech clear. Able to uses call light appropriately.\n\n\nC/ Pt is pale, grey and dusky looking. B/P ranges 70-140/30-90's. Goal SBP in the 80's. No edema noted. Extremities warm to touch. R-IJ TLC patent.\n\nResp- No SoB noted, Lungs clear...sat's 94-97 % on RA\n\nG/I- continues on TID Lactulose, No BM overnight. Abd distended, but soft, +BS. Remains NPO for U/S Abd and gallbladder. Planned U/S @ 8:30a and transport called.\n\nG/U- voiding small amounts of concentrated urine.\n\nSkin- Intact\n\nPlan----\n\nU/S of abd and gallbladder in am( to be done in ultrsound dept) Monitor B/P, goal keep SBP >80\n?C/O to floor\nMonitor for mental status changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-12-02 00:00:00.000",
"description": "Report",
"row_id": 1654647,
"text": "npn\npt is 46 yo M with cryptogenic cirrhosis, ,gerd, OSA, awiting liver translplant, , orig. admitted on for hypostension and mental status changes, US done this am showing thrombis in portal vein, ? old or new. pt scheduled for MRI to evaluate. awaiting call.\npt has been call out to 10 for a few days\n\nneuro: aox3, no confusion noted during day,s 1400 lactulose held due to impending MRI.\n\ncad: vss hr 80's nbp 100/40's no issues\n\npain: denies\n\nresp: ls left side clear, right side diminished upper and lower lobes\nsats 99% on RA.\n\ngi: abd soft bs+ loose stool this am. should have lactulose on return from MRI\n\ngu: voiding amber color urine.\n\nid: afebrile\n\nplan: pt is call out to 10 for continuation of care as trasplant pt. evaluation of thromsis by MRI scheduled for today.\n"
},
{
"category": "ECG",
"chartdate": "2174-11-30 00:00:00.000",
"description": "Report",
"row_id": 209144,
"text": "Sinus bradycardia with baseline artifact. Rightward transition point.\nDiffuse non-diagnostic T wave flattening. Compared to previous tracing\nof no diagnostic change.\n\n"
}
] |
15,538 | 195,067 | pt admitted {Pt pre-oped ) pt undergoes rt CEA with stent and selective carotid angiogram. The stent was placed due to very high bifurcation and plaque extension. Pt tolerated the procedure well. . Pt transfered to the PACU in stable condition. Pt found to have hematoma over surgical site. Slight difficulty breathing It was also found that the pt's tongue deviates to the right, slightly swollen. Pt started on steroids. Anesthesia feels that he did not need to reintubated. Pt transfered to the SICU for observation. Pt feeling better. Pt transfered to th VICU. Still c/o difficulty swallowing. Nitro weaned off, home meds started. A-line dc'd. Pt recieves levonex bridge untill coumadin restarted for PE. Dr from ENT to evaluate. Pt remained NPO. Speech and swallow consult obtained. Likely neuropraxia of cranial nerve XII and IX Pt fails speech and swallow study. Coumadin started Pt fails video swallow. Pt recieves DHFT under flouro. Pt requests to leave hospital with DHFT. ENT, pt to follow up. GI for PEG placement (pt on lovenox SQ ) would have to reverse to have PEG tube placed. Recommended to have pt readmitted under Dr service, have pt reversed off coumadin and leovenox. Then Cosult GI for PEG placement. | Dextran later d/c'd. COVERED W/ SSI X1. BS'S STARTING TO RISE W/ DECADRON. PERRL. BACK IN A-FIB ~ 4AM W/ RATES ~ 100. SNP CHANGED TO NTG, NOW AT 1.4 MCG/KG/MIN. Upon arrival, pt having sob. BP up to the 190's when nipride is off. Pt alert and oriented x3. c/o neck pain. 02 sats 97-99% on 4L NC. Unable to speak without difficulty. SBP'S HAVE BEEN ~ 130 AT THIS RATE. SATS IN HIGH 90'S ON R/A. UO ADEQUATE. REMAINS NPO. LS are coarse. SBP goal <150. 2 mg morphine given x1. HE STILL HAS MILD STRIDOR AND HOARSENESS, BUT RR IN TEENS TO 20'S, UNLABORED. Atrial fibrillation with rapid ventricular responseLeft axis deviation - anterior fascicular blockOld anteroseptal infarctPossible biventricular hypertrophySince previous tracing of , atrial fibrillation is new Condition UpdatePlease see carevue for specifics.pt arrived from the pacu approx 1300. Pt expectorating brown/ yellow sputum. RECIVED IVMS X2 W/ GOOD CONTROL OF INCISIONAL PAIN. Moving all extremities. Dyspnea later improved as well as speech. Right neck swollen with purple bruising extending to his chest. No c/o pain, nipride gtt and dextran infusing. NECK SWELLING DOES NOT APPEAR INCREASED. Steri strips to right neck with dried blood. SAT UP IN CHAIR UNTIL ~ 1AM AND AFTER THAT HAS SAT UP ON EDGE OF BED. HE IS UNABLE TO SWALLOW PILLS. | 3 | [
{
"category": "ECG",
"chartdate": "2185-05-20 00:00:00.000",
"description": "Report",
"row_id": 265250,
"text": "Atrial fibrillation with rapid ventricular response\nLeft axis deviation - anterior fascicular block\nOld anteroseptal infarct\nPossible biventricular hypertrophy\nSince previous tracing of , atrial fibrillation is new\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-05-19 00:00:00.000",
"description": "Report",
"row_id": 1464016,
"text": "Condition Update\nPlease see carevue for specifics.\n\npt arrived from the pacu approx 1300. Pt alert and oriented x3. No c/o pain, nipride gtt and dextran infusing. SBP goal <150. BP up to the 190's when nipride is off. Dextran later d/c'd. Right neck swollen with purple bruising extending to his chest. Steri strips to right neck with dried blood. PERRL. Moving all extremities. c/o neck pain. 2 mg morphine given x1. 02 sats 97-99% on 4L NC. Pt expectorating brown/ yellow sputum. LS are coarse. Upon arrival, pt having sob. Unable to speak without difficulty. Dyspnea later improved as well as speech.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-05-20 00:00:00.000",
"description": "Report",
"row_id": 1464017,
"text": "NPN (NOC): PT WAS UNCOMFORTABLE FOR MOST OF THE NIGHT, NOT SO MUCH FROM INCISIONAL PAIN BUT MORE FROM NOT BEING ABLE TO FIND A COMFORTABLE POSITION. SAT UP IN CHAIR UNTIL ~ 1AM AND AFTER THAT HAS SAT UP ON EDGE OF BED. RECIVED IVMS X2 W/ GOOD CONTROL OF INCISIONAL PAIN. HE STILL HAS MILD STRIDOR AND HOARSENESS, BUT RR IN TEENS TO 20'S, UNLABORED. SATS IN HIGH 90'S ON R/A. NECK SWELLING DOES NOT APPEAR INCREASED. HE IS UNABLE TO SWALLOW PILLS. BACK IN A-FIB ~ 4AM W/ RATES ~ 100. SNP CHANGED TO NTG, NOW AT 1.4 MCG/KG/MIN. SBP'S HAVE BEEN ~ 130 AT THIS RATE. BS'S STARTING TO RISE W/ DECADRON. COVERED W/ SSI X1. REMAINS NPO. UO ADEQUATE.\n"
}
] |
66,093 | 100,888 | 67M with metastatic pancreatic cancer who presented with small volume hematemesis, subsequently became hemodynamically unstable and expired upon transfer to the MICU. . Hematemesis: The patient was NG Lavaged in the ED with bright red blood after 500cc lavage. He subsequently dropped his BP to the 60s systolic and was intubated in the ED, Cordis was placed for access, Levophed was started He was transfused 4 units PRBCs in the ED. GI and surgery were consulted. GI initially planned to perform EGD upon transfer to the ICU. Surgery felt he was not a surgical candidate and suggested getting IR involved for possible embolization. He was transferred to the MICU on Levophed and Dopamine. He had 600cc bright red blood output during transfer from the ED to the MICU. Massive transfusion protocol was initiated and PRBC, PLT, FFP transfusion was started with calcium supplementation. The patient went into monomorphic VT soon after transfer to the MICU and returned to a sinus rhythm after 1 shock. The NG tube subsequently stopped functioning and he began to extravasate bright red blood per mouth. Rapid transfusion protocol was continued while the family was contact. Ultimately, he went into PEA and then asystolic arrest and the family did not wish to pursue continued aggressive measures. He expired at 0100 on . Immediate cause of death was cardiopulmonary arrest, chief cause of death was pancreatic cancer, other cause of death was acute blood loss. Significant time was spent with the family and they seemed satisfied with care provided. | Probable ectopic atrial rhythm. Clips and coil material are seen in the right upper quadrant. IMPRESSION: 1. Compared to the previous tracingof ectopic atrial rhythm is new.TRACING #1 Lines and tubes as described above. Left ventricular hypertrophy withsecondary repolarization abnormalities. Sinus tachycardia. A right central venous catheter tip sits in the right brachiocephalic vein. The right-sided Port-A-Cath tip sits in the superior right atrium. The cardiomediastinal and hilar contours are normal. Additionally, a stent like structure is seen in the left upper quadrant. STUDY: AP chest radiograph. COMPARISON: . Clinical correlation is suggested.TRACING #2 9:46 PM CHEST (PORTABLE AP) Clip # Reason: assess for ETT placement. 2. There are now more prominent ST-T waveabnormalities throughout diffusely - may be related to the rate but cannot ruleout underlying myocardial ischemia. FINDINGS: Initial images demonstrate the endotracheal tube to be 7.5 cm above the carina, although later images after adjustment showed to be 6 cm above the carina. An endogastric tube courses inferiorly and into the stomach. The lungs are clear. Compared to tracing #1 the patient is now in sinus rhythmbut the rate is significantly faster. There is no large pleural effusion or pneumothorax. No acute cardiopulmonary process. FINAL REPORT HISTORY: 67-year-old male status post intubation. | 3 | [
{
"category": "Radiology",
"chartdate": "2175-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197259,
"text": " 9:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p intubation\n REASON FOR THIS EXAMINATION:\n assess for ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male status post intubation.\n\n STUDY: AP chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: Initial images demonstrate the endotracheal tube to be 7.5 cm above\n the carina, although later images after adjustment showed to be 6 cm above the\n carina. An endogastric tube courses inferiorly and into the stomach. The\n right-sided Port-A-Cath tip sits in the superior right atrium. A right\n central venous catheter tip sits in the right brachiocephalic vein. Clips and\n coil material are seen in the right upper quadrant. Additionally, a stent\n like structure is seen in the left upper quadrant.\n\n The cardiomediastinal and hilar contours are normal. The lungs are clear.\n There is no large pleural effusion or pneumothorax.\n\n IMPRESSION:\n\n 1. Lines and tubes as described above.\n\n 2. No acute cardiopulmonary process.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-05-24 00:00:00.000",
"description": "Report",
"row_id": 231340,
"text": "Probable ectopic atrial rhythm. Left ventricular hypertrophy with\nsecondary repolarization abnormalities. Compared to the previous tracing\nof ectopic atrial rhythm is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2175-05-24 00:00:00.000",
"description": "Report",
"row_id": 231341,
"text": "Sinus tachycardia. Compared to tracing #1 the patient is now in sinus rhythm\nbut the rate is significantly faster. There are now more prominent ST-T wave\nabnormalities throughout diffusely - may be related to the rate but cannot rule\nout underlying myocardial ischemia. Clinical correlation is suggested.\nTRACING #2\n\n"
}
] |
61,566 | 113,423 | The patient is a 72yo gentleman who presented to the ED with a hypertensive emergency and ruled in for NSTEMI by EKG and enzymes. Cardiac cath revealed multi-vessel disease and cardiac surgery consultation was requested. The patient underwent the routine preoperative workup. He was taken to the operating room on where he underwent coronary artery bypass x3 LIMA-LAD, SVG to Oobtuse marginal and SVG to PDA. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was restarted on his preoperative medication Lisinopril but at a lower dose given marginal systolic blood pressure in the 80's. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. was consulted for blood sugar management and his insulin regimen was changed to Lantus. He is to follow up Dr. as an outpatient for further adjustments in insulin. By the time of discharge on POD #5 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was cleared for discharge to rehab in good condition with appropriate follow up instructions. | Percocet for pain 1 tab Q4hr. IMPRESSION: Resolved edema. + pp by doppler. + pp by doppler. Distant hypoactive bS 4Qs. Distant hypoactive bS 4Qs. HTN->treated with NTG gtt. Mild perihilar opacities are likely related to postoperative state. Phenylephrine 18. Phenylephrine 18. Diuresing well after lasix given Plan: Hypertension, benign Assessment: Action: Response: Plan: Hyperglycemia Assessment: Action: Response: Plan: Hct and coags sent and Hct was 21.8 and INR was 1.3. Response: Distant, hypoactive BS 4Qs. Diuresing well after lasix given. Metoprolol Tartrate 13. Metoprolol Tartrate 13. EKG showed diffuse ST depression. EKG showed diffuse ST depression. Pt with 1 episode of hypertension (see below). Pt with 1 episode of hypertension (see below). Tolerated PO sips, clears and meds. Tolerated PO sips, clears and meds. Response: Remains oliguric. POD#1 CABG Assessment: POD #1CABGx3. Vancomycin 24 Hour Events::Extubated postoperative. U/O trending down at hs. Pt titrated off neo and remains on insulin and BSs checked q1h. Sodium Chloride 0.9% Flush 21. Sodium Chloride 0.9% Flush 21. LS-CTA/dim at bases with chest tubes intact draining moderate amounts of serosang. Endocrine: IDDM. Discontinue PA monitor, S/P CABG - hemodynamically stable. Metoclopramide 14. Metoclopramide 14. Tx 2uPRBC for HCT=21.8. Docusate Sodium 10. Docusate Sodium 10. Atorvastatin 7. Atorvastatin 7. CHEST, PA AND LATERAL: Diffuse perihilar opacities and vascular congestion have resolved. Extubated . Extubated . Aspirin EC 6. Aspirin EC 6. Mild perihilar opacities are likely related to postoperative changes. The patient's ECG was inNSR and showed diffuse ST depression with elevation in AVR. The patient's ECG was inNSR and showed diffuse ST depression with elevation in AVR. The patient's ECG was inNSR and showed diffuse ST depression with elevation in AVR. The patient's ECG was inNSR and showed diffuse ST depression with elevation in AVR. 3:08 PM CHEST PORT. SBP 110mmHg. SBP 110mmHg. Nausea resolved after reglan given. A Swan-Ganz catheter demonstrates expected course. Patient was startedon Hep gtt and plavix loaded.CCATH Date: Place: 90% RCA 90% LADserial OM1- 2VDECHO with preserved Ef-55-60% CABGx3 Uneventful. Patient was startedon Hep gtt and plavix loaded.CCATH Date: Place: 90% RCA 90% LADserial OM1- 2VDECHO with preserved Ef-55-60% CABGx3 Uneventful. Small amount of pneumomediastinum and mild perihilar opacities are likely expected postoperative changes. Small amount of pneumomediastinum and mild perihilar opacities are likely expected postoperative changes. Ls clear with fine bibasilar crackles this am. Ls clear with fine bibasilar crackles this am. Pt to the OR for CABG x3. Pt to the OR for CABG x3. Full resolution of symptoms after Reglan IV. Normal regional LV systolicfunction. Normal ascending aortadiameter. Traceaortic regurgitation is seen. Right ventricular conduction delay. Mild mitral regurgitation present. Trivialmitral regurgitation is seen. There is nopericardial effusion. Trace aorticregurgitation is seen. There are simpleatheroma in the descending thoracic aorta. + pp by doppler. + pp by doppler. + pp by doppler. There isno pericardial effusion.Followup imaging of the apex is recommended. Posterior MI.Height: (in) 67Weight (lb): 175BSA (m2): 1.91 m2BP (mm Hg): 112/71HR (bpm): 64Status: InpatientDate/Time: at 01:58Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. There is mild symmetric left ventricularhypertrophy with normal cavity size. EKG showed diffuse ST depression. EKG showed diffuse ST depression. EKG showed diffuse ST depression. EKG showed diffuse ST depression. The mitral valveappears structurally normal with trivial mitral regurgitation. The QRS interval hasnarrowed. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Nausea resolved after reglan given. Nausea resolved after reglan given. Nausea resolved after reglan given. Diffuse non-specific.ST-T wave changes. HCT stable. HCT stable. HCT stable. Ls clear with fine bibasilar crackles this am. Ls clear with fine bibasilar crackles this am. Ls clear with fine bibasilar crackles this am. The mitral valve appears structurally normalwith trivial mitral regurgitation. Diuresing well after lasix given. Diuresing well after lasix given. Diuresing well after lasix given. Emergencystudy. Pt with 1 episode of hypertension (see below). Pt with 1 episode of hypertension (see below). Pt with 1 episode of hypertension (see below). Extubated . Extubated . Extubated . Left ventricular function. Thepatient appears to be in sinus rhythm. Right bundle-branch block is absent. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Evaluate apexHeight: (in) 67Weight (lb): 175BSA (m2): 1.91 m2BP (mm Hg): 179/96HR (bpm): 66Status: InpatientDate/Time: at 09:16Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Overall normal LVEF (>55%).LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Overall left ventricular ejection fraction is normal (LVEF 65%). Precordial lead ST-T wave changesmay be primary and are non-specific. Low precordial lead voltage. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right ventricular function.Height: (in) 66Weight (lb): 180BSA (m2): 1.91 m2BP (mm Hg): 123/67HR (bpm): 67Status: InpatientDate/Time: at 11:33Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. Absent BS this am. Absent BS this am. Absent BS this am. Overall leftventricular ejection fraction appears normal (LVEF 65%). Biventricular systolic functionis unchanged. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). | 30 | [
{
"category": "Radiology",
"chartdate": "2157-06-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1131831,
"text": " 11:49 AM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CABG\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: CABG, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is improved\n ventilation of both lung bases, as reflected by better distention of the\n costophrenic sinuses. Unchanged moderate cardiomegaly without evidence of\n pulmonary edema. Unchanged minimal thickening of the right minor fissure.\n Unchanged position of the central venous access line, with its tip projecting\n over the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-06-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131577,
"text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PTX\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p CABg\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient after CABG with chest tube removal.\n\n STUDY: Portable AP upright chest x-ray at 15:18, .\n\n FINDINGS:\n\n Compared to , the left chest tube has been removed and there is no\n evidence of pneumothorax. Basilar atelectasis at the left lung base is\n slightly improved but atelectasis within the right lung base appears slightly\n increased. Swan-Ganz catheter has been removed with a right internal jugular\n central venous catheter now in place with tip in the upper right atrium.\n Endotracheal tube has been removed, as has the NG tube. Wide mediastinum is\n unchanged.\n\n IMPRESSION:\n Removal of ET tube, left chest tube, and NG tube with exchange of Swan-Ganz\n catheter for a right internal jugular catheter with tip in right atrium. No\n pneumothorax with persistent bilateral atelectasis and widened mediastinum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-05-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1130749,
"text": " 2:13 PM\n CHEST (PA & LAT) Clip # \n Reason: Pneumonia vs. Heart Failure. Radiologist thought xray looked\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with NSTEMI.\n REASON FOR THIS EXAMINATION:\n Pneumonia vs. Heart Failure. Radiologist thought xray looked like pneumonia. No\n signs clinically of pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with NSTEMI.\n\n COMPARISON: and CT torso from .\n\n CHEST, PA AND LATERAL: Diffuse perihilar opacities and vascular congestion\n have resolved. The cardiomediastinal silhouette is normal. There are no\n pleural effusions. Chronic elevation of the right hemidiaphragm is stable\n since .\n\n IMPRESSION: Resolved edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-06-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131411,
"text": " 2:53 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n with issues. Pt will be in CSRU in 90 mins.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YGd WED 4:24 PM\n 1. Small amount of pneumomediastinum and mild perihilar opacities are likely\n expected postoperative changes.\n\n 2. No evidence of pneumothorax, pulmonary edema, or cardiac tamponade.\n Possible small left pleural effusion.\n\n 3. Drains, tubes, lines in acceptable positions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with CABG. Study to evaluate for pleural\n effusion, tamponade, pneumothorax.\n\n COMPARISON: Multiple prior exams including most recently .\n\n SINGLE PORTABLE CHEST RADIOGRAPH: Interval CABG has been performed with\n multiple vascular clips overlying the left heart border. Median sternotomy\n wires are intact. Patient has an endotracheal tube in place with tip\n approximately 4 cm above the carina. An OG tube has its side port positioned\n at the expected location of GE junction. A left-sided chest tube and two\n mediastinal drains are in place. A Swan-Ganz catheter demonstrates expected\n course.\n\n The lungs are reduced in volume. There is no evidence of pneumothorax. A\n small pleural effusion is present on the left with likely adjacent\n atelectasis. Mild perihilar opacities are likely related to postoperative\n state. There is no evidence of overt pulmonary edema. The cardiac silhouette\n appears upper limits of normal, accentuated by low lung volumes. Trace\n pneumomediastinum is suspected, and this is expected postoperative change.\n\n IMPRESSION:\n 1. Mild perihilar opacities are likely related to postoperative changes.\n 2. No evidence of pneumothorax or pulmonary edema.\n 3. Small left pleural effusion with likely accompanying atelectasis.\n 4. Drains, tubes, lines in standard positions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-06-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131412,
"text": ", R. CSURG CSRU 2:53 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n with issues. Pt will be in CSRU in 90 mins.\n ______________________________________________________________________________\n PFI REPORT\n 1. Small amount of pneumomediastinum and mild perihilar opacities are likely\n expected postoperative changes.\n\n 2. No evidence of pneumothorax, pulmonary edema, or cardiac tamponade.\n Possible small left pleural effusion.\n\n 3. Drains, tubes, lines in acceptable positions.\n\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534634,
"text": "72yo man with HTN and DM who presented to ER with chest pain that occurred at re\nst. chest pain was associated with diaphoresis and mild shortness of breath. In\nthe ED, patient's initial VS were 97.4 84 220/96 20 94% on\nBipap. The patient was started on Bipap and was given NTG SL x 3 and started on\nNTG gtt. The patient was also given Lasix 20mg IV x 1. The patient's ECG was in\nNSR and showed diffuse ST depression with elevation in AVR. Patient was started\non Hep gtt and plavix loaded.\nCCATH Date: Place: \nno hard copy, by report\n90% RCA\n90% LAD\nserial OM1\nECHO Date:\nEchocardiographic Measurements\nResults Measurements Normal Range\nLeft Ventricle - Ejection Fraction: 65% >= 55%\nFindings\nLEFT VENTRICLE: Overall normal LVEF (>55%).\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\nPERICARDIUM: No pericardial effusion.\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\nConclusions\nOverall left ventricular ejection fraction is normal (LVEF 65%).\nHowever, the basal segment of the inferior wall and the apex are\nhypokinetic. Right ventricular chamber size and free wall motion\nare normal. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion.\n"
},
{
"category": "Physician ",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Generic Note",
"row_id": 534758,
"text": "TITLE:\n CVICU\n HPI:\n HD8 POD 1-CABGx\n Ejection Fraction:65%\n Hemoglobin A1c:9.9\n Pre-Op Weight:175 lbs 79.38 kgs\n Baseline Creatinine:1.1\n PMH: IDDM,Dyslipidemia,HTN,RT arm atrophy,pilonidal \n :Atenolol 100mg daily,Lipitor 40mg daily,HCTZ 25mg Twice Weekly,\n Isosorbide 15mg daily,Lisinopril 40mg daily,Metformin ER 1000mg Daily,\n Aspirin 81mg daily,Novolog (70-30) 33/17\n Plavix - last dose:\n Assessment:crescendo angina-cath 3 vx -> CABG\n Chief complaint:\n PMHx:\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Aspirin EC 6. Atorvastatin 7.\n Calcium Gluconate 8. Dextrose 50%\n 9. Docusate Sodium 10. Insulin 11. Magnesium Sulfate 12. Metoprolol\n Tartrate 13. Metoclopramide\n 14. Milk of Magnesia 15. Nitroglycerin 16. Oxycodone-Acetaminophen 17.\n Phenylephrine 18. Potassium Chloride\n 19. Ranitidine 20. Sodium Chloride 0.9% Flush 21. Vancomycin\n 24 Hour Events:\n:Extubated postoperative. HTN->treated with NTG gtt. Tx 2uPRBC for\n HCT=21.8. HD stable.\n INTUBATION - At 02:09 PM\n OR RECEIVED - At 02:09 PM\n ARTERIAL LINE - START 02:10 PM\n PA CATHETER - START 02:11 PM\n CORDIS/INTRODUCER - START 02:11 PM\n INVASIVE VENTILATION - START 02:12 PM\n NASAL SWAB - At 02:30 PM\n INVASIVE VENTILATION - STOP 07:03 PM\n EXTUBATION - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 AM\n Infusions:\n Nitroglycerin - 1 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 04:00 PM\n Morphine Sulfate - 07:45 PM\n Furosemide (Lasix) - 11:54 PM\n Other medications:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.1\nC (97\n HR: 81 (74 - 88) bpm\n BP: 123/48(66) {95/42(57) - 153/62(82)} mmHg\n RR: 27 (10 - 29) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.8 kg (admission): 98 kg\n Height: 66 Inch\n CVP: 15 (5 - 67) mmHg\n PAP: (30 mmHg) / (17 mmHg)\n CO/CI (Thermodilution): (6.38 L/min) / (3.1 L/min/m2)\n SVR: -1,467 dynes*sec/cm5\n SV: 73 mL\n SVI: 35 mL/m2\n Total In:\n 7,906 mL\n 580 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 6,794 mL\n 420 mL\n Blood products:\n 1,012 mL\n Total out:\n 1,340 mL\n 1,230 mL\n Urine:\n 390 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,566 mL\n -650 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 295 (221 - 295) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n Plateau: 19 cmH2O\n SPO2: 94%\n ABG: 7.37/41/84./23/-1\n Ve: 10.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), pericardial rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : @bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, hypoactive bowel sounds\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 143 K/uL\n 11.0 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 108 mEq/L\n 138 mEq/L\n 31.7 %\n 12.1 K/uL\n [image002.jpg]\n 01:10 PM\n 01:13 PM\n 01:45 PM\n 02:26 PM\n 02:39 PM\n 03:59 PM\n 04:00 PM\n 06:46 PM\n 08:40 PM\n 04:00 AM\n WBC\n 8.5\n 11.6\n 10.1\n 12.1\n Hct\n 24.6\n 28\n 27.6\n 26.9\n 21.8\n 32.6\n 31.7\n Plt\n 145\n 145\n 137\n 143\n Creatinine\n 0.9\n 1.0\n TCO2\n 27\n 28\n 25\n Glucose\n 166\n 124\n 139\n 124\n 102\n Other labs: PT / PTT / INR:14.8/35.5/1.3, Differential-Neuts:80.0 %,\n Lymph:15.9 %, Mono:2.4 %, Eos:1.3 %, Fibrinogen:289 mg/dL, Lactic\n Acid:1.4 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Alert ,awake,\n responsive, morphine/PCT prn for pain\n Cardiovascular: Aspirin, Beta-blocker, Statins, Resume ACE-I as\n tolerated. Discontinue PA monitor, S/P CABG - hemodynamically stable.\n Wean nitro drip off\n Pulmonary: IS, Encourage DB&C,IS. OOB\n Gastrointestinal / Abdomen: prophylaxis, bowel regimen\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Lasix for diuresis\n Hematology: stable. Repeat HCT after overnight transfusions=31.7,\n PLTs=143.\n Endocrine: IDDM. HgBA1c= 9.9. Lantus/RISS->plan to resume po meds when\n eating. consulted for education/glycemic recs\n Infectious Disease: periop antibiotics. No issues.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CXR today->plan post pull/TLC CXR\n Fluids:\n Consults: /PT\n Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Lantus/RISS\n Lines:\n Arterial Line - 02:10 PM\n Cordis/Introducer - 02:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: tx F6\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534608,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt out from OR on nitro, propofol, and insulin. Pt intubated on a rate\n of 16 with PEEP-5. PERRLA sluggish pinpoint to 2mm bilat. TOF-Upon\n arrival, pt with no twitches and then as shift went on, pt with 2\n twitches in evening. LS-CTA/dim at bases with chest tubes intact\n draining moderate amounts of serosang. Small air bubbles noted at\n times.\n HR-A-paced at 80 upon arrival with no ectopy. Lytes checked and\n repleted. SBP-90\ns-120\ns throughout most of shift. CI >2 with good\n filling pressures. A wires sense and capture appropriately.\n Abd. soft with absent BS and OG tube in place draining bilious.\n Foley intact draining 30-80cc/hr of clear, yellow urine.\n Action:\n Pt given 50mg of protamine sulfate IV per PA due to chest\n tube drainage. Hct and coags sent and Hct was 21.8 and INR was 1.3.\n Pt given 2 units of PRBC\ns for Hct. Pt also given 3+ liters of fluid\n for labile BP during shift. Pt warmed, waked, and weaned. Pt very\n sleepy and slow to wake. Pt following commands and MAE\ns toward the\n end of shift and pt with good ABG on CPAP 5/5 and extubated per PA with\n no complications. Pt put on 100% face mask with sats >95% and pt\n continually encouraged to C&DB.\n Pt titrated off neo and remains on insulin and BS\ns checked q1h.\n Response:\n No further changes in assessment at this time.\n Plan:\n Continue to monitor neuro status and orient. Assess pain level and\n administer pain meds prn.\n Monitor hemodynamics and check labs.\n Pulmonary toilet.\n Monitor UOP.\n Check BS\ns and wean insulin drip per CVICU protocol.\n"
},
{
"category": "Physician ",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 534725,
"text": "CVICU\n HPI:\n HD8 POD 1-CABGx\n Ejection Fraction:65%\n Hemoglobin A1c:9.9\n Pre-Op Weight:175 lbs 79.38 kgs\n Baseline Creatinine:1.1\n PMH: IDDM,Dyslipidemia,HTN,RT arm atrophy,pilonidal \n :Atenolol 100mg daily,Lipitor 40mg daily,HCTZ 25mg Twice Weekly,\n Isosorbide 15mg daily,Lisinopril 40mg daily,Metformin ER 1000mg Daily,\n Aspirin 81mg daily,Novolog (70-30) 33/17\n Plavix - last dose:\n Assessment:crescendo angina-cath 3 vx -> CABG\n Chief complaint:\n PMHx:\n Current medications:\n 1. 2. 3. 250 mL D5W 4. Acetaminophen 5. Aspirin EC 6. Atorvastatin 7.\n Calcium Gluconate 8. Dextrose 50%\n 9. Docusate Sodium 10. Insulin 11. Magnesium Sulfate 12. Metoprolol\n Tartrate 13. Metoclopramide\n 14. Milk of Magnesia 15. Nitroglycerin 16. Oxycodone-Acetaminophen 17.\n Phenylephrine 18. Potassium Chloride\n 19. Ranitidine 20. Sodium Chloride 0.9% Flush 21. Vancomycin\n 24 Hour Events:\n INTUBATION - At 02:09 PM\n OR RECEIVED - At 02:09 PM\n ARTERIAL LINE - START 02:10 PM\n PA CATHETER - START 02:11 PM\n CORDIS/INTRODUCER - START 02:11 PM\n INVASIVE VENTILATION - START 02:12 PM\n NASAL SWAB - At 02:30 PM\n INVASIVE VENTILATION - STOP 07:03 PM\n EXTUBATION - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 AM\n Infusions:\n Nitroglycerin - 1 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 04:00 PM\n Morphine Sulfate - 07:45 PM\n Furosemide (Lasix) - 11:54 PM\n Other medications:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.1\nC (97\n HR: 81 (74 - 88) bpm\n BP: 123/48(66) {95/42(57) - 153/62(82)} mmHg\n RR: 27 (10 - 29) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.8 kg (admission): 98 kg\n Height: 66 Inch\n CVP: 15 (5 - 67) mmHg\n PAP: (30 mmHg) / (17 mmHg)\n CO/CI (Thermodilution): (6.38 L/min) / (3.1 L/min/m2)\n SVR: -1,467 dynes*sec/cm5\n SV: 73 mL\n SVI: 35 mL/m2\n Total In:\n 7,906 mL\n 580 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 6,794 mL\n 420 mL\n Blood products:\n 1,012 mL\n Total out:\n 1,340 mL\n 1,230 mL\n Urine:\n 390 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,566 mL\n -650 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 295 (221 - 295) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n Plateau: 19 cmH2O\n SPO2: 94%\n ABG: 7.37/41/84./23/-1\n Ve: 10.3 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), pericardial rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : @bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, hypoactive bowel sounds\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 143 K/uL\n 11.0 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 15 mg/dL\n 108 mEq/L\n 138 mEq/L\n 31.7 %\n 12.1 K/uL\n [image002.jpg]\n 01:10 PM\n 01:13 PM\n 01:45 PM\n 02:26 PM\n 02:39 PM\n 03:59 PM\n 04:00 PM\n 06:46 PM\n 08:40 PM\n 04:00 AM\n WBC\n 8.5\n 11.6\n 10.1\n 12.1\n Hct\n 24.6\n 28\n 27.6\n 26.9\n 21.8\n 32.6\n 31.7\n Plt\n 145\n 145\n 137\n 143\n Creatinine\n 0.9\n 1.0\n TCO2\n 27\n 28\n 25\n Glucose\n 166\n 124\n 139\n 124\n 102\n Other labs: PT / PTT / INR:14.8/35.5/1.3, Differential-Neuts:80.0 %,\n Lymph:15.9 %, Mono:2.4 %, Eos:1.3 %, Fibrinogen:289 mg/dL, Lactic\n Acid:1.4 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Alert\n ,awake,responsive,morphine for pain\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n S/P CABG - hemodynamically stable.Wean nitro drip\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Lasix for diuresis\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: periop antibiotics\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids:\n Consults:\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:10 PM\n Cordis/Introducer - 02:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534668,
"text": "72yo man with HTN and DM who presented to ER with chest pain that occurred at re\nst. chest pain was associated with diaphoresis and mild shortness of breath. In\nthe ED, patient's initial VS were 97.4 84 220/96 20 94% on\nBipap. The patient was started on Bipap and was given NTG SL x 3 and started on\nNTG gtt. The patient was also given Lasix 20mg IV x 1. The patient's ECG was in\nNSR and showed diffuse ST depression with elevation in AVR. Patient was started\non Hep gtt and plavix loaded.\nCCATH Date: Place: \n90% RCA 90% LAD\nserial OM1-\n 2VD\nECHO with preserved Ef-55-60%\n CABGx3 Uneventful.\n POD#1\n CABG\n Assessment:\n POD #1CABGx3. Afebrile. A&Ox3. MAE\ns (RUE- birth defect). LSC dim bases\n bilat FT 35% mist, O2 sats 99%. A paced early evening 80\ns CI 2.4 CO 4.\n SBP 110mmHg. Tolerated PO sips, clears and meds. C/o Nausea. Distant\n hypoactive bS 4Q\ns. Foley catheter draining clear amber unit.\n Action:\n Off temp pacer maintaining SR 70-80\ns. Hypertense 140\ns requiring NTG\n gtt overnight. Received Reglan 10mg for c/o nausea with full resolution\n of symptoms. Percocet for pain 1 tab Q4hrRegular Insulin GTT per CVICU\n protocol.\n Response:\n Remains oliguric. FMS draining liquid stool, irrigated system. Active\n BS 4Q\n Plan:\n TRACH/PEG/HD CATH today\n Bradycardia\n Assessment:\n Remains in S-Arrhythmia with HR between 30-50. Pacer set at V demand\n 35bpm\n Action:\n V demand backup 35bpm.\n Response:\n Rhythm remains irregular thoughout the shift, extremely brady at times\n Plan:\n Continue monitoring for hemodynamics\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534675,
"text": "72yo man with HTN and DM who presented to ER with chest pain that occurred at re\nst. chest pain was associated with diaphoresis and mild shortness of breath. In\nthe ED, patient's initial VS were 97.4 84 220/96 20 94% on\nBipap. The patient was started on Bipap and was given NTG SL x 3 and started on\nNTG gtt. The patient was also given Lasix 20mg IV x 1. The patient's ECG was in\nNSR and showed diffuse ST depression with elevation in AVR. Patient was started\non Hep gtt and plavix loaded.\nCCATH Date: Place: \n90% RCA 90% LAD\nserial OM1-\n 2VD\nECHO with preserved Ef-55-60%\n CABGx3 Uneventful.\n Received 2 units PRBC\ns post op for HCT 21.8. HCT post transfusion is\n 32.\n POD#1\n CABGx 3\n Assessment:\n POD #1CABGx3. Afebrile. A&Ox3. MAE\ns (RUE- birth defect). LSC dim bases\n bilat FT 35% mist, O2 sats 99%. A paced early evening 80\ns CI 2.4 CO 4.\n SBP 110mmHg. Tolerated PO sips, clears and meds. C/o Nausea. Distant\n hypoactive bS 4Q\ns. Foley catheter draining clear amber unit. U/O\n trending down at hs. FSBS 140-160mgdL. c/o incisional pain rated\n . FSBS 150\n Action:\n Off temp pacer maintaining SR 70-80\ns. . Hypertense 140\ns requiring\n NTG gtt overnight. Received Reglan 10mg for c/o nausea. Percocet for\n pain 1 tab Q4hr. Regular Insulin GTT per CVICU protocol. Received 20mg\n Iv Lasix. C/T draining moderate serosanguinous DRG 20-40cc/hr. Stable\n HCT this am.\n Response:\n Distant, hypoactive BS 4Q\ns. Full resolution of symptoms after Reglan\n IV. SBP 100-120mmHg on NTG. FSBS 120\ns on gtt, transitioned this am.\n CI3 CO4-5.\n Plan:\n De-line, advance diet, activity and transfer to stepdown.\n HTN\n Assessment:\n Remains SBP 140-150mmHg per A-line tracing\n Action:\n NTG gtt per guideline . Cuff started\n Response:\n Good SBP control. Gtt on/off overnight. Cuff 20pt below A-line\n Plan:\n Continue monitoring SBP. De-line, advance diet, activity and transfer\n to stepdown\n"
},
{
"category": "Respiratory ",
"chartdate": "2157-06-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 534597,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt slowly waking up post up currently weaned to PSV 10/5 plan\n to continue to wean and extubate as toelrated\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534665,
"text": "72yo man with HTN and DM who presented to ER with chest pain that occurred at re\nst. chest pain was associated with diaphoresis and mild shortness of breath. In\nthe ED, patient's initial VS were 97.4 84 220/96 20 94% on\nBipap. The patient was started on Bipap and was given NTG SL x 3 and started on\nNTG gtt. The patient was also given Lasix 20mg IV x 1. The patient's ECG was in\nNSR and showed diffuse ST depression with elevation in AVR. Patient was started\non Hep gtt and plavix loaded.\nCCATH Date: Place: \n90% RCA 90% LAD\nserial OM1-\n 2VD\nECHO with preserved Ef-55-60%\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534774,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on showed 3 vessel disease.\n Pt to the OR for CABG x3. uneventful OR course.\n Extubated . On nitro and insulin gtt overnight. Insulin gtt\n turned off at 7 am per protocol.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert and oriented x3. MAE and able to follow commands. Pt remains\n NSR, no ectopy noted. SBP ~ 100-140/50-60\ns. Pt with 1 episode of\n hypertension (see below). Pt on nitro gtt this am. + pp by doppler.\n HCT stable. Ls clear with fine bibasilar crackles this am. Pt on 6 L\n NC, o2 sats 92-97%. Absent BS this am. Pt with 1 episode of nausea\n this am.CT draining minimal amount of this serousanginous drainage, no\n airleak noted. Foley draining clear yellow urine. UO low this am.\n Action:\n CT dc\n R IJ -> changed over a guide wire to a multi lumen\n Pt started on lopressor and Lisinopril PO\n Nitro gtt weaned to off\n Pt started on lasix IV\n Started on reglan IV q6h x 24 hours\n OOB to chair, using IS to 500\n Response:\n LS clear with fine crackles in RLL, LL dim. Pt remains on 6 L NC, o2\n sat > 92%. Diuresing well after lasix given\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534777,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on showed 3 vessel disease.\n Pt to the OR for CABG x3. uneventful OR course.\n Extubated . On nitro and insulin gtt overnight. Insulin gtt\n turned off at 7 am per protocol.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert and oriented x3. MAE and able to follow commands. Pt remains\n NSR, no ectopy noted. SBP ~ 100-150\ns/50-60\ns. Pt with 1 episode of\n hypertension (see below). Pt on nitro gtt this am. + pp by doppler.\n HCT stable. Ls clear with fine bibasilar crackles this am. Pt on 6 L\n NC, o2 sats 92-97%. Absent BS this am. Pt with 1 episode of nausea\n this am.CT draining minimal amount of this serousanginous drainage, no\n airleak noted. Foley draining clear yellow urine. UO low this am.\n Action:\n CT dc\n R IJ -> changed over a guide wire to a multi lumen\n Pt started on lopressor and Lisinopril PO\n Nitro gtt weaned to off\n Pt started on lasix IV\n Started on reglan IV q6h x 24 hours\n OOB to chair, using IS to 500\n Response:\n LS clear with fine crackles in RLL, LL dim. Pt remains on 6 L NC, o2\n sat > 92%. Diuresing well after lasix given. + hypoactive BS noted this\n evening. Nausea resolved after reglan given. CXR confirmed placement of\n multi lumen\n Plan:\n BP control, pain control, continue diuresis, advance diet and activity\n as tolerated,\n Hypertension, benign\n Assessment:\n SBP ~ 90-150\ns with MAP 60-80\ns this am via Aline. SBP by cuff ~ 20 mm\n HG lower then Aline. Pt on nitro gtt this am. Pt had 1 episode htn\n during line change -> SBP ~ 200-220\ns. team in the room. Pt reports he\n is\nclaustrophobic\n -> HTN started when his face was drapped\n Action:\n Pt started on 25 mg lopressor this am -> lopressor dose\n increased to TID this afternoon\n Pt started on 10 mg lisinoprol this am -> pt given\n additional 10 mg Lisinopril this afternoon\n During hypertensive episode -> (no IV access) -> pt given 2\n mg morphine SC per team -> once line placed -> pt given 20 mg\n Hydralazine IV\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534782,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on showed 3 vessel disease.\n Pt to the OR for CABG x3. uneventful OR course.\n Extubated . On nitro and insulin gtt overnight. Insulin gtt\n turned off at 7 am per protocol.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert and oriented x3. MAE and able to follow commands. Pt remains\n NSR, no ectopy noted. SBP ~ 100-150\ns/50-60\ns. Pt with 1 episode of\n hypertension (see below). Pt on nitro gtt this am. + pp by doppler.\n HCT stable. Ls clear with fine bibasilar crackles this am. Pt on 6 L\n NC, o2 sats 92-97%. Absent BS this am. Pt with 1 episode of nausea\n this am.CT draining minimal amount of this serousanginous drainage, no\n airleak noted. Foley draining clear yellow urine. UO low this am.\n Action:\n CT dc\n R IJ -> changed over a guide wire to a multi lumen\n Pt started on lopressor and Lisinopril PO\n Nitro gtt weaned to off\n Pt started on lasix IV\n Started on reglan IV q6h x 24 hours\n OOB to chair, using IS to 500\n Response:\n LS clear with fine crackles in RLL, LL dim. Pt remains on 6 L NC, o2\n sat > 92%. Diuresing well after lasix given. + hypoactive BS noted this\n evening. Nausea resolved after reglan given. CXR confirmed placement of\n multi lumen\n Plan:\n BP control, pain control, continue diuresis, advance diet and activity\n as tolerated,\n Hypertension, benign\n Assessment:\n SBP ~ 90-150\ns with MAP 60-80\ns this am via Aline. SBP by cuff ~ 20 mm\n HG lower then Aline. Pt on nitro gtt this am. Pt had 1 episode htn\n during line change -> SBP ~ 200-220\ns. team in the room. Pt reports he\n is\nclaustrophobic\n -> HTN started when his face was drapped\n Action:\n Pt started on 25 mg lopressor this am -> lopressor dose\n increased to TID this afternoon\n Pt started on 10 mg lisinoprol this am -> pt given\n additional 10 mg Lisinopril this afternoon\n Nitro gtt weaned off this am\n During hypertensive episode -> (no IV access) -> pt given 2\n mg morphine SC per team -> once line placed -> pt given 20 mg\n Hydralazine IV\n Response:\n Aline remains higher the cuff. Plan to dc\nd aline per team. SBP down to\n 120-140\ns (after hydralazine given)\n Plan:\n Bp control, continue lopressor and lisniopril PO, Hydralazine prn\n Hyperglycemia\n Assessment:\n Insulin gtt dc\nd at 7am per protocol.\n Action:\n Glucose\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534784,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on showed 3 vessel disease.\n Pt to the OR for CABG x3. uneventful OR course.\n Extubated . On nitro and insulin gtt overnight. Insulin gtt\n turned off at 7 am per protocol.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert and oriented x3. MAE and able to follow commands. Pt remains\n NSR, no ectopy noted. SBP ~ 100-150\ns/50-60\ns. Pt with 1 episode of\n hypertension (see below). Pt on nitro gtt this am. + pp by doppler.\n HCT stable. Ls clear with fine bibasilar crackles this am. Pt on 6 L\n NC, o2 sats 92-97%. Absent BS this am. Pt with 1 episode of nausea\n this am.CT draining minimal amount of this serousanginous drainage, no\n airleak noted. Foley draining clear yellow urine. UO low this am.\n Action:\n CT dc\n R IJ -> changed over a guide wire to a multi lumen\n Pt started on lopressor and Lisinopril PO\n Nitro gtt weaned to off\n Pt started on lasix IV\n Started on reglan IV q6h x 24 hours\n OOB to chair, using IS to 500\n Response:\n LS clear with fine crackles in RLL, LL dim. Pt remains on 6 L NC, o2\n sat > 92%. Diuresing well after lasix given. + hypoactive BS noted this\n evening. Nausea resolved after reglan given. CXR confirmed placement of\n multi lumen\n Plan:\n BP control, pain control, continue diuresis, advance diet and activity\n as tolerated,\n Hypertension, benign\n Assessment:\n SBP ~ 90-150\ns with MAP 60-80\ns this am via Aline. SBP by cuff ~ 20 mm\n HG lower then Aline. Pt on nitro gtt this am. Pt had 1 episode htn\n during line change -> SBP ~ 200-220\ns. team in the room. Pt reports he\n is\nclaustrophobic\n -> HTN started when his face was drapped\n Action:\n Pt started on 25 mg lopressor this am -> lopressor dose\n increased to TID this afternoon\n Pt started on 10 mg lisinoprol this am -> pt given\n additional 10 mg Lisinopril this afternoon\n Nitro gtt weaned off this am\n During hypertensive episode -> (no IV access) -> pt given 2\n mg morphine SC per team -> once line placed -> pt given 20 mg\n Hydralazine IV\n Response:\n Aline remains higher the cuff. Plan to dc\nd aline per team. SBP down to\n 120-140\ns (after hydralazine given)\n Plan:\n Bp control, continue lopressor and lisniopril PO, Hydralazine prn\n Hyperglycemia\n Assessment:\n Insulin gtt dc\nd at 7am per protocol.\n Action:\n Glucose at 08:30 am was 163 -> tx with 4 units reg insulin\n SC\n Glucose at 12:00 was 199 -> treated with 15 units reg\n insulin SC and 20 units lantus SC\n Glucose at 14:00 was 191 -> plan to restart insulin gtt\n Insulin gtt restarted this evening and titrated per protocol\n consulted (\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534787,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on showed 3 vessel disease.\n Pt to the OR for CABG x3. uneventful OR course.\n Extubated . On nitro and insulin gtt overnight. Insulin gtt\n turned off at 7 am per protocol.\n Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert and oriented x3. MAE and able to follow commands. Pt remains\n NSR, no ectopy noted. SBP ~ 100-150\ns/50-60\ns. Pt with 1 episode of\n hypertension (see below). Pt on nitro gtt this am. + pp by doppler.\n HCT stable. Ls clear with fine bibasilar crackles this am. Pt on 6 L\n NC, o2 sats 92-97%. Absent BS this am. Pt with 1 episode of nausea\n this am.CT draining minimal amount of this serousanginous drainage, no\n airleak noted. Foley draining clear yellow urine. UO low this am.\n Action:\n CT dc\n R IJ -> changed over a guide wire to a multi lumen\n Pt started on lopressor and Lisinopril PO\n Nitro gtt weaned to off\n Pt started on lasix IV\n Started on reglan IV q6h x 24 hours\n OOB to chair, using IS to 500\n Response:\n LS clear with fine crackles in RLL, LL dim. Pt remains on 6 L NC, o2\n sat > 92%. Diuresing well after lasix given. + hypoactive BS noted this\n evening. Nausea resolved after reglan given. CXR confirmed placement of\n multi lumen\n Plan:\n BP control, pain control, continue diuresis, advance diet and activity\n as tolerated,\n Hypertension, benign\n Assessment:\n SBP ~ 90-150\ns with MAP 60-80\ns this am via Aline. SBP by cuff ~ 20 mm\n HG lower then Aline. Pt on nitro gtt this am. Pt had 1 episode htn\n during line change -> SBP ~ 200-220\ns. team in the room. Pt reports he\n is\nclaustrophobic\n -> HTN started when his face was drapped\n Action:\n Pt started on 25 mg lopressor this am -> lopressor dose\n increased to TID this afternoon\n Pt started on 10 mg lisinoprol this am -> pt given\n additional 10 mg Lisinopril this afternoon\n Nitro gtt weaned off this am\n During hypertensive episode -> (no IV access) -> pt given 2\n mg morphine SC per team -> once line placed -> pt given 20 mg\n Hydralazine IV\n Response:\n Aline remains higher the cuff. Plan to dc\nd aline per team. SBP down to\n 120-140\ns (after hydralazine given)\n Plan:\n Bp control, continue lopressor and lisniopril PO, Hydralazine prn\n Hyperglycemia\n Assessment:\n Insulin gtt dc\nd at 7am per protocol. HgBA1c= 9.9\n Action:\n Glucose at 08:30 am was 163 -> tx with 4 units reg insulin\n SC\n Glucose at 12:00 was 199 -> treated with 15 units reg\n insulin SC and 20 units lantus SC\n Glucose at 14:00 was 191 -> plan to restart insulin gtt\n Insulin gtt restarted this evening and titrated per protocol\n consulted (Pt is followed by outpatient)\n Response:\n Glcuoses better controlled this evening\n Plan:\n Continue insulin gtt, pt needs education -> pt reports he rarely checks\n his glucoses at home\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534771,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2157-06-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 534772,
"text": "Pt presented to the ED (on ) with c/o chest pain that radiated down bilat\neral arms. Pt was diaphoretic and SOB. EKG showed diffuse ST depression. The pt\nwas given SL nitro x 3 and started on nitro gtt. Pt was given lasix and ASA, pla\nced on BIPAP and transferred to CCU\n Cardiac cath on\n Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 102452,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Evaluate apex\nHeight: (in) 67\nWeight (lb): 175\nBSA (m2): 1.91 m2\nBP (mm Hg): 179/96\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:16\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nOverall left ventricular ejection fraction is normal (LVEF 65%). However, the\nbasal segment of the inferior wall and the apex are hypokinetic. Right\nventricular chamber size and free wall motion are normal. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2157-06-01 00:00:00.000",
"description": "Report",
"row_id": 102365,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG procedure. Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function.\nHeight: (in) 66\nWeight (lb): 180\nBSA (m2): 1.91 m2\nBP (mm Hg): 123/67\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 11:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal regional LV systolic\nfunction. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPrebypass\n\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. There is no pericardial effusion. Dr. \nwas notified in person of the results on at 1030am.\n\nPost bypass\n\nPatient is on phenylephrine and is AV paced. Biventricular systolic function\nis unchanged. Mild mitral regurgitation present. Aorta is intact post\ndecannulation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 102366,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain. ? Posterior MI.\nHeight: (in) 67\nWeight (lb): 175\nBSA (m2): 1.91 m2\nBP (mm Hg): 112/71\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 01:58\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Emergency\nstudy. Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular ejection fraction appears normal (LVEF 65%). However, the apex was\nNOT visualized and, therefore, apical hypokinesis cannot be excluded (limited\nvisualization of the midventricular segments raises the suspicion for apical\nhypokinesis, but this could not be confirmed with certainty). The aortic valve\nleaflets (?#) appear structurally normal with good leaflet excursion. Trace\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. There is\nno pericardial effusion.\n\nFollowup imaging of the apex is recommended.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2157-06-01 00:00:00.000",
"description": "Report",
"row_id": 291954,
"text": "Sinus rhythm. Right ventricular conduction delay. Diffuse non-specific.\nST-T wave changes. Low precordial lead voltage. Compared to the previous\ntracing of the precordial voltage has diminished. The QRS interval has\nnarrowed. Right bundle-branch block is absent. Otherwise, no diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 291955,
"text": "Sinus rhythm. Right bundle-branch block. Precordial lead ST-T wave changes\nmay be primary and are non-specific. Since the previous tracing of \nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 291956,
"text": "Sinus rhythm. Right bundle-branch block. ST-T wave changes may be primary and\nare non-specfic but clinical correlation is suggested. Since the previous\ntracing of the same date probably no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 291957,
"text": "Sinus rhythm. Right bundle-branch block. Diffuse ST-T wave changes are\nprimary and are non-specific. Clinical correlation is suggested. Since the\nprevious tracing of the same date there may be no significant change but\nbaseline artifact on previous tracing makes comparison difficult.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 291958,
"text": "Sinus rhythm. Right bundle-branch block. Primary ST-T wave changes are\nsuggested but baseline artifact makes assessment difficult. Since the previous\ntracing of ST-T wave changes appear decreased but baseline artifact\nmakes comparison difficult.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-25 00:00:00.000",
"description": "Report",
"row_id": 291959,
"text": "Sinus rhythm. Right bundle-branch block. Diffuse ST-T wave abnormalities are\nprimary and cannot exclude ischemia. Clinical correlation is suggested.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130445,
"text": " 12:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hx CP/SOB\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Shortness of breath.\n\n COMPARISON: CT torso from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Hazy opacity in the left perihilar region\n is seen. Heart is not enlarged. The aorta is normal in contour. Low lung\n volumes limit evaluation of the lung parenchyma.\n\n IMPRESSION: Probable left perihilar pneumonia with probable left hilar\n lymphadenopathy. PA and Lateral veiws are suggested for better evaluation.\n\n Discussed with Dr. at 8:05 am .\n\n\n"
}
] |
46,776 | 187,516 | 62yoM with HTN, DLP, DM presenting with symptomatic bradycardia in the 30's in the setting of third degree heart block with ventricular escape rhythm and presenting with NSTEMI whose hospital course included cardiac cath showing triple vessel disease requiring Cardiac surgery evaluation and subsequent CABG. During pre-op evaluation, found to have adrenal lesions concerning for metastatic disease versus pheochromacytoma. ============= HOSPITAL COURSE: - ================ # Coronary Artery Disease/CAD: Patient presented with NSTEMI and had cardiac catherization on showing multivessel disease. Cardiac surgery was consulted for CABG evaluation. Patient was medically managed with aspirin, statin and . Plavix was held in preparation for surgery. Given heart block, beta-blockaged was also held. . # Heart Block: Prior to presentation to , patient was reportedly in 3rd degree heart block. Upon arrival to , he was in normal sinus rhythm. Patient was monitored on telemetry during his hospitalization. AV nodal blockade was held given this history. . # Adrenal nodules: As part of pre-op evaluation, cardiac surgery requested a CT abdomen given history of hepatitis C. On CT, adrenal nodules were found with specific concern for pheochromacytoma versus metastatic disease. Endocrine was consulted for work-up for pheo. Serum and urine labs were sent showing...... Prior to surgery, patient was started phenoxybenzamine if lesions are in fact pheo. . # Chronic Hepatitis C: Hepatology was consulted prior to surgery for any pre-operative recommendations. No changes were made to management. On CT, right liver lesion was noted. Radiology recommended follow-up CT in 6 months. . # HTN: Poorly controlled during admission prior surgery. Anxiety appeared to contribute slightly to hypertension. Patient was started on hydralazine and phenoxybenzamine with better control of BP. . # DM: Patient's blood sugars were not controlled during admission with last A1c 9.8. Endocrine recommended changing insulin regimen to..... with better control of blood sugars thereafter. =================== SURGICAL SERVICE: - =================== On , Dr. performed coronary artery bypass grafting surgery. For surgical details, please see operative note. | Mild (1+) aorticregurgitation is seen. Normal ascending aortadiameter. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. Normal aortic arch diameter. Borderline normal global left ventricular systolic functionwith hypokinesis of the basal and mid septal and inferior wall segments. The estimated pulmonary artery systolic pressure is normal.There is a trivial/physiologic pericardial effusion.IMPRESSION: Normal left ventricular cavity size and wall thickness. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild [1+] TR. The tricuspid valve leaflets are mildlythickened. Mildly depressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: midinferoseptal - hypo; mid inferior - hypo; inferior apex - hypo; apex - hypo;RIGHT VENTRICLE: Mild global RV free wall hypokinesis.AORTA: Normal aortic diameter at the sinus level. Trivialmitral regurgitation is seen. Mild mitral regurgitation and mildaortic regurgitation persist. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; basal inferior - hypo; mid inferior - hypo;RIGHT VENTRICLE: Abnormal septal motion/position.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Normal aortic valve leaflets (3). Prior inferior myocardialinfarction. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Normal descending aorta diameter.Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. (<140ms)transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets. Prior inferior myocardial infarction. Left ventricular function. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderate baseline artifact. The mitral valve appears structurally normal with trivial mitralregurgitation. Thepatient appears to be in sinus rhythm. No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild regional LV systolic dysfunction. Trace aortic regurgitation isseen. Borderlinenormal global left ventricular systolic function with wall motionabnormalities as described above. The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. RV function is mildly depressed.There aresimple atheroma in the descending thoracic aorta. Sinus rhythm. Sinus rhythm. Aorta is intact post decannulation. Left ventricular wall thickness and cavitysize are normal. Left anterior fascicular block.Compared to the previous tracing of the rate is slower. No atrial septal defect is seen by 2D or color Doppler.There is mild regional left ventricular systolic dysfunction with hypokinesisof the apex, apical and mid portions of the inferior and inferoseptal walls.Overall left ventricular systolic function is mildly depressed (LVEF= 45%).Right ventricular chamber is normal. There is abnormal septalmotion/position. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.Height: (in) 72Weight (lb): 230BSA (m2): 2.26 m2BP (mm Hg): 121/79HR (bpm): 91Status: InpatientDate/Time: at 09:42Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). There arenon-diagnostic Q waves in the inferior leads. Sinus tachycardia. Sinus tachycardia. Right bundle-branch block.Q waves in leads III and aVF. The rhythm is probably normal sinus rhythm,rate 82 with slight P-R interval prolongation. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. RV function is mildly depressed. Mitral valve disease. Right bundle-branchblock. Aortic valve disease. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Compared to the previous tracing of no diagnostic interimchange.TRACING #1 The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic stenosis. Compared to the previous tracing of nodiagnostic interval change. Right ventricular function.Height: (in) 71Weight (lb): 220BSA (m2): 2.20 m2BP (mm Hg): 145/67HR (bpm): 71Status: InpatientDate/Time: at 11:09Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. Preoperative assessment. The mitral valve leaflets are mildly thickened. No clinically significant valvular disease. The patient was undergeneral anesthesia throughout the procedure. Compared to the previous tracing of no diagnostic interimchange.TRACING #2 No AS. No AS. Compared to the previous tracingof right bundle-branch block is new. Coronary artery disease. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for CABG. Thereis considerable beat-to-beat variability of the left ventricular ejectionfraction due to an irregular rhythm/premature beats. Dr. was notified inperson of the results at the time of the study.PostbypassPatient is in sinus rhythm. No TEE related complications. Beat-to-beat variability on LVEF due toirregular rhythm/premature beats. There is no pericardial effusion. Results were personally reviewed withthe MD caring for the patient.Conclusions:PrebypassNo spontaneous echo contrast is seen in the body of the left atrium or leftatrial appendage. I certifyI was present in compliance with HCFA regulations. Chest pain. Artifact is present. | 7 | [
{
"category": "Echo",
"chartdate": "2186-01-04 00:00:00.000",
"description": "Report",
"row_id": 96851,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG. Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function.\nHeight: (in) 71\nWeight (lb): 220\nBSA (m2): 2.20 m2\nBP (mm Hg): 145/67\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:09\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferoseptal - hypo; mid inferior - hypo; inferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPrebypass\n\nNo spontaneous echo contrast is seen in the body of the left atrium or left\natrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nThere is mild regional left ventricular systolic dysfunction with hypokinesis\nof the apex, apical and mid portions of the inferior and inferoseptal walls.\nOverall left ventricular systolic function is mildly depressed (LVEF= 45%).\nRight ventricular chamber is normal. RV function is mildly depressed.There are\nsimple atheroma in the descending thoracic aorta. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is no pericardial effusion. Dr. was notified in\nperson of the results at the time of the study.\n\nPostbypass\n\nPatient is in sinus rhythm. Patient is receiving an infusion of phenylephrine.\nLVEF= 45%. RV function is mildly depressed. Mild mitral regurgitation and mild\naortic regurgitation persist. Aorta is intact post decannulation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2185-12-29 00:00:00.000",
"description": "Report",
"row_id": 96852,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 72\nWeight (lb): 230\nBSA (m2): 2.26 m2\nBP (mm Hg): 121/79\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 09:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Beat-to-beat variability on LVEF due to\nirregular rhythm/premature beats. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Abnormal septal motion/position.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. (<140ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness and cavity\nsize are normal. Borderline normal global left ventricular systolic function\nwith hypokinesis of the basal and mid septal and inferior wall segments. There\nis considerable beat-to-beat variability of the left ventricular ejection\nfraction due to an irregular rhythm/premature beats. There is abnormal septal\nmotion/position. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic stenosis. Trace aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness. Borderline\nnormal global left ventricular systolic function with wall motion\nabnormalities as described above. No clinically significant valvular disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2186-01-02 00:00:00.000",
"description": "Report",
"row_id": 265605,
"text": "Sinus rhythm. Right bundle-branch block. Left anterior fascicular block.\nCompared to the previous tracing of the rate is slower.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-01-04 00:00:00.000",
"description": "Report",
"row_id": 265604,
"text": "Moderate baseline artifact. The rhythm is probably normal sinus rhythm,\nrate 82 with slight P-R interval prolongation. Right bundle-branch block.\nQ waves in leads III and aVF. Compared to the previous tracing of no\ndiagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2185-12-28 00:00:00.000",
"description": "Report",
"row_id": 265606,
"text": "Sinus tachycardia. Right bundle-branch block. Prior inferior myocardial\ninfarction. Compared to the previous tracing of no diagnostic interim\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2185-12-28 00:00:00.000",
"description": "Report",
"row_id": 265607,
"text": "Sinus rhythm. Prior inferior myocardial infarction. Right bundle-branch\nblock. Compared to the previous tracing of no diagnostic interim\nchange.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2185-12-28 00:00:00.000",
"description": "Report",
"row_id": 265608,
"text": "Artifact is present. Sinus tachycardia. Right bundle-branch block. There are\nnon-diagnostic Q waves in the inferior leads. Compared to the previous tracing\nof right bundle-branch block is new.\n\n"
}
] |
202 | 108,295 | 75 year old female with right staghorn calculi for >20 years and new left obstructing calculi with hydronephrosis, ureteral dilation and perinephric stranding associated with increasedd WBC count, tachycardia, hypotension refractory to fluids and increased creatinine. . 1. Sepsis: Although pt has no fever and no tachypnea, pt does have an elevated white count, with tachycardia as well as a positive UA suggesting pylonephritis and urosepsis. . A). Source was most likely urosepsis with positive UA, and obstructing stone by CT scan. She was treated with broad spectrum antibiotics with cefepime and cipro. Urology was already consulted as was IR. A percutaneous nephrostomy tube was placed by IR with resultant good urine output. . B). Hemodynamics: Pt had hypotension temporarily requiring pressors and IVF to bring up CVP. Pressors were successfully weaned. She had been mentating appropriately suggesting mental status would be an appropriate measure. . 2. Acute Renal Failure: It was secondary to obstructive stone lesion (pt already with atrophic R kidney, now presenting with obstructive lesion in L kidney). No history of renal insufficiency as per patient. The percutaneous nephrostomy tube was placed and the patient's creatinine improved with fluid hydration. . 3. Anemia of chronic decrease with decreased hematocrit over past 9 months (HCT 36 in )plus possible blood loss from nephrostomy stent placement and IVF this admission. The patient has a history of colon cancer with a normal colonoscopy last year. Iron studies were normal and the patient was guaiac negative. . 4. Hypertension was controlled on metoprolol. . The patient was discharged in good condition with follow up in urology clinic with Dr. . She was restarted on prophylactic amoxicillin as an outpatient. | PT IS AFEBRILE, WITH SINUS RHYTHM, NO ECTOPY.ADMISSION NOTE DONE, ORDERS CHECKED.PLAN: PLACE LEFT NEPHROSTOMY TUBE THIS AM. A hand injection of nonionic contrast confirmed the appropriate positioning of the nephroureteral stent. An antegrade nephrostogram was then performed via hand injection of nonionic contrast. At this time, the vertebral catheter and 6-French angiographic sheath were removed. MEDICATIONS: 1% Lidocaine. Note is made of a hiatal hernia. Taking po fluids well.GU: Foley intact; draining 100-220cc/hr prior to nephrostomy tube placement. RR 14-20, regular, unlabored.GI: Abdomen soft, ND, NT, +BS. A .035 wire was then advanced through the Accustick sheath into the distal ureter. Rectal tube in place, drained 150cc light brown loose stool since recieving CT contrast. Successful placement of a 24 cm 8 French internal/external nephroureteral stent via a left posterior middle pole calyx. A Stat- Lock device was applied, followed by a dry sterile dressing. Antegrade nephrostogram revealed mild left hydronephrosis with a complete obstruction identified at the level of the distal ureter, secondary to stone presence. The access needle was exchanged for a 6-French Accustick sheath with inner dilator and metallic stiffener. Upon entry into the renal parenchyma, the metallic stiffener was removed. IMPRESSION: 1) Cardiomegaly and minor left basilar atelectatic changes. 2) Hiatal hernia. PT HAS TWO PIV'S - RIGHT AC AND RFA PLACED AT HOSPITAL ED.VSS STABLE, FOLEY BAG INTACT WITH YELLOW, CLEAR QS. A .018 guide wire was advanced through the Chiba needle into the proximal ureter under fluoroscopic visualization. AM labs sent.GI: +BS, non tender, soft abd. The skin and subcutaneous tissues in the left flank region were anesthetized with 10 cc of 1% Lidocaine. This revealed a mildly dilated collecting system with complete obstruction identified at the level of the distal ureter. With the glidewire positioned in the bladder, beyond the area of obstruction, the Kumpe catheter was exchanged for a 5-French vertebral catheter. Using fluoroscopy, a new 22-gauge Chiba needle was advanced through an anesthetized region in the left flank into an opacified middle pole calyx. Again seen is a hiatal hernia. MAE's, speech clear.CV: Dopamine gtt weaned off by 0900. The super-stiff Amplatz wire was removed. Given 500cc fluid bolus X3 in ICU, X1 in L2 to maintain CVP >=8; NBP 103-121/41-55; HR 63-73, NSR no ectopy. AP CHEST: There has been interval placement of a right IJ line whose tip is in the SVC/RA junction. After the stylet was removed, urine was aspirated confirming our position within the renal collecting system. Linear opacities at the left lung bases are consistent with atelectasis. The glidewire was then exchanged for a .035 super-stiff Amplatz wire. The Accustick sheath and inner dilator were advanced over the wire until the tip was positioned in the proximal ureter. Right bundle-branch block with left anteriorfascicular block. Right bundle-branch block with left anteriorfascicular block. MD SENT PT TO HOSPITAL AND THEY DETERMINED IT WAS RIGHT SIDED KIDNEY STONES.DX: ARF, BUN 54 CR 2 K 2.7 (REPLACED IN BIMC EW WITH 60 MEQ PO)TLC RIJ PLACED IN OUR EW FOR DOPAMINE INFUSION. The guide wire and inner dilator were removed. At this time, the Accustick sheath was exchanged for a 6-French 23 cm bright-tip angiographic sheath. An 8-French 24 cm internal/external nephroureteral stent was then advanced over the Amplatz wire into the bladder. Output from tube and foley qs, together >130mls/hr. NPN 0700-1900Events/General: To L2 for placement of nephroureteral stent at ~10am, open to drainage bag for L obstructive renal calculi. 10:20 AM PERC NEPHROSTO Clip # Reason: Please place nephrostomy tube Admitting Diagnosis: UROSEPSIS Contrast: OPTIRAY Amt: 40 ********************************* CPT Codes ******************************** * INTRO CATH OR STENT INTO URETH INTRO CATH OR STENT TO URETHER * * ANTEGRADE UROGRAPHY C1769 GUID WIRES INCL INF * * C1769 GUID WIRES INCL INF STENT NOCOAT.NOCOVER W/ SYSTEM * * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 50 CC * **************************************************************************** MEDICAL CONDITION: 75 year old woman with L obstructive UVJ stone, renal failure, and urosepisis REASON FOR THIS EXAMINATION: Please place nephrostomy tube FINAL REPORT HISTORY: A 75-year-old female with urosepsis, ureteral stone, and need for decompression of the renal collecting system. With the sheath tip positioned in the proximal ureter, a 5-French Kumpe catheter was advanced through the angiographic sheath into the distal ureter. Teach pt to care for nephro tube. Pt denies pain at site.ID: Tmax 98.2; remains on cipro 500mg po bid.Plan: Monitor urine output; flush drain prn; change dressing daily; monitor temp and hemodynamic status. Dressing D&I. Adequate output from foley and nephro tube. PT REC CONTRAST AT HOSPITAL AND FECAL BAG PLACED FOR DIARRHEA. FINDINGS: Heart is at the upper limits of normal for size. Possible inferior myocardial infarction - age undetermined.Compared to the previous tracing no significant change.TRACING #2 The catheter pigtails were formed and locked in the bladder and in the right renal pelvis. Given local and sedated with fentanyl and midaz. Using the wire, attempts (Over) 10:20 AM PERC NEPHROSTO Clip # Reason: Please place nephrostomy tube Admitting Diagnosis: UROSEPSIS Contrast: OPTIRAY Amt: 40 FINAL REPORT (Cont) were made to traverse the area of obstruction. | 8 | [
{
"category": "Radiology",
"chartdate": "2145-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 845738,
"text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tlc placement in r IJ\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with WBC -27 and crackles at L base\n REASON FOR THIS EXAMINATION:\n tlc placement in r IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate right IJ placement.\n\n Comparison: .\n\n AP CHEST: There has been interval placement of a right IJ line whose tip is\n in the SVC/RA junction. There is no pneumothorax. Again seen is a hiatal\n hernia. There is continued atelectasis at the left base.\n\n There is no CHF.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 845734,
"text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CRACKLES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with WBC -27 and crackles at L base\n REASON FOR THIS EXAMINATION:\n R/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 75 year old female with leukocytosis and abnormal physical\n exam at the right lung base.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: None available.\n\n FINDINGS: Heart is at the upper limits of normal for size. The aorta is\n unfolded. The pulmonary vasculature is not engorged. Linear opacities at the\n left lung bases are consistent with atelectasis. There may be a very small\n left pleural effusion. The right lung appears grossly clear. Note is made of\n a hiatal hernia.\n\n IMPRESSION:\n 1) Cardiomegaly and minor left basilar atelectatic changes.\n\n 2) Hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-10-22 00:00:00.000",
"description": "INTRO CATH OR STENT INTO URETHER",
"row_id": 845778,
"text": " 10:20 AM\n PERC NEPHROSTO Clip # \n Reason: Please place nephrostomy tube\n Admitting Diagnosis: UROSEPSIS\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * INTRO CATH OR STENT INTO URETH INTRO CATH OR STENT TO URETHER *\n * ANTEGRADE UROGRAPHY C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF STENT NOCOAT.NOCOVER W/ SYSTEM *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with L obstructive UVJ stone, renal failure, and urosepisis\n REASON FOR THIS EXAMINATION:\n Please place nephrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 75-year-old female with urosepsis, ureteral stone, and need for\n decompression of the renal collecting system.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and supervising\n throughout. After the risks and benefits of the procedure were discussed with\n the patient and informed consent was obtained, the patient was placed prone on\n the angiography table. Her left flank was prepped and draped in the standard\n sterile fashion. 400 mg of intravenous Ciprofloxicin was administered. The\n skin and subcutaneous tissues in the left flank region were anesthetized with\n 10 cc of 1% Lidocaine. Using ultrasound guidance, attempts were made to\n advance a 22-gauge Chiba needle into a posterior lower pole calyx. After\n several attempts, however, this proved unsuccessful. The patient was then\n given 40 cc of 60% Optiray intravenously. Using fluoroscopy, a new 22-gauge\n Chiba needle was advanced through an anesthetized region in the left flank\n into an opacified middle pole calyx. After the stylet was removed, urine was\n aspirated confirming our position within the renal collecting system. The\n urine sample was sent for culture.\n\n An antegrade nephrostogram was then performed via hand injection of nonionic\n contrast. This revealed a mildly dilated collecting system with complete\n obstruction identified at the level of the distal ureter. A .018 guide wire\n was advanced through the Chiba needle into the proximal ureter under\n fluoroscopic visualization. The skin entry site was incised with a #11 blade\n scalpel. The access needle was exchanged for a 6-French Accustick sheath with\n inner dilator and metallic stiffener. Upon entry into the renal parenchyma,\n the metallic stiffener was removed. The Accustick sheath and inner dilator\n were advanced over the wire until the tip was positioned in the proximal\n ureter. The guide wire and inner dilator were removed. A .035 wire\n was then advanced through the Accustick sheath into the distal ureter. The\n wire could not be advanced beyond the area of obstruction into the\n bladder. At this time, the Accustick sheath was exchanged for a 6-French 23\n cm bright-tip angiographic sheath. With the sheath tip positioned in the\n proximal ureter, a 5-French Kumpe catheter was advanced through the\n angiographic sheath into the distal ureter. Using the wire, attempts\n (Over)\n\n 10:20 AM\n PERC NEPHROSTO Clip # \n Reason: Please place nephrostomy tube\n Admitting Diagnosis: UROSEPSIS\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n were made to traverse the area of obstruction. Again, this was unsuccessful\n and the wire was exchanged for a .035 angled glidewire.\n\n Using this wire, in combination with the 5-French Kumpe catheter, the area of\n obstruction was successfully passed. With the glidewire positioned in the\n bladder, beyond the area of obstruction, the Kumpe catheter was exchanged for\n a 5-French vertebral catheter. The glidewire was then exchanged for a .035\n super-stiff Amplatz wire. At this time, the vertebral catheter and 6-French\n angiographic sheath were removed. An 8-French 24 cm internal/external\n nephroureteral stent was then advanced over the Amplatz wire into the bladder.\n The super-stiff Amplatz wire was removed. The catheter pigtails were formed\n and locked in the bladder and in the right renal pelvis. A hand injection of\n nonionic contrast confirmed the appropriate positioning of the nephroureteral\n stent. The catheter was secured to the skin using a #0 silk suture. A Stat-\n Lock device was applied, followed by a dry sterile dressing. The catheter was\n placed to external bag drainage and may be capped in approximately 24 hours.\n\n COMPLICATIONS: None.\n\n MEDICATIONS: 1% Lidocaine. 400 mg intravenous Ciprofloxicin. 2 mg of Versed\n and 100 mcg of Fentanyl were administered in intermittent doses with\n continuous monitoring of vital signs by the nursing staff.\n\n CONTRAST: 90 cc of 60% Optiray.\n\n IMPRESSION:\n 1. Antegrade nephrostogram revealed mild left hydronephrosis with a complete\n obstruction identified at the level of the distal ureter, secondary to stone\n presence.\n\n 2. Successful placement of a 24 cm 8 French internal/external nephroureteral\n stent via a left posterior middle pole calyx. The catheter has side holes\n extending throughout its length and was placed to external bag drainage. The\n catheter may be capped for internal drainage in approximately 24 hours.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2145-10-22 00:00:00.000",
"description": "Report",
"row_id": 158183,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left anterior\nfascicular block. Possible inferior myocardial infarction - age undetermined.\nCompared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-10-22 00:00:00.000",
"description": "Report",
"row_id": 158184,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left anterior\nfascicular block. Possible inferior myocardial infarction - age undetermined.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-10-22 00:00:00.000",
"description": "Report",
"row_id": 1263027,
"text": "PT 0400 AFTER GOING TO MD'S OFFICE AND WBC'S VERY HIGH AT 29.7. MD SENT PT TO HOSPITAL AND THEY DETERMINED IT WAS RIGHT SIDED KIDNEY STONES.\n\nDX: ARF, BUN 54 CR 2 K 2.7 (REPLACED IN BIMC EW WITH 60 MEQ PO)\n\nTLC RIJ PLACED IN OUR EW FOR DOPAMINE INFUSION. PT HAS TWO PIV'S - RIGHT AC AND RFA PLACED AT HOSPITAL ED.\n\nVSS STABLE, FOLEY BAG INTACT WITH YELLOW, CLEAR QS. PT REC CONTRAST AT HOSPITAL AND FECAL BAG PLACED FOR DIARRHEA. PT IS AFEBRILE, WITH SINUS RHYTHM, NO ECTOPY.\n\nADMISSION NOTE DONE, ORDERS CHECKED.\n\nPLAN: PLACE LEFT NEPHROSTOMY TUBE THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-10-22 00:00:00.000",
"description": "Report",
"row_id": 1263028,
"text": "NPN 0700-1900\n\nEvents/General: To L2 for placement of nephroureteral stent at ~10am, open to drainage bag for L obstructive renal calculi. Given local and sedated with fentanyl and midaz. Tolerated procedure well.\nNeuro: A&OX3, pleasant, cooperative. MAE's, speech clear.\n\nCV: Dopamine gtt weaned off by 0900. Given 500cc fluid bolus X3 in ICU, X1 in L2 to maintain CVP >=8; NBP 103-121/41-55; HR 63-73, NSR no ectopy. Currently pt is getting NS @100/hr, with CVP 6-8.\n\nResp: Lungs clear; O2sat 96-98% on 2L. RR 14-20, regular, unlabored.\n\nGI: Abdomen soft, ND, NT, +BS. Rectal tube in place, drained 150cc light brown loose stool since recieving CT contrast. Diet advanced to renal and tolerated dinner of soup, crackers and tea. Taking po fluids well.\n\nGU: Foley intact; draining 100-220cc/hr prior to nephrostomy tube placement. Post procedure foley drained 220cc first hour then very little. Nephrostomy tube drained 500cc blood tinged urine. Dressing D&I. Pt denies pain at site.\n\nID: Tmax 98.2; remains on cipro 500mg po bid.\n\nPlan: Monitor urine output; flush drain prn; change dressing daily; monitor temp and hemodynamic status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-10-23 00:00:00.000",
"description": "Report",
"row_id": 1263029,
"text": "NPN 1900-0700\nUneventful night. Adequate output from foley and nephro tube. Afebrile. No c/o pain.\n\nNeuro: A&Ox3. Calm, cooperative, conversant. No c/o pain or other symptoms. mae.\n\nResp: Sats 100% on 2L so d/c'd o2 ~ 2200. On RA good o2 sats >96%. LS clear, no sob, no cough.\n\nCV: Stable BP 98/41-125/59. HR 79-91, nsr, no ectopy. Tmax 98.2. AM labs sent.\n\nGI: +BS, non tender, soft abd. Tol food and flds well. Mushroom cath in, minimal liquid stool.\n\nGU: Nephrostomy tube on , draining pink, clear fld. Dsg D&I. No pain at site. Output from tube and foley qs, together >130mls/hr. Foley not putting out urine every hour, when not putting u out, more fld out from nephrostomy tube.\n\nEndo: FS wnl.\n\nSkin: intact.\n\nSocial: No phone calls overnight.\n\nPlan: F/u on am labs, monitor output from nephro tube and foley, monitor vs. Teach pt to care for nephro tube.\n"
}
] |
471 | 135,879 | BRIEF HISTORY: is a 75 year old woman with hypertension, hyperlipidemia, prior tobacco use and positive family history of CAD. She has a prior history of CABG (LIMA to ramus, SVG to LAD, SVG to OM). While undergoing a bronchoscopic procedure for ablation of a bronchial carcinoid tumour, the patient suffered a cardiac arrest. Resuscitation was begun, TEE revealed that there was air in the left ventricle. The patient was placed on extra-corporeal membrane oxygenation and transferred emergently to the cath lab. There was a visible pocket of air in the left ventricular cavity. A pigtail catheter was advanced into the LV and used to aspirate the air. There was reduction in the appearance of the air pocket on fluoroscopy. When maximal efforts to aspirate the air were completed, the patient was defibrillated with one shock and sinus rhythm was restored. Small doses of levophed were used to maintain blood pressure. The patient was placed on the ventilator with good oxygenation and CO2 exchange. Uncrossmatched blood was administered with improvement in filling pressures. Fluroscopy did not reveal any evidence of pneumothorax. The patient was transferred to surgery for removal of the ECMO cannulas. Patient supported in ICU and successfully extubated and weaned of pressors and transferred to floor. Pt made DNR/DNI per her wishes in agreement w/ family. Was recovering well and approaching discharge to previous inpatient facility. POD#8- Pt found unresponsive w/ agonal respirations with stable hemodynamics. Family wished no further intervention and comfort measures to be a priority and were initiated. Pt expired at 1806 with family at bedside. Pronounced by thoracic team. Attending physician . | Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? pnuemo Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? COMPARISON: Left upper extremity ultrasound dated . Partially occlusive thrombus in the greater saphenous, and common femoral veins. There has been interval extubation and removal of a Swan-Ganz catheter and nasogastric tube. s/p codenew dophoff tube REASON FOR THIS EXAMINATION: eval for pleural effusion, edema, /chf FINAL REPORT This is a portable chest of . COMPARISON: Left lower extremity ultrasound dated . RETROPERITONEAL BLEED Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? IMPRESSION: Essentially occlusive thrombus extending from the popliteal vein through the mid superficial femoral vein, and partially occlusive thrombus in the proximal superficial femoral vein, greater saphenous, and common femoral veins. Partial flow with a normal venous waveform is seen in the proximal superficial femoral vein, common femoral vein, and greater saphenous vein. The left subclavian venous access catheter appears to have been partially withdrawn in the interval. 10:37 AM BILAT LOWER EXT VEINS Clip # Reason: LLE CLOT Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? Sinus rhythmProbable left ventricular hypertrophyDiffuse nonspecific ST-T wave abnormalities - clinical correlation is suggestedSince previous tracing of same date, Qtcinterval appears shorter There has been placement of a nasogastric tube, which terminates in the gastric body and replacement of the pulmonary artery catheter, previously entering from an inferior approach, with a pulmonary artery catheter entering via the right internal jugular vein with tip terminating in the main pulmonary artery. IMPRESSION: Essentially occlusive thrombus extending from the popliteal vein through the mid superficial femoral vein. 8:24 AM CHEST (PORTABLE AP) Clip # Reason: eval effusion/edema Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? 10:37 AM UNILAT UP EXT VEINS US LEFT Clip # Reason: LUE SWELLING Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? There has been interval worsening in a bilateral alveolar pattern with relative sparing of the right upper lobe. amiodarone drip cont. HYPO BSP. hypo bsp. r fem incision draining scant serous, changed. ?wean epi/milrinone/levo/amio.F/u cxr. Left plantar sl mottleresp: Ls cl. CSRU UPDATENEURO: SEDATION WEAN TO OFF FOR EXTUBATION.SLEEPY, ORIENTED TO PLACE/PERSON. Sr w rare pvc's/couplets->replete lytes. EKG done. levo to off, epi weaned down. bilous dng via ogt. Repeat Cxr to r/o pneumo. Hct stabled. PEDITUBE PLACED RT NARES. nsr w/ ectopy. Monitor CO maintaining epi and milrinone. repport to . R groin doc as aboved.Access: R IJ Pa cco swan/introducer. csru update/transfer:stable am. ->Min spon movement of both ues' , les' withdraw to nail bed pressure. Initial ABG wnl. Bs cta. arrived to CSRU s/p rigid bronch, VF arrest, ECMO placement, and cardiac cath. Co via thermo mid 3s-4/via fick -->both w ci >2. Returned from OR post cannula removal on epi, milrinone, ntg, and propofol.Allergies: Keflex and cephalosporins.Neuro: Arrived sedated on propofol. Gave mag sulated-frequent k replete 3.2-4.5. afebrile. CXR x2.Gi: NPO. REQUEST PT TO BE DNR, HAD SPOKE W/ DR . SVO2 REMIANS LOW 70'S W/ GOOD CI BY BOTH THERMODILUTION AND FICK. COMBO PAD REMOVED. Large area of eccymosis noted mid sternally.A: Htn. uop marginal via foley. Vagues c/o about status at b/g of shift->felt better after RN explain aobut status/poc as pt stated . LT FEM LINES D/C BY NP AND SITE C+D. K+ 3.2->potassium repletion started. CONVERSES APPROP. vent changes as noted, abg pending. Pupil bilat. Left sc cordis. Back/buttock/both heels skin cdiComfort: pt denies pain. XRAY FOR PEDITUBE PLACEMENT. afbrile. Maintain sedation and SIMV overnight. Pulses weak palp, strong by doppler. mae x4 to command. pedal pulses palp. awakens through propofol. Pulm toilet. But sxn oral w cl bloody secretions. Sat 100% on 3lncgi: Swallow cl liquid okay.belly soft/nt/ndEndo: Bs normalizedGu: Uo oliguric to marginal>gave lasix w sufficient diuresisWound: sternal bruises faden. AMIO DRIP CHANGE TO PER FT. NSR, NO VEA NOTED TODAY. Right femoral site with large area of soft eccymosis. add SNP if necessary. Skin w+dLabs: Lactic acid and Lft's trending up slightly->Dr. MSO4 PRN W/ EFFECT.ASSESS: GOOD DAY. Placed pad to chest/posteriorVasc: R groin remain swollen/ecchymotic/soft resolving hematoma. CSRU Admission NoteMrs. EPINEPHRINE WEAN TO OFF AND MILRINONE DECREASED. more comfortable up and oob.Please see carevue flowsheet for further details and values. BP ALLOWING LEVOPHED TO OFF. adequate uo. COREG TO RESTART.RESP: LUNGS ESSENTIALLY CLEAR, FEW CRACKLES AT BASES. Svo2 70s w co >6/ci >. Wean off milrinone and amio to po. Bp good. ^diet/activityMonitor confusion/ms LATER IN DAY C/O LEFT LEG PAIN-> MSO4 4 MG SQ W/ EFFECT.ASSESS: STABLE DAY. d/t hoh (pmh hoh required hear aids) vs. deficit? MD aware. FAILED SWALLOW STUDY.PLAN: ULTRASOUND EXTREMS. CSRU UPDATENEURO: ALERT. Svo2 70s-80s-recal done in am. Coarse BS throughout.GI: Abd soft. l dp and pt, radial and ulnar pulses all present. acidosis w resp compensation. Ntg for BP control. Belly soft/distended. Gave supportA/P: Monitor ectopies and bp status. PT FAILED SWALLOW EVAL. Left top plantar foot remain mottle-> Easily palpable pulses on both feet. | 28 | [
{
"category": "Radiology",
"chartdate": "2122-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 874216,
"text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusion/edema\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid.\n REASON FOR THIS EXAMINATION:\n eval effusion/edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY\n\n Portable chest of , at 9:00 a.m. compared to previous study of\n , at 6:52 p.m.\n\n INDICATION: Bronchial carcinoid. Evaluate effusion and edema.\n\n A feeding tube remains in place, terminating below the diaphragm. There has\n been prior median sternotomy and coronary artery bypass surgery. The heart\n remains enlarged. There has been interval worsening in a bilateral alveolar\n pattern with relative sparing of the right upper lobe. The right upper lobe\n volume loss and partially calcified pleural thickening appear stable. Dense\n left retrocardiac opacity is unchanged. Bilateral pleural effusions are\n stable allowing for positional differences.\n\n IMPRESSION: Worsening bilateral alveolar pattern, which may be due to\n pulmonary edema. Differential diagnosis includes pulmonary infection,\n aspiration, and evolving ARDS.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873495,
"text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumothorax\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid. s/p code. ? fistula from bronchus\n to pulm vein.\n REASON FOR THIS EXAMINATION:\n ?pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE.\n\n INDICATION: 75-year-old woman with bronchial carcinoid, status post cold.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed. No\n previous study is available for comparison.\n\n Tip of the endotracheal tube is identified at thoracic inlet. The left\n subclavian catheter terminates in the left innominate vein. Femoral Swan-Ganz\n catheter terminates in the right main PA. No pneumothorax is seen.\n\n There is extensive biapical thickening. There is mild-to-moderate pulmonary\n edema with opacity in the right lower lobe indicating pneumonia versus\n aspiration. The heart is normal in size.\n\n IMPRESSION: Mild-to-moderate pulmonary edema with right lower lobe\n consolidation indicating pneumonia versus aspiration. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 873755,
"text": " 5:54 PM\n PORTABLE ABDOMEN Clip # \n Reason: check dophoff placement\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid. s/p codenew dophoff tube\n REASON FOR THIS EXAMINATION:\n check dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post new Dobbhoff placement.\n\n ABDOMEN, SINGLE VIEW\n\n A Dobbhoff tube is present. The radiopaque marker localized expected position\n of the lower gastric body.\n\n Note is made of some residual contrast in the colon and, at the periphery of\n this film, clips over the right upper quadrant. There is a probable small\n effusion vs. pleural thickening at the right base lung and there is increased\n density consistent with collapse and/or consolidation at the left base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 874173,
"text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusion, edema, /chf\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid. s/p codenew dophoff tube\n\n REASON FOR THIS EXAMINATION:\n eval for pleural effusion, edema, /chf\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest of .\n\n COMPARISON: .\n\n INDICATION: Evaluate for pleural effusion, edema and congestive heart\n failure.\n\n There has been interval extubation and removal of a Swan-Ganz catheter and\n nasogastric tube. A feeding tube is in place in the interval and terminates\n below the diaphragm. The cardiac silhouette is mildly enlarged but stable.\n There is bilateral upper lobe volume loss. There are worsening areas of\n alveolar opacification within both the left upper lobe and in the right\n perihilar region. There has been interval worsening of opacification in the\n left retrocardiac region, which is now densely opacified. A left pleural\n effusion has increased in size in the interval, and a right pleural effusion\n has also increased. -apical pleural thickening and right upper lobe\n scarring appears unchanged.\n\n IMPRESSION:\n 1. Worsening multifocal alveolar opacities, which are somewhat asymmetric.\n Differential diagnosis includes asymmetrical pulmonary edema and multifocal\n pneumonia.\n 2. Increasing bilateral pleural effusions.\n 3. Feeding tube terminates below the diaphragm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-27 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 873989,
"text": " 10:37 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LUE SWELLING\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with New onset of left upper ext swelling with history of\n CVL on that side\n REASON FOR THIS EXAMINATION:\n ? left upper extrem DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with history of new-onset left upper extremity\n swelling and history of central venous catheter on that side.\n\n COMPARISON: Left upper extremity ultrasound dated .\n\n LEFT UPPER EXTREMITY ULTRASOUND: Grayscale, color flow and Doppler ultrasound\n of the left internal jugular, subclavian, brachial, cephalic and basilic veins\n were obtained. Color flow and Doppler ultrasound only of the axillary vein\n was performed. Although compression of the axillary vein was not performed,\n relative loss of color flow was demonstrated within the axillary vein. Normal\n flow, augmentation, compressibility and waveforms were demonstrated in the\n right internal jugular, brachial veins were seen. The cephalic vein was not\n previously imaged and demonstrates non-compressibility consistent with\n intraluminal thrombus.\n\n IMPRESSION:\n 1. No evidence of left axillary DVT extension.\n 2. Limited exam of the left axillary vein. No visualized thrombus is seen,\n with demonstrated normal wall- to wall flow. If clinical concern persists,\n reimaging with axillary vein could be performed at no additional charge for\n the patient.\n 3. Intraluminal thrombus of the left cephalic vein, which was not previously\n imaged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873550,
"text": " 11:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? pnuemo\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid. s/p code. ? fistula from bronchus\n to pulm vein.\n REASON FOR THIS EXAMINATION:\n ? pnuemo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bronchial carcinoid, status post code, evaluate for pneumothorax.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: Since the previous examination dated , the endotracheal\n tube, nasogastric tube, pulmonary artery catheter, and left subclavian venous\n access catheter appear in unchanged position.\n\n The heart is stably within normal limits in size. Pulmonary edema is stable\n to slightly improved. There is slight increase in right infrahilar opacity\n possibly consistent with aspiration.\n\n Nodular opacity is again seen at the right lung apex with density suggestive\n of possible calcification. An additional nodular opacity within the right\n lung laterally is probably unchanged from two prior radiographs and may\n represent a pulmonary nodule. Continued follow up with chest radiography\n following treatment is recommended to assess resolution.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-28 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 874152,
"text": " 4:46 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval swallow ability\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with s/p rigid bronch w/ cardiac arrest; failed bedside\n REASON FOR THIS EXAMINATION:\n eval swallow ability\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female status post cardiac arrest with difficulties\n swallowing. The patient failed bedside swallow evaluation.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: This study was performed in conjunction with the speech and\n swallow therapist. The patient was given multiple consistencies of barium.\n\n FINDINGS: During the oral phase, there was mildly slow chewing. There is\n premature spillover of liquids and nectar.\n\n During the pharyngeal phase, there is normal elevation of the pharynx. The\n vallecula reflection occurs most of the times but not consistently. After the\n swallow, there was a large amount of residual in the vallecula. There is a\n smaller degree of residue in the piriform sinuses. The residue in the\n vallecula tends to spill in laryngeal penetration. There was one episode of\n aspiration with thin liquids. This aspirate cleared with cued cough.\n\n IMPRESSION: Mild deficit in the oral phase. A large amount of the residue,\n especially in the vallecula. There is vallecula overflow and laryngeal\n penetration in most of the swallows. There was one episode of aspiration.\n Please review the report of the speech and swallow therapist for a more\n detailed report.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-24 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 873751,
"text": " 4:48 PM\n UNILAT LOWER EXT VEINS LEFT; -76 BY SAME PHYSICIAN # \n Reason: PAIN LEFT LEG ASSESSF OR DVT\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with New onset of left lower ext swelling with history of CVL\n on that side\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old with left lower extremity swelling, history of\n central venous catheter on that side.\n\n scale and pulse color Doppler images of the left common femoral,\n superficial femoral, greater saphenous, deep femoral, and popliteal veins were\n performed. Thrombus is seen extending from the popliteal through the\n superficial femoral vein into the common femoral and greater saphenous vein.\n No significant color flow is noted within the popliteal vein or the distal and\n mid portions of the superficial femoral vein. Partial flow with a normal\n venous waveform is seen in the proximal superficial femoral vein, common\n femoral vein, and greater saphenous vein. Augmentation was not performed.\n\n IMPRESSION: Essentially occlusive thrombus extending from the popliteal vein\n through the mid superficial femoral vein, and partially occlusive thrombus in\n the proximal superficial femoral vein, greater saphenous, and common femoral\n veins. These findings were communicated at the completion of the study to Dr.\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-22 00:00:00.000",
"description": "ABDOMINAL AORTOGRAM",
"row_id": 873543,
"text": " 9:35 PM\n OR VASCULAR A-GRAM Clip # \n Reason: ANGIO OF ABD, RIGHT HEMATOMA S/P ECMO CANNULA PLACEMENT, ? RETROPERITONEAL BLEED\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ********************************* CPT Codes ********************************\n * ABDOMINAL AORTOGRAM *\n * *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb Clinical Lookup.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 873541,
"text": " 8:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: effusion?\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with bronchial cardinoid. s/p code. ? fistula from bronchus\n to pulm vein.\n REASON FOR THIS EXAMINATION:\n effusion?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bronchial carcinoid, status post code, question of fistula from\n bronchus to pulmonary vein.\n\n COMPARISON: , at 14:31 hours.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: Since the previous examination of several hours earlier, an\n endotracheal tube and left subclavian venous access catheter are again seen.\n The left subclavian venous access catheter appears to have been partially\n withdrawn in the interval. There has been placement of a nasogastric tube,\n which terminates in the gastric body and replacement of the pulmonary artery\n catheter, previously entering from an inferior approach, with a pulmonary\n artery catheter entering via the right internal jugular vein with tip\n terminating in the main pulmonary artery.\n The heart size is within normal limits. Biapical pleural density consistent\n with pleural thickening versus effusion is stable. Stable pulmonary edema and\n consolidation within the right lower lobe, which could be due to aspiration.\n Changes of prior right thoracotomy are again visualized. There is nodular\n thickening within the right lung apex that may represent scarring.\n\n IMPRESSION:\n\n 1. Lines and tubes in satisfactory position.\n\n 2. Stable pulmonary edema.\n\n 3. Stable right lower lobe consolidation that may represent aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-24 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 873749,
"text": " 4:03 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: SWELLING LEFT ARM ASSESS FOR DVT\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with New onset of left upper ext swelling with history of CVL\n on that side\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old with new-onset left upper extremity swelling. History\n of central venous catheter in the left arm.\n\n FINDINGS: Grayscale and pulse color Doppler images of the left internal\n jugular, subclavian, axial, brachial, and basilic veins was performed. Within\n the axillary vein, there is partially occlusive thrombus identified such that\n the axillary vein is not compressible. However, wall-to-wall flow is seen\n within the axillary vein. This thrombus may extend into the left brachial\n vein. The remainder of the vessels in the upper left extremity is normal in\n appearance with normal compressibility, color flow, waveform, and\n augmentation. Mild soft tissue edema is seen in the forearm.\n\n IMPRESSION:\n\n Non-occlusive thrombus within the left axillary vein, possibly extending into\n the brachial vein. This was communicated to Dr. at the\n completion of the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-27 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 873990,
"text": " 10:37 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: LLE CLOT\n Admitting Diagnosis: BRONCIAL CARCINOID, RIGHT MIDDLE LOBE\\BRONCHOSCOPY RIGID; ENDOBRONCHIAL U/S; ? PLASMA COAGULATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with New onset of left lower ext swelling with history of\n CVL on that side\n REASON FOR THIS EXAMINATION:\n ? left lower extrem DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with new onset of left lower extremity\n swelling, and history of central venous catheter placement. Evaluate for left\n lower extremity DVT.\n\n COMPARISON: Left lower extremity ultrasound dated .\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale, color flow, and Doppler imaging\n of the left common femoral, superficial femoral, and popliteal veins were\n performed. As previously indicated, thrombus is seen extending from the\n popliteal vein through the superficial femoral vein, and into the common\n femoral and greater saphenous vein. There has been no significant interval\n resolution or progression of the identified thrombus. Although a normal\n waveform is demonstrated within the mid and distal superficial femoral vein,\n no visualized color flow is demonstrated, and no compression was visualized.\n\n IMPRESSION: Essentially occlusive thrombus extending from the popliteal vein\n through the mid superficial femoral vein. Partially occlusive thrombus in the\n greater saphenous, and common femoral veins. These findings are unchanged\n from prior study dated .\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-22 00:00:00.000",
"description": "Report",
"row_id": 158682,
"text": "Sinus rhythm\nProbable left ventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities - clinical correlation is suggested\nSince previous tracing of same date, Qtcinterval appears shorter\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-22 00:00:00.000",
"description": "Report",
"row_id": 158683,
"text": "Sinus rhythm\nLeft ventricular hypertrophy\nDiffuse ST-T wave abnormalities with prolonged Q-Tc interval - could be due in\npart to left ventricular hypertrophy but Clinical correlation is suggested for\npossible in part metabolc/drug effect\nNo previous tracing for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-25 00:00:00.000",
"description": "Report",
"row_id": 1267312,
"text": "ekg nsr, had i 3 beat vt and a 9 beat run of ? svt. sbp stable. afbrile. adequate uo. breath sounds clear, decreased at r base, coughs and gags freq, produces mod to large amts thick old bloody sputum. maintains spo2 > 95% on 2 l nc. abd soft, bowel sounds present, tf started at 10cc/hr, to advance to goal of 50cc, no resisual so far. remains npo due to failure of swallowing study, tolerating ice chips, but is begging for fluid and food. l arm and leg remain edematous and dusky looking with l foot noticeably cooler than r. able to lift and hold l arm, but able to lift l leg only slightly. l dp and pt, radial and ulnar pulses all present. r fem incision draining scant serous, changed. alert, but confused as to place time, reason for hospitalizaton - daughter says she is usually like this after anesthesia. seems a little clearer this am, asking questions about procedure, why she can't drink, etc. denies pain except for some discomfort in affected limbs. becomes anxious and calls out, gets fixated on specific things such as drinking, going home and repeats over and over, then appears to forget that issue and goes on to something else. slept in naps, up in chair this am, with two assist, but able to stand on both feet and step sideways.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-25 00:00:00.000",
"description": "Report",
"row_id": 1267313,
"text": "Neuro: alert and oriented x 3, at times is forgetful to place and time, pt does repot that she is having some short tem memory loss, is mae, is following commands correctly, pearl, denies pain.\n\nCardiac: nsr with no ectopy noted, sbp's wnl's, dopplerable pedial pulses, dopplerable radial pulses, skin warm dry and intact, edema in left arm and left leg, left hand is cool and dusky, continues heparin gtt, afebrile.\n\nResp: lungs dim in bases, is on 2 liters nc satting at 97%, is coughing and deep breathing and using i/s.\n\nSkin: right fem dsd is cdi, left arm edema and left hand is cool and dusky but does have dopplerable radial pulse.\n\nGi/Gu: Npo with ice chips, on tf's advancing towards goal with no residuals, good bowel sounds, abd is soft round and nontender, on riss, making 30 or >/hr of u/o.\n\nPlan: monitor ptt's, transfer to f2 when bed is ready, monitor blood sugars, encourage to cough and deep breath and to use i/s, increase activity as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-26 00:00:00.000",
"description": "Report",
"row_id": 1267314,
"text": "Nursing Note\nCVS: HR 70 SR no ectopy, SBP and temp stable no issues. c/o back pain received morphine with sleep as relief. Pulses weak palp, strong by doppler. multiple areas of echymosis and edema, fingers cool early in shift, now warm/normal. only access is left IJ cordis with one port. Heparin at 1000units/hour returned a ptt of 150. Heparin off x 4 hours and restarted at 800 units per hour.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nRESP: LS clear to dim initially, now after attempting ice chips she is coarse in both uppers and decreased in the lowers. Hemoptisis, mahogany to brown tinged.\n\nNeuro: needs extensive assesment, waking better now from neuro based sedation. ? psych component in behavior. The patient tells me (the nurse) The psych pt had no idea what wad doing on.\n\n\nGI: abd bd very hypo,\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-26 00:00:00.000",
"description": "Report",
"row_id": 1267315,
"text": "Nursing Note\nNEURO AND GI ENTERED IN ERROR PLEASE SEE FOLLOWING NOTE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-24 00:00:00.000",
"description": "Report",
"row_id": 1267309,
"text": "Neuro: pt a +ox2 to person and place at times. Confuse overnoc asking \"go to airport and home w daughter\"--easily reorient x3 and reinforced w smooth effect. perl 6mm. mae x4 to command. No apparent focal deficit. cooperative\n\nCv. afebrile. Sr w rare pvc's/couplets->replete lytes. Bp good. Svo2 70s w co >6/ci >. Both rij introducer and pa cco swan fell out when reposition ->Pa was notify->cont milrinone at .25/amio at .5 overnoc via lsc cordis per PA.\nVas: left arm and and left upper thigh swollen 3+pitting->+csm, Pa examined ->keep elevated on pillow. Left plantar sl mottle\n\nresp: Ls cl. good cough raised sm amt blood-tinged. No distress. Gas good-res compensate for metabolic acidosis. Sat 100% on 3lnc\n\ngi: Swallow cl liquid okay.belly soft/nt/nd\nEndo: Bs normalized\nGu: Uo oliguric to marginal_>gave lasix w sufficient diuresis\nWound: sternal bruises faden. facial petechias remain no changed. Back/buttock/both heels skin cdi\nComfort: pt denies pain. Vagues c/o about status at b/g of shift->felt better after RN explain aobut status/poc as pt stated . NO family call yet overnoc\n\na/p: Hemos. Wean off milrinone and amio to po. Pulm toilet. ^diet/activity\nMonitor confusion/ms\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-24 00:00:00.000",
"description": "Report",
"row_id": 1267310,
"text": "Add:\n\nCorrection : Gi->Pt cough after each sip of water ->notify team ->need further swallow eval done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-24 00:00:00.000",
"description": "Report",
"row_id": 1267311,
"text": "CSRU UPDATE\nNEURO: ALERT. ORIENTED TO PERSON, TO HOSPITAL AT TIMES. CONFUSED AND FORGETFUL MUCH OF TIME. CONVERSES APPROP. PERL, 4MM.\n\nCV: VSS. AMIO DRIP CHANGE TO PER FT. NSR, NO VEA NOTED TODAY. LEFT EXTREMS QUITE SWOLLEN DUE FOR ULTRASOUND. PULSES PRESENT. COREG TO RESTART.\n\nRESP: LUNGS ESSENTIALLY CLEAR, FEW CRACKLES AT BASES. STRONG, DRY COUGH. O2 SATS 95-99% ON 2L N/C.\n\nGI/GU: COUGH NOTED W/ H20 INTACT. PT FAILED SWALLOW EVAL. TAKING ONLY FEW ICE CHIPS, WILL RE EVAL ON MONDAY. PEDITUBE PLACED RT NARES. UOP QS VIA FOLEY.\n\nSOCIAL: FAMILY AT BEDSIDE MUCH OF DAY. AWARE ON PLAN OF CARE.\n\nPAIN: PT C/O GENERALIZED PAIN RELIEVED W/ BACK TO BED AND REPOSITION. LATER IN DAY C/O LEFT LEG PAIN-> MSO4 4 MG SQ W/ EFFECT.\n\nASSESS: STABLE DAY. FAILED SWALLOW STUDY.\n\nPLAN: ULTRASOUND EXTREMS. XRAY FOR PEDITUBE PLACEMENT. INCREASE ACTIVITY AS TOL.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-23 00:00:00.000",
"description": "Report",
"row_id": 1267305,
"text": "Resp Care\nPT remains on vent. Intubated with #8 ett @ 21 lip; patent and secure. Bs cta. Decreased rr due to hyperventilation shown in abgs. Plan to maintain settings and planned transfer to other unit.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-23 00:00:00.000",
"description": "Report",
"row_id": 1267306,
"text": "Add:\n\nResp: Correction --> Pt has been on CMV mode (not SIMV)\nGi: OGt drg became brown to bilious\n\nNeuro: Lighten prop to 30mcg/kg/min->pt open eyes wide spontanously, no tracking or focus. No follow command ? d/t hoh (pmh hoh required hear aids) vs. deficit? ->Min spon movement of both ues' , les' withdraw to nail bed pressure. -->notify status to team am round->closely monitor--Will wait for further neuro eval and order from Dr.\n\nPer team, pt is to be tx to Micu when ready\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-23 00:00:00.000",
"description": "Report",
"row_id": 1267307,
"text": "csru update/transfer:\nstable am. awakens through propofol. mae min in bed. pedal pulses palp. levo to off, epi weaned down. nsr w/ ectopy. amiodarone drip cont. has combo pads on. abd soft. hypo bsp. bilous dng via ogt. insulin drip to off for glucose of 99. lungs clear. vent changes as noted, abg pending. sx for nothing. uop marginal via foley. repport to . willnotify daughter prior to transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-23 00:00:00.000",
"description": "Report",
"row_id": 1267308,
"text": "CSRU UPDATE\nNEURO: SEDATION WEAN TO OFF FOR EXTUBATION.SLEEPY, ORIENTED TO PLACE/PERSON. FOLLOWS COMMANDS. MAE WEAKLY IN BED. PUPILS REMAIN LARGE (6MM) AND REACTIVE.\n\nCV: VS/HEMOS AS PER FLOWSHEET. BP ALLOWING LEVOPHED TO OFF. EPINEPHRINE WEAN TO OFF AND MILRINONE DECREASED. SVO2 REMIANS LOW 70'S W/ GOOD CI BY BOTH THERMODILUTION AND FICK. CONT ON AMIODARONE, VENT ECTOPY DECREASING BY THIS AFTERNOON. COMBO PAD REMOVED. PEDAL PULSES EASILY PALP. LT FEM LINES D/C BY NP AND SITE C+D. NO HEMATOMA NOTED.\n\nRESP: LUNGS CLEAR BILAT. ABG'S GOOD, EXTUBATED TO 3L N/C AND TOL WELL. FAIR NON-PRODUCTIVE COUGH. O2 SATS 95-98%.\n\nGI/GU: ABD SOFT. HYPO BSP. TOL FEW ICE CHIPS SO FAR. UOP MARGINAL VIA FOLEY.\n\nSOCIAL: FAMILY UPDATED AND IN TO VISIT. REQUEST PT TO BE DNR, HAD SPOKE W/ DR . HE HAS BEEN PAGED TO SEE FAMILY.\n\nPAIN: C/O PAIN. POINTS TO RT GROIN FOR LOCATION. MSO4 PRN W/ EFFECT.\n\nASSESS: GOOD DAY. TOL WEAN TO EXTUBATION AND DRUGS AS NOTED.\n\nPLAN: CONT WEAN AS TOL. INCREASE PO INTAKE/ACTIVITY AS TOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-22 00:00:00.000",
"description": "Report",
"row_id": 1267303,
"text": "CSRU Admission Note\n\nMrs. arrived to CSRU s/p rigid bronch, VF arrest, ECMO placement, and cardiac cath. ECMO weaning initiated in cath lab with good effect. Back to OR within 1 hour of arrival for decannulation. Returned from OR post cannula removal on epi, milrinone, ntg, and propofol.\n\nAllergies: Keflex and cephalosporins.\n\nNeuro: Arrived sedated on propofol. Pupils 8mm and unreactive bilat. MD aware. Will continue to monitor.\n\nCV: NSR with PVC's noted. K+ 3.2->potassium repletion started. CI's greater than 2.0. Epi weaned and ntg increased by anesthesia shortly after arrival for htn. Continue to increase ntg for BP control->team aware. Right femoral site with large area of soft eccymosis. Feet warm bilat with intact PP's.\n\nResp: SIMV on arrival. Initial ABG wnl. Coarse BS throughout.\n\nGI: Abd soft. OGT with minimal pink tinged secretions. Mouth suctioned for blood tinged secretions. Had large amt blood suctioned from oropharyngeal area in OR.\n\nGU: Adequate u/o.\n\nEndo: Insulin gtt started for hyperglycemia.\n\nSkin: Intact to anterior inspection. Large area of eccymosis noted mid sternally.\n\nA: Htn. PVC's. Dilated unreactive pupils.\n\nP: Monitor neuro status. Monitor CO maintaining epi and milrinone. Ntg for BP control. ? add SNP if necessary. Maintain sedation and SIMV overnight. Monitor oral bleeding. Insulin gtt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-23 00:00:00.000",
"description": "Report",
"row_id": 1267304,
"text": "Neuro: Pt remain sedated on prop at 75mcg/kg/min->no weaning or attempt to wake pt up overnoc per team. Pupil 7mmm dilated, non-reactive->team was re-notify and dr ->examine pt ->no Ct/or any indications order. No s/s pain. Pupil bilat. sl reactive to light toward am at 6mm.\n\nId: Became normalthermic tmax 36.8. D'c bair hugger.\n\nCv: Initially, pt is hypertensive w sbp 140s and map 100s->per team, wean EPI to .02. Titrate nitro ^3.25mcg/kg/min w effect. Pt had frequent multifocal PVC's from singular to couplets and run of multible vtach 3-4 beats to 12-14beats -?vs abbarent afib w perfusion compromised. Gave mag sulated-frequent k replete 3.2-4.5. Start on Amio gtt at 1mg/min per team. EKG done. Subsequently-bp became extreme labile to low sbp 70s, both NBP +art bp marginally correlated->gave 500ml fluid bolus w/o effect. Turn off nitro and start titrate on Levo. Weaned Milrinone .5/and propofol to 40 w marginal effect. Repeat Cxr to r/o pneumo. Gave 500ml Hespan per Dr in room w much improvement. Hct stabled. Filling pressure good. Svr 800s-1200s. Svo2 70s-80s-recal done in am. Co via thermo mid 3s-4/via fick -->both w ci >2. Placed pad to chest/posterior\n\nVasc: R groin remain swollen/ecchymotic/soft resolving hematoma. Left top plantar foot remain mottle-> Easily palpable pulses on both feet. Skin w+d\n\nLabs: Lactic acid and Lft's trending up slightly->Dr. ->closely monitor\n\nResp: Wean simv to .50/500x18/Peep 10 ->good gas, sl metab. acidosis w resp compensation. Ls coarses->sxn none. But sxn oral w cl bloody secretions. CXR x2.\n\nGi: NPO. Belly soft/distended. OGT to lcx w cl bloody drg->notify team about gi prophylactic meds.\nGu: UO trended down to 30-40cc/hr correlated during the low bp->improved after hespan given.\nEndo: Initial shift ->pt bs high required ^insulin gtt to 13units/hr ->weaned insulin to current .5unit/hr w BS 90s-100s.\nWound: Facial w scatter/diffuse petechias vs rash-no drg. Sternal remain bruises from previous cpr?. Back and bottom/both heels skin intact. R groin doc as aboved.\n\nAccess: R IJ Pa cco swan/introducer. Left sc cordis. Left radial art line. Left fem both venous and arterial sheath. Left had piv gave 20.\n\nSocial: Children visited->spoke to attending/team->status updated.Gave family routine icu info and reinforce on status/poc. Gave support\n\nA/P: Monitor ectopies and bp status. ?wean epi/milrinone/levo/amio.\nF/u cxr. Wean vent and sedation to assess for neuro status->closely monitor pupil->possible CT head today. ?\nMonitor vasc status -r groin site.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-26 00:00:00.000",
"description": "Report",
"row_id": 1267316,
"text": "Nursing Note update\nPsych: continues sedate at times although non medicated, at times appropriate discussing family at other times talking ragtime.\nanxious, continues to ask for water although she has been educated many times regarding her aspiration and also continues to ask what time she is going home today. Poor short term memory.\n\nGI: abd benign, bs present, no flatus noted. tolerating promote with fiber at 40 cc/ hour increased to goal rate of 50 cc hr.\n\nendo: fs bs covered with ssri per csru protocol.\n\ninteg/skin: covered in large areas of echymois and edema, r hip is the largest and most tender to groin. Chest is sore to palpation, appears to have bruising where compressions were done. LUE and LLE both with 2+ pitty edemam R side WNL no edema except already mentioned.\n\ngu: foley patent color darkening, concentrated yellow, becoming very cluody, turbid with sediment. pt c/o sensation of needing to void.\n\nlabs: K and mag replaced this am.\n\nactivity: oob to chair with max 2 assist, becomes dizzy, no change in vitals. more comfortable up and oob.\n\nPlease see carevue flowsheet for further details and values.\n"
}
] |
23,405 | 100,907 | 1. Cardiovascular: a. Ischemia. The patient did not have any episodes of ischemia on admission. She denied any chest pain at that time. It was felt that her congestive heart failure could be worsened by ischemia; therefore, the patient was referred for cardiac catheterization. She underwent cardiac catheterization on , that demonstrated severe three vessel disease. She had a LMCA with 30% proximal lesion. The left anterior descending was diffusely diseased proximally and totally occluded in the mid-segment, with filling via collaterals. The left circumflex had diffuse disease up to 70%. The right coronary artery had a calcified ostial 80% lesion. She had an saphenous vein graft to left anterior descending that was totally occluded proximally. She had a normal filling pressure with reduced cardiac output of 2.3. She had renal artery angiography with no renal artery stenosis. She underwent successful percutaneous transluminal coronary angioplasty and stenting of the mid-left anterior descending lesion with two stents. Following the patient's catheterization, she had a brief episode of hypotension requiring dopamine. She was then transferred to the Coronary Care Unit for further monitoring. On arrival to the Coronary Care Unit, she was found to be short of breath and hypertensive, with diffuse wheezes bilaterally. She had the dopamine discontinued, and a nitro drip was started. She was also noted to be in congestive heart failure at that time, and was diuresed aggressively. The patient had a Swan floated for help with management of her volume status. Then she was brought back to the catheterization laboratory on . At that time, intervention on the right coronary artery lesion was attempted. She had rotatherapy on the right coronary artery. She then underwent stenting with a final residual of 10%. The patient then attempted to have intervention on her left circumflex proximal R1 that had a 90% lesion. The lesion could not be crossed, and therefore was not treated. The patient then underwent adjustment of her medicines to optimize her medical management of her ischemia in light of her severe disease. | Pt weaned off dopa in am. Area around ecchymotic, dressing w/ elastoplast C/D/I.Heme: S/P 1uPRBC, Hct 32.6. LS exp wheezes through out with rales 1/2 up bilaterally. Mixed venous 63%.Dopplerable pulses bilaterally.Resp: Pt remains on nasal canula 2.0L 02. Post transfusion HCT 29.0. Heparin dc'd; coumadin started. DOPPLERABLE PULSES BILATERALLY.RESP: D/C'D COOL MIST MASK EARLY AM AND CHANGED TO 2.0L VIA NASAL CANULA. BP low 91-109/39-50 Pt on 650 u/hr heparin, PTT theraputic. 0430- pt having bil wheezes, RR 20's, spo2 93%, HR & BP stable/ pt treated with atrovent neb with good effect. SBP 78-120 One episode of hypotension (3hrs after captopril)resolved on own. R IJ in place with elasto plast dressing for bl oozing, may be d/c'd today. On Milrinone .750 6.1/4.69/ M Venous 70. Chest Xray yesterday revealed R pleural effusion.ID: Pt remains afebrile. BP tolerating Lopressor and Captopril doses. Last numbers CO 3.0 CI 2.31 SVR 1093 PVR 381. PA line site oozing & moderate hematoma present. CO/ CI/SVR 3.9/3.0/1415. UO decreased and patient was given 180 IVB of with some effect. TITRATE AND WEAN DOPAMINE AS TOLERATED. BP tolerating po meds. Assess pt for desaturation/ MD. CO/CI/SVR before Dopa 7.9/6.08/395 with M Venous of 74%. IMPRESSION: 1) Stable small to moderate right-sided pleural effusion since examination. Tolerating Lopressor and Captopril po meds. Distal pulses audible with DP. Remains on 5.0 mcg of Tolerating po Lopressor and Captopril doses. GIVEN FLUID BOLUS X1. Shortly after episode of resp distress, pt became hypotensive- Arterial SBP 60-80's and MAP 30-40's. HH 29/9.7 urine noted t/b bl tinged toward end of shift and MD aware, pt may need transfusion. IMPRESSION: CHF. Receiving nebs qid and with relief.ID afebrile WBC 8.1 MRSA/bloodGU- foley draining 10-20cc/hr responded poorly to 40mg po and 40mg IV . Wheeze auscultated with rales half way up bilaterally. PAP 46-61/19-29. IMPRESSION: CHF with pulmolnary edema and right pleural effusion. Receiving Zoloft in the am. RIJ -PA pressure 41-52/14-23 PCWP 22 CVP 11-18. Bun/ Cr slightly gradually decreasing to 21/1.2.Skin: RIJ pressure dressing removed. NBP 100-139/ 36-70. Pulses dopplerable bilaterally. Pulses dopplerable bilaterally. PT RATE WAS DECREASED TO 70-120 AND MODE REMAINED AT DDD. BUN/CR 27/1.0.ID: REMAINS AFEBRILE.ACCESS: SHEATH DISCONTINUED. CCU NPN 7A-7PCV: Remains on Dopamine gtt at 5ug/min, BP 88-90's/, CO 4.5, CI 3.4, SVR 853. GIVEN LASIX 160 MG IV WITH MINIMAL EFFECT ~100 CC X2. Follwing commands MAE.CV: HR 70 No ectopy noted. effusions by P.E. MD aware and will order 1uPRBC's to be transfused.Resp: LS exp wheeze with crackle auscultated in bases. PO temp 97.8-98.3. Again is seen a right-sided pleural effusion. +BS + flatus. Temp 96.8- 97.8 orally. PT ON 40% NEB- O2 SATS 98%, RESP RATE- 16- 20.CRACKLES ALL UP WITH PULM EDEMA- CURRENTLY AT BASES.ABG WNL- PH- 7.40 SEE FLOWSHEET.APPEARS COMFORTABLE.ID- AFEBRILE- MRSA (+) - CONTACT PRECAUTIONS.TO CLARIFY MRSA STATUS.GU- SEE ABOVE- UO- 110-160CC.VIA FOLEY CATH.GI- EMESIS ON ARRIVALCURRENTLY COMFORTABLE(+) BOWEL SOUNDS- SOFT ABD. Resolving nonpitting edema to BUE.Pulm: O2 1l NC. Renal consulted for elevated BUN/Cr 40/2.5.Id: Pt remains afebrile. Am K 4.2/Mag 2.0/ HH 32/10.3/ PLT 166/ NA 139. Cr decr to 1.4 (2.0).ID: afebrile. Await specimen results.GI: Abd softly distended with +BS. Denies pain.CV: Hr 70 V-paced. D/C NOW THAT PRESSORS ARE D/C'D. Hgb 8.1am #'s 3.9/3.0/752. CO/CI/SVR 3.5/2.69/1074. Po temp 97.6-98.1. Am bun/creat 28/1.0. Natrecor drip dc'd. There ismoderate mitral annular calcification. Continues on Atrovent QID, Salmeterol & Flovent regim. am #'s 5.2/4.0/692.Conts on , , plavix, lopressor and Captopril for 3VD. CO/CI/SVR 4.0/3.08/1160. Last Co/Ci/SVR 3.6/2.77/1289. CCU NPN 0700-1900Neuro: AO x3, Perrl 3.0mm, Mae weakly, + commands. BUN 42 Crea 2.0. baseline 1.2. Levofloxacin abx started for UTI. PO temp 97.2-98.1. -189cc since mn and +4562 LOS.BUN/Creat pending. NBP 87-117/28-48. NBP 87-111/32-48. 2+ nonpitting edema to BUE. BP 94-109/34-47. Pulses dopplerable. drip dc'd. HELD PM SENNA AND COLACE REGIMEN. WBC 8.6Skin: Stage 2 coccyx sore drsg . ECCHYMOTIC RIJ AND ARMS. D/c when dopamine off. Wbc 13Skin: Ecchymosis RIJ and Right antecube. Trace aortic regurgitation is seen. -474/24hrs and even for LOSID: Afebrile. Groin sites ecchymotic but CDI. Cr trending up ?secondary dye pt rec'd for cath.ID: afebrile. Hgb 9.4 CVP 13 PCWP 20. Changed d/t UTI. HCT 28.6. Check pm K+. Cont on current bowel regimen. HCT 32.0. PA numbers reflect current gtt's infusing pm#'s C.O./C.I./SVR 4.6/3.54/800. Extremities warm/pale.PAP's 45-46/15-19. Lungs clear upper lobes and crackles noted in bases.gi: Abd soft, non distended, +Bs. RF d/t contrast received in cath on and . BP 87-104/34-46. Am k level 2.9- total of 60meq kcl given. Ambien requested for insomnia.CV: HR 70. Wean dopamine gtt as tolerated. Await am PTT adjust hep gtt per ss. Takes alittle while to "wake up".CV-HR V paced 70, SBP 96-128 on dopamine 3mcg/kg. Hemodynamics done this am- CO/Index 3.7/2.8. NBP 94-102/38-50. Pt tol PO captopril and lopressor. + BM, + Flatus. PAP 37-47/7-13. Denies vertigo or pain.CV: HR 70 Vpaced. PT/PTT/INR 14.1/54.4/1.4. Soft formed BM x2, guiac (-). Currently on regimen of Dopamine 3.7 mcg/kg/min, Heparin 700u/hr, and Natrecor 0.010 mcg. Dopplerable pulses. Pt conts on regimen dopamine 7.5mcg/kg/min, heparin 700u/hr(am PTT pending), natrecor 0.01mcg/kg/min, and 30mg/hr. Stage 2 coccyx sore dressing CDI. CONTINUES ON LEVO FOR UTI. Cont pulm support. +Bs. + Bs. PCWP 25 CVP 6-11. Pt aiding with turning.Pt denies pain.CV: V paced HR 70. no acute resp distress.gi: Npo after MN for possible c. cath today. Am PCWP 18. Heparin drip remains @ 700u/hr. ARF likely secondary to dye pt rec'd for cath and .-974 since mn and +2753 LOS. Pt to rec 60meq KCL, first 20meq KCL infusing.PULM: LS with crackles bilbasilary. Teille dressing applied. AM K+ REPLETED. Old groin sites remain C,D & I. PAP 41-52/16-25RESP: 4.0 L via nasal cannula. SVR 1319. Clinical correlation issuggested.TRACING #1 R IJ swan in place. | 38 | [
{
"category": "Radiology",
"chartdate": "2182-09-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 768326,
"text": " 10:12 PM\n CHEST (PA & LAT) Clip # \n Reason: CAD,CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with h/o AS, CAD, transferred from outside hospital with\n CHF and bilat. effusions by P.E.\n REASON FOR THIS EXAMINATION:\n r/o PNA, effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n HISTORY: Coronary artery disease and CHF with shortness of breath. To evaluate\n for pneumonia.\n\n S/P CABG and AVR. Dual chamber left sided pacemaker with atrial and\n ventricular leads in situ. There is cardiomegaly and a right pleural effusion.\n No definite pneumonia allowing for obscuration of the right base by the\n effusion and no definite CHF/pulmonary edema.\n\n IMPRESSION: Right pleural effusion. S/P CABG and AVR. No previous films for\n comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 768572,
"text": " 10:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for CHF/ pulm edema/ ?pneumonia resolved\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with h/o CHF, CAD s/p CABG , AF, s/p cath today.\n REASON FOR THIS EXAMINATION:\n Eval for CHF/ pulm edema/ ?pneumonia resolved\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of CABG with atrial fibrillation and catheterization. To evaluate for\n pneumonia or pulmonary edema.\n\n S/P CABG. A left-sided dual chamber pacemaker is present with atrial and\n ventricular leads insitu unchanged in the patient since prior study. There is\n slight cardiomegaly with upper zone redistribution, interstitial pulmonary\n edema and a right pleural effusion. No pneumothorax.\n\n IMPRESSION: CHF with pulmolnary edema and right pleural effusion. The\n pulmonary edema is new since the prior study of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769261,
"text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusions, pneumonia, failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with h/o CHF, CAD s/p CABG , AF, known bilat effusions, s/p\n tap R pleural effusion, with worsening exam.\n REASON FOR THIS EXAMINATION:\n eval for effusions, pneumonia, failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P TAP on right pleural effusion with worsening ____ evaluate\n for pneumonia or failure.\n\n COMPARISON STUDY: \n\n CHEST SINGLE VIEW: Lines and tubes are in stable position. The\n cardiomediastinal silhouette is stable. There is a small to moderate sized\n right-sided pleural effusion which is not significantly changed since the \n examination. There is also associated atelectasis. There is a minimal left-\n sided pleural effusion or a small left-sided pleural effusion with\n atelectasis as well. Noted is a fracture of the second sternal wire which is\n unchanged. The patient is S/P valve replacement and CABG.\n\n IMPRESSION:\n\n 1) Stable small to moderate right-sided pleural effusion since \n examination. There is associated basilar atelectasis. A small left-sided\n pleural effusion is also identified with atelectasis.\n\n 2) Lines and tubes in stable position.\n\n 3) Fracture at second sternal wire.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 768991,
"text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with h/o CHF, CAD s/p CABG , AF, s/p cath now with\n increasing SOB.\n REASON FOR THIS EXAMINATION:\n eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with CHF and with increasing shortness of breath.\n\n The heart is enlarged. A pacemaker is again noted with RA and RV leads. The\n Swan-Ganz catheter is in the proximal left pulmonary artery. There is\n pulmonary venous cephalization, and there are bilateral pleural effusions.\n\n The patient has had an AVR.\n\n IMPRESSION: CHF.\n\n No change in the chest since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-16 00:00:00.000",
"description": "P CHEST (LAT DECUB ONLY) PORT",
"row_id": 769070,
"text": " 2:40 PM\n CHEST (LAT DECUB ONLY) PORT Clip # \n Reason: eval for layering of effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with b/l pleural effusions\n REASON FOR THIS EXAMINATION:\n eval for layering of effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 85 year old woman with bilateral effusions.\n\n BILATERAL DECUBITUS FILMS: In the right decubitus a layering effusion is seen\n on the right side. The left lung appears clear.\n\n On the left decubitus a layering effusion is seen in the left side and the\n right lung appears clear.\n\n IMPRESSION: Bilateral layering effusions. No underlying lung disease seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 768728,
"text": " 9:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P pa CATHETER PLACEMENT. eVALUATE POSITION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with h/o CHF, CAD s/p CABG , AF, s/p cath today.\n\n REASON FOR THIS EXAMINATION:\n S/P pa CATHETER PLACEMENT. eVALUATE POSITION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac history, s/p cardiac cath, with PA catheter placement.\n\n TECHNIQUE: Single portable AP view of the chest is compared with .\n\n FINDINGS: Unchanged are the left-sided dual chamber pacemaker and sternotomy\n wires, with a metallic aortic valve. There has been interval placement of a\n right IJ Swan-Ganz catheter, with the tip in the main pulmonary artery. There\n has been interval improvement of pulmonary edema. Again is seen a right-sided\n pleural effusion. The heart is enlarged. There is a small 3 mm nodular\n opacity at the left costophrenic angle. This was not seen on the prior study\n and may represent a nipple shadow.\n\n IMPRESSION: Tip of the Swan-Ganz catheter in the main pulmonary artery with\n improving congestive failure.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-14 00:00:00.000",
"description": "Report",
"row_id": 1568290,
"text": "7p-7a Nursing note:\nPlease see carevue for objective data: Pt s/p Rotal blade and stent to RCA, arrived to unit from cath lab 2200.\n\nNeuro: Pt A/Ox3. Follows and obeys all commands. Pt HOH, wears bil hearing aids. Ambien given for sleep with good effect. Daughter in law phoned last night, update given.\n\nPulm: Pt dev resp distress shortly after arriving to unit, Diff breathing/SOB/LS Crackles with exp wheezes/ RR20's/HR stable/ SBP 150-170's/ SPO2 92%. Pt treated with Albuterol and atrovent neb, 40mg IV , PO captopril and lopressor given all with good effect. Pt on 3L NC. 0430- pt having bil wheezes, RR 20's, spo2 93%, HR & BP stable/ pt treated with atrovent neb with good effect. MDI's at -Atrovent QID/ Advair .\n\nCV: Pt s/p cardiac cath/stent to RCA. L femoral arterial sheath D/C'd @ 0100 for ACT 138. Shortly after episode of resp distress, pt became hypotensive- Arterial SBP 60-80's and MAP 30-40's. MD , pt received 200cc IVF bolus and started on IV dopa and currently at 2mcg/kg/min. titrate off. R IJ in place with elasto plast dressing for bl oozing, may be d/c'd today. L groin with DSD and sm amt of oozing. Distal pulses audible with DP. AM numbers CO/index 4.5/3.4, SVR 1013/ CVP 14. Unable to wedge, MD aware. HH 29/9.7 urine noted t/b bl tinged toward end of shift and MD aware, pt may need transfusion. IVF- D51/2 @ 125ml/hr x1500ml. Integrilin at 2mcg/kg/min.\n\nGI/GU: Pt on cardiac diet. Abd soft, BS present. Foley draining bl tinged urine. Pt on po 40mg .\n\nPlan: Monitor hemodynamics and tirtrate dopa off.\n may be d/c'd today.\nMonitor for resp distress and use MDI's at \nPt may move L leg @ 0800-S/P cardiac cath\nD/C IV integrilin at 1600\nEKG this am\nUpdate pt and family on plan of care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-14 00:00:00.000",
"description": "Report",
"row_id": 1568291,
"text": "CCU Nursing Progress Note\nS-\" I'm so thirsty\", \"I need my inhalers\"\nO-Neuro alert and oriented x3. Pleasant and cooperative, taking long naps 1-3hrs at a time. Receiving Zoloft in the am. Having difficulty speaking for any length without getting SOB.\nCV-remains V paced at 70 with occ increase to 90 with minimal exertion, on lopressor 25mg . SBP 78-120 One episode of hypotension (3hrs after captopril)resolved on own. Hemodynamics still remain labile. PWP 25 with V waves up to 45, PAP 60/18-30 CVP 12-22. Captopril decreased back to 25mg TID, tolerated dose. However CO/CI/SVR 2.5/1.92/1248 at 1600 with mixed venous sat 49. Ho aware and plan to attempt to aggressivly diurese and then start milrinone or dobutamine to improve CO and then add natrecor if BP tolerates. CPK negative 30 post cath.\nResp- easily SOB up to 38 labored with minimal exertion. O2 sats remain stable on 3l np 92-97%. LS exp wheezes through out with rales 1/2 up bilaterally. Receiving nebs qid and with relief.\nID afebrile WBC 8.1 MRSA/blood\nGU- foley draining 10-20cc/hr responded poorly to 40mg po and 40mg IV . Received 80mg IVB at 1830. Presently 2liters +\nGI-appetite improved taking small amts of food with assist. Soft BM Pt face turning purple while on bedpan.\nSkin- Right IJ bleeding at suture site not IJ site. Gelfoam placed and no further bleeding noted. Coccyx and heels red. Turned and repositioned q3-4hrs.\nSocial-daughter in to visit, brought robe and slippers. Needs to have health care proxy filled out.\nA-Severe MR apparent with elevated V waves on wedge tracing.\nPoor CO/CI with elevated SVR. Respiratory failure with COPD wheezes increased.\nP- Follow hemodynamics closely q2hrs.Recheck CO/CI/SVR at .\nStart doubutamine or milrinone to improve CO/CI and decreased SVR.\nUse dopamine for hypotension. Monitor electrolytes recheck at .\nReplete . Offer emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-15 00:00:00.000",
"description": "Report",
"row_id": 1568292,
"text": "CCU Nursing Progress Note\n85 year old female with diastolic dysfunction with MR admitted from OSH for resp distress/CHF and episodes of flash pulmonary edema. Transferred to c/cath CAD and 3VD. Stented LAD X 2. Repeat cath last night roto blade and stent to RCA.\n\nS: \" I am so thirsty\"\n\nO: Neuro: A&O x3. Pleasant and cooperative. HOH. Hearing aids in both ears. Following commands. Fatigued easily with minimal exertion. Ambien given per patient's request with good effect.\n\nCV: VPaced. VVI pacemaker. HR 70-79. No ectopy noted. NBP range 86-137/25-53. Increased MAPS observed once Dopamine was initiated. PAP 45-61/17-28. PCWP 28 with V waves as high as 50. CVP teens. At Dopamine started and titrated to 5 mcg to maintain BP Milrinone then was started and titrated up to max of .750 mcg. CO/CI/SVR before Dopa 7.9/6.08/395 with M Venous of 74%. While on 5 mcq of Dopamine CO/CI/SVR 5.8/4.46/800 with M venous of 71%. On Milrinone .750 6.1/4.69/ M Venous 70. MD decided that perfusion was adequate enough while on the dopa alone. Titrated Milrinone and turned off by 0200am. Latest CI/CO/SVR taken after Milrinone was 4.0/3.08/1080 at 0600 with Mvenous of 60%. Remains on 5.0 mcg of Tolerating po Lopressor and Captopril doses. Both groin sites C, D & I. RIJ pressure dressing removed. No further ooze or bleeding noted since integrellin was d/c'd. HCT @ 2130 was 30.7. Repeat draw this am was 26.5. Electrolytes stable. No repletion necessary overnight. Attempted to diurese X 2 with poor effect. Pulses dopplerable bilaterally. Denies any chest pain or discomfort.\n\nResp: Increased NC to 4.0L. Patient desaturated to 88-92 overnight. RR 19-30. Increased SOB observed with exertion and bedpan use. Wheeze auscultated with rales half way up bilaterally. Given nebs Atrovent and Advair with some relief. Continues to produce yellow - white sputum tinged with scant amounts of blood.\n\nId: Pt remains afebrile. Temp 96.8- 97.8 orally. WBC elevated from 8.1- 12.7. Bld cultures + MRSA\n\nGI/GU: Experiencing gas discomfort. + BS. Bedpan x 1 light brown undigested food guiac negative. Held colace d/t liquid stool. Tolerating po meds, liquids and soft diet. Abdomen soft. Denies any tenderness. Foley catheter patent draining poor amounts of amber urine despite aggressive diuresis. Given 120 mg IVB @ 2300 and 180 mg IVB at 0600 with minimal results. Overnight UO ~ 250cc. + 200 cc/24hrs and remains 6L+/LOS. Bun/ Cr slightly gradually decreasing to 21/1.2.\n\nSkin: RIJ pressure dressing removed. Oozing/bleeding seized . transparent dressing applied. Coccyx and r heel reddened. Encouraged frequent position change.\n\nSocial: Need family to complete Health Care Proxy. calls or visitors overnight.\n\nA/P: Hemodynamically stable overnight. No episodes of hypotension. BP , MAPS and CO/CI improved while on Milrinone and Dopamine gtt. Tolerating cardiac meds. Increase doses as tolerated. Urine output remains poor despite aggressive IVB. need to begin Zoroxalyn/ regimen. Continue present co\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-15 00:00:00.000",
"description": "Report",
"row_id": 1568293,
"text": "CCU Nursing Progress Note\n(Continued)\narse of managment. Support patient and family with\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-15 00:00:00.000",
"description": "Report",
"row_id": 1568294,
"text": "CCU NPN 7A-7P\nCV: Remains on Dopamine gtt at 5ug/min, BP 88-90's/, CO 4.5, CI 3.4, SVR 853. HR 81 Vpaced, no ectopy. Repeat K+ was 4.1. Given 500mg diuril, followed by 180mg of IV, UO picked up to 100-120cc/hr. As of 5PM is ~even for the day. Will recheck K+ this eve. Denies CP, becomes dyspneic with exertion, ie turning side-side.\n\nNeuro: A&Ox3, cooperative, discouraged.\n\nResp: sating 97-99% on 4L NC. LS crackles at bases, exp wheezes.\n\nGI: BM today, loose brown, OB (-). HCT 27.2, appetite fair, taking in sm amts at meals.\n\nSkin: reddend heal and coccyx, no breakdown, turned side-side, on 1st step bed.\n\nSoc: daughter in this am, to return this eve.\n\nA/P: responding to diuril/. cont to follow #'s, CO/CI stable. plan was to cont dopa for renal perfusion, cont lopressor/captopril.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-16 00:00:00.000",
"description": "Report",
"row_id": 1568295,
"text": "CCU NURSING PROGRESS NOTE\n85 year old female with a history of diastolic dysfunction, CHF and valve disease admitted for respiratory distress/ CHF and episodes of flash pulmonary edema. Transferred to c/cath found 3VD. Stented LAD X 2. Repeat cath Friday night roto blade and stent to RCA.\n\nS: \" I am still so thirsty\"\n\nO: Neuro: A&OX3. Very pleasant and cooperative. Following commands. Fatigued easily with minimal exertion. Assists with turning. HOH. Hearing aids in both ears. Zoloft given with little effect. Ambien given per patient's request with good effect.\n\nCV: HR 70-82. V Paced. VVI. No ectopy noted. NBP range 88-115/32-44. PAP 47-56/20-25. CVP 18-21. Dopamine gtt remained on all day and night at renal dose of 3.0 mcg assisting in perfusion. CO/CI/SVR 4.6/3.54/626 with a Mixed Venous of 65%. Diuril started on days with outputs of 100cc. UO decreased and patient was given 180 IVB of with some effect. MD decided to start gtt once uo tapered again. Currently pt is receiving 15.0 mg/hr of IV . Tolerating Lopressor and Captopril po meds. Groin sites clean, dry and with some ecchymosis. Dressings removed and open to air. AM labs electrolytes stable. No repletion necessary overnight. Pulses dopplerable bilaterally. Pt denies and chest discomfort or pain. HCT 25. MD aware and will order 1uPRBC's to be transfused.\n\nResp: LS exp wheeze with crackle auscultated in bases. O2 sats 97% or greater on 4.0L of oxygen. RR 19-21. Pt continues to have episodes of dyspnea with exertion and/or position changes. Given Atrovent with some relief. Advair from home ran out. HO needs to order new nebs similar to her dose at home. Seems to be producing less sputum.\n\nGI/GU: Abdomen soft. Pt denies tenderness. Tolerating po meds and soft cardiac diet. Appetite is poor despite encouragement to eat.+ BS + flatus. No stool this shift. C/O gas pain. Pt claimed it passed but order was written for simethicone if needed. Held colace d/t report of liquid stools on day shift. Foley catheter patent draining amber to yellow urine. UO for 24 hours -90cc. Pt remains + 5 1/2 liters for LOS. BUN/ CR still increasing and currently values are 28/1.8.\n\nID: Pt remains afebrile. PO temp 97.8-98.3. WBC 12.3. Blood cultures + for MRSA.\n\nSkin: Reddened heels and coccyx. No breakdown noted at this time. Frequent position changes and encouragement to not remain supine through out the night/ Ecchymosis on neck d/t PA Line placement. No oozing or bleeding since Integrellin was d/c'd. Transparent dressing changed. Right arm phlebitic/ edematous. Raised on pillow with some improvement. ? need for ultrasound to r/o hematoma.\n\nSocial: Both children and their spouses were in to visit. Asking questions which were resolved by RN. Spoke to son regarding designation of Health Care Proxy. stated that his sister would need to sign appropriate documentation.\n\nA/P: Hemodynamically stable. Maps improving while on Dopa gtt- continue on for renal perfusion. No episodes of respitory distress or hypotensi\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-13 00:00:00.000",
"description": "Report",
"row_id": 1568289,
"text": "CCU NPN 7A-7P\nNeuro: A&Ox3, HOH, wears hearing aid in L ear. MAE, answering questions appropriately.\n\nCV: Tele-Vpaced @70 without ectopy. NBP 101-126/45-53. Captopril increased to 12.5 tid, tol well. RIJ -PA pressure 41-52/14-23 PCWP 22 CVP 11-18. Last numbers CO 3.0 CI 2.31 SVR 1093 PVR 381. PTT 33.1, bolus 1700u hep and hep gtt increased to 450u/hr. Recheck PTT @ 2130. Pt. down to cath lab @1630 for stent to 80% RCA lesion, waiting for return to unit.\n\nPulm: LS-fine crackles @ bases, diminished on R. Cont on 3L NC, SaO2 94-97%. Taking MDIs independently.\n\nGI/GU: +BS, abd. soft, non-tender. Tol cardiac diet, very loose/liquid BM x 2, guiac neg. Foley patent, draining cl yellow urine. Creatinine down from 1.5 yesterday to 1.0 today. 40mg started, only 55cc u/o 2 hrs after first dose. Extra 40mg po given with some effect. -1300cc today, +3.3L LOS.\n\nID: Afebrile, cont. on MRSA precautions for blood cultures at OSH.\n\nActivity: OOB, pivot to chair, up for several hours. PT consult ordered.\n\nSkin: Coccyx and heels sl pink, air matress placed on bed. Area around ecchymotic, dressing w/ elastoplast C/D/I.\n\nHeme: S/P 1uPRBC, Hct 32.6. Will need to recheck Hct tonight. No s/s bleeding.\n\nSocial: son called this AM, spoke with pt. No visitors today.\n\nPlan: Post-cath orders, monitor urine output. need additional for decreased u/o. Increase ACE for afterload reduction as tol for 3+MR. may be d/c in AM. PT consult, OOB as tol, guiac all stools. Emotional support for pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-20 00:00:00.000",
"description": "Report",
"row_id": 1568305,
"text": "CCU NPN 0700-1900\n\nS: \"Am I going to a new room today\"\n\nO: Pt very pleasant and appropriate. AO x3, mae weakly, assists with turning, OOB x 1 assist. c/o \"my butt hurt\" - requires requent repositioning. Hemodynamically stable. HR 70 v-paced. /introducer changed over wire to TLC. Heparin dc'd; coumadin started. NO IVF. 1+ BUE swelling slowly improving. O2 1L NC spo2 94-97%. Desats to 87% on RA. slightly sOB with exertion. Lungs clear upper lobes, scattered crackles in bases. Abd soft, non distended, + BS. tolerating cardiac healthly diet without difficulty, appetite improving. foley patent draining clear yellow urine.\n\nSocial: Daughter visited and updated on pt status/POC.\n\nPlan: C/o to floor. No beds available @ present (private room required for isolation). Transfer note completed. con't to monitor hemodynamics, resp status, uop.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-11 00:00:00.000",
"description": "Report",
"row_id": 1568285,
"text": "CCU Nursing Progress Note\nNeuro: Pt A&O x3 able to MAE and helps with turning. Pt slightly needy.\n\nCardiac: Pt has perminent pacemaker set on DDI HR 70, pacing well no ectopy. BP low 91-109/39-50 Pt on 650 u/hr heparin, PTT theraputic. Pt weaned off dopa in am. Pt needs EKG (post interrigation of pacer). Pt will go to cath on .\n\nResp: Pt on 3L via NC. BS decreased on R secondary to Pleural effusion, clear bilaterally.\n\nGI: Pt tolerating cardiac diet well, loose stool G-, I advise not to administer colace. NPO after MN due to cath tomorrow.\n\nGU: Poor! urine output via f/c. MD aware, BP stable, but 15 cc/hr of urine.\n\nID: afebrile.\n\nAccess PIV x2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-12 00:00:00.000",
"description": "Report",
"row_id": 1568286,
"text": "CCU Nursing Progress Note\n85 year old female s/p cath stent x2 to LAD. Repeat cath postponed until Monday for occlusion of RCA.\n\nS: \" My throat is so sore\"\n\nO: Neuro: A&Ox3. Pt cooperative and pleasant. Assisting with position changes. Follwing commands MAE.\n\nCV: HR 70 No ectopy noted. AV Paced DDD. NBP 100-139/ 36-70. RIJ swan placed last pm. PAP 46-61/19-29. CVP 14-27. CO/ CI/SVR 3.9/3.0/1415. PAP and CVP trending upwards post transfusion. All fluids d/c'd. BP tolerating Lopressor and Captopril doses. Next Lopressor dose decreased to 25mg. HCT 25.3 received 1u PRBC's over 4 hrs which was completed at 1000. Post transfusion HCT 29.0. Heparin was 650U but PTT results were 150. Heparin was held for an hour and decreased by 100 to 550u/hr as indicated per s/s. Repeat PTT and HCT send at 1430 and results are still pending. PA line site oozing & moderate hematoma present. Pressure dressing applied to site. Groin site C,D & I. K+ 3.4 repleted with 60meq PO. Mixed venous 63%.Dopplerable pulses bilaterally.\n\nResp: Pt remains on nasal canula 2.0L 02. Sats 95% or greater. Increased SOB following use of bedpan and with position changes.\nLS expiratory wheeses throughout requiring nebs with relief. Now clear diminished bases. RR 15-22. + Cough producing small amts of clear sputum. Chest Xray yesterday revealed R pleural effusion.\n\nID: Pt remains afebrile. WBC 7.3.\n\nGI/GU: Pt tolerating sips of water and soft cardiac diet. +BS + flatus. Moderate loose light brown stool X1 Guiac negative. Foley catheter patent voiding varying amts 15-30cc/hr of amber - yellow urine. HO aware of urine output. UA sent @ 1230. ? prerenal ?Early ATN. No muddy brown casts present in urine at this time. +1400 for 24hrs. BUN/Cr 30/1.5.\n\nSocial: Son called informed of pt's status and postponement of cath today.\n\nA/P: Intervention to LCX postponed until Monday. Goal to have pt be hemodynamically stable, and BUN/Cr back to WNL before contrast is reintroduced to kidneys. BP tolerating po meds. Plan is to decrease Betablockers and increase ace inhibitors as tolerated. Assess pt for desaturation/ MD. . MOnitor for further CHF. Also monitor hematoma/bleeding at RIJ site. Offer support to pt and family.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-10 00:00:00.000",
"description": "Report",
"row_id": 1568282,
"text": "CCU NSG ADMIT/PROGRESS NOTE 9:30P- 7A/ S/P STENT LAD\n\nS- \" I CAN'T BREATHE!!!\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\nREFER TO CCU FHPA/CCU TEAM ADMIT NOTE FOR DETAILS R/T HPI/PMH.\n\n85 YR OLD PT ADMITTED TO CCU FROM 3 VIA CATH LAB FOR CLOSER MONITORING.\nIN CATH LAB- LAD MID - STENTED X 2\n RCA 80% OCCLUDED- PLAN TO GO BACK TO CATH LAB FOR INTERVENTION WED/THURS ( D/T DYR LOAD)\n LCX- 70% OCCLUSION- NO TX\n (-) RENAL ARTERY STENOSIS.\n\n PT STARTED ON DOPA GTT 5 MCG FOR BP- 80-90/ THEN TITRATED BACK TO RENAL RANGE AND INTEGRILLEN STARTED. PT CHEST PAIN FREE AND ADMITTED TO CCU 9:30 PM ON INTEGRILLEN 1 MCG/KG AND DOPA 2.5 MCG/KG AS WELL AS IVF. GROIN SITE CLEAN/PULSES ALL PRESENT; PT ALERT AND ORIENTED ON ARRIVAL. PT DEVELOPED NAUSEA/EMESIS ON ARRIVAL S/P PLAVIX DOSE IN CATH LAB- TREATED WITH PHENERGAN 25 MG.\nEVENT- SHORTLY AFTER VOMITING, PT DEVELOPED HTN/PULM EDEMA/DESATURATION TO HIGH 80 ON NP.\nTREATMENT-\nD/C DOPA AND STARTED IV TNG- DIALED UP TO 10MCG/KG, GIVEN TOTAL 3 MG IV MSO4 OVER 30 MINUTES, LASIX 40 MG, FOLLOWED BY 80 MG IVP AS WELL AS INCREASING O2 TO 100% NR.\nPT APPEARING VERY DISTRESSED/AGITATED- REQUIRING RESTRAINTS FOR SAFETY.\nONCE MEDS TAKEN EFFECT- BP DOWN TO 140/- 120/ AND PT APPEARING MORE CALM WITH BETTER OXYGENATION.\nEVENTUALLY D/C TNG FOR BP 90'S/\nFAIR TO GOOD RESPONSE TO LASIX AND REPEATED LASIX- 160 MG-\nI/O EVEN AS OF 12AM AND (-) 600CC AS OF 5 AM.\n\n PT CURRENTLY WITH BP- 101/48- 112/54; HR- 86-90 AV PACED.\nNO VEA.\nK- 3.2- RECEIVED 80 KCL IV.\nRT GROIN SITE CLEAN/NO OOZE- PULSES ALL (+).\nINTEGRILLEN AT 1 MCG/KG; HEPARIN STARTED AT 400U NO BOLUS(KEEPING SHEATHS IN); IVF AT 50/HOUR.\nTNG ON STANDBY.\n\n PT ON 40% NEB- O2 SATS 98%, RESP RATE- 16- 20.\nCRACKLES ALL UP WITH PULM EDEMA- CURRENTLY AT BASES.\nABG WNL- PH- 7.40 SEE FLOWSHEET.\nAPPEARS COMFORTABLE.\n\nID- AFEBRILE- MRSA (+) - CONTACT PRECAUTIONS.\nTO CLARIFY MRSA STATUS.\n\nGU- SEE ABOVE- UO- 110-160CC.\nVIA FOLEY CATH.\n\nGI- EMESIS ON ARRIVAL\nCURRENTLY COMFORTABLE\n(+) BOWEL SOUNDS- SOFT ABD.\n\n PT AGITATED WITH RESP DISTRESS- NOW SLEEPING AND ORIENTED X 3.\nCOMFORTABLE CURRENTLY.\nNO FAMILY CALLS.\n\nA/ PT ADMITTED TO CCU FOR STENT LAD/ R/O MI- C/B FLASH PULM EDEMA ON ARRIVAL\n\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS- KEEP BP WNL TO PREVENT FLASHING- MAXIMIZE CV MEDS TO CONTROL RPP.\nDIURESIS AS NEEDED- FOLLOW RESP STATUS/UO CLOSELY- AM CXR.\nKEEP HEPARING AT THERAPEUTIC CHECK PTT 5:30 AM WITH CYCLE CPK.\nR/O FOR MI,\nKEEP PT SAFE/AWARE OF PLAN OF CARE.\nC/O BACK TO FLOOR ONCE ISCHEMIA/FLUID STATUS/PULM EDEMA ISSUES RESOLVED .\nPLAN FOR RETURN TO CATH LAB WED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-10 00:00:00.000",
"description": "Report",
"row_id": 1568283,
"text": "CCU NURSING PROGRESS NOTE\n85 YR OLD FEMALE W/ HX OF DIASTOLIC DYSFUNCTION- CHF ADMITTED ON A COUPLE OCCASSIONS TO OSH MOST RECENT ADMISSION PT FLASHED WITH PULMONARY EDEMA & BC WAS + FOR MRSA. TX WITH ANTIBIOTICS AND TRANSFERRED TO FOR CATH/CARDIAC EVAL. CATH FOUND CAD 3VD. 2 STENTS PLACED TO LAD.\n\nS: \" I AM SO THIRSTY\"\nO: NEURO: A&O X3. PLEASANT AND COOPERATIVE. PT C/O POSITIONAL BACK PAIN BUT RELIEVED ONCE ABLE TO CHANGE POSITION.\n\nCV: AV PACED. DDD PACEMAKER. HR 70S -100S. HEPARIN AND SHEATHS D/C'D AT 1200. PRESSURE DSG INTACT. NO OOZING OBSERVED. RESUMED HEPARIN AT 400U/ HR. D/C'D INTEGRELLIN AT 1800. PER HO REPRESENTATIVE FROM PACEMAKER MANUFACTURER IN TO DECREASE RATE AND MODE TO DD1. AT THAT TIME PT 30 PT DROP IN BP. PT RATE WAS DECREASED TO 70-120 AND MODE REMAINED AT DDD. PT BP REMAINED IN THE 80S-90S. MAP REMAINS IN 50S. HO AWARE. HELD AFTERNOON LOPRESSOR. GIVEN 6.25 MG DOSE OF CAPTOPRIL AT 1730. PT BP DROPPED TO 60S. STARTED ON DOPAMINE GTT 5.0MCG UP TO 7.5MCG. GIVEN FLUID BOLUS X1. CURRENT BP 122/24. GIVEN 160MG OF LASIX WITH MINIMAL EFFECT. DENIES ANY CHEST PAIN OR LIGHTHEADNESS. DOPPLERABLE PULSES BILATERALLY.\n\nRESP: D/C'D COOL MIST MASK EARLY AM AND CHANGED TO 2.0L VIA NASAL CANULA. O2 SATS 94% OR BETTER. RR 20S. LUNG SOUNDS CLEAR WITH SOME WHEEZES HEARD. GIVEN INHALERS AND IMPROVED LUNG EXCHANGE HEARD UPON AUSCULTATION. NO CRACKLES. DENIES ANY SOB.\n\nGI/GU: PT TOLERATING PO MEDS AND SOFT CARDIAC DIET. +BS. + FLATUS. NO BM SINCE YESTERDAY. FOLEY CATHETER DRAINING SM AMOUNTS OF YELLOW URINE. GIVEN LASIX 160 MG IV WITH MINIMAL EFFECT ~100 CC X2. BUN/CR 27/1.0.\n\nID: REMAINS AFEBRILE.\n\nACCESS: SHEATH DISCONTINUED. 2 PERIPHERAL IV'S REMAIN\n\nSOCIAL: NO VISITORS TODAY.\n\nA/P: D/C'D SHEATH. MOST OF DAY STABLE. ATTEMPT TO CHANGE PACEMAKER TO DD1 CAUSED DROP IN BP. RESUMED DDD AND PT IMPROVED BUT MAPS REMAINED IN 50S. NOT TOLERATING LOPRESSOR OR CAPTOPRIL DOSES. BP DROPPED 30 PTS AFTER ADMINISTRATION OF CAPTOPRIL. NEED DOPAMINE AND FLUID RESUSCITATION. CONTINUE BP MONITOR AND RESCUSCITATE AS NEEDED. TITRATE AND WEAN DOPAMINE AS TOLERATED. RESUME CARDIAC MEDS AND INCREASE AS TOLERATED. CONTINUE GENTLE DIURESIS. PROVIDE SUPPORT FOR PT AND FAMILY\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-12 00:00:00.000",
"description": "Report",
"row_id": 1568287,
"text": "CCUNursing Progress note--CCU Team\n3p-7p\n\nResp- 2l NP, lungs clear throughout, inhalers given, resting comfortably. O2 sat 95-96%\nCV- BP 126-134/58-64, map 75-85; PA line 55-58/22-25. EP came to change mode of pacemenaker to V demand-is now in VVI Mode.\nNeuro- Mental Status- alert, very pleasant, able to sleep for 1-2 hrs this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-13 00:00:00.000",
"description": "Report",
"row_id": 1568288,
"text": "7p-7a Nursing Note\nPlease see carevue for objective data:\n\nNeuro: Pt A/Ox3. Obeys and follows all commands. Pt freq c/o of sore throat, po fluids given. MAE. Ambien given at night for sleep per pt.'s request with good effect.Daughter in last night to visit.\n\nResp: Pt maintained on 2L NC. LS clear. SOB noted at rest, using bedside inhalers. Pt mouth breaths during sleep, SPO2 86-88%. O2 increased to 4L NC with good effect. SPO2 increases when pt awake.\n\nCV: Tele: V paced 70. R IJ swan in place. PAP-40-50's/14-24. CVP 10-20. NBP 100's/50's. Pt tol PO captopril and lopressor. Hemodynamics done this am- CO/Index 3.7/2.8. SVR 1319. CVP 14. PCWP 15. Am K 4.2/Mag 2.0/ HH 32/10.3/ PLT 166/ NA 139. Pt on Heparin gtt at 400units/hr. PTT level drawn with results received at 0130 of 150. Per protocol, heparin gtt shut off x1hr. Heparin gtt restarted at 0230 at 300units/hr. See heparin protocol for further details. Next PTT t/b drawn 0730. No c/o chest pain. Pt scheduled for cardiac cath on Mon.\n\nGI/GU: Foley in place with urine o/p < 30cc/hr. Md made aware and pt received 80mg IV @ 0100 with good effect. LOS +4L/ 24H -600's. Am bun/creat 28/1.0. Pt on cardiac diet.\n\nPlan:\nMOnitor VS and hemodynamics\nMOnitor Pulm status\nNext PTT 0730\nPt scheduled for cardiac cath on mon\nUpdate pt and family on plan of care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-19 00:00:00.000",
"description": "Report",
"row_id": 1568303,
"text": "CCU NPN 0700-1900\n\nS: \"I feel much better. My bottom hurts.\"\n\nO: Neuro: neurologically , ao x 3, speech clear, pleasant and appropriate, MAE weakly, OOB x 1.5hrs with light assist. Denies pain except noted above.\n\nCv: Hr 70 V-paced, no ectopy. SBP 90s-110s. Slow wean of dopamine con't(currently @ 3 mcg/kg/min), keeping MAP > 60. 1 unit rbc transfused for HCT 27 (repeat 32). Natrecor drip dc'd. CO/CI/SVR 4.0/3.08/1160. CVP 6-9. Am PCWP 18. PAD 11-18. Heparin drip remains @ 700u/hr. Resolving nonpitting edema to BUE.\n\nPulm: O2 1l NC. spo2 91-97%. Unable to wean o2 spo2 87% on RA. Lungs clear in upper lobes and scattered crackles in bases. con't with inhalers as ordered.\n\ngi: Abd soft, non distended. +Bs. Soft formed BM x2, guiac (-). tolerating Cardiac diet without difficulty, fair appetite.\n\nGu: foley patent, draining clear, yellow urine. Bumex 4mg po x 1 along with zaroxalyn 5 mg . Net I/O -1500 for 24hrs. Cr decr to 1.4 (2.0).\n\nID: afebrile. Tmax 98.9. Con't levo for UTI. WBC 8.6\n\nSkin: Stage 2 coccyx sore drsg . C/ pain requiring frequent q1.5-2 turning/repositioning. Heels pink but improving with use of sheep wool.\n\nSocial: Daughter visited and updated on pt status/POC. Pt clearly perked up with visit. Encouraged more family to visit.\n\nPlan: Con't slow wean of dopamine. Monitor hemodynamics/ electrolytes/ UOP. Weigh pt daily per renal team. ?hold further diuesis until am ( pt already - 1500 for 24hrs.). D/c when dopamine off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-20 00:00:00.000",
"description": "Report",
"row_id": 1568304,
"text": "CCU NURSING PROGRESS NOTE\nS: \"I AM FEELING MUCH BETTER\"\n\nO: NEURO: A&OX3. VERY PLEASANT AND COOPERATIVE. ASSISTING WITH OWN CARE.\n\nCV: HEMODYNAMICALLY STABLE. HR 70 VPACED. NBP 87-117/28-48. PAP 37-47/7-13. CVP 8-13. DOPAMINE GTT WAS WEANED AND TURNED OFF AT 2200. PT MAINTAINED MAPS OF 60 OR GREATER OVERNIGHT EXCEPT WHEN IN A DEEP SLEEP STILL HAVING GOOD UO DESPITE OCCASSIONAL DROPS IN MAPS. CO/CI/SVR 5.1/3.92/675 AFTER BEING OFF DOPA FOR 3HRS. HCT 28.6. PT/PTT/INR 14.1/54.4/1.4. AM K+ REPLETED. GROIN SITES WNL. NO ACTIVE BLEEDING.\n\nRESP: REMAINS ON 1.0L VIA NC. O2 SATS 93% OR GREATER. DIDN'T TOLERATE ROOM AIR ALONE. DESATS TO 88%. LUNG SOUNDS CLEAR WITH CRACKLES AUSCULTATED IN BASES. RR 16-25 REMAINS ON INHALERS QID/. NO C/O SOB\n\nGI/GU: ABD SOFT +BS. + SOFT BROWN GUIAC - STOOL X2. HELD PM SENNA AND COLACE REGIMEN. FOLEY CATHETER PATENT DRAINING LG AMTS OF LIGHT YELLOW CLEAR URINE. -690 FOR 24HRS/ -3100 FOR LOS BUN/CR 36/1.5\n\nID: AFEBRILE OVERNIGHT. CONTINUES ON LEVO FOR UTI. WBC STILL TRENDING DOWNWARD TO 7.5\n\nSKIN: REDDENED HEELS IMPROVING WITH SHEEP WOOL USE. ECCHYMOTIC RIJ AND ARMS. STAGE 2 COCCYX SORE. TEILEY DRESSING REMAINS IN PLACE. PT C/O BUTTOCKS PAIN. ENCOURAGING FREQUENT POSITION CHANGE.\n\nA/P: PT SUCCESSFULLY WEANED OF DOPA AND BP TOLERATING WEAN. MAP GOAL OF 6O REMAINS. D/C NOW THAT PRESSORS ARE D/C'D. DISCONTINUE DIURETIC USE SINCE PT IS -3000 FOR LOS. PT TO ASSIST WITH AMBULATION.CONTINUE TO SUPPORT PT AND FAMILY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-11 00:00:00.000",
"description": "Report",
"row_id": 1568284,
"text": "Ccu NPN 1900-0700\n\n85yr old s/p c. cath, stent x2 to LAD. Plan for repeat c. cath today with tx to 805 occluded RCA.\n\nNeuro: Sleeping intermittantly, pt easily arousable, oriented x 3. speech clear, Perrl. MAE with equal but weak strength, + commands. denies pain or cp.\n\nCv: Hr 45-70s Av paced. Occasional ectopy. BP labile, requiring 1.5-10mcgs/kg/min of dopamine (See Carevue) and a total 1250cc nss bolus to keep sbp > 80. R groin C&D, pressure drsg . All PT/DP pulses dopplerable. IVf NSS @ 75cc/hr. Heparin @ 550u/hr (coags pending).\n\nPulm: O2 3L Nc spo2 > 95%. Lungs exp wheezes prior to puffers then clear in upper lobes; diminished in lower lobes. no acute resp distress.\n\ngi: Npo after MN for possible c. cath today. Abd soft, non distended. + Bs. +flatus.\n\ngu: foley patent, UOP 10-25cc/hr - multiple fluid bolus for decreased uop.\n\nSkin: skin grossly , no breakdown on back or buttocks. turn q2-3hrs.\n\nIV access: L FA/wrist PIV x2. Need for TLC expressed to ccu team if pt continues on dopamine; TLC deferred at this time.\n\nsocial: multiple family members visited and updated last pm. family very supportive.\n\nPlan: EP see pt to increase pacer rate. c. cath for tx of RCA. continue to monitor hemodynamics, and uop. monitor resp status. Provide emotional support and reassurance to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-17 00:00:00.000",
"description": "Report",
"row_id": 1568298,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Alert and oriented x 3. Very pleasant and cooperative with nursing interventions. Pt very HOH, hearing aides at table. Moving all extremitites spontaneously. Pt aiding with turning.\nPt denies pain.\n\nCV: V paced HR 70. BP 87-104/34-46. Conts on Dopamine gtt @ 4.5mcg/kg/min(7.5), Natrecor 0.01mcg/kg/min, 30mg/hr, and hep gtt 700u/hr(hung at 11pm)for Afib. PTT 70.5 no change in gtt per hep ss. No signs of bleeding noted. R &L groin sites . Palpable pulses. Extremities warm/pale.\n\nPAP's 45-46/15-19. CVP 15. PA numbers reflect current gtt's infusing pm#'s C.O./C.I./SVR 4.6/3.54/800. am #'s 5.2/4.0/692.\n\nConts on , , plavix, lopressor and Captopril for 3VD. Captopril and lopressor po held due to low BP per parameters.\n\nPm HCT 29.1/am HCT 27.0. PRBC's placed on hold overnight secondary to fluid status. Team to readdress transfusing pt this am.\n\nPULM: 3L NC Sats 95-98%. LS with crackles bibasilary. Pt denies SOB/dyspnea. Pt tolerating HOB at 15 degrees. Breathing appears even and unlabored. Due to pt's prescription advair not formulary pt started on salmeterol and flovent MDI's for COPD. No cough noted. RR 14-24. Thoracentesis site-bandaide with old bloody drainage. Await specimen results.\n\nGI: Abd softly distended with +BS. Pt denies ABD pain. Taking po fluids overnight. Swallowing pills w/o difficulty. Denies n/v. Cont on current bowel regimen. LBM Sunday 9/15 per report.\n\nGU: Foley cath patent draining clear yellow urine 50-100cc/hr on current IV regimen. -189cc since mn and +4562 LOS.\nBUN/Creat pending. Cr trending up ?secondary dye pt rec'd for cath.\n\nID: afebrile. WBC 14.1(12.0). Diff added on to am labs, MRSA bact at OSH. No temp spikes.\n\nSKIN: Coccyx red/unborken, cream appiled pt repositioned. Heels red/cream appiled and heels elevated off bed. ?ordering sheep skin.\nR tricep with hematoma/ecchymotic. L arm swollen/ecchymotic, ?secondary to BP cuff. Pt with total body edema.\n\nLINES: RIJ PA line, site clean. Area around site ecchymotic. Pt denies Pain at site, no oozing noted. Area cleansed and dsg reappiled.\n\nPROPH: hep gtt\n\nSOCIAL: No phone calls this shift.\n\nDISPO: Full Code\n\nA: 85 y/o with 3VD, hx of COPD, CABG with diastolic dysfunction ef 40-45%, severe MR/TR, V paced whom is being treated for CHF(recent episodes of pulm edema) on dopa, natrecor, gtts in attempt to optimize diuresis.\n\nP: Provide support. Wean dopamine gtt as tolerated. Goal fluid status is negative. Cont pulm support. Follow temp curves. ?transfusion for HCT. Lytes pending, replete as indicated. Encourage po's. Skin care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-17 00:00:00.000",
"description": "Report",
"row_id": 1568299,
"text": "CCU Nursing Progress Note\n85 year old female s/p cath with CAD & 3VD. LAD stented X2. Flashed pulmonary edema post cath. Recathed RCA 80% occluded and stented. Decreased renal function and rising serum creatinine.\n\nS: \"I feel a little better\"\n\nO: Neuro: A&O x3. Pt very pleasant and cooperative. Assisting with turning in bed. OOB to chair X 1 today (for the first time this hospitalization) tolerated well with the assistance of 2. Denies vertigo or pain.\n\nCV: HR 70 Vpaced. No ectopy noted. NBP 87-111/32-48. At 1100 pt experienced an episode of unexplained hypotension 78/36. Unable to resolve for 10 minutes increased Dopa gtt to 6.0 mcg. MAPS were still below 60 resulting in another increase of Dopamine gtt to 7.5mcg ( where it still remains). All other drips remain unchanged this shift and are currently set at 30mg/hr, Natrecor 0.010 mcg and Heparin 700U. AM PTT 70.5 therapeutic and requiring no adjustment per s/s. No active bleeding noted. HCT 27.0 this am (29 posttransfusion yesterday). Dopplerable pulses. Tolerating Lopressor 25 mg. Continues on , Plavix, Amiodarone and Atorvastatin regimen. Old groin sites remain C,D & I. PAP 41-52/16-25\n\nRESP: 4.0 L via nasal cannula. O2 sat 94% or greater. RR 20s. No episodes of resp distress. Air exchange improved with rales auscultated in the bases. Continues on Atrovent QID, Salmeterol & Flovent regim. Denies any SOB.\n\nGI/GU: Pt tolerating po meds and cardiac diet. Appetite seems to be improving. Abdomen soft + BS, +flatus but no bowel movement since Sunday. Continued bowel regimen of colace and senna.\nFoley catheter patent draining 80cc+/hr. - 664cc/ 24hrs and +4 L for LOS. Renal consulted for elevated BUN/Cr 40/2.5.\n\nId: Pt remains afebrile. PO temp 97.2-98.1. WBC 14.1 without explanation. No temp spikes. Urine specimen sent. + bacteria plan to change foley and start Vanco renal dose per renal consult.\n\nSkin: Heels reddened placed on bed today. Upper body edema remains. Left arm particularly ecchymotic and edematous. Arms elevated with minimal relief. Coccyx sore reddened and slightly broken down. Teille dressing applied. Pt states some relief felt.\n\n\n\nA: CHF/ COPD with CAD AND 3VD MR& TR with EF of 40% s/p cath to LAD and RCA on separate occassions. Compromised renal function decreased UO and increased Creatinine d/t contrast insult/ Captopril. Pt continues on aggressive diuresis remaining on Dopa, Natrecor and gtt improving MAPs and renal perfusion. Urine output 80 cc or greater this shift. Renal consult completed. Tolerating OOB activity.\n\nP: Continue current regimen to optimize renal perfusion as tolerated. Wean dopa gtt as tolerated as long as MAPs are greater than 65. Support patient and family as needed. Check hemodynamics and follow CO q shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-16 00:00:00.000",
"description": "Report",
"row_id": 1568296,
"text": "CCU NURSING PROGRESS NOTE\n(Continued)\non. Tolerating po cardiac meds. Urine output still not at desired goal despite IVB and start of gtt. Will need to continue aggressive diuresis especially if transfused blood in prevention of patient flashing and exhibiting s/s of pulmonary edema/ CHF that has occurred in the past.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-18 00:00:00.000",
"description": "Report",
"row_id": 1568300,
"text": "CCU Nursing Progress Note 7p-7a:\n\nNeuro: Alert and oriented x 3. Pt moving all extremities spontaneously. Aidng with turning. Pt requested ambiem 5mg po for insomnia.\n\nCV: V paced HR 70. BP 94-109/34-47. Pt conts on regimen dopamine 7.5mcg/kg/min, heparin 700u/hr(am PTT pending), natrecor 0.01mcg/kg/min, and 30mg/hr. No change in gtt rates overnight.\nHCT 28.3(27.0)\n\npm #'s C.O/C.I/SVR 5.0/3.85/752. Hgb 8.1\nam #'s 3.9/3.0/752. Hgb 9.4 CVP 13 PCWP 20. PAD's 27-30.\n\nGroin sites ecchymotic. Weak palpable pulses.\nK+2.9 on am labs. Pt to rec 60meq KCL, first 20meq KCL infusing.\n\nPULM: LS with crackles bilbasilary. Sats >95% on 3L NC. Pt denies SOB. Tolerating HOB 15 degrees. RR teens to 20.\nPt with total body edema.\n\nGI: Abd soft +BS. Pt taking water overnight. Denies n/v.\nNo stool this shift. Pt conts on bowel regimen.\n\nGU: Foley cath changed per Renal rec due to bacteria on UA spec. BUN 42 Crea 2.0. baseline 1.2. ARF likely secondary to dye pt rec'd for cath and .\n-974 since mn and +2753 LOS. u/o >100cc/hr.\n\nSKIN: Coccyx dsg c/d/i (stage 2). Heels red, placed on sheep skin. Upper extremities swollen and ecchymotic.\n\nID: Afebrile. WBC 13.5(14.1). Pt tx for MRSA bact at OSH. No recent temp spikes. +WBC in urine. No treatment at this time.\n\nLINES: RIJ pa line site ecchymotic, dsg C/D/I.\n\nPROPH: hep gtt.\n\nSOCIAL: son visited.\n\nDISPO: Full Code.\n\nA: Improving pulm status with aggressive diuresis on current IV regimen. Increase Hgb 9.4(8.1). C.O. trending down.\n\nP: Cont current cardiac regimen. Follow HCT. Await am PTT adjust hep gtt per ss. Follow numbers. Wean oxygen as tolerated. OOB to chair. Check pm K+. Provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-18 00:00:00.000",
"description": "Report",
"row_id": 1568301,
"text": "CCU NPN 0700-1900\n\nNeuro: AO x3, Perrl 3.0mm, Mae weakly, + commands. OOB x 2.5 hrs today, tol well. Denies pain.\n\nCV: Hr 70 V-paced. No ectopy. BP 92-115/38-51. Dopamine weaned to keep Map > 60 (currently @ 4.5mcg/kg/min). Natrecor and heparin infusions unchanged. Hct 28. Epogen 3x week started. Last Co/Ci/SVR 3.6/2.77/1289. Pcwp 16 Cvp 6-9. PAD 11-23. Palpable peripheral pulses. 2+ nonpitting edema to BUE. Am k level 2.9- total of 60meq kcl given. Repeat k level 3.7 - 40meq Kcl ivpb x 1.\n\nPulm: O2 weaned to 1L NC spo2 > 95%. Lungs clear upper lobes and crackles noted in bases.\n\ngi: Abd soft, non distended, +Bs. Soft BM x 3, guiac (-). Tolerating Cardiac diet without difficulty. Appetite fair.\n\nGu; foley patent, draining lt yellow urine with sediment. Levofloxacin abx started for UTI. drip dc'd. Zaroxalyn 5mg po bid started, and bumex 4mg po x 1 given. Good duiretic effect, currently -2300. Started discussion of need for dialysis in future. Pt clearly upset, emotional support given to pt. Further discussion/education needed when family present.\n\nId: Tmax 98.1. On levo abx.\n\nSocial: No family contact today. Emotional support given to pt.\n\nPlan: Continue slow wean of Dopamine. Monitor numbers (goal Ci > 2.0). Monitor electrolytes. Update pt/family on pt status and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-19 00:00:00.000",
"description": "Report",
"row_id": 1568302,
"text": "CCU Nursing Progress Note 11p-7am\n85 year old with hx of diastolic dysfunction, MR & TR s/p cath with CAD & 3VD. LAD stented X2. Flashed pulmonary edema postcath in CCU. Recathed RCA 80% occluded and stented. ARF d/t constrast insult and hypotension.\n\nS: \" I feel a little better\"\n\nO: Neuro: A&OX3. Cooperative and assisting with turning. Turning side to side independently. HOH. Uses hearing aids both ears. Ambien requested for insomnia.\n\nCV: HR 70. VPaced. NBP 94-102/38-50. PAP 43-48/9-15. PCWP 25 CVP 6-11. CO/CI/SVR 3.5/2.69/1074. Currently on regimen of Dopamine 3.7 mcg/kg/min, Heparin 700u/hr, and Natrecor 0.010 mcg. No adjustments needed overnight. HCT 32.0. K+ 3.6. Repleted with 40 meq IV. Repeat labs pending. Groin sites ecchymotic but CDI. Pulses dopplerable. No c/o chest pain or discomfort\n\nResp: Remains on 1.0L of 02 via nasal canula. RR 21-29. O2 sats 91-97. (Lower O2 sat occuring while pt is sleeping). Lung sounds clear upper airway crackles auscultated in bases.\n\nGI/GU: Tolerating cardiac diet. Abd soft. No tenderness noted. + BM, + Flatus. -BM this shift. Held Senecot & Colace regimen at d/t three loose stools. Foley catheter patent. Changed d/t UTI. Draining 100CC or light yellow urine since given Zoroxalyn and Bumex last shift. BUN/CR 40/1.6 (creat slightly improved). RF d/t contrast received in cath on and . -474/24hrs and even for LOS\n\nID: Afebrile. Po temp 97.6-98.1. + UTI. Wbc 13\n\nSkin: Ecchymosis RIJ and Right antecube. Upper body edema improving with diuresis. Heels pink but improving with use of sheep wool. Stage 2 coccyx sore dressing CDI. Frequent position changes q 2-3 hrs.\n\nSocial: No visitors or calls this shift\n\nA/P: Renal consult in to discuss possibility for dialysis in future. Pt clearly upset with prognosis. No changes this shift on current drips. Pt aggressively diuresed and finally even for LOS. Encourage pt to keep off of bottom to decrease discomfort. Continue current regimen of Dopa/ Natrecor to improve perfusion of kidneys. Continue Heparin and follow S/S as indicated. Maintain hemodynamics and wean Dopa maintaining a MAP >60 and CO>2.0. Follow electrolytes and replete as necessary. D/C today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-09-16 00:00:00.000",
"description": "Report",
"row_id": 1568297,
"text": "CCU Nursing Progress Note\nS-\" My breathing could be better\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. Taking long naps after meals and exertion. Takes alittle while to \"wake up\".\nCV-HR V paced 70, SBP 96-128 on dopamine 3mcg/kg. Started natrcor at 1500 received 2mcg/kg bolus over 60sec and started on .01mcg/kg/min. SBP dropped to 68 after bolus requiring dopamine increased gradually to 7.5mcg/kg. PAP 45-60/18-30 PWP 25 with V waves to 40. Tolerating captopril 25mg TID- on hold while on natrecor.\nResp-Rales 1/2 up with exp wheezes easily SOB with minimal activity. rr 20-38 O2 4lnp O2 sats 92-98%. right thoracentesis for large pleural effusion removed ~1500cc straw colored fluid/sent for usual tests.\nPt tolerated procedure well. O2 sats improved to 100% and O2 decreased to 3l np.\nID afebrile WBC 12\nGU- foley draining minimal urine 25-50cc/hr while on gtt at 15mg/hr. Increased gtt to 20mg without effect and 30mg/hr at1800. Added diuril 500mg at 12noon without effect and again at 1800. Plan to bolus 200mg IVB when available.\nGI- appetite has improved and now able to eat after setting pt up for meals. HCT 25 plan to transfuse 1 unit of PRBC but pt need to be diuresing first before blood tx started.\nSkin- RUA hematoma/eccymosis from possible RIJ catheter bleeding,\ntracking down right arm but not definate. Coccyx and heels remain red despite first step mattress and turning q3-4hrs.\nSocial- no calls or visitors today. WHen daughter comes in please have her sign health care proxy.\nA/P- large pleural effusions improved after thoracentesis.\nUnable to diurese started on natrecor\nFollow hemodynamics closely check CO/CI this eve.\nTansfuse PRBC when diursesing.\nFollow electrolytes and replete K+.\n\n"
},
{
"category": "Echo",
"chartdate": "2182-09-11 00:00:00.000",
"description": "Report",
"row_id": 99528,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Prosthetic valve function.\nHeight: (in) 63\nWeight (lb): 93\nBSA (m2): 1.40 m2\nBP (mm Hg): 93/41\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 12:52\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nOverall left ventricular systolic function is mildly depressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is mildly dilated. Right\nventricular systolic function is borderline normal. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: A bioprosthetic aortic valve prosthesis is present. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. There is moderate thickening of the\nmitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Severe\n[4+] tricuspid regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is mildly\ndepressed with mid to distal septal and apical akinesis/dyskinesis. The right\nventricular cavity is mildly dilated. Right ventricular systolic function is\nborderline normal. There is abnormal diastolic septal motion/position\nconsistent with right ventricular volume overload. A bioprosthetic aortic\nvalve prosthesis is present. Trace aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is moderate thickening of the\nmitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. Severe [4+] tricuspid regurgitation is seen. There is at least\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-14 00:00:00.000",
"description": "Report",
"row_id": 283481,
"text": "Regular ventricular pacing\nAtrial activity or pacing artifact not seen\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-13 00:00:00.000",
"description": "Report",
"row_id": 283482,
"text": "Regular ventricular pacing\nAtrial activity or pacing artifact not seen\nPacemaker rhythm - no further analysis\nSince previous tracing, probably no longer paced\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-12 00:00:00.000",
"description": "Report",
"row_id": 283483,
"text": "A-V paced rhtyhm.\nSince previous tracing no eveidence of sensing.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-11 00:00:00.000",
"description": "Report",
"row_id": 283484,
"text": "A-V sequentially paced rhythm in the context of atrial fibrillation with\ninappropriate atrial activity. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-10 00:00:00.000",
"description": "Report",
"row_id": 283485,
"text": "Junctional rhythm. A-V paced rhythm and failure to sense with variation in\npaced A-V interval. Question pacemaker failure. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-09 00:00:00.000",
"description": "Report",
"row_id": 283486,
"text": "A-V sequential and ventricular pacing. Failure to sense. Varying A-V intervals.\nQuestion pacemaker malfunction.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-09-06 00:00:00.000",
"description": "Report",
"row_id": 283487,
"text": "A-V sequential paced rhythm. No previous tracing available for comparison.\n\n"
}
] |
518 | 143,946 | 1. hypertensive urgency: Patient came on due to nausea and vomiting and was found to be in hypertensive urgency. Patient had no mental status changes, most likely due to not taking antihypertensives prior to dialysis, and vomiting the medications the day prior. In the ICU, patient transiently on nipride drip, but was changed to ntg gtt due to nipride being relatively contra-indicated in renal failure due to possiblity of CN- accumulation. HD helped remove fluid wiht 2.8L UF the day after admission. Patient restarted on home regimine of lisinopril, diovan, nifedipine and atenolol. Clonidine was added for addional control. Controlling nausea to help keep medications down. Patient stable with systolics in 140's on discharge. . 2. N/V: The patient has a history of gastroparesis and found in hypertensive urgency, both of which likely contributed to his nausea/vomiting. Patient had benign abdominal exam, however given diabetic with neuropathy, checked LFTs, amylase, lipase, which were negative. Continued aggressive antiemetics reglan, compazine, zofran. Schedule as outpatient for gastric emptying scan. Nausea/vomiting resolved prior to coming to ED. pressure stablized in transferred to denying nausea, vomiting, lightheadedness. . 3. Pulmonary embolism Patient recently diagnosed with PE, on coumadin. In hospital, patients INR found to be subtherapeutic (1.3 - 1.5). Patient put on heparin drip while INR becomes therapuetic with coumadin. Patient very anxious to go home. Sent home on Lovenox SC with close followup as outpatient to get INR checked. Patient is non compliant with medications. . 4. SOB: Patient with known recent PE, non therapeutic INR. Patient also due for dialysis on admission, although does not appear volume overloaded. Patient may also have pulmonary edema secondary to hypertensive urgency. Patient ruled out for ACS, no EKG changes, CKs flat, with trop leak, likely secondary to CRF (BL trop 0.18-.29) . 5. CKD stage V Patient on hemodialysis: Complicated history, had been on PD, on transplant list. Hemodialized in hospital. continue lanthanum and sensipar. . 6. HIV: HAART regimen continued. Meds given after dialysis on dialysis days. Pt has not been able to take meds due to nausea. . 7. med non-compliance. pt only selectively takes meds. Discussed the imprortance of med compliance in terms of BP control and history of clots. . 8. Anemia: Felt to be result of longstanding ESRD. Continued Epogen w/ HD . 9. Peripheral Neuropathy: Longstanding secondary to DM1. Continue gabapentin . 10. Type I Diabetes Mellitus: will continue outpatient regimen - NPH 10 , with 5U regular qAM and humalog sliding scale. | A left inguinal lymph node is made measuring 1.6 x 0.7 x 1.2 cm is seen, demonstrating normal configuration and fatty hilum. Sinus rhythmModest ST-T wave changes with peaked T waves - cannot exclude in parthyperkalemia - clinical correlation is suggestedSince previous tracing of the same date, Q-Tc interval appears shorter The bilateral common femoral, superficial femoral, and popliteal veins demonstrated normal waveforms, compressibility, augmentation, and respiratory variability. Received Loracepam 1mg and Morphine 2mg x2 in ED.Hr 74/min NSR, BP 199/98. B/P HAS RANGED 154-210/80-110. Comparedto tracing of peaked T waves persist. ONE UPRIGHT RADIOGRAPH OF THE CHEST WAS OBTAINED. REMAINS ON NITROGLYCERINE GTT AT 2MCG'S. The double lumen dialysis catheter is demonstrated in unchanged position inserted through the right subclavian vein with its tip terminating at the level of mid SVC. Sinus rhythm. Unchanged interstitial pulmonary edema. Sinus rhythmBorderline prolonged/upper limits of normal Q-Tc intervalModest ST-T wave changes with peaked T wavesFindings are nonspecific but clinical correlation is suggested for in parthyperkalemiaSince previous tracing of , T waves slightly more prominent but may beno significant change DENIES ANY SOB, WHICH IS AN APPROVEMENT.PT. PULSE ARE WEAK, BUT PALPABLE, NO EDEMA.LUNGS ARE RHONCHUS AND SATS REMAIN >95% AND RESP RATE IS CONTROLLED. New left lower lobe retrocardiac consolidation. HAS ALLERGIES TO CLINDAMYCIN.PT. Junctional ST segment depression that is non-specific. The heart demonstrates mild interval enlargement. 10:57 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: HYPERTENSIVE URGENCY FINAL ADDENDUM ADDENDUM: Findings were communicated to Dr. at the time of dictation. Mediastinal and hilar contours are normal. MICU RN REPORT 0545-17000545 pt received from ED awake and oriented. HAVE PT. REMAINS A/A/O AND CONTINUES TO C/O DULL HEADACHE, AND CONTRIBUTES IT TO HIS NITRO GTT. COMPARISON: Lower extremity Dopplers, ; ; and . HAD REMAINED QUITE NAUSOUS YESTERDAY. REMAINS AFEBRILE THROUGHOUT THIS SHIFT.PT. PT. PT. PT. PT. PT. PT. IMPRESSION: 1. IMPRESSION: 1. The surgical clips of previous cholecystectomy are again noted. Portable AP chest radiograph compared to . The major change is the large left retrocardiac consolidation, new compared to the previous study, accompanied by small bilateral pleural effusions. B/P REMAINS ELEVATED, BUT MUCH MORE CONTROLLED THAN PREVIOUS SHIFTS. 7am-7pm nsg progress notes46 y/o man with PMH of DM,ESRD,HIV and recent PE admitted with SOB,and hypertensive urgency.Events;u/s of bilateral lower extrimity to evaluate DVTHeamodialysis c/o body pain Inj.Morphine 2 mg/IV given with moderate effect.cvs;HR 55-65 NSR to SB no ectopy,NBP were remained high to 190-200 inspite of nitro infusion finally infusion was changed to nitroglycrine as advised by renal Dr Hydralazine 20 mg was given stat and started on PO Clonidine,nothing has been efffective so far.Presently on Nitroglycerine 2mcg/kg/mt is on flow.Has 2 PIV in place.All pedal pulses are palpable.On Heparin infusion 900 u/hr for PE.PTT to be repeated at 2200.RESP;Gets SOB easily with activity like moving in bed and sitting up,prn dose of nebs and face mask was added on during SOB.LS were crackles to ronchi at the same time no wheezing or desats.RR 12-20 sats maintained 95-100 throughout.Cough is productive at times to whitish secretions.NEURO;Alert and oriented follows all commands,moves all limbs,and he was uot of bed to chair for a short period and would like to sit up all time in favour of breathing.GI; Abdomen soft,BS + on cardiac healthy/renal diet.Vomitted twice brownish stomach contents,Zofran/IV given still nasuaeted and regular dose of metoclopromide was given.No bowel movement at this shift.GU;He is anuric,getting HD on mon/wed/fri he was dialysed yesterday.In view of his HTN and renal function he is getting dialysed now via lt AV fistula.ID;All HIV meds to be given after dialysis. There is interval worsening of pulmonary vascular congestion. The dual lumen dialysis catheter is in place with its tip projecting at level of distal SVC. REMAINS A FULL CODE AT THIS TIME.PT. Evaluate for deep venous thrombosis. The heart size is unchanged. RESUME ALL MEDS. IS ANUREIC AND RECEIVED DIALYSIS YESTERDAY.SKIN REMAINS INTACT, AND ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL.PLAN IS TO WEAN NITRO WHEN POSSIBLE. NS KVO.Labs sent result pending. ENDO;Blood sugar 110-130 on fixed dose and sliding scale recieved only fixed dose today.PLAN;FULL CODEMonitor HR,NBP titrate nitro dripPTT at 2200HIV meds to restart after dialysisprn nebs for SOB. On nipride infusion 0.5mic/kg/min. Comparison is made to the prior study done on . Small bilateral pleural effusion might be present. There are surgical clips projecting in the right upper quadrant area. Cannot rule out hyperkalemia.Otherwise, no other significant diagnostic change. HAS REMAINED NSB/SR 52-68 WITH NO NOTED ECTOPY. 10:17 AM BILAT LOWER EXT VEINS Clip # Reason: eval for DVT Admitting Diagnosis: HYPERTENSIVE URGENCY MEDICAL CONDITION: 46 year old man with recent PE subtherapeutic on coumadin presenting with SOB REASON FOR THIS EXAMINATION: eval for DVT FINAL REPORT BILATERAL LOWER EXTREMITY VENOUS DOPPLER HISTORY: Recent pulmonary embolism, subtherapeutic on Coumadin, presenting with shortness of breath. Pt is case of HIV,renal failure, Geting hemodialysis and waiting for transplant. | 10 | [
{
"category": "Radiology",
"chartdate": "2109-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970236,
"text": " 11:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with dyspnea, productive cough, fever.\n\n REASON FOR THIS EXAMINATION:\n eval failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with dyspnea and productive cough.\n\n Comparison is made to the prior study done on .\n\n ONE UPRIGHT RADIOGRAPH OF THE CHEST WAS OBTAINED.\n\n The heart demonstrates mild interval enlargement. Mediastinal and hilar\n contours are normal. There is interval worsening of pulmonary vascular\n congestion. Bibasilar opacities have also worsened. Small bilateral pleural\n effusion might be present. The dual lumen dialysis catheter is in place with\n its tip projecting at level of distal SVC. There are surgical clips\n projecting in the right upper quadrant area.\n\n IMPRESSION: Interval increase in the heart size with increased pulmonary\n vascular congestion suggests worsening of heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-06-27 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 970298,
"text": " 10:17 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVT\n Admitting Diagnosis: HYPERTENSIVE URGENCY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with recent PE subtherapeutic on coumadin presenting with SOB\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS DOPPLER\n\n HISTORY: Recent pulmonary embolism, subtherapeutic on Coumadin, presenting\n with shortness of breath. Evaluate for deep venous thrombosis.\n\n COMPARISON: Lower extremity Dopplers, ; ; and\n .\n\n FINDINGS: The bilateral lower extremities were examined from the groin to the\n mid calf. The bilateral common femoral, superficial femoral, and popliteal\n veins demonstrated normal waveforms, compressibility, augmentation, and\n respiratory variability.\n\n A left inguinal lymph node is made measuring 1.6 x 0.7 x 1.2 cm is seen,\n demonstrating normal configuration and fatty hilum.\n\n IMPRESSION:\n 1. No evidence for deep venous thrombosis in bilateral lower extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970454,
"text": " 10:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HYPERTENSIVE URGENCY\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Findings were communicated to Dr. at the time of dictation.\n\n\n\n 10:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HYPERTENSIVE URGENCY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with dyspnea, productive cough, fever s/p dialysis\n\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Productive cough and fever in a patient after\n dialysis.\n\n Portable AP chest radiograph compared to .\n\n The double lumen dialysis catheter is demonstrated in unchanged position\n inserted through the right subclavian vein with its tip terminating at the\n level of mid SVC. The heart size is unchanged. The mediastinal contours are\n unremarkable. There is no significant change in the degree of mild-to-\n moderate interstitial abnormality representing volume overload or pulmonary\n edema.\n\n The major change is the large left retrocardiac consolidation, new compared to\n the previous study, accompanied by small bilateral pleural effusions. There is\n no pneumothorax.\n\n The surgical clips of previous cholecystectomy are again noted.\n\n IMPRESSION:\n\n 1. New left lower lobe retrocardiac consolidation. This may represent\n developing pneumonia and/or atelectasis.\n\n 2. Unchanged interstitial pulmonary edema.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-06-28 00:00:00.000",
"description": "Report",
"row_id": 1268011,
"text": "pt is for transfer,please see transfer notes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-06-27 00:00:00.000",
"description": "Report",
"row_id": 1268009,
"text": "7am-7pm nsg progress notes\n\n46 y/o man with PMH of DM,ESRD,HIV and recent PE admitted with SOB,and hypertensive urgency.\n\nEvents;u/s of bilateral lower extrimity to evaluate DVT\nHeamodialysis c/o body pain Inj.Morphine 2 mg/IV given with moderate effect.\n\ncvs;HR 55-65 NSR to SB no ectopy,NBP were remained high to 190-200 inspite of nitro infusion finally infusion was changed to nitroglycrine as advised by renal Dr Hydralazine 20 mg was given stat and started on PO Clonidine,nothing has been efffective so far.Presently on Nitroglycerine 2mcg/kg/mt is on flow.Has 2 PIV in place.All pedal pulses are palpable.On Heparin infusion 900 u/hr for PE.PTT to be repeated at 2200.\n\nRESP;Gets SOB easily with activity like moving in bed and sitting up,prn dose of nebs and face mask was added on during SOB.LS were crackles to ronchi at the same time no wheezing or desats.RR 12-20 sats maintained 95-100 throughout.Cough is productive at times to whitish secretions.\n\nNEURO;Alert and oriented follows all commands,moves all limbs,and he was uot of bed to chair for a short period and would like to sit up all time in favour of breathing.\n\nGI; Abdomen soft,BS + on cardiac healthy/renal diet.Vomitted twice brownish stomach contents,Zofran/IV given still nasuaeted and regular dose of metoclopromide was given.No bowel movement at this shift.\n\nGU;He is anuric,getting HD on mon/wed/fri he was dialysed yesterday.In view of his HTN and renal function he is getting dialysed now via lt AV fistula.\n\nID;All HIV meds to be given after dialysis.\n\n ENDO;Blood sugar 110-130 on fixed dose and sliding scale recieved only fixed dose today.\n\nPLAN;FULL CODE\nMonitor HR,NBP titrate nitro drip\nPTT at 2200\nHIV meds to restart after dialysis\nprn nebs for SOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-06-28 00:00:00.000",
"description": "Report",
"row_id": 1268010,
"text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO CLINDAMYCIN.\n\nPT. REMAINS A/A/O AND CONTINUES TO C/O DULL HEADACHE, AND CONTRIBUTES IT TO HIS NITRO GTT. PT. HAS RECEIVED MORPHINE 2MG IV AND ATIVAN 1MG IV TWICE WITH NOTED EFFECTS REACHED. PT. REMAINS AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS REMAINED NSB/SR 52-68 WITH NO NOTED ECTOPY. B/P REMAINS ELEVATED, BUT MUCH MORE CONTROLLED THAN PREVIOUS SHIFTS. B/P HAS RANGED 154-210/80-110. PT. REMAINS ON NITROGLYCERINE GTT AT 2MCG'S. PULSE ARE WEAK, BUT PALPABLE, NO EDEMA.\n\nLUNGS ARE RHONCHUS AND SATS REMAIN >95% AND RESP RATE IS CONTROLLED. PT. DENIES ANY SOB, WHICH IS AN APPROVEMENT.\n\nPT. HAS TOLERATED A CUP OF TEA BUT OTHERWISE HAS NOT WANTED TO TAKE ANY SOLID NUTRITION. PT. HAD REMAINED QUITE NAUSOUS YESTERDAY. PT'S BLOOD SUGARS HAVE NOT REQUIRED INSULIN AND NO FIXED DOSES GIVEN.\nPT. IS ANUREIC AND RECEIVED DIALYSIS YESTERDAY.\n\nSKIN REMAINS INTACT, AND ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL.\n\nPLAN IS TO WEAN NITRO WHEN POSSIBLE. HAVE PT. RESUME ALL MEDS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-06-27 00:00:00.000",
"description": "Report",
"row_id": 1268008,
"text": "MICU RN REPORT 0545-1700\n\n0545 pt received from ED awake and oriented. Pt is case of HIV,renal failure, Geting hemodialysis and waiting for transplant. Received Loracepam 1mg and Morphine 2mg x2 in ED.Hr 74/min NSR, BP 199/98. On nipride infusion 0.5mic/kg/min. NS KVO.Labs sent result pending. To start HIV meds after hemodialysis.\n"
},
{
"category": "ECG",
"chartdate": "2109-06-26 00:00:00.000",
"description": "Report",
"row_id": 272849,
"text": "Sinus rhythm. Junctional ST segment depression that is non-specific. Compared\nto tracing of peaked T waves persist. Cannot rule out hyperkalemia.\nOtherwise, no other significant diagnostic change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2109-06-24 00:00:00.000",
"description": "Report",
"row_id": 272850,
"text": "Sinus rhythm\nModest ST-T wave changes with peaked T waves - cannot exclude in part\nhyperkalemia - clinical correlation is suggested\nSince previous tracing of the same date, Q-Tc interval appears shorter\n\n"
},
{
"category": "ECG",
"chartdate": "2109-06-24 00:00:00.000",
"description": "Report",
"row_id": 272851,
"text": "Sinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval\nModest ST-T wave changes with peaked T waves\nFindings are nonspecific but clinical correlation is suggested for in part\nhyperkalemia\nSince previous tracing of , T waves slightly more prominent but may be\nno significant change\n\n"
}
] |
19,649 | 132,894 | The day following his admission his Swan-Ganz catheter was removed as well as his temporary pacer. His ACE inhibitor was continued, and was increased to 25 mg . Also a beta blocker was added at that time, metoprolol 12.5 . At that time, he was also transferred to the floor. On the following day, , he was on the floor. He was switched from captopril to lisinopril 10 mg q day. On telemetry, some ectopic beats were noted as well as a right bundle branch block. The following day on , telemetry showed decreased frequency of these ectopic beats, but continued right bundle branch block. His lisinopril was increased to 15 mg q day, and patient was discharged. | R groin is C&D distal pulses by doppler. CHEST, PORTABLE: A temporary pacing lead has been placed, with lead terminating in the expected location of the right ventricle. Creat 1.3 Received 190 of contrast. Sinus rhythmMultiform PVCsRight bundle branch blockInferior ST elevation - repeat if myocardial injury is suspectedSince previous tracing of : no significant change Nursing Progress NoteS/P IMIO: Tele sinus rhythm with occ PVC's. PATIENT/TEST INFORMATION:Indication: Rule out tamponadeBP (mm Hg): 110/62HR (bpm): 72Status: InpatientDate/Time: at 08:58Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: The left ventricular cavity size is normal. Sinus rhythm - premature ventricular contractionsConduction defect of RBBB typeSince previous tracing of : Wenckebach block resolved and right bundlebranch block seen CKs trending down.RESP: LS clear and dim. (+) 2.7L since MN.Post cath fluid complete. Denies SOB.GU/GI: Foley draining CYU in adequate amounts. Abd soft with (+) BSs. Taking POs well.ID: Afebrile. Temp pacer dc'd. 4:3 and 3:2 wenckebach blockIntraventricular conduction delayLong QTc intervalRight axis deviation - left posterior fascicular blockInferior ST elevation - repeat if myocardial injury is suspectedST junctional depression is nonspecificSince previous tracing of : Wenckebach block is variable Intergrillin off. 930 pt arrived from cardiac cath lab hemodynamically stable. R groin is C&D without evidence of hematoma.Resp: Lungs CTA. Right groin CDI with palpable distal. REASON FOR THIS EXAMINATION: Please evaluate for pulm edema and widened mediastinum FINAL REPORT INDICATION: Pacemaker placement. Distal pulses by doppler. Tele sinus rhythm with frequent VEA upon arrival. Denies chest pain. Denies chest pain. O2 at 3l O2 sat 95-98%.GU/GI: Tolerating sm amts of liquids. No issues.HEME: Hct stable. Thereis a very small pericardial effusion. Right ventricularchamber size is normal. Given Atropine, Dopa and IV fluids. Abd is soft and lgwith bowel sounds present. IMPRESSION: 1) Satisfactory placement of temporary pacing leads, with no evidence of pneumothorax. Tx'd with Lasix 20mg IV x's 2. 2.6 minutes of fluoro time was used. I&O is positive d/t lg volume of fluid given in ED (~6liters). There are noechocardiographic signs of tamponade.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Conclusions:The left ventricular cavity size is normal. CK's trending down. ECG CHB 30-40's, ST elevation inferiorly. Lungs with expiratory wheezes off and on. 4:3 Wenckebach AV blockVentricular premature complexesIntraventricular conduction delayRight axis deviation - left posterior fascicular blockInferior ST elevation - repeat if myocardial injury is suspectedLateral T wave changes may be due to myocardial ischemiaRepolarization changes may be partly due to rhythm CK #2 2700. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.Overall left ventricular systolic function is normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size is normal.MITRAL VALVE: The mitral valve leaflets are mildly thickened.PERICARDIUM: There is a small pericardial effusion. Swan dc'd. House staff aware.Resp: Arrived on 100% NRB. Responding well to Lasix. Oral held.GU/GI: Pt tolerating sips of clear liquids well. MAEsCV: HR 80s to 90s. SBP 70's. Integrilin at 2mcgs/kg/min. Eventually temp wire inserted and pt taken to cardiac cath lab. Denies any abd or back pain. Atrial sensed ventricular paced rhythm with 100% captureNo previous tracing C/o being "tired. See flow sheet for vital signs. SBPs 110s to 130s. "SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSMS:A/O/X/3. 2 Hepacoat stents placed in RCA. Wife updated on pts progress by RN.A&P: Stable post IMI. AM Labs redrawn showing discrepancy. Overallleft ventricular systolic function is normal (LVEF>55%). Captopril increased to 12.5mg and tolerating well. CHF by CXR responding well to Lasix given in cath lab.Neuro: Alert and oriented. AM Hct pending.A/P: s/p IMI c/b by CHBPacing wire and swan to be DC'd this AMPossible transfer to floor later in day Continue Integrilin until 2am, check serial CK's and continue to monitor hemodynamics. NSR with no noted ectopy. O2Sat 98-99% on 2Ls. Transfer to floor when bed available. Temp pacing wire via R subclavian VVI rate of 50 MA 10. Abd is soft with bowel sounds present. Ride sided pressures elevated. Wife updated on pts condition by RN and Dr .A&P: Ruling in for IMI with stents to RCA. The mitral valve leaflets are mildly thickened. BP stable Captopril increased to 25mg and restarted on Lopressor. Denies CP. O2 sat 100% O2 requiriment weaned down to 3 l np with O2 sat 95-98%. PAD 14-18s. Requiring no use overngight. 5:57 AM CHEST FLUORO WITHOUT RADIOLOGIST Clip # Reason: TEMPORARY WIRE PLACEMENT FINAL REPORT A chest fluoro was performed without a radiologist present. Able to move all extremities.BS: Initial BS 316 tx'd with 10u regular insulin. IV 1/2 NS at 125 for 2500cc. Maintained on bedrest according to sheath protocol. CCU Nursing Progress Note 1900-0700S-"When are they going to take this thing out? Vomited after breakfast sm amt. 2) Congestive heart failure with interstitial pulmonary edema. Maintain bedrest for 6hrs today. Appetite remains poor. In addition c/o back pain, given 2 percs and turned and responded well.Sleeping most of night. Nursing Progress Note 54 yo man who presented to the ED early this am with chest pain and diaphoresis. The heart is enlarged, there is vascular engorgement, and there is a bilateral diffuse interstitial pattern with associated peribronchial cuffing. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2149-06-22 00:00:00.000",
"description": "Report",
"row_id": 1520970,
"text": "Nursing Progress Note\n\n\nS/P IMI\n\nO: Tele sinus rhythm with occ PVC's. Temp pacer dc'd. BP stable Captopril increased to 25mg and restarted on Lopressor. Denies chest pain. CK's trending down. Swan dc'd. Distal pulses by doppler. R groin is C&D without evidence of hematoma.\n\nResp: Lungs CTA. O2 at 3l O2 sat 95-98%.\n\nGU/GI: Tolerating sm amts of liquids. Vomited after breakfast sm amt. Appetite remains poor. Abd is soft with bowel sounds present. Foley draining sm amts of dark urine with some hematuria. House staff aware. Creat 1.0 post cath.\n\nSocial: Wife and family in to visit. Wife updated on pts progress by RN.\n\nA&P: Stable post IMI. Maintain bedrest for 6hrs today. Transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 1520968,
"text": "Nursing Progress Note\n\n 54 yo man who presented to the ED early this am with chest pain and diaphoresis. ECG CHB 30-40's, ST elevation inferiorly. SBP 70's. Given Atropine, Dopa and IV fluids. Eventually temp wire inserted and pt taken to cardiac cath lab. 2 Hepacoat stents placed in RCA. Ride sided pressures elevated. Tx'd with Lasix 20mg IV x's 2. 930 pt arrived from cardiac cath lab hemodynamically stable. See flow sheet for vital signs. Temp pacing wire via R subclavian VVI rate of 50 MA 10. Tele sinus rhythm with frequent VEA upon arrival. Integrilin at 2mcgs/kg/min. R groin is C&D distal pulses by doppler. Denies chest pain. CK #2 2700. AM Labs redrawn showing discrepancy. House staff aware.\n\nResp: Arrived on 100% NRB. O2 sat 100% O2 requiriment weaned down to 3 l np with O2 sat 95-98%. Lungs with expiratory wheezes off and on. CHF by CXR responding well to Lasix given in cath lab.\n\nNeuro: Alert and oriented. Maintained on bedrest according to sheath protocol. Able to move all extremities.\n\nBS: Initial BS 316 tx'd with 10u regular insulin. Oral held.\n\nGU/GI: Pt tolerating sips of clear liquids well. Abd is soft and lg\nwith bowel sounds present. Denies any abd or back pain. Foley draining lg amts of clear yellow urine. I&O is positive d/t lg volume of fluid given in ED (~6liters). Creat 1.3 Received 190 of contrast. IV 1/2 NS at 125 for 2500cc. Mg, K & Ca repleted.\n\nSocial: Wife and sons in to visit with pt after procedure. Wife updated on pts condition by RN and Dr .\n\nA&P: Ruling in for IMI with stents to RCA. Responding well to Lasix. Continue Integrilin until 2am, check serial CK's and continue to monitor hemodynamics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-06-22 00:00:00.000",
"description": "Report",
"row_id": 1520969,
"text": "CCU Nursing Progress Note 1900-0700\nS-\"When are they going to take this thing out?\"\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nMS:A/O/X/3. Very pleasant and cooperative. C/o being \"tired. In addition c/o back pain, given 2 percs and turned and responded well.\nSleeping most of night. MAEs\nCV: HR 80s to 90s. NSR with no noted ectopy. TV wire sensing and capturing. Requiring no use overngight. SBPs 110s to 130s. Captopril increased to 12.5mg and tolerating well. Denies CP. PAD 14-18s. Right groin CDI with palpable distal. Intergrillin off. CKs trending down.\nRESP: LS clear and dim. O2Sat 98-99% on 2Ls. Denies SOB.\nGU/GI: Foley draining CYU in adequate amounts. (+) 2.7L since MN.\nPost cath fluid complete. Abd soft with (+) BSs. Taking POs well.\nID: Afebrile. No issues.\nHEME: Hct stable. AM Hct pending.\nA/P: s/p IMI c/b by CHB\nPacing wire and swan to be DC'd this AM\nPossible transfer to floor later in day\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796105,
"text": " 12:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pulm edema and widened mediastinum\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p AMI and stent and pacer placement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pulm edema and widened mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pacemaker placement.\n\n CHEST, PORTABLE: A temporary pacing lead has been placed, with lead\n terminating in the expected location of the right ventricle. No pneumothorax\n is identified. The heart is enlarged, there is vascular engorgement, and there\n is a bilateral diffuse interstitial pattern with associated peribronchial\n cuffing.\n\n IMPRESSION:\n\n 1) Satisfactory placement of temporary pacing leads, with no evidence of\n pneumothorax.\n 2) Congestive heart failure with interstitial pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-21 00:00:00.000",
"description": "CHEST FLUORO WITHOUT RADIOLOGIST",
"row_id": 796076,
"text": " 5:57 AM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: TEMPORARY WIRE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n A chest fluoro was performed without a radiologist present. 2.6 minutes of\n fluoro time was used. No films submitted.\n\n"
},
{
"category": "Echo",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 75837,
"text": "PATIENT/TEST INFORMATION:\nIndication: Rule out tamponade\nBP (mm Hg): 110/62\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 08:58\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size is normal. The mitral valve leaflets are mildly thickened. There\nis a very small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 180382,
"text": "Sinus rhythm\nMultiform PVCs\nRight bundle branch block\nInferior ST elevation - repeat if myocardial injury is suspected\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 180383,
"text": "Sinus rhythm\n - premature ventricular contractions\nConduction defect of RBBB type\nSince previous tracing of : Wenckebach block resolved and right bundle\nbranch block seen\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 180616,
"text": "4:3 Wenckebach AV block\nVentricular premature complexes\nIntraventricular conduction delay\nRight axis deviation - left posterior fascicular block\nInferior ST elevation - repeat if myocardial injury is suspected\nLateral T wave changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 180617,
"text": "Atrial sensed ventricular paced rhythm with 100% capture\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-21 00:00:00.000",
"description": "Report",
"row_id": 180615,
"text": "4:3 and 3:2 wenckebach block\nIntraventricular conduction delay\nLong QTc interval\nRight axis deviation - left posterior fascicular block\nInferior ST elevation - repeat if myocardial injury is suspected\nST junctional depression is nonspecific\nSince previous tracing of : Wenckebach block is variable\n\n"
}
] |
10,896 | 170,323 | On the scene, he was (per EMS) awake and confused and found lying on the road. On arrival at his GCS was 15. He was hemodynamically stable on arrival and throughout his hospital stay. On arrival he complained of chest pain, especially with deep inspiration, but denied headache or any focal neurologic complaints such as tingling, weakness or numbness. His initial evaluation revealed the following injuries: small parenchymal and subarrachnoid hemorrhages in the frontal lobe; a left pulmonary contusion; and a fracture of the 2nd metacarpal in the left hand. There were no mediastinal or internal organ injuries or other fractures. He was admitted to the Trauma Surgery service and seen by Neurosurgery. He initially was followed with frequent neurologic exams, and a repeat head CT the day after admission showed no change. He was started on dilantin for a 7 day course. He had no seizures while admitted and his neurologic exam remained unchanged. He was seen by Plastic Surgery for the metacarpal fracture and placed in a splint, with instructions for follow-up and elective repair. He was noted to have elevated LFTs during his admission, but had no symptoms or signs of liver or gall bladder disease, and the LFTs trended down during his admission. His PCP was , who reported no known history of hepatitis but agreed to follow the condition. The results of his hepatitis tests were still pending at discharge. He was seen by physical and occupational therapy and cleared for discharge home. | TECHNIQUE: Non-contrast head CT. TECHNIQUE: Non-contrast head CT. No significant degenerative changes are seen within the lumbar spine. There is no significant displacement of the fracture fragments. IMPRESSION: Stable small left anterior frontal parenchymal hemorrhage. The visualized osseous structures are unchanged. NKDA's, no meds, minimal smoker and occaisional ETOH. There is minimal amount of associated edema. No intra-articular extent of the fracture is noted. There is no pericardial or pleural effusion. IMPRESSION: No evidence of intrathoracic or intrapelvic trauma. IMPRESSION: No fracture or malalignment. There is no prevertebral soft tissue swelling. There is no mediastinal hematoma. No fractures are identified. No fractures are identified. There is no evidence of tracheobronchial injury. FINDINGS: There is no fracture or malalignment. There is no shift of normally midline structures. There is no shift of normally midline structures. No fracture or malalignment. FINDINGS: The small left anterior frontal parenchymal hemorrhage appears unchanged in size, measuring 6 x 4 mm. There is no pneumothorax identified on this supine radiograph. Both lungs are clear without consolidations or effusions. FINDINGS: There is a very small left anterior frontal parenchymal hemorrhage. There is no significant associated mass effect. There is no evidence of a spinal fracture. There is no fracture or subluxation. C/O L chest/rib pain, but denies any need for pain medicine.CV: HR 70-80's SR no ectopy noted, NBP 90-100's systolic. No subarachnoid blood products are seen at this time. AP PELVIS: The sacroiliac joints, bilateral hips, and pubic symphysis appear intact. CHEST CT ANGIOGRAM: There is no evidence of aortic transection, dissection, or other injury. No significant mass effect. IMPRESSION: Very small left anterior frontal parenchymal hemorrhage with a very small associated subarachnoid hemorrhage, probably representing a hemorrhagic contusion. COMPARISON: No previous studies. COMPARISON: No previous studies. COMPARISON: No previous studies. COMPARISON: No previous studies. COMPARISON: No previous studies. AP CHEST X-RAY, TRAUMA: The cardiac silhouette, mediastinal, and hilar contours are normal. TECHNIQUE: Axial non-contrast multidetector CT images of the cervical spine were obtained. No evidence of subarachnoid blood products. The surrounding soft tissue and osseous structures are unremarkable. The surrounding soft tissues are unremarkable. However, pneumonia cannot be excluded based on imaging findings. pt hemodynamically stable w/ HR 70-80's SR, BP 90-110/50-60, extremities all warm and dry w/ easily palpable pulses, AM labs pnd. There is no intraventricular or cisternal blood. No previoustracing available for comparison. There is no evidence of acute traumatic injury to the liver, pancreas, adrenal glands, or kidneys. Unopacified bowel loops appear unremarkable. The ventricles are normal in size. The ventricles are normal in size. AM labs pnd, pt stable s/p MVC, con't to monitor neuro satus closely, check w/ team re spinal status, Advance diet and activity as ordered. There is residual thymic tissue in the anterior mediastinum. Intervertebral disc space height is preserved throughout. Left apical pulmonary opacity. The visualized joint spaces appear unremarkable. Backside intact. Intervertebral disk space height is preserved throughout. There is a simple cyst in the upper/mid right kidney. TECHNIQUE: Axial multidetector CT images of the chest were obtained without contrast utilizing low dose expiratory technique and then with 100 cc of intravenous Optiray per CT angiogram protocol. The visualized paranasal sinuses are normally aerated. Pt has minimal recall of accident yet had GCS of 15 on arrival to hospital. Evaluation of the visualized upper abdominal organs is limited by the early phase of enhancement per CT angiogram protocol. However, pneumonia cannot be excluded based on the imaging findings as discussed above, and clinical correlation is recommended. There is an opacity in the anterior portion of the left upper lobe and a peribronchovascular opacity in the lingula. Tolerating regular diet without difficulty. An opacity is noted at the left anterior lung apex. The upper thoracic spine is suboptimally visualized on the lateral view. There is a faint linear density extending from this hemorrhage into an adjacent sulcus, consistent with a small subarachnoid hemorrhage likely related to a subarachnoid tear. Right bundle-branch block with ST-T wave changes. IMPRESSION: Left upper lobe and lingular pulmonary opacities which probably represent contusions. Pneumo boots on.Resp- RR 12-16 non labored on room air, pt satting 95-98%. Breath sounds clear bilaterally, pt pulling 750-1100cc's on incentive spirometer.GI- abd soft nondistended, hypoactive bowel sounds present.GU- foley intact and draining clear yellow urine.ID- T max 99.2 PO,Endo - glucose pnd, pt getting NS at 75cc's hr.Skin- small lac on left chin intact w/ 3 sutures. Knees w/ superficial abrasions bilaterally. T/SICU RN Progress NoteNeuro: Head CT his morning, remains alert and oriented. Review of Systems as follows: pt alert and oriented times 3 throughout the night, PERL at 4mm, moving extremities w// full strengths, no pronator drift noted. Sagittal and coronal reformatted images were obtained. While peribronchovascular location is atypical for contusion, these opacities probably represent contusions given the setting of trauma. Sagittal and coronal reformatted images were performed. Sinus rhythm. Pt denies HA, visual changes at this time, Nausea times one after morpine dose administered for c/o left chest pain. IMPRESSION: 1. Radiopaque contrast is noted in the renal collecting systems bilaterally, ureters, and bladder. CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the findings demonstrated on the axial images. DFDkq (Over) 8:51 PM CTA CHEST W&W/O C &RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # CT 100CC NON IONIC CONTRAST Reason: r/o aortic injury, pulmonary contusion Field of view: 40 Contrast: OPTIRAY Amt: 100 FINAL REPORT (REVISED) (Cont) | 10 | [
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 879929,
"text": " 8:36 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man status post motorcycle accident. Evaluate for\n fracture.\n\n AP CHEST X-RAY, TRAUMA: The cardiac silhouette, mediastinal, and hilar\n contours are normal. There is no pneumothorax identified on this supine\n radiograph. Both lungs are clear without consolidations or effusions. The\n surrounding soft tissue and osseous structures are unremarkable.\n\n AP PELVIS: The sacroiliac joints, bilateral hips, and pubic symphysis appear\n intact. No significant degenerative changes are seen within the lumbar spine.\n The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879953,
"text": " 8:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval change in SAH\n Admitting Diagnosis: MOTORCYCLE ACCIDENT;SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p mcc with SAH\n REASON FOR THIS EXAMINATION:\n eval change in SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The small left anterior frontal parenchymal hemorrhage appears\n unchanged in size, measuring 6 x 4 mm. There is minimal amount of associated\n edema. No subarachnoid blood products are seen at this time. There is no\n shift of normally midline structures. There is no intraventricular or\n cisternal blood. The ventricles are normal in size. The visualized osseous\n structures are unchanged. The visualized paranasal sinuses are normally\n aerated.\n\n IMPRESSION: Stable small left anterior frontal parenchymal hemorrhage. No\n evidence of subarachnoid blood products.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879931,
"text": " 8:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleeding/trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with\n REASON FOR THIS EXAMINATION:\n bleeding/trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 9:14 PM\n very small left anterior frontal parenchymal hemorrhage with a very small\n associated linear subarachnoid hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle trauma.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a very small left anterior frontal parenchymal hemorrhage.\n There is a faint linear density extending from this hemorrhage into an\n adjacent sulcus, consistent with a small subarachnoid hemorrhage likely\n related to a subarachnoid tear. There is no significant associated mass\n effect. There is no shift of normally midline structures. The ventricles are\n normal in size. No fractures are identified. A bone island is noted in the\n left frontal bone, in the roof of the left orbit.\n\n IMPRESSION: Very small left anterior frontal parenchymal hemorrhage with a\n very small associated subarachnoid hemorrhage, probably representing a\n hemorrhagic contusion. No significant mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 879932,
"text": " 8:51 PM\n CTA CHEST W&W/O C &RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: r/o aortic injury, pulmonary contusion\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p motorcycle accident with widened mediastinum & possible\n early L pulmonary contusion\n REASON FOR THIS EXAMINATION:\n r/o aortic injury, pulmonary contusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 9:25 PM\n -pulmonary contusion in the left upper lobe\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Motorcycle accident trauma.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial multidetector CT images of the chest were obtained without\n contrast utilizing low dose expiratory technique and then with 100 cc of\n intravenous Optiray per CT angiogram protocol. Sagittal and coronal\n reformatted images were obtained.\n\n CHEST CT ANGIOGRAM: There is no evidence of aortic transection, dissection,\n or other injury. There is no mediastinal hematoma. There is residual thymic\n tissue in the anterior mediastinum. There is no evidence of tracheobronchial\n injury. There is no pericardial or pleural effusion. There is an opacity in\n the anterior portion of the left upper lobe and a peribronchovascular opacity\n in the lingula. While peribronchovascular location is atypical for contusion,\n these opacities probably represent contusions given the setting of trauma.\n However, pneumonia cannot be excluded based on imaging findings.\n\n Evaluation of the visualized upper abdominal organs is limited by the early\n phase of enhancement per CT angiogram protocol. There is mixing artifact in\n the spleen. There is no evidence of acute traumatic injury to the liver,\n pancreas, adrenal glands, or kidneys. There is a simple cyst in the upper/mid\n right kidney. Unopacified bowel loops appear unremarkable.\n\n No fractures are identified.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the findings\n demonstrated on the axial images. In addition, they are useful for evaluating\n the spine. There is no evidence of a spinal fracture. Value grade is 3.\n\n IMPRESSION: Left upper lobe and lingular pulmonary opacities which probably\n represent contusions. However, pneumonia cannot be excluded based on the\n imaging findings as discussed above, and clinical correlation is recommended.\n\n\n DFDkq\n (Over)\n\n 8:51 PM\n CTA CHEST W&W/O C &RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: r/o aortic injury, pulmonary contusion\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 879933,
"text": " 9:00 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval fxs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p motorcycle crash\n REASON FOR THIS EXAMINATION:\n eval fxs\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 9:31 PM\n no fracture or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motorcycle accident trauma.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial non-contrast multidetector CT images of the cervical spine\n were obtained. Sagittal and coronal reformatted images were performed.\n\n FINDINGS: There is no fracture or malalignment. There is no prevertebral\n soft tissue swelling. Intervertebral disc space height is preserved\n throughout. An opacity is noted at the left anterior lung apex. Please refer\n to the chest CT performed concurrently for further detail.\n\n IMPRESSION:\n 1. No fracture or malalignment.\n 2. Left apical pulmonary opacity. Please refer to the chest CT of the same\n day for further detail.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "T-SPINE",
"row_id": 879934,
"text": " 9:22 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motorcycle accident.\n\n COMPARISON: No previous studies.\n\n FINDINGS: These two examinations consist of AP and lateral views of the\n thoracic spine, and AP and lateral views of the lumbar spine. The upper\n thoracic spine is suboptimally visualized on the lateral view. There is no\n fracture or subluxation. Intervertebral disk space height is preserved\n throughout. Radiopaque contrast is noted in the renal collecting systems\n bilaterally, ureters, and bladder.\n\n IMPRESSION: No fracture or malalignment.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-10-21 00:00:00.000",
"description": "L HAND (AP, LAT & OBLIQUE) LEFT",
"row_id": 879935,
"text": " 9:22 PM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motorcycle accident.\n\n COMPARISON: No previous studies.\n\n FINDINGS: AP, oblique, and lateral views of the left hand. There is an\n oblique fracture of the second metacarpal. No intra-articular extent of the\n fracture is noted. There is no significant displacement of the fracture\n fragments. The visualized joint spaces appear unremarkable.\n\n IMPRESSION: Second metacarpal fracture.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-10-21 00:00:00.000",
"description": "Report",
"row_id": 212742,
"text": "Sinus rhythm. Right bundle-branch block with ST-T wave changes. No previous\ntracing available for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-22 00:00:00.000",
"description": "Report",
"row_id": 1405742,
"text": "TSICU Nsg Admit Note\n Pt is a 28y/o male admitted via EW s/p motorcycle crash where pt was thrown over the handle bars after he braked and skidded to avoid car in front of him. Pt has minimal recall of accident yet had GCS of 15 on arrival to hospital. His injuries include a left pulmonary contusion, small left frontal SAH, left 2nd metacarpal fx, and small left chin lac. Pt's only PMHx is surgery on his left arm after it was broken when he was a child.\n NKDA's, no meds, minimal smoker and occaisional ETOH.\n\n Review of Systems as follows:\n\n pt alert and oriented times 3 throughout the night, PERL at 4mm, moving extremities w// full strengths, no pronator drift noted. Pt denies HA, visual changes at this time, Nausea times one after morpine dose administered for c/o left chest pain.\n\n pt hemodynamically stable w/ HR 70-80's SR, BP 90-110/50-60, extremities all warm and dry w/ easily palpable pulses, AM labs pnd. Pneumo boots on.\n\nResp- RR 12-16 non labored on room air, pt satting 95-98%. Pt c/o pain on inspiration, med w/ morphine 1mg IVP times two over night w/ good results. Breath sounds clear bilaterally, pt pulling 750-1100cc's on incentive spirometer.\n\nGI- abd soft nondistended, hypoactive bowel sounds present.\n\nGU- foley intact and draining clear yellow urine.\n\nID- T max 99.2 PO,\n\nEndo - glucose pnd, pt getting NS at 75cc's hr.\n\nSkin- small lac on left chin intact w/ 3 sutures. Knees w/ superficial abrasions bilaterally. Backside intact.\n\n pt's girl friend in briefly.\n\nA/P- neurologically intact thusfar, cooperative w/ pulmonary toilet, Cervical collar on and logroll precautions maintained over night pnd TLS w/up. AM labs pnd, pt stable s/p MVC, con't to monitor neuro satus closely, check w/ team re spinal status, Advance diet and activity as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-10-22 00:00:00.000",
"description": "Report",
"row_id": 1405743,
"text": "T/SICU RN Progress Note\nNeuro: Head CT his morning, remains alert and oriented. Pupils equal and reactive. C/O L chest/rib pain, but denies any need for pain medicine.\n\nCV: HR 70-80's SR no ectopy noted, NBP 90-100's systolic. NS@75cc/hr.\n\nResp: Lungs clear NARD RR 12-18 with Sats 97-99% on RA.\n\nGU/GI: Foley with clear yellow urine, d/c'd at 1600 due to void by 2200. Tolerating regular diet without difficulty. On Pepcid\n\nSkin/Mobility: C-collar and TLS cleared, remains on bedrest, L hand is splint seen by plastic surgery.\n\nSocial: Family in to visit updated.\n\nPlan: Transfer to floor when bed avaliable.\n\n"
}
] |
1,186 | 166,695 | 71 y.o. M hx pulmonary fibrosis, sarcoidosis, ? COPD presenting with worsened dyspnea from baseline. . # Dyspnea - Likely community aquired pneumonia in setting of terrible base line lung functino (pulmonary fibrosis, sarcoid, and COPD). Treated in ED with BIPAPA, solumedrol, levofloxacin and nebs. Was admitted to the MICU. pt feeling back to baseline by the time he arrived in MICU off BIPAP and on 3L nasal cannula. Doing well over the course of the day. Next morning had an episode of acute dyspnea after minimal exertion, resolved spontaneously, associated with tachycardia to 110, hypertension to 240/120s. Was called out to the floor. Did well and was able to tirtate of oxygen. Will be treated with a steroid taper and ten day course of levofloxacin. Echo obtained was consistent with known pulmonary hypertension related to underlying pulmonary disease. . # Dynamic ECG changes - CE's negative, . Started on ASA, cont lipitor (LDL 62), no beta blockers given likely COPD exacerbation. . # BPH - cont flomax . # hx of orthostatic hypotension - held minearalocorticoid as he was hypertensive, consider restarting once BP improved. . # FEN - regular diet, replete electrolytes prn . FULL code | Sinus tachycardiaConsider right atrial abnormalityIndeterminate QRS axis - is nonspecificSince previous tracing of 1-0604, ST-T wave changes decreased Echocardiographic signs of tamponade may be absent in the presenceof elevated right sided pressures.Conclusions:The left atrium is normal in size. Sinus tachycardiaModest right ventricular conduction delay pattern - may be normal variantSince previous tracing of , sinus tachycardia rate slower and modestright ventricular conduction delay pattern present RV function depressed.AORTA: Normal aortic root diameter. There is moderatepulmonary artery systolic hypertension. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion. The previously seen small left-sided pneumothorax appears to have resolved. Interval improvement of small left-sided pneumothorax. PATIENT/TEST INFORMATION:Indication: LV functionHeight: (in) 66Weight (lb): 112BSA (m2): 1.56 m2BP (mm Hg): 147/72HR (bpm): 100Status: InpatientDate/Time: at 11:46Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.LEFT VENTRICLE: Mild symmetric LVH.RIGHT VENTRICLE: Mildly dilated RV cavity. Again seen are enlarged mediastinal and hilar lymph nodes, many of which appear calcified, not significantly changed from prior study. ekg done, albuterol tx given by resp. There is mild symmetric left ventricularhypertrophy. The right ventricular cavity is mildly dilated. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3).MITRAL VALVE: Mildly thickened mitral valve leaflets.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3) are mildlythickened. UPRIGHT AP VIEW OF THE CHEST: Increased interstitial opacities with superior retraction of the hila and elevation of the hemidiaphragms reflect fibrotic change from sarcoidosis. Right ventricularsystolic function appears depressed. Echocardiographic signs oftamponade may be absent in the presence of elevated right sided pressures. 2) Residual small left pneumothorax. Extensive fibrotic and architectural distortion within both lungs, not significantly changed from prior study, consistent with history of pulmonary fibrosis. TECHNIQUE: MDCT acquired axial images of the chest were obtained with and without IV contrast. AFter albuterol .. breath sounds improved. A small left pneumothorax persists. PT often wonders Why people are asking certain questions like " How is your breathing" pt wonders if there is some indication on monitor that cause people to ask this question.Very cooperative and calmintegumentary: pt is very thin.. skin intagrity is intact.EVENT: pt was seen by this RN at 0700. sbp 138/ 62 and hr 80's. Possibility of superimposed semi- invasive aspergillosis again remains as there is marked pleural thickening and cavitary changes in the upper lobes. positive bowel sounds no bm. Again seen is marked architectural distortion throughout both lungs, predominantly the upper and mid lung zones with dense fibrotic changes and volume loss consistent with pulmonary fibrosis, by report, likely secondary to sarcoidosis. CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: The pulmonary arteries appear opacified without evidence of pulmonary embolism. Mild [1+] TR. Bilateral increased interstitial opacities with fibrotic change in both upper lobes, superior retraction of both hila, and volume loss bilaterally are changes consistent with fibrotic sarcoidosis. Several parenchymal and pleural-based nodular opacities are again seen. (Over) 3:18 PM CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # Reason: evaluate for PE Admitting Diagnosis: ASTHA/COPD EXACERBATION Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Compared to prior study, there does appear to be some increase in poorly defined opacities distributed throughout the left lung, concerning for superimposed infection. COMPARISON: Chest radiograph and chest CTA from . He received ASA solumedrol, levofloxacin and combivent nebs x3. IMPRESSION: 1) Extensive fibrotic change secondary to sarcoidosis involving both upper lobes. cv: hr 80- no ectopy. COMPARISON: Chest CT from and chest radiograph from . New scattered foci of poorly defined opacities seen predominantly within the left lung, concerning for superimposed multifocal pneumonia. No interval change in the appearance of extensive fibrosis secondary to sarcoidosis within both upper lobes. The mitral valve leaflets are mildly thickened. breath sounds at time of event were diminished. sbp 130-160/resp: o2 at 2 l nc. 800cc emptied upon arrival.Neuro: Pt is awake alert, pleasant and cooperative. 3:18 PM CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # Reason: evaluate for PE Admitting Diagnosis: ASTHA/COPD EXACERBATION Field of view: 36 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 71 year old man with acute SOB REASON FOR THIS EXAMINATION: evaluate for PE No contraindications for IV contrast FINAL REPORT INDICATION: Acute shortness of breath, evaluate for pulmonary embolism. Limited views of the upper abdomen appear unremarkable. He was started on BiPAP w/ ABG 7.43/42/194. This RN went into room and pt very pale gasping for breath. pulled pt up in ed and elevated hob upright. Blunting of the costophrenic angles bilaterally is due to pleural thickening. Micu Nursing Admission Notes71 yo admitted with hx pulmonary fibrosis, sarcoidosis -dx w/ lung Bx, COPD; BPH; hypercholesterolemia; prthostatic hypotension.Allergies: NKDAPt was with several days of increasing dyspnea from baseline. Multiplanar reformatted images confirm the axial findings. o2 sats 93- 94 % on room air but with 2 l nc sats 96-98 %. His sat was ~ 93 %. 10:06 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for infiltrate, overload Admitting Diagnosis: ASTHA/COPD EXACERBATION MEDICAL CONDITION: 71 year old man with COPD and acute sob this AM REASON FOR THIS EXAMINATION: evaluate for infiltrate, overload FINAL REPORT INDICATION: COPD, fibrosing sarcoidosis, acute shortness of breath this morning. | 9 | [
{
"category": "Echo",
"chartdate": "2140-07-20 00:00:00.000",
"description": "Report",
"row_id": 95750,
"text": "PATIENT/TEST INFORMATION:\nIndication: LV function\nHeight: (in) 66\nWeight (lb): 112\nBSA (m2): 1.56 m2\nBP (mm Hg): 147/72\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 11:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Mild symmetric LVH.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The right ventricular cavity is mildly dilated. Right ventricular\nsystolic function appears depressed. The aortic valve leaflets (3) are mildly\nthickened. The mitral valve leaflets are mildly thickened. There is moderate\npulmonary artery systolic hypertension. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade. Echocardiographic signs of\ntamponade may be absent in the presence of elevated right sided pressures.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-07-20 00:00:00.000",
"description": "Report",
"row_id": 259323,
"text": "Sinus tachycardia\nModest right ventricular conduction delay pattern - may be normal variant\nSince previous tracing of , sinus tachycardia rate slower and modest\nright ventricular conduction delay pattern present\n\n"
},
{
"category": "ECG",
"chartdate": "2140-07-19 00:00:00.000",
"description": "Report",
"row_id": 259324,
"text": "Sinus tachycardia\nConsider right atrial abnormality\nIndeterminate QRS axis - is nonspecific\nSince previous tracing of 1-0604, ST-T wave changes decreased\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915762,
"text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for chf, pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sob\n REASON FOR THIS EXAMINATION:\n evaluate for chf, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, history of sarcoidosis.\n\n COMPARISON: Chest CT from and chest radiograph from .\n\n UPRIGHT AP VIEW OF THE CHEST: Increased interstitial opacities with superior\n retraction of the hila and elevation of the hemidiaphragms reflect fibrotic\n change from sarcoidosis. Additionally, increased pleural thickening with\n cavitary changes within both lung apices raises the possibility of\n superimposed semiinvasive aspergillosis. A small left pneumothorax persists.\n Blunting of the costophrenic angles bilaterally is due to pleural thickening.\n The heart is normal in size. Osseous structures are unremarkable.\n\n IMPRESSION:\n 1) Extensive fibrotic change secondary to sarcoidosis involving both upper\n lobes. Increasing pleural thickening and cavitary changes within the lung\n apices raise the possibility of superimposed semiinvasive aspergillosis.\n\n 2) Residual small left pneumothorax.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915894,
"text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, overload\n Admitting Diagnosis: ASTHA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with COPD and acute sob this AM\n\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, fibrosing sarcoidosis, acute shortness of breath this\n morning.\n\n COMPARISON: Chest radiograph and chest CTA from .\n\n UPRIGHT AP VIEW OF THE CHEST: There is no significant interval change in the\n appearance of the chest from the prior study. Bilateral increased\n interstitial opacities with fibrotic change in both upper lobes, superior\n retraction of both hila, and volume loss bilaterally are changes consistent\n with fibrotic sarcoidosis. Increased pleural thickening predominantly within\n the lung apices and areas of cavitation in the upper lobes suggest the\n presence of a superimposed semi- invasive aspergillosis infection. Cardiac and\n mediastinal contours are unchanged, and there is no evidence of pulmonary\n edema. No pneumothorax is present.\n\n IMPRESSION:\n\n 1. No interval change in the appearance of extensive fibrosis secondary to\n sarcoidosis within both upper lobes. Possibility of superimposed semi-\n invasive aspergillosis again remains as there is marked pleural thickening and\n cavitary changes in the upper lobes.\n\n 2. No pneumothorax identified and no significant interval change from the\n prior study.\n DFDdp\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-19 00:00:00.000",
"description": "Report",
"row_id": 1277585,
"text": "Micu Nursing Admission Notes\n71 yo admitted with hx pulmonary fibrosis, sarcoidosis -dx w/ lung Bx, COPD; BPH; hypercholesterolemia; prthostatic hypotension.\n\nAllergies: NKDA\n\nPt was with several days of increasing dyspnea from baseline. 4 days PTA he became progressively SOB with walking to hte bathroom from his bedroom - steps, even sleeping on the bathroom floor to save him the steps. He called his pulmonologist who prescribed a new inhaler but he did not improve. When he called his pulmonologist today he was told to come to the ER.\nIn the ER he was tachypnic to 40's, O2 sat on RA was 99%. He was started on BiPAP w/ ABG 7.43/42/194. He received ASA solumedrol, levofloxacin and combivent nebs x3. He received a CT of chest before coming to the MICU for further management.\n\nReview of systems: Pt arrived on floor on 100% NRB RR 24. He was weaned to 100% cool face tent with O2 sats 100%, then 2l NC. O2 sats were 95-96% on the 2l.\n\nCardiac: B/P 130-145/70's, HR 100-110 ST, with occasional PVC's.\n\nGI: Able to eat regular diet dinner without difficulty. Abd soft and non-tender, (+) BS.\n\nGU: Foley draining light yellow urine. Pt received lasix 40mg from the EMT's and he continued to diurese from that. 800cc emptied upon arrival.\n\nNeuro: Pt is awake alert, pleasant and cooperative. He has a steady gait and moves around the bed independently.\n\nID: Pt is afebrile with WBC's 23.9 (no bands) He received levofloxacin 500mg in the ER.\n\nSocial: Pt was found in an very cluttered apartment, when they went to transport him out of the apartment they could not get him out, they had to break a window due the clutter. Social service was contact and his apartment has been condemned. He has 2 brothers, is next of -.\n\nPlan: Monitor resp status, monitor I&O, probably C/O in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-20 00:00:00.000",
"description": "Report",
"row_id": 1277586,
"text": "cv: hr 80- no ectopy. sbp 130-160/\n\nresp: o2 at 2 l nc. o2 sats 93- 94 % on room air but with 2 l nc sats 96-98 %. breath sounds clear bilateral.\n\ngi: pt eating and snacking throughout the night, bananas, toast. positive bowel sounds no bm. pt is very thin.\n\ngu: foley draining clear yellow urine~ 40 cc/hr most of night.,.past few hours 4a-7A pt made 80cc over 3 hours.\n\nmental status: alert and oriented. pt asks many questions. PT often wonders Why people are asking certain questions like \" How is your breathing\" pt wonders if there is some indication on monitor that cause people to ask this question.Very cooperative and calm\n\nintegumentary: pt is very thin.. skin intagrity is intact.\n\nEVENT: pt was seen by this RN at 0700. sbp 138/ 62 and hr 80's. o2 sat 95%. At ~ 0705 hr alarm rang hr increased to 120 and sbp up 220/. This RN went into room and pt very pale gasping for breath. pt hob was at a 30 degree angle. pulled pt up in ed and elevated hob upright. ekg done, albuterol tx given by resp. breath sounds at time of event were diminished. AFter albuterol .. breath sounds improved. Of note pt did not seem to be aware of his distress initially .. he did not call for help he was just lying there gasping and was pale. His sat was ~ 93 %.\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-19 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 915798,
"text": " 3:18 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: ASTHA/COPD EXACERBATION\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with acute SOB\n REASON FOR THIS EXAMINATION:\n evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute shortness of breath, evaluate for pulmonary embolism.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired axial images of the chest were obtained with and\n without IV contrast. Multiplanar reformatted images were also displayed.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: The pulmonary arteries appear\n opacified without evidence of pulmonary embolism. Again seen is marked\n architectural distortion throughout both lungs, predominantly the upper and\n mid lung zones with dense fibrotic changes and volume loss consistent with\n pulmonary fibrosis, by report, likely secondary to sarcoidosis. Again seen is\n elevation of both hila. The previously seen small left-sided pneumothorax\n appears to have resolved. Several parenchymal and pleural-based nodular\n opacities are again seen. Compared to prior study, there does appear to be\n some increase in poorly defined opacities distributed throughout the left\n lung, concerning for superimposed infection. Again seen are enlarged\n mediastinal and hilar lymph nodes, many of which appear calcified, not\n significantly changed from prior study. Limited views of the upper abdomen\n appear unremarkable.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. New scattered foci of poorly defined opacities seen predominantly within\n the left lung, concerning for superimposed multifocal pneumonia.\n 3. Extensive fibrotic and architectural distortion within both lungs, not\n significantly changed from prior study, consistent with history of pulmonary\n fibrosis.\n 4. Interval improvement of small left-sided pneumothorax.\n\n Discussed with Dr. following completion of study.\n (Over)\n\n 3:18 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: ASTHA/COPD EXACERBATION\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-20 00:00:00.000",
"description": "Report",
"row_id": 1277587,
"text": "See Transfer note\n"
}
] |
95,782 | 131,544 | 73 yo man with CAD, PVD, valvular heart dz s/p bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who presents with melena and symptomatic anemia. Stabilized with transfusions and bleeding stopped. No sources found on upper or lower scopes. Patient was bridged on coumadin for high risk afib (CHADS 4), and then discharged home with follow up for outpatient capsule endoscopy. . # GI bleeding: Given his history of melena for 3-4 days prior to admission, upper source was suspected. His anticoagulation was reversed with 5 mg of PO vitamin K. He was transfused a total of 3 U FFP and 4 U PRBC in the ED/MICU. His INR trended down to 1.3 and his HCT came up to 28 and stablized. By AM after admission, patient felt much better and an EGD showed no obvious source of bleeding. He had a colonoscopy that was unrevealing of any source. His hct remained stable and he had normal stools that were guiac negative. A CT scan showed no arterio-enteric fistulas. Plan is for outpatient capsule endoscopy. . # CAD: Patient has no stents. No recent angina. BB and ASA held initially. Restarted once on the floor and BP was stable and patient stopped bleeding. . # Atrial fibrillation: rate controlled, anticoagulation reversed as above. After colonoscopy and when hct had stabalized, heparin gtt was started and coumadin was restarted. His INR was trended daily and the heparin was stopped and when his INR was 2.0 on the day of discharge. He was sent home on his usual regimen on 3 mg, 3 mg, 1.5 mg cycle. He will have his INR checked the day after discharge and follow up with his PCP. . # h/o CHF with Valvular heart disease: s/p bioprosthetic AVR & MVR. Clinically, he appears euvolemic after transfusions. Lisinopril & BB were held initially given hypotension, but then restarted on the floor. He was on 20 lasix at home, which was also held initially. He developed some mild pedal edema and lasix 40 mg was given for 2 days and then he was discharged on his home does. He had no pedal edema on discharge. . # h/o stroke/carotid disease: stable, anticoagulated as above, no changes to regimen. . # emphesema: continued home inhalers. . # OSA: should be evaluated for CPAP as an outpatient. . # AV fistula: on CT scan, a known AV fistula was seen again in his R groin. Has been present since after cath in . Was initially seen by vascular surgery at that time and no intervention was needed. An email was sent to both the cardiologist who did that cath and the vascular surgeon who had evaluated him in that it was still present. As he was asymptomatic, it was decided that he could have outpatient follow up and probably would not need an intervention unless symptoms changed. | - hold lisinopril & BB given hypotension . - hold lisinopril & BB given hypotension . - Holding lisinopril & BB given hypotension . - Holding lisinopril & BB given hypotension . # PPX: pneumoboots, IV PPI . # PPX: pneumoboots, IV PPI . NG lavage in ED negative. Taking coumadin for a-fib, elevated INR, reversed with Vit k in ED. Taking coumadin for a-fib, elevated INR, reversed with Vit k in ED. Taking coumadin for a-fib, elevated INR, reversed with Vit k in ED. On coumadin for a-fib. On coumadin for a-fib. - hold ASA - hold BB in setting of hypotension & bleeding. - hold ASA - hold BB in setting of hypotension & bleeding. # GI bleeding: Most likely upper source given melena. # GI bleeding: Most likely upper source given melena. appears euvolemic. appears euvolemic. Appears euvolemic. Appears euvolemic. Txd with Vit K, Fluid, FFP. Appears slightly volume overloaded after transfusions with elevated JVP but maintaining O2 sats. Appears slightly volume overloaded after transfusions with elevated JVP but maintaining O2 sats. VS stable in MICU with BP 132/72, Pulse 78, 95% on RA Cor- sys murmur Lungs- Clear Abd = soft BS active No edema Labs signif for nl creat WBC 7.7 Afib on EKG Plan: Differential as above. # Atrial fibrillation: rate controlled. # Atrial fibrillation: rate controlled. # Atrial fibrillation: Rate controlled. # Atrial fibrillation: Rate controlled. # Atrial fibrillation: Rate controlled. # Atrial fibrillation: Rate controlled. Check orthostatic Bp Last Hct 24.4 (after 2 units PRBCs). Last Hct 24.4 (after 2 units PRBCs). stool guiac +, NG lavage negative. stool guiac +, NG lavage negative. ------ Protected Section Addendum Entered By: , MD on: 00:19 ------ Of note, in he had a similar episode of GI bleding and had upper and lower endoscopy at SHH. Of note, in he had a similar episode of GI bleding and had upper and lower endoscopy at SHH. hold anticoagulation. hold anticoagulation. Hold anticoagulation. Hold anticoagulation. Hold anticoagulation. Hold anticoagulation. Most recent c Diff toxin negative, Occ lighthededness and fatiue but no CP, SOB, nausea, vomiting. S/p 4 units with appropriate bump in Hct... - F/u post-txn Hct, coags - Maintain active T&C - Q4 hour Hct - IV PPI - GI to scope today; will likely need C-scope as well - Holding ASA and Coumadin . S/p 4 units with appropriate bump in Hct... - F/u post-txn Hct, coags - Maintain active T&C - Q4 hour Hct - IV PPI - GI to scope today; will likely need C-scope as well - Holding ASA and Coumadin . In MICU Hct noted to be 19.8 w/o further melena. Hold cardiac meds for the moment. Transfused o/n with 4 units PRBCs and 3 units FFP. Transfused o/n with 4 units PRBCs and 3 units FFP. - Holding ASA - Holding BB in setting of hypotension & bleeding. - Holding ASA - Holding BB in setting of hypotension & bleeding. Last Hct 29. Last Hct 29. # GI bleeding: S/p 4 units. # GI bleeding: S/p 4 units. - Holding ASA - Holding BB and ACE in setting of hypotension & bleeding. - Holding ASA - Holding BB and ACE in setting of hypotension & bleeding. - last echo in OMR # s/p aortic valve replacement and mitral valve replacement with tissue valves on for moderate aortic stenosis with a valve area of .2 cm, 2+ aortic regurgitation # CAD s/p MI in 12/. - last echo in OMR # s/p aortic valve replacement and mitral valve replacement with tissue valves on for moderate aortic stenosis with a valve area of .2 cm, 2+ aortic regurgitation # CAD s/p MI in 12/. Bilateral pleural effusions with compression atelectasis. (Over) 4:58 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: evaluate for any arterio-enteric fistula that could be cause Admitting Diagnosis: UPPER GI BLEED Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) CT PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST: The urinary bladder, seminal vesicles, rectum, sigmoid colon are unremarkable. Trace pelvic ascites. - reverse anticoagulation with 5mg po vitamin K + FFP - transfuse 4U pRBCs - type & cross 4 U - q 4 hour hct - IV PPI - GI to scope from above in AM. - reverse anticoagulation with 5mg po vitamin K + FFP - transfuse 4U pRBCs - type & cross 4 U - q 4 hour hct - IV PPI - GI to scope from above in AM. - Holding lisinopril & BB given hypotension # H/o stroke/carotid disease: Stable # Emphysema: Continue home nebulizers # OSA: Should be evaluated for CPAP as an outpatient ICU Care Nutrition: NPO->AD to clears today and then NPO at MN for c-scope in am Glycemic Control: None Lines: 18 Gauge - 12:25 AM Prophylaxis: DVT: Pneumoboots; anticoagulated on coumadin on admission now being held Stress ulcer: IV PPI Communication: Comments: With pt status: Full Disposition: If HCt stable this pm will transfer to floor ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. | 12 | [
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 681695,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Hct 19.8 on arrival. Received 2 units of blood with Hct bump to 24.4.\n Received add'l 2 units of blood.\n - Received vitamin K 5mg po and 3 units of FFP for INR 3 with decrease\n to 1.6 after 2nd unit.\n - No further melena.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 80 (72 - 91) bpm\n BP: 121/66(80) {82/39(51) - 123/66(80)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 346 mL\n 3,922 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n 346 mL\n 1,912 mL\n Total out:\n 0 mL\n 675 mL\n Urine:\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 346 mL\n 3,247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, NAD\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic. JVP slightly elevated after\n transfusion.\n Cardiovascular: S1-S2 nl, +systolic murmur\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Non-distended, Bowel sounds present\n Extremities: No edema\n Skin: Warm\n Neurologic: AAO x 3\n Labs / Radiology\n 196 K/uL\n 8.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 112 mEq/L\n 142 mEq/L\n 24.4 %\n 7.7 K/uL\n [image002.jpg]\n 10:57 PM\n 02:27 AM\n WBC\n 7.7\n 7.7\n Hct\n 19.8\n 24.4\n Plt\n 200\n 196\n Cr\n 0.8\n Glucose\n 95\n Other labs: PT / PTT / INR:18.0/28.8/1.6, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: S/p 4 units. EGD negative. have slow lower GIB vs\n small bowel bleed.\n - Maintain active T&C\n - Q4 hour Hct\n - IV PPI \n - GI did EGD and found no source of bleeding. C-scope tomorrow. If\n negative small bowel study.\n - Holding ASA and Coumadin\n - F/U GI recs\n # CAD: No stents. No recent angina.\n - Holding ASA\n - Holding BB and ACE in setting of hypotension & bleeding.\n # Atrial fibrillation: Rate controlled. Hold anticoagulation. Monitor\n on telemetry\n # H/o CHF with valvular heart disease: S/p bioprosthetic AVR & MRV.\n Appears slightly volume overloaded after transfusions with elevated JVP\n but maintaining O2 sats.\n - Holding lisinopril & BB given hypotension\n # H/o stroke/carotid disease: Stable\n # Emphysema: Continue home nebulizers\n # OSA: Should be evaluated for CPAP as an outpatient\n ICU Care\n Nutrition: NPO->AD to clears today and then NPO at MN for c-scope in am\n Glycemic Control: None\n Lines:\n 18 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Pneumoboots; anticoagulated on coumadin on admission now being\n held\n Stress ulcer: IV PPI \n Communication: Comments: With pt\n status: Full\n Disposition: If HCt stable this pm will transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 681589,
"text": "Chief Complaint: melena\n HPI:\n Patient is a 73 y/o M hx aortic stenosis, afib on coumadin, h/o GI\n bleeding who is admitted to the MICU with 4 days black stools, \n stools per day. He endorses weakness/light-headedness, he also\n endorsed some mild abdominal pain a few days ago. this has resolved.\n He does not have nausea/vomiting, fevers, chills, LE edema. Denies\n EtOH or ibuprofen. His PCP checked his HCT which was found to be 6\n points lower than baseline (26 down from 33) & INR 3.0, so he was\n referred to the ED. Of note, in he had a similar episode of GI\n bleding and had upper and lower endoscopy at SHH. the patient believes\n that no source of bleeding was found.\n .\n In the ED his presenting vitals were: BP was 102/50, HR 73, AF 98.4,\n 99% on Ra. stool guiac +, NG lavage negative. He was given 2L IVF,\n 5mg IV vitamin K, and 40mg IV protonix & was consented for 2U blood, 2U\n FFP.\n .\n In the ICU he feels fatigued. He denies CP, dyspnea, LH currently. He\n has had 3 episodes of melena today, none since being at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n home meds\n ALBUTEROL SULFATE (not taking)\n FLUTICASONE-SALMETEROL 500 mcg-50 mcg (not taking) inhaled twice a day\n FUROSEMIDE - 40mg po daily\n LISINOPRIL - 2.5 mg po daily\n LORAZEPAM - 1 mg prn\n METOPROLOL TARTRATE 25mg po daily\n NITROGLYCERIN - prn (not needed)\n SIMVASTATIN 40mg po daily\n WARFARIN - 1.5mg po daily\n Medications - OTC\n ASPIRIN - 81 mg Tablet daily (not taking for past 5 days)\n FERROUS SULFATE - (not taking)\n Past medical history:\n Family history:\n Social History:\n # afib on coumadin\n # Rheumatic heart disease with moderate aortic stenosis, aortic\n regurgitation, mitral regurgitation and right atrial pressure.\n - last echo in OMR \n # s/p aortic valve replacement and mitral valve replacement with tissue\n valves on for moderate aortic stenosis with a valve\n area of .2 cm, 2+ aortic regurgitation\n # CAD s/p MI in 12/. Had cath but no angioplasty or stents. No\n angina.\n # Emphysema: asbestos exposure\n # CKD baseline Cr 1.3-1.5\n # h/o congestive hepatopathy\n # OSA\n # Peripheral vascular disease status post carotid endarterectomy\n # Recent left body stroke\n # Cough\n # s/p GI bleed with melena; ?etiology\n # prostate CA s/p radiation\n # Carotid stenosis s/p L CEA in \n The patient has 9 children by his first wife who is deceased. He has\n been married to his current wife for 4 years. He is a retired\n firefighter for 30 years and for the early years of fighting fires, he\n often did not wear a mask. He smoked a quarter of a pack a day for 20\n years, but quit 27-years-ago. He was, in fact, exposed to asbestos in\n his job as a firefighter. He does not drink.\n Occupation: retired fireman\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 11:32 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 86 (85 - 88) bpm\n BP: 123/59(75) {123/59(75) - 123/59(75)} mmHg\n RR: 14 (13 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 152 mL\n PO:\n TF:\n IVF:\n Blood products:\n 152 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 152 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): 3,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 200 K/uL\n 6.6 g/dL\n 19.8 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A6/15/ 10:57 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 19.8\n Plt\n 200\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: most likley upper source given melena. Many etiologies\n are possible, including angioectasias (bleeding is painless), or peptic\n ulcer disease, or variceal bleed (given h/o congestive hepatopathy).\n Patient quite anemic with hct of 20.\n - reverse anticoagulation with 5mg po vitamin K + FFP\n - transfuse 4U pRBCs\n - type & cross 4 U\n - q 4 hour hct\n - IV PPI \n - GI to scope from above in AM. Will need C-scope as well.\n - hold ASA\n .\n # CAD: No stents. No recent angina.\n - hold ASA\n - hold BB in setting of hypotension & bleeding.\n .\n # Atrial fibrillation: rate controlled. hold anticoagulation.\n telemetry\n .\n # h/o CHF with Valvular heart disease: s/p bioprosthetic AVR & MRV.\n appears euvolemic.\n - hold lisinopril & BB given hypotension\n .\n # h/o stroke/carotid disease: stable\n .\n # emphesema: continue nebulizers\n .\n # OSA: should be evaluated for CPAP as an outpatient\n .\n # FEN/GI: NPO for scope. PPI . hold lasix.\n .\n # PPX: pneumoboots, IV PPI\n .\n # Access: 2 18-guage PIV's.\n .\n # Code: full\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines: 2 18-guage PIV\n Prophylaxis:\n DVT: anticoagulated; pneumoboots\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 681590,
"text": "Chief Complaint: melena\n HPI:\n Patient is a 73 y/o M hx aortic stenosis, afib on coumadin, h/o GI\n bleeding who is admitted to the MICU with 4 days black stools, \n stools per day. He endorses weakness/light-headedness, he also\n endorsed some mild abdominal pain a few days ago. this has resolved.\n He does not have nausea/vomiting, fevers, chills, LE edema. Denies\n EtOH or ibuprofen. His PCP checked his HCT which was found to be 6\n points lower than baseline (26 down from 33) & INR 3.0, so he was\n referred to the ED. Of note, in he had a similar episode of GI\n bleding and had upper and lower endoscopy at SHH. the patient believes\n that no source of bleeding was found.\n .\n In the ED his presenting vitals were: BP was 102/50, HR 73, AF 98.4,\n 99% on Ra. stool guiac +, NG lavage negative. He was given 2L IVF,\n 5mg IV vitamin K, and 40mg IV protonix & was consented for 2U blood, 2U\n FFP.\n .\n In the ICU he feels fatigued. He denies CP, dyspnea, LH currently. He\n has had 3 episodes of melena today, none since being at .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n home meds\n ALBUTEROL SULFATE (not taking)\n FLUTICASONE-SALMETEROL 500 mcg-50 mcg (not taking) inhaled twice a day\n FUROSEMIDE - 40mg po daily\n LISINOPRIL - 2.5 mg po daily\n LORAZEPAM - 1 mg prn\n METOPROLOL TARTRATE 25mg po daily\n NITROGLYCERIN - prn (not needed)\n SIMVASTATIN 40mg po daily\n WARFARIN - 1.5mg po daily\n Medications - OTC\n ASPIRIN - 81 mg Tablet daily (not taking for past 5 days)\n FERROUS SULFATE - (not taking)\n Past medical history:\n Family history:\n Social History:\n # afib on coumadin\n # Rheumatic heart disease with moderate aortic stenosis, aortic\n regurgitation, mitral regurgitation and right atrial pressure.\n - last echo in OMR \n # s/p aortic valve replacement and mitral valve replacement with tissue\n valves on for moderate aortic stenosis with a valve\n area of .2 cm, 2+ aortic regurgitation\n # CAD s/p MI in 12/. Had cath but no angioplasty or stents. No\n angina.\n # Emphysema: asbestos exposure\n # CKD baseline Cr 1.3-1.5\n # h/o congestive hepatopathy\n # OSA\n # Peripheral vascular disease status post carotid endarterectomy\n # Recent left body stroke\n # Cough\n # s/p GI bleed with melena; ?etiology\n # prostate CA s/p radiation\n # Carotid stenosis s/p L CEA in \n The patient has 9 children by his first wife who is deceased. He has\n been married to his current wife for 4 years. He is a retired\n firefighter for 30 years and for the early years of fighting fires, he\n often did not wear a mask. He smoked a quarter of a pack a day for 20\n years, but quit 27-years-ago. He was, in fact, exposed to asbestos in\n his job as a firefighter. He does not drink.\n Occupation: retired fireman\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 11:32 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 86 (85 - 88) bpm\n BP: 123/59(75) {123/59(75) - 123/59(75)} mmHg\n RR: 14 (13 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 152 mL\n PO:\n TF:\n IVF:\n Blood products:\n 152 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 152 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to): 3,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 200 K/uL\n 6.6 g/dL\n 19.8 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A6/15/ 10:57 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 19.8\n Plt\n 200\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: most likley upper source given melena. Many etiologies\n are possible, including angioectasias (bleeding is painless), or peptic\n ulcer disease, or variceal bleed (given h/o congestive hepatopathy).\n Patient quite anemic with hct of 20.\n - reverse anticoagulation with 5mg po vitamin K + FFP\n - transfuse 4U pRBCs\n - type & cross 4 U\n - q 4 hour hct\n - IV PPI \n - GI to scope from above in AM. Will need C-scope as well.\n - hold ASA\n .\n # CAD: No stents. No recent angina.\n - hold ASA\n - hold BB in setting of hypotension & bleeding.\n .\n # Atrial fibrillation: rate controlled. hold anticoagulation.\n telemetry\n .\n # h/o CHF with Valvular heart disease: s/p bioprosthetic AVR & MRV.\n appears euvolemic.\n - hold lisinopril & BB given hypotension\n .\n # h/o stroke/carotid disease: stable\n .\n # emphesema: continue nebulizers\n .\n # OSA: should be evaluated for CPAP as an outpatient\n .\n # FEN/GI: NPO for scope. PPI . hold lasix.\n .\n # PPX: pneumoboots, IV PPI\n .\n # Access: 2 18-guage PIV's.\n .\n # Code: full\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines: 2 18-guage PIV\n Prophylaxis:\n DVT: anticoagulated; pneumoboots\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: ICU\n ------ Protected Section ------\n 73 yr man with afib on coumadin, aortic, MV replacement with\n bioprotheses, hx of GI bleed of unknown cause now with 4 days of\n melena.\n MID GASTRIC PAIN SEVERAL DAYS AGO WHICH RESOLVED. Has had several bouts\n of C Diff Colitis since discharge in . Most recent c Diff toxin\n negative,\n Occ lighthededness and fatiue but no CP, SOB, nausea, vomiting. Hct 33\n to 26. to ED.\n Hct 26 in ED with INR of 3.9, plats 260K. NG lavage in ED negative.\n GI recommended admit MICU for endo tomorrow.\n Tx\nd with Vit K, Fluid, FFP.\n In MICU Hct noted to be 19.8 w/o further melena.\n PMH outlined in note above.\n VS stable in MICU with BP 132/72, Pulse 78, 95% on RA\n Cor- sys murmur\n Lungs- Clear\n Abd = soft BS active\n No edema\n Labs signif for nl creat\n WBC 7.7\n Afib on EKG\n Plan:\n Differential as above. Angiodysplastic lesions are a possibility.\n Transfusing 4 units overnight with 2 units FFP, third pending with\n plans for endoscopy in AM\n Repeat C Diff toxins\n Hold beta blocker, ACE lasix for now\n 45 min spent evaluating, discussing case with HO\ns, examining patient\n and developing plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:19 ------\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 681658,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Hct 19.8 on arrival. Received 2 units of blood with Hct bump to 24.4.\n Received add'l 2 units of blood.\n - Given 3 units of FFP for INR 3 with decrease to 1.6 after 2nd unit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 80 (72 - 91) bpm\n BP: 121/66(80) {82/39(51) - 123/66(80)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 346 mL\n 3,922 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n 346 mL\n 1,912 mL\n Total out:\n 0 mL\n 675 mL\n Urine:\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 346 mL\n 3,247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 196 K/uL\n 8.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 112 mEq/L\n 142 mEq/L\n 24.4 %\n 7.7 K/uL\n [image002.jpg]\n 10:57 PM\n 02:27 AM\n WBC\n 7.7\n 7.7\n Hct\n 19.8\n 24.4\n Plt\n 200\n 196\n Cr\n 0.8\n Glucose\n 95\n Other labs: PT / PTT / INR:18.0/28.8/1.6, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ACTIVITY INTOLERANCE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:25 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 681661,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Hct 19.8 on arrival. Received 2 units of blood with Hct bump to 24.4.\n Received add'l 2 units of blood.\n - Received vitamin K 5mg po and 3 units of FFP for INR 3 with decrease\n to 1.6 after 2nd unit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 80 (72 - 91) bpm\n BP: 121/66(80) {82/39(51) - 123/66(80)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 346 mL\n 3,922 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n 346 mL\n 1,912 mL\n Total out:\n 0 mL\n 675 mL\n Urine:\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 346 mL\n 3,247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, NAD\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: S1-S2 nl, +systolic murmur\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Non-distended, Bowel sounds present\n Extremities: No edema\n Skin: Warm\n Neurologic: AAO x 3\n Labs / Radiology\n 196 K/uL\n 8.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 112 mEq/L\n 142 mEq/L\n 24.4 %\n 7.7 K/uL\n [image002.jpg]\n 10:57 PM\n 02:27 AM\n WBC\n 7.7\n 7.7\n Hct\n 19.8\n 24.4\n Plt\n 200\n 196\n Cr\n 0.8\n Glucose\n 95\n Other labs: PT / PTT / INR:18.0/28.8/1.6, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: Most likely upper source given melena. Many etiologies\n are possible, including angioectasias (bleeding is painless), or peptic\n ulcer disease, or variceal bleed (given h/o congestive hepatopathy).\n Patient quite anemic with Hct of 20 and symptomatic. S/p 4 units with\n appropriate bump in Hct...\n - F/u post-txn Hct, coags\n - Maintain active T&C\n - Q4 hour Hct\n - IV PPI \n - GI to scope today; will likely need C-scope as well\n - Holding ASA and Coumadin\n .\n # CAD: No stents. No recent angina.\n - Holding ASA\n - Holding BB in setting of hypotension & bleeding.\n .\n # Atrial fibrillation: Rate controlled. Hold anticoagulation. Monitor\n on telemetry\n .\n # H/o CHF with valvular heart disease: S/p bioprosthetic AVR & MRV.\n Appears euvolemic.\n - Holding lisinopril & BB given hypotension\n .\n # H/o stroke/carotid disease: Stable\n .\n # Emphesema: Continue home nebulizers\n .\n # OSA: Should be evaluated for CPAP as an outpatient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Pneumoboots; anticoagulated on coumadin on admission now being\n held\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments: With pt\n status: Full\n Disposition: ICU pending EGD and stable Hct\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 681662,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Hct 19.8 on arrival. Received 2 units of blood with Hct bump to 24.4.\n Received add'l 2 units of blood.\n - Received vitamin K 5mg po and 3 units of FFP for INR 3 with decrease\n to 1.6 after 2nd unit.\n - No further melena.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 80 (72 - 91) bpm\n BP: 121/66(80) {82/39(51) - 123/66(80)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 346 mL\n 3,922 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n 346 mL\n 1,912 mL\n Total out:\n 0 mL\n 675 mL\n Urine:\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 346 mL\n 3,247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, NAD\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: S1-S2 nl, +systolic murmur\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Non-distended, Bowel sounds present\n Extremities: No edema\n Skin: Warm\n Neurologic: AAO x 3\n Labs / Radiology\n 196 K/uL\n 8.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 112 mEq/L\n 142 mEq/L\n 24.4 %\n 7.7 K/uL\n [image002.jpg]\n 10:57 PM\n 02:27 AM\n WBC\n 7.7\n 7.7\n Hct\n 19.8\n 24.4\n Plt\n 200\n 196\n Cr\n 0.8\n Glucose\n 95\n Other labs: PT / PTT / INR:18.0/28.8/1.6, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: Most likely upper source given melena. Many etiologies\n are possible, including angioectasias (bleeding is painless), or peptic\n ulcer disease, or variceal bleed (given h/o congestive hepatopathy).\n Patient quite anemic with Hct of 20 and symptomatic. S/p 4 units with\n appropriate bump in Hct...\n - F/u post-txn Hct, coags\n - Maintain active T&C\n - Q4 hour Hct\n - IV PPI \n - GI to scope today; will likely need C-scope as well\n - Holding ASA and Coumadin\n .\n # CAD: No stents. No recent angina.\n - Holding ASA\n - Holding BB in setting of hypotension & bleeding.\n .\n # Atrial fibrillation: Rate controlled. Hold anticoagulation. Monitor\n on telemetry\n .\n # H/o CHF with valvular heart disease: S/p bioprosthetic AVR & MRV.\n Appears euvolemic.\n - Holding lisinopril & BB given hypotension\n .\n # H/o stroke/carotid disease: Stable\n .\n # Emphesema: Continue home nebulizers\n .\n # OSA: Should be evaluated for CPAP as an outpatient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Pneumoboots; anticoagulated on coumadin on admission now being\n held\n Stress ulcer: IV PPI \n VAP:\n Comments:\n Communication: Comments: With pt\n status: Full\n Disposition: ICU pending EGD and stable Hct\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681623,
"text": "Pt is a 73 yr old with complaints of dark stools x 4 days ; instructed\n by PCP to go to ED for workup. Taking coumadin for a-fib, elevated INR,\n reversed with Vit k in ED. Pmhx: aortic/mitral valve replacement ;\n MI ; stroke/?TIA to left side ; CHF, c-diff, pneumonia, PVD-\n carotid endartectomy, emphysema d/t asbestos exposure, GIB, prostate CA\n with Rad tx, rheumatic heart disease.\n Arrived to MICU with second unit FFP infusing. Received an additional 1\n unit FFP and 4 units PRBC. Admitting HCt in ED was 26; repeat prior to\n any PRBC 19 in MICU. Given 2 units with increased HCt to 24.4; given\n additional 2 units with next Hct due 1 hour after 4^th unit completed.\n Slept poorly d/t freq interruptions, pt has no complaints or\n discomforts. No stool overnight. Voiding without difficulty via\n urinal.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Reported 4 days black stools at home. On coumadin for a-fib\n Action:\n Pt monitored for s/s bleeding; transfused with total 4unit PRBC and 3\n FFP\n Response:\n Tol transfusion. Vital signs stable, hypotensive 80\ns/50-60\ns. pt\n baseline reported at 130\n Plan:\n Repeat hct at 8am. ?plans to scope. Assess s/s bleeding. GAS\n Activity Intolerance\n Assessment:\n Complaints of increased weakness/fatigue at home with inability to\n complete normal ADLs\n Action:\n BR maintained overnight; oxygen at 2L nc; assisted with position\n changes.\n Response:\n Slept intermittently\n Plan:\n OOB to chair as tolerated with assist. Advance activity slowly. Check\n orthostatic Bp\n"
},
{
"category": "Physician ",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 681742,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Hct 19.8 on arrival. Received 2 units of blood with Hct bump to 24.4.\n Received add'l 2 units of blood.\n - Received vitamin K 5mg po and 3 units of FFP for INR 3 with decrease\n to 1.6 after 2nd unit.\n - No further melena.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.6\n HR: 80 (72 - 91) bpm\n BP: 121/66(80) {82/39(51) - 123/66(80)} mmHg\n RR: 16 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 346 mL\n 3,922 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n 346 mL\n 1,912 mL\n Total out:\n 0 mL\n 675 mL\n Urine:\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 346 mL\n 3,247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n General Appearance: Thin, NAD\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic. JVP slightly elevated after\n transfusion.\n Cardiovascular: S1-S2 nl, +systolic murmur\n Respiratory / Chest: CTA b/l\n Abdominal: Soft, Non-tender, Non-distended, Bowel sounds present\n Extremities: No edema\n Skin: Warm\n Neurologic: AAO x 3\n Labs / Radiology\n 196 K/uL\n 8.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 112 mEq/L\n 142 mEq/L\n 24.4 %\n 7.7 K/uL\n [image002.jpg]\n 10:57 PM\n 02:27 AM\n WBC\n 7.7\n 7.7\n Hct\n 19.8\n 24.4\n Plt\n 200\n 196\n Cr\n 0.8\n Glucose\n 95\n Other labs: PT / PTT / INR:18.0/28.8/1.6, Ca++:7.9 mg/dL, Mg++:2.1\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 73 yo man with CAD, PVD, valvular heart dz s/p\n bioprosthetic AVR and MRV, on coumadin for atrial fibrillation who\n presents with melena and symptomatic anemia.\n .\n # GI bleeding: S/p 4 units. EGD negative. have slow lower GIB vs\n small bowel bleed.\n - Maintain active T&C\n - Q4 hour Hct\n - IV PPI \n - GI did EGD and found no source of bleeding. C-scope tomorrow. If\n negative small bowel study.\n - Holding ASA and Coumadin\n - F/U GI recs\n # CAD: No stents. No recent angina.\n - Holding ASA\n - Holding BB and ACE in setting of hypotension & bleeding.\n # Atrial fibrillation: Rate controlled. Hold anticoagulation. Monitor\n on telemetry\n # H/o CHF with valvular heart disease: S/p bioprosthetic AVR & MRV.\n Appears slightly volume overloaded after transfusions with elevated JVP\n but maintaining O2 sats.\n - Holding lisinopril & BB given hypotension\n # H/o stroke/carotid disease: Stable\n # Emphysema: Continue home nebulizers\n # OSA: Should be evaluated for CPAP as an outpatient\n ICU Care\n Nutrition: NPO->AD to clears today and then NPO at MN for c-scope in am\n Glycemic Control: None\n Lines:\n 18 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Pneumoboots; anticoagulated on coumadin on admission now being\n held\n Stress ulcer: IV PPI \n Communication: Comments: With pt\n status: Full\n Disposition: If HCt stable this pm will transfer to floor\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M DM, CAD, AF/CVA on coumadin, RHD s/p\n bioprosthetic AVR/MVR, prior GIB p/w HCT 20 and INR 3. NGL negative.\n HCT up to 28 s/p 4 units of PRBCs. INR 1.3 after 3 units FFP.\n Exam notable for Tm 98.5 BP 110/60 HR 80 RR 16 with sat 99 on 2LNC. WD\n man, NAD. Irreg s1s2. CTA B. Soft +BS. No edema. Labs notable for WBC\n 7K, HCT 20, K+ 3.9, Cr 0.8.\n Agree with plan to manage GIB / blood loss anemia with serial HCT q8h,\n xfusion to HCT >25%, IV PPI . GI consult appreciated, will prep for\n colonoscopy overnight if stable. Hold cardiac meds for the moment. For\n AF / CVA, will need to hold coumadin until bleeding source is\n clarified. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:14 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 681735,
"text": "Pt is a 73 yr old with complaints of dark stools x 4 days ; instructed\n by PCP to go to ED for workup. Taking coumadin for a-fib, elevated INR,\n reversed with Vit k in ED. Pmhx: aortic/mitral valve replacement ;\n MI ; stroke/?TIA to left side ; CHF, c-diff, pneumonia, PVD-\n carotid endartectomy, emphysema d/t asbestos exposure, GIB, prostate CA\n with Rad tx, rheumatic heart disease.\n Arrived to MICU with second unit FFP infusing. Received an additional 1\n unit FFP and 4 units PRBC. Admitting HCt in ED was 26; repeat prior to\n any PRBC 19 in MICU. Given 2 units with increased HCt to 24.4; given\n additional 2 units with next Hct 28. Slept poorly d/t freq\n interruptions, pt has no complaints or discomforts. Voiding without\n difficulty via urinal.\n Dispo: FULL code\n Allergies: NKDA\n Access: 2 piv\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Reported 4 days black stools at home. On coumadin for a-fib.\n Transfused o/n with 4 units PRBCs and 3 units FFP. Last Hct 24.4\n (after 2 units PRBCs). NBPs this shift ranging 104-140s/50-60s. Pt\n with 1 stool- soft/formed black GUIAIC positive this shift.\n Action:\n Pt monitored for s/s bleeding; EGD this AM, pt rec\nd 2 mg versed ivp\n and 50mcg ivp fentanyl for procedure, uneventful.\n Response:\n EGD negative. Vital signs stable. Last Hct 29.\n Plan:\n Follow hct, with next due at 1800. Plan is for golytely prep tonight\n beginning at about 1900, pt NPO once prep has begun. Plan for\n colonoscopy in AM. Assess s/s bleeding. GUIAIC all stools.\n Activity Intolerance\n Assessment:\n Complaints of increased weakness/fatigue at home with inability to\n complete normal ADLs\n Action:\n BR maintained overnight; oxygen at 2L nc; assisted with position\n changes.\n Response:\n Slept intermittently\n Plan:\n OOB to commode as tolerated with assist. Advance activity slowly.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Height:\n Admission weight:\n 73 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed, Smoker\n CV-PMH: CAD, CHF, CVA, Hypertension, MI, PVD\n Additional history: aortic and mitral valve replacement with tissue\n valves ; MI ; a-fib--coumadin; LE harvest site; c-diff;\n rheumatic heart disease with mod aortic stenosis and aortic regurg,\n mitral regurg; emphysema--abestos exposure, carotid endartectomy,\n GIB-melena, prostate CA with rad tx.\n Surgery / Procedure and date: vavlue surgery \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:66\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 4,042 mL\n 24h total out:\n 1,175 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:27 AM\n Potassium:\n 3.9 mEq/L\n 02:27 AM\n Chloride:\n 112 mEq/L\n 02:27 AM\n CO2:\n 24 mEq/L\n 02:27 AM\n BUN:\n 43 mg/dL\n 02:27 AM\n Creatinine:\n 0.8 mg/dL\n 02:27 AM\n Glucose:\n 95 mg/dL\n 02:27 AM\n Hematocrit:\n 29.3 %\n 11:33 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 225\n Date & time of Transfer: 1700\n"
},
{
"category": "Nursing",
"chartdate": "2133-05-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 681728,
"text": "Pt is a 73 yr old with complaints of dark stools x 4 days ; instructed\n by PCP to go to ED for workup. Taking coumadin for a-fib, elevated INR,\n reversed with Vit k in ED. Pmhx: aortic/mitral valve replacement ;\n MI ; stroke/?TIA to left side ; CHF, c-diff, pneumonia, PVD-\n carotid endartectomy, emphysema d/t asbestos exposure, GIB, prostate CA\n with Rad tx, rheumatic heart disease.\n Arrived to MICU with second unit FFP infusing. Received an additional 1\n unit FFP and 4 units PRBC. Admitting HCt in ED was 26; repeat prior to\n any PRBC 19 in MICU. Given 2 units with increased HCt to 24.4; given\n additional 2 units with next Hct 28. Slept poorly d/t freq\n interruptions, pt has no complaints or discomforts. Voiding without\n difficulty via urinal.\n Dispo: FULL code\n Allergies: NKDA\n Access: 2 piv\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Reported 4 days black stools at home. On coumadin for a-fib.\n Transfused o/n with 4 units PRBCs and 3 units FFP. Last Hct 24.4\n (after 2 units PRBCs). NBPs this shift ranging 104-140s/50-60s. Pt\n with 1 stool- soft/formed black GUIAIC positive this shift.\n Action:\n Pt monitored for s/s bleeding; EGD this AM, pt rec\nd 2 mg versed ivp\n and 50mcg ivp fentanyl for procedure, uneventful.\n Response:\n EGD negative. Vital signs stable. Last Hct 29.\n Plan:\n Follow hct, with next due at 1800. Plan is for golytely prep tonight\n beginning at about 1900, pt NPO once prep has begun. Plan for\n colonoscopy in AM. Assess s/s bleeding. GUIAIC all stools.\n Activity Intolerance\n Assessment:\n Complaints of increased weakness/fatigue at home with inability to\n complete normal ADLs\n Action:\n BR maintained overnight; oxygen at 2L nc; assisted with position\n changes.\n Response:\n Slept intermittently\n Plan:\n OOB to commode as tolerated with assist. Advance activity slowly.\n"
},
{
"category": "ECG",
"chartdate": "2133-05-25 00:00:00.000",
"description": "Report",
"row_id": 111373,
"text": "Atrial fibrillation\nLateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , ST-T wave abnormalities more apparent\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-05-27 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1084270,
"text": " 4:58 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: evaluate for any arterio-enteric fistula that could be cause\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL ADDENDUM\n Finding regarding AV fistula in right groin and the need for a workup was\n communicated over the phone to Dr. at around 11:20 am on by Dr.\n .\n\n\n 4:58 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: evaluate for any arterio-enteric fistula that could be cause\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with hx of AVR/MVR on anticoagulation who presents with large\n GI bleed and EGD/ are negative, no source of bleeding found yet\n REASON FOR THIS EXAMINATION:\n evaluate for any arterio-enteric fistula that could be cause of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc WED 6:01 PM\n 1. No definite evidence for active bleeding. Density along the posterior wall\n of the stomach likely artifactual due to an adjacent air-fluid level.\n 2. No AV malformation or small bowel lesion, noting lack of distension.\n 3. Preserved fat plane detween the duodenum and the aorta, strongly arguing\n again an aortoduodenal fistula.\n 4. AV fistula in the right groin with early venous drainage.\n 5. Heterogenous liver perfusion perhaps due to valvular disease.\n Will re-examine with reconstructions.\n ______________________________________________________________________________\n FINAL REPORT\n CTA ABDOMEN AND PELVIS\n\n INDICATION: 73-year-old male with history of AVR/MVR, on anticoagulation,\n presenting with large gastrointestinal bleeding, EGD and colonoscopy are\n unrevealing, no source of bleeding found yet, evaluate for aortoenteric\n fistula.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained prior to\n and following administration of 150 cc of Optiray intravenously per CTA\n protocol. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: There are small right greater than left bilateral pleural\n effusions, with bibasal opacities, which likely represent atelectasis.\n\n CT ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is nutmeg\n (enhancement of the liver) in the venous phase as well as reflux of the\n contrast into the hepatic veins, which can be seen in the setting of heart\n failure. The stomach contains large amount of nonhemorrhagic fluid.\n\n The adrenal glands, pancreas, gallbladder, spleen are unremarkable. The\n kidneys enhance equally and excrete contrast normally. Bilateral tiny\n hypodensities in the renal parenchyma are too small to definitely\n characterize. There is no free air and no free fluid in the abdomen. Allowing\n for lack of oral contrast, abdominal loops of large and small bowel are\n unremarkable. There is no evidence of aortoenteric fistula. There is no\n retroperitoneal or mesenteric lymphadenopathy. The appendix is normal.\n\n (Over)\n\n 4:58 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: evaluate for any arterio-enteric fistula that could be cause\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST: The urinary bladder, seminal\n vesicles, rectum, sigmoid colon are unremarkable. There is a small amount of\n free pelvic fluid. The prostate contains multiple radiation seeds. There is\n no pelvic or inguinal lymphadenopathy.\n\n CTA ABDOMEN AND PELVIS: Atherosclerotic calcifications involve abdominal\n aorta, which is normal in caliber. The celiac axis, SMA and are widely\n patent. There is no evidence of aortoenteric fistula. AV fistula of the\n femoral vessels in the right groin.\n\n BONE WINDOWS: Demonstrate no concerning lytic or sclerotic lesions. There\n are multilevel degenerative changes in the lumbar spine, with decreased disc\n heights and vacuum phenomenon at L3-4, and 5-S1 level, with suggestion of\n a disc bulging. There is minimal retrolisthesis of L5 on S1.\n\n IMPRESSION:\n 1. No evidence of aortoenteric fistula or colitis.\n\n 4. AV fistula right groin.\n\n 2. Trace pelvic ascites.\n\n 3. Bilateral pleural effusions with compression atelectasis.\n\n\n\n\n"
}
] |
44,490 | 157,694 | The patient was admitted to the hospital and brought to the operating room on where he underwent aortic valve replacement, ascending aorta replacement, patch closure of aortic root abscess, maze procedure, and left atrial appendage resection with Dr. . Please see op note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on propofol and phenylephrine in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He was neurologically intact and hemodynamically stable, weaned from vasoactive support. Beta blockade and diuresis were initiated and the patient was transferred to the telemetry floor. Chest tubes and pacing wires were discontinued without complication. Physical therapy worked with the patient on post-op mobility and strength. Anti-coagulation was started with coumadin/heparin bridge for mechanical valve. Post-op course was uneventful and the patient was discharged home on POD 6 with INR 2.2. | Ct drg serousang fluid. aorta replacement/MAZE/LAA .on . aorta replacement/MAZE/LAA .on . Returned to @ end of w/ palpitations, diploplia, and near-syncope. Returned to @ end of w/ palpitations, diploplia, and near-syncope. Returned to @ end of w/ palpitations, diploplia, and near-syncope. Post-op EKG done. Post-op EKG done. Foley to CD, QS HUO. Foley to CD, QS HUO. Foley to CD, QS HUO. Foley to CD, QS HUO. MV02 re- calibrated. Pt w/u by C- for AVR. Pt w/u by C- for AVR. Pt w/u by C- for AVR. aorta replacement/MAZE/LAA . aorta replacement/MAZE/LAA . aorta replacement/MAZE/LAA . CDB. UO adeq. UO adeq. Nitroglycerin 18. Nitroglycerin 18. : AVR(mech)/Asc. : AVR(mech)/Asc. : AVR(mech)/Asc. Adeq. RR and SPO2 wnl. RR and SPO2 wnl. 1l LR. Phenylephrine 20. Phenylephrine 20. Response: HR down to 60s., sinus. Response: HR down to 60s., sinus. Response: HR down to 60s., sinus. Response: HR down to 60s., sinus. Plan: Enc. H/O atrial fibrillation (Afib) Assessment: Sinus rhythm 70s, occasional PACs. Action: RIJ Cordis, swan dcd. Action: RIJ Cordis, swan dcd. Action: RIJ Cordis, swan dcd. Action: RIJ Cordis, swan dcd. Metoclopramide 14. Metoclopramide 14. Aspirin EC 6. Aspirin EC 6. Pt. Pt. Pt. Pt. Instruct .I.S. Instruct .I.S. Morphine Sulfate 17. Morphine Sulfate 17. CefazoLIN 8. CefazoLIN 8. Plan: P.O. Plan: P.O. HUO. Start p.o Start p.o Action: Weaned OFM to off . Amiodarone 5. Amiodarone 5. RIJ CCO, hemodynamics stable. RIJ CCO, hemodynamics stable. RIJ CCO, hemodynamics stable. RIJ CCO, hemodynamics stable. HydrALAzine 11. HydrALAzine 11. Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that time. Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that time. Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that time. C.I. C.I. CVICU HPI: POD 1-AVR(mech)/Asc. Valve replacement, aortic mechanical (AVR) Assessment: Labile BP post-op. Valve replacement, aortic mechanical (AVR) Assessment: Labile BP post-op. , PAS 30's. Foley is still in; Lasix 20mg Iv given at . Foley is still in; Lasix 20mg Iv given at . Ca+2 repleted. Ca+2 repleted. BP 106-110 via R radial arterial line. BP 106-110 via R radial arterial line. BP 106-110 via R radial arterial line. BP 106-110 via R radial arterial line. Total 1L NS given so far. Total 1L NS given so far. Milk of Magnesia 16. Milk of Magnesia 16. Action: IV/NEO NTG on/off to keep SBP<110 per Dr. . Trivial MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Simple atheroma in ascending aorta.Normal aortic arch diameter. PFO is present.Left-to-right shunt across the interatrial septum at rest.LEFT VENTRICLE: Mild symmetric LVH. Unchanged patchy ill-defined opacity projected onto the right lower medial lung, near the right cardiophrenic angle, likely residual effect from prior tube placement. There is moderate aortic valve stenosis (valve area 1.4cm2). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Low normal LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic sinus. There is mild symmetric left ventricularhypertrophy with normal cavity size. Trivial mitral regurgitation is seen. Significant AR, but cannot bequantified.MITRAL VALVE: Mildly thickened mitral valve leaflets. RIJ CCO, hemodynamics stable. There is mild symmetric left ventricular hypertrophy. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic sinus. IMPRESSION: Unremarkable first postoperative chest findings. Moderately dilated ascending aorta. The ascending aorta is moderately dilated.There are simple atheroma in the ascending aorta. A left-to-right shunt across theinteratrial septum is seen at rest.3. Moderate AS (area 1.0-1.2cm2) Moderate to severe (3+) AR.MITRAL VALVE: No MS. There is mild regional left ventricularsystolic dysfunction with mild hypokinesis of the basal to mid inferior andinferolateral segments. Arch and descending aorta appear intact post decannulation.4. Mildly dilated descending aorta.AORTIC VALVE: Bicuspid aortic valve. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild regional LVsystolic dysfunction. Theascending aorta is moderately dilated. Bi ventricular function is unchanged.3. No thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. Mild inferior and inferolateralhypokinesis.If clinically suggested, the absence of a vegetation by 2D echocardiographydoes not exclude endocarditis.Compared with the prior study (images reviewed) of , comparison isdifficult as the rhythm was atrial fibrillation with rapid ventricularresponse on the prior study. Postoperative cardiomediastinal contours remain nonenlarged. The left ventricularcavity size is normal. Moderately dilated ascending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Right ventricular chamber size and free wall motionare normal. The descending thoracicaorta is mildly dilated.6. The aortic valve is bicuspid. FINDINGS: AP single view of the chest has been obtained with patient in supine position. aorta/closure root abscess/res. aorta/closure root abscess/res. The aortic root is moderately dilated at the sinus level. The aortic root is moderately dilated at the sinus level. FINDINGS: There has been interval removal of the ET tube, Swan-Ganz catheter, chest tube, and mediastinal drains. There is no pericardialeffusion.IMPRESSION: Severely thickened aortic valve leaflets. Normal regional LVsystolic function. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for AVR, Ascending Aorta replacement, PVI-MAZEHeight: (in) 73Weight (lb): 170BSA (m2): 2.01 m2BP (mm Hg): 134/78HR (bpm): 87Status: InpatientDate/Time: at 09:16Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement. There isborderline pulmonary artery systolic hypertension. | 23 | [
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511399,
"text": ": AVR(mech)/Asc. aorta replacement/MAZE/LAA . EF 50%\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n .H/O atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm 70\ns, occasional PAC\ns. BP 106-110 via R radial arterial\n line.\n Action:\n Lopressor 25mg po started at 0800.\n OOB to chair.\n Response:\n HR down to 60\ns., sinus.\n Plan:\n Transfer to 6 to continue cardiac rehab.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n A&O x 3, MAE x 4, pleasant and cooperative\n Epicardial A & V wires sense and pace appropriately.\n RIJ CCO, hemodynamics stable.\n Chest tubes draining small amounts serosanguinous fluid, no air leaks\n or crepitus.\n Foley to CD, QS HUO.\n Abdomen soft, + bowel sounds,.\n FSBS 125 at 12n\n L upper arm double lumen PICC, both ports flush, # 18 insyte peripheral\n IV patent L arm.\n Action:\n RIJ Cordis, swan dc\nd. R radial arterial line dc\n Advanced from clear liquids to full liquids\n OOB to chair.\n Lasix 20mg IVP started at 0800.\n Response:\n hemodynamically stable\n Plan:\n Transfer to 6 for continued cardiac rehab. ? Chest tubes and\n epicardial wires out on .\n Aggressive pulm hygiene.\n"
},
{
"category": "Physician ",
"chartdate": "2166-02-14 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 511351,
"text": "CVICU\n HPI:\n POD 1-AVR(mech)/Asc. aorta replacement/MAZE/LAA\n Ejection Fraction:50%\n Hemoglobin A1c:5.2\n Pre-Op Weight:172.84 lbs 78.4 kgs\n Baseline Creatinine:1.0\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n Chief complaint:\n PMHx:\n POD 1-AVR(mech)/Asc. aorta replacement/MAZE/LAA\n Ejection Fraction:50%\n Hemoglobin A1c:5.2\n Pre-Op Weight:172.84 lbs 78.4 kgs\n Baseline Creatinine:1.0\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n Current medications:\n Acetaminophen , Amiodarone ,Aspirin EC , Calcium Gluconate , CefazoLIN\n ,Dextrose 50% , Docusate Sodium, Furosemide , HydrALAzine , Insulin ,\n Magnesium Sulfate , Metoclopramide , Metoprolol Tartrate, Milk of\n Magnesia, Morphine Sulfate , Nitroglycerin, Oxycodone-Acetaminophen ,\n Phenylephrine , Potassium Chloride , Ranitidine , Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n OR RECEIVED - At 01:30 PM\n AVR, maze, Ao patch\n INVASIVE VENTILATION - START 01:30 PM\n ARTERIAL LINE - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n PA CATHETER - START 02:00 PM\n PICC LINE - START 02:11 PM\n L AC, double lumen placed in \n EKG - At 02:32 PM\n EXTUBATION - At 05:55 PM\n INVASIVE VENTILATION - STOP 05:55 PM\n EXTUBATION - At 06:00 PM\n Post operative day:\n POD#1 - AVR(mech), Maze, Aortic patch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 01:30 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 07:05 PM\n Hydralazine - 06:15 AM\n Other medications:\n Flowsheet Data as of 02:24 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.8\nC (98.3\n HR: 65 (57 - 76) bpm\n BP: 109/70(78) {98/57(66) - 114/70(78)} mmHg\n RR: 20 (8 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 76.8 kg\n Height: 73 Inch\n CVP: 1 (-2 - 8) mmHg\n PAP: (18 mmHg) / (5 mmHg)\n CO/CI (Fick): (5.8 L/min) / (2.9 L/min/m2)\n CO/CI (CCO): (7.1 L/min) / (3.1 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 61 - 62\n Total In:\n 2,298 mL\n 2,341 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,298 mL\n 2,341 mL\n Blood products:\n Total out:\n 1,356 mL\n 1,693 mL\n Urine:\n 860 mL\n 1,203 mL\n NG:\n Stool:\n Drains:\n Balance:\n 942 mL\n 648 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: 7.39/37/163/24/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 256 K/uL\n 8.9 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 112 mEq/L\n 139 mEq/L\n 25.6 %\n 12.9 K/uL\n [image002.jpg]\n 05:45 PM\n 07:00 PM\n 08:59 PM\n 09:00 PM\n 09:54 PM\n 10:00 PM\n 11:00 PM\n 12:00 AM\n 01:00 AM\n 02:01 AM\n WBC\n 12.9\n Hct\n 27.1\n 25.6\n Plt\n 256\n Creatinine\n 1.0\n TCO2\n 23\n Glucose\n 121\n 151\n 133\n 115\n 115\n 99\n 84\n 98\n 85\n Other labs: PT / PTT / INR:15.0/38.9/1.3, Fibrinogen:173 mg/dL, Lactic\n Acid:1.8 mmol/L\n Imaging: CXR: clear, all lines in good position\n Microbiology: Neg\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC MECHANICAL\n (AVR)\n Assessment and Plan: Pt. doing very well post op. Start Lopressor,\n Lasix. Anticoagulate with Coumadin today and d/c pacing wires\n tomorrow. Tx to floor.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Start Lasix\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 PM\n PICC Line - 02:11 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511358,
"text": ": AVR(mech)/Asc. aorta replacement/MAZE/LAA . EF 50%\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n .H/O atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm 70\ns, occasional PAC\ns. BP 106-110 via R radial arterial\n line.\n Action:\n Lopressor 25mg po started at 0800.\n OOB to chair.\n Response:\n HR down to 60\ns., sinus.\n Plan:\n Transfer to 6 to continue cardiac rehab.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n A&O x 3, MAE x 4, pleasant and cooperative\n Epicardial A & V wires sense and pace appropriately.\n RIJ CCO, hemodynamics stable.\n Chest tubes draining small amounts serosanguinous fluid, no air leaks\n or crepitus.\n Foley to CD, QS HUO.\n Abdomen soft, + bowel sounds,.\n FSBS 125 at 12n\n L upper arm double lumen PICC, both ports flush, # 18 insyte peripheral\n IV patent L arm.\n Action:\n RIJ Cordis, swan dc\nd. R radial arterial line dc\n Advanced from clear liquids to full liquids\n OOB to chair.\n Lasix 20mg IVP started at 0800.\n Response:\n hemodynamically stable\n Plan:\n Transfer to 6 for continued cardiac rehab. ? Chest tubes and\n epicardial wires out on .\n Aggressive pulm hygiene.\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511220,
"text": "Pt is a 54 y.o. male w/ known AS and Ao aneurysm who had flu\nlike sx\n around . BCX done revealed Strep Viridans and pt was adm\n for abx and echo which showed Ao valve vegetation. Pt also tested +\n for flu and underwent Tamaflu rx. Returned to @ end of w/\n palpitations, diploplia, and near-syncope. Found to be in new AF.\n Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that\n time. Pt w/u by C- for AVR. Today he underwent Asc Aortic\n replacement, mechanical AVR , Maze, and L atrial appendage resection.\n .H/O atrial fibrillation (Afib)\n Assessment:\n NSR/SB since arrival from OR, no ectopy.\n Action:\n Continuous telemetry. Post-op EKG done.\n Response:\n Stable SR. No afib episodes post-op.\n Plan:\n P.O. Amio due this eve. Continue monitoring.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n Labile BP post-op. SVO2 high 50\ns-60 range. C.I. ~2. UO adeq. Feet\n w/ palpable DP\ns. Pt appearing comfortable. K+=5.4, ion ca+2=1.10.\n Mod amt sang CT drng. Post-op hct=30.\n Action:\n IV/NEO NTG on/off to keep SBP<110 per Dr. . Total 1L NS given\n so far. A&V Epicardial wires tested and work; Set on AAI backup @ 50.\n Morphine given prior to turning. Vent weaned and ETT extubated @ 1755\n to humidified FT 50%. Partner, brother, and sister-in-law in to\n visit. Ca+2 repleted. Insulin drip started per protocol this eve.\n Response:\n SBP currently=105. Filling pressures low. SVO2 up to 60 but dips into\n 50\ns on occasion. Pt oriented but sleepy, w/ tolerable pain\n level(#). RR and SPO2 wnl.\n Plan:\n Cont to keep SBP<110. Giving an additional 1L NS slowly. Pain med\n prn. Instruct .I.S. tonight. Start p.o\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511315,
"text": "Valve replacement, aortic mechanical (AVR)\n Assessment:\n Received extubated on 45% OFM. Lsc-> dim at bases. Ct drg serousang\n fluid. Adeq. HUO. Dopplerable pulses. Afebrile htn-> low filling\n pressures.MV02 60-> 55% with activity. Hct 30->27->25. NTG & insulin\n gtts. Incisional pain.\n Action:\n Weaned OFM to off . MV02 re- calibrated. Ntg gtt titrated to keep sbp<\n 110. 1l LR. q1h glucose levels. Morphine ivpx2 Pecocet x1\n Response:\n MV02 results = 62%, no change in 1^st liter of LR -> repeated x1.\n failed Ntg wean-> 10mg hydralazine x1. with effect.CVICU insulin\n protocol follwed.> transitioned to sub q and then shut off. Pain\n controlled.\n Plan:\n Enc. CDB. Start scheduled doses of lopressor and lasix. DC lines.\n Increase diet and activity as tolerated. Transfer to 6 when bed\n available.\n"
},
{
"category": "Physician ",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 511291,
"text": "CVICU\n HPI:\n HD2 POD 1-AVR(mech)/Asc. aorta replacement/MAZE/LAA\n Ejection Fraction:50%\n Hemoglobin A1c:5.2\n Pre-Op Weight:172.84 lbs 78.4 kgs\n Baseline Creatinine:1.0\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial \n : preop: SC Heparin 5000U TID, Ceftriaxone x 1 month\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN\n 8. Dextrose 50% 9. Docusate Sodium 10. HydrALAzine 11. Insulin 12.\n Magnesium Sulfate 13. Metoclopramide\n 14. Metoprolol Tartrate 15. Milk of Magnesia 16. Morphine Sulfate 17.\n Nitroglycerin 18. Oxycodone-Acetaminophen\n 19. Phenylephrine 20. Potassium Chloride 21. Ranitidine\n 24 Hour Events:\n OR RECEIVED - At 01:30 PM\n AVR, maze, Ao patch\n INVASIVE VENTILATION - START 01:30 PM\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 02:32 PM\n EXTUBATION - At 05:55 PM\n INVASIVE VENTILATION - STOP 05:55 PM\n EXTUBATION - At 06:00 PM\n Post operative day:\n POD#1 - AVR(mech), Maze, Aortic patch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 3 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 07:05 PM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 75 (57 - 76) bpm\n BP: 112/52(68) {85/44(59) - 126/62(80)} mmHg\n RR: 16 (10 - 20) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 5 (-2 - 13) mmHg\n PAP: (24 mmHg) / (8 mmHg)\n CO/CI (Fick): (6.2 L/min) / (3.1 L/min/m2)\n CO/CI (CCO): (7 L/min) / (3.6 L/min/m2)\n SvO2: 59%\n Mixed Venous O2% sat: 61 - 70\n Total In:\n 2,298 mL\n 2,243 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,298 mL\n 2,243 mL\n Blood products:\n Total out:\n 1,356 mL\n 523 mL\n Urine:\n 860 mL\n 333 mL\n NG:\n Stool:\n Drains:\n Balance:\n 942 mL\n 1,720 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 690 (690 - 690) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 10 cmH2O\n SPO2: 93%\n ABG: 7.39/37/163/24/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 466\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 256 K/uL\n 8.9 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 112 mEq/L\n 139 mEq/L\n 25.6 %\n 12.9 K/uL\n [image002.jpg]\n 05:45 PM\n 07:00 PM\n 08:59 PM\n 09:00 PM\n 09:54 PM\n 10:00 PM\n 11:00 PM\n 12:00 AM\n 01:00 AM\n 02:01 AM\n WBC\n 12.9\n Hct\n 27.1\n 25.6\n Plt\n 256\n Creatinine\n 1.0\n TCO2\n 23\n Glucose\n 121\n 151\n 133\n 115\n 115\n 99\n 84\n 98\n 85\n Other labs: PT / PTT / INR:15.0/38.9/1.3, Fibrinogen:173 mg/dL, Lactic\n Acid:1.8 mmol/L\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC MECHANICAL\n (AVR)\n Assessment and Plan: 54M s/p AVR(25mm ON-X mechanical)/Asc. aorta\n repacement(28 Gelweave)/patch closure aortic root\n abcess(pericardium)/MAZE/LAA resection \n Neurologic: Pain controlled, Percocet PRN.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Post-op hypertension\n --> NTG gtt for SBP < 100 per cardiac surgery.\n Pulmonary: OOB / IS / PT consult\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, start lasix for diuresis.\n Hematology: Mod anemia\n Endocrine: RISS\n Infectious Disease: Periop antibx per ID, will send blood cx's if\n spikes fever\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:00 PM\n PA Catheter - 02:00 PM\n Cordis/Introducer - 02:00 PM\n 16 Gauge - 02:00 PM\n 18 Gauge - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511313,
"text": "Valve replacement, aortic mechanical (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 511337,
"text": "CVICU\n HPI:\n HD2 POD 1-AVR(mech)/Asc. aorta replacement/MAZE/LAA\n Ejection Fraction:50%\n Hemoglobin A1c:5.2\n Pre-Op Weight:172.84 lbs 78.4 kgs\n Baseline Creatinine:1.0\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial \n : preop: SC Heparin 5000U TID, Ceftriaxone x 1 month\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN\n 8. Dextrose 50% 9. Docusate Sodium 10. HydrALAzine 11. Insulin 12.\n Magnesium Sulfate 13. Metoclopramide\n 14. Metoprolol Tartrate 15. Milk of Magnesia 16. Morphine Sulfate 17.\n Nitroglycerin 18. Oxycodone-Acetaminophen\n 19. Phenylephrine 20. Potassium Chloride 21. Ranitidine\n 24 Hour Events:\n OR RECEIVED - At 01:30 PM\n AVR, maze, Ao patch\n INVASIVE VENTILATION - START 01:30 PM\n ARTERIAL LINE - START 02:00 PM\n PA CATHETER - START 02:00 PM\n CORDIS/INTRODUCER - START 02:00 PM\n EKG - At 02:32 PM\n EXTUBATION - At 05:55 PM\n INVASIVE VENTILATION - STOP 05:55 PM\n EXTUBATION - At 06:00 PM\n Post operative day:\n POD#1 - AVR(mech), Maze, Aortic patch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 3 mcg/Kg/min\n Other ICU medications:\n Insulin - Regular - 07:05 PM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 75 (57 - 76) bpm\n BP: 112/52(68) {85/44(59) - 126/62(80)} mmHg\n RR: 16 (10 - 20) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 5 (-2 - 13) mmHg\n PAP: (24 mmHg) / (8 mmHg)\n CO/CI (Fick): (6.2 L/min) / (3.1 L/min/m2)\n CO/CI (CCO): (7 L/min) / (3.6 L/min/m2)\n SvO2: 59%\n Mixed Venous O2% sat: 61 - 70\n Total In:\n 2,298 mL\n 2,243 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,298 mL\n 2,243 mL\n Blood products:\n Total out:\n 1,356 mL\n 523 mL\n Urine:\n 860 mL\n 333 mL\n NG:\n Stool:\n Drains:\n Balance:\n 942 mL\n 1,720 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 690 (690 - 690) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 10 cmH2O\n SPO2: 93%\n ABG: 7.39/37/163/24/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 466\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 256 K/uL\n 8.9 g/dL\n 85 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 112 mEq/L\n 139 mEq/L\n 25.6 %\n 12.9 K/uL\n [image002.jpg]\n 05:45 PM\n 07:00 PM\n 08:59 PM\n 09:00 PM\n 09:54 PM\n 10:00 PM\n 11:00 PM\n 12:00 AM\n 01:00 AM\n 02:01 AM\n WBC\n 12.9\n Hct\n 27.1\n 25.6\n Plt\n 256\n Creatinine\n 1.0\n TCO2\n 23\n Glucose\n 121\n 151\n 133\n 115\n 115\n 99\n 84\n 98\n 85\n Other labs: PT / PTT / INR:15.0/38.9/1.3, Fibrinogen:173 mg/dL, Lactic\n Acid:1.8 mmol/L\n Assessment and Plan\n .H/O ATRIAL FIBRILLATION (AFIB), VALVE REPLACEMENT, AORTIC MECHANICAL\n (AVR)\n Assessment and Plan: 54M s/p AVR(25mm ON-X mechanical)/Asc. aorta\n repacement(28 Gelweave)/patch closure aortic root\n abcess(pericardium)/MAZE/LAA resection \n Neurologic: Pain controlled, Percocet PRN.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Post-op hypertension\n --> NTG gtt for SBP < 100 per cardiac surgery.\n Pulmonary: OOB / IS / PT consult\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, start lasix for diuresis.\n Hematology: Mod anemia\n Endocrine: RISS\n Infectious Disease: Periop antibx per ID, will send blood cx's if\n spikes fever\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:00 PM\n PA Catheter - 02:00 PM\n Cordis/Introducer - 02:00 PM\n 16 Gauge - 02:00 PM\n 18 Gauge - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511405,
"text": ": AVR(mech)/Asc. aorta replacement/MAZE/LAA . EF 50%\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n .H/O atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm 70\ns, occasional PAC\ns. BP 106-110 via R radial arterial\n line.\n Action:\n Lopressor 25mg po started at 0800.\n OOB to chair.\n Response:\n HR down to 60\ns., sinus.\n Plan:\n Transfer to 6 to continue cardiac rehab.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n A&O x 3, MAE x 4, pleasant and cooperative\n Epicardial A & V wires sense and pace appropriately.\n RIJ CCO, hemodynamics stable.\n Chest tubes draining small amounts serosanguinous fluid, no air leaks\n or crepitus.\n Foley to CD, QS HUO.\n Abdomen soft, + bowel sounds,.\n FSBS 125 at 12n\n L upper arm double lumen PICC, both ports flush, # 18 insyte peripheral\n IV patent L arm.\n Action:\n RIJ Cordis, swan dc\nd. R radial arterial line dc\n Advanced from clear liquids to full liquids\n OOB to chair.\n Lasix 20mg IVP started at 0800.\n Response:\n hemodynamically stable\n Plan:\n Transfer to 6 for continued cardiac rehab. ? Chest tubes and\n epicardial wires out on .\n Aggressive pulm hygiene.\n 54. YO male s/p AVR(mech)/Asc. aorta replacement/MAZE/LAA .on .\n A/A/O. starting to take po\ns today. Pt. states minimal appetite but is\n trying to eat to regain strength. Finished last dose of Kefzol this\n evening. Pt. has a double lumen PIC in left AC. DSG changed this\n evening. Chest tubes, mediastinal & pleaural are still in and drng is\n minimal serosang. To straw colored. Pacing wires are in. pacer settings\n checked and settings are documented in Metavision. Sense & capture\n appropriately. Foley is still in; Lasix 20mg Iv given at . Will\n transfer to 6 when bed is clean; spoke with floor RN at 2105.\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 511406,
"text": "H/O atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm 70\ns, occasional PAC\ns. BP 106-110 via R radial arterial\n line.\n Action:\n Lopressor 25mg po started at 0800.\n OOB to chair.\n Response:\n HR down to 60\ns., sinus.\n Plan:\n Transfer to 6 to continue cardiac rehab.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n A&O x 3, MAE x 4, pleasant and cooperative\n Epicardial A & V wires sense and pace appropriately.\n RIJ CCO, hemodynamics stable.\n Chest tubes draining small amounts serosanguinous fluid, no air leaks\n or crepitus.\n Foley to CD, QS HUO.\n Abdomen soft, + bowel sounds,.\n FSBS 125 at 12n\n L upper arm double lumen PICC, both ports flush, # 18 insyte peripheral\n IV patent L arm.\n Action:\n RIJ Cordis, swan dc\nd. R radial arterial line dc\n Advanced from clear liquids to full liquids\n OOB to chair.\n Lasix 20mg IVP started at 0800.\n Response:\n hemodynamically stable\n Plan:\n Transfer to 6 for continued cardiac rehab. ? Chest tubes and\n epicardial wires out on .\n Aggressive pulm hygiene.\n 54. YO male s/p AVR(mech)/Asc. aorta replacement/MAZE/LAA .on .\n A/A/O. starting to take po\ns today. Pt. states minimal appetite but is\n trying to eat to regain strength. Finished last dose of Kefzol this\n evening. Pt. has a double lumen PIC in left AC. DSG changed this\n evening. Chest tubes, mediastinal & pleaural are still in and drng is\n minimal serosang. To straw colored. Pacing wires are in. pacer settings\n checked and settings are documented in Metavision. Sense & capture\n appropriately. Foley is still in; Lasix 20mg Iv given at . Will\n transfer to 6 when bed is clean; spoke with floor RN at 2105.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY BENTAL PROCEDURE; ASCENDING AORT\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 76.8 kg\n Daily weight:\n 84.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: Aortic arch aneurysm, AS, tinnitus, diploplia,\n depression, cataracts, hernia repair, root canal, influenza A (given\n Tamaflu)\n Surgery / Procedure and date: Maze, Asc Ao\n replacement(Gelweave), Aortic root patch, AVR(On-X mech) #25, LAA\n resection\n EZ intiubation EF 45-50% C.O. , PAS 30's. CPB 174\", XC 117\"\n 2A wires(intermittently pace), 2V wires O.K. 2L cryst, 570ml UO, 500ml\n CS , K+^, gluc 150's-->5units Insulin\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:58\n Temperature:\n 97.5\n Arterial BP:\n S:123\n D:49\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 35% %\n 24h total in:\n 3,089 mL\n 24h total out:\n 2,733 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 56 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 2.5 mV\n Temporary atrial sensitivity setting:\n 1.6 mV\n Temporary atrial stimulation threshold :\n 3.5 mA\n Temporary atrial stimulation setting:\n 7 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 3 mV\n Temporary ventricular sensitivity setting:\n 1.5 mV\n Temporary ventricular stimulation threshold :\n 6 mA\n Temporary ventricular stimulation setting :\n 10 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 02:01 AM\n Potassium:\n 4.2 mEq/L\n 02:01 AM\n Chloride:\n 112 mEq/L\n 02:01 AM\n CO2:\n 24 mEq/L\n 02:01 AM\n BUN:\n 13 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 85 mg/dL\n 02:01 AM\n Hematocrit:\n 25.6 %\n 02:01 AM\n Finger Stick Glucose:\n 120\n 08:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU B\n Transferred to: 6\n Date & time of Transfer: 21:30\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511219,
"text": "Pt is a 54 y.o. male w/ known AS and Ao aneurysm who had flu\nlike sx\n around . BCX done revealed Strep Viridans and pt was adm\n for abx and echo which showed Ao valve vegetation. Pt also tested +\n for flu and underwent Tamaflu rx. Returned to @ end of w/\n palpitations, diploplia, and near-syncope. Found to be in new AF.\n Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that\n time. Pt w/u by C- for AVR. Today he underwent Asc Aortic\n replacement, mechanical AVR , Maze, and L atrial appendage resection.\n .H/O atrial fibrillation (Afib)\n Assessment:\n NSR/SB since arrival from OR, no ectopy.\n Action:\n Continuous telemetry. Post-op EKG done.\n Response:\n Stable SR. No afib episodes post-op.\n Plan:\n P.O. Amio due this eve. Continue monitoring.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n Labile BP post-op. SVO2 high 50\ns-60 range. C.I. ~2. UO adeq. Feet\n w/ palpable DP\ns. Pt appearing comfortable. K+=5.4, ion ca+2=1.10.\n Mod amt sang CT drng. Post-op hct=30.\n Action:\n IV/NEO NTG on/off to keep SBP<110 per Dr. . Total 1L NS given\n so far. Morphine given prior to turning. Vent weaned and ETT\n extubated @ 1755 to humidified FT 50%. Partner, brother, and\n sister-in-law in to visit. Ca+2 repleted. Insulin drip started per\n protocol this eve\n Response:\n SBP currently=105. Filling pressures low. SVO2 up to 60 but dips into\n 50\ns on occasion. Pt oriented, w/ tolerable pain level(#). RR and\n SPO2 wnl.\n Plan:\n Cont to keep SBP<110. Giving an additional 1L NS slowly. Pain med\n prn. Instruct .I.S. tonight. Start p.o\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511216,
"text": "Pt is a 54 y.o. male w/ known AS and Ao aneurysm who had flu\nlike sx\n around . BCX done revealed Strep Viridans and pt was adm\n for abx and echo which showed Ao valve vegetation. Pt also tested +\n for flu and underwent Tamaflu rx. Returned to @ end of w/\n palpitations, diploplia, and near-syncope. Found to be in new AF.\n Mult old, subacute infarcts seen on head CT. Pt started on Amio @ that\n time. Pt w/u by C- for AVR. Today he underwent Asc Aortic\n replacement, mechanical AVR , Maze, and L atrial appendage resection.\n .H/O atrial fibrillation (Afib)\n Assessment:\n NSR/SB since arrival from OR, no ectopy.\n Action:\n Response:\n Plan:\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511206,
"text": "Pt is a 54 y.o. male who had flu sx\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2166-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 511365,
"text": ": AVR(mech)/Asc. aorta replacement/MAZE/LAA . EF 50%\n PMHx: AS, aortic aneurysm, Strep Viridens endocarditis, tinnitus,\n diploplia, depression, anxiety, s/p bilat. cataract surgery, s/p RIH,\n s/p R radial fx\n .H/O atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm 70\ns, occasional PAC\ns. BP 106-110 via R radial arterial\n line.\n Action:\n Lopressor 25mg po started at 0800.\n OOB to chair.\n Response:\n HR down to 60\ns., sinus.\n Plan:\n Transfer to 6 to continue cardiac rehab.\n Valve replacement, aortic mechanical (AVR)\n Assessment:\n A&O x 3, MAE x 4, pleasant and cooperative\n Epicardial A & V wires sense and pace appropriately.\n RIJ CCO, hemodynamics stable.\n Chest tubes draining small amounts serosanguinous fluid, no air leaks\n or crepitus.\n Foley to CD, QS HUO.\n Abdomen soft, + bowel sounds,.\n FSBS 125 at 12n\n L upper arm double lumen PICC, both ports flush, # 18 insyte peripheral\n IV patent L arm.\n Action:\n RIJ Cordis, swan dc\nd. R radial arterial line dc\n Advanced from clear liquids to full liquids\n OOB to chair.\n Lasix 20mg IVP started at 0800.\n Response:\n hemodynamically stable\n Plan:\n Transfer to 6 for continued cardiac rehab. ? Chest tubes and\n epicardial wires out on .\n Aggressive pulm hygiene.\n"
},
{
"category": "Echo",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Report",
"row_id": 63492,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for AVR, Ascending Aorta replacement, PVI-MAZE\nHeight: (in) 73\nWeight (lb): 170\nBSA (m2): 2.01 m2\nBP (mm Hg): 134/78\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 09:16\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast is seen in\nthe LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. PFO is present.\nLeft-to-right shunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Complex (>4mm) atheroma in aortic\nroot. Moderately dilated ascending aorta. Simple atheroma in ascending aorta.\nNormal aortic arch diameter. Mildly dilated descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Moderate AS (area 1.0-1.2cm2) Moderate to severe (3+) AR.\n\nMITRAL VALVE: No MS. Trivial MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data The\npost-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is markedly dilated. No spontaneous echo contrast is seen\nin the left atrial appendage. No thrombus is seen in the left atrial\nappendage.\n2. A patent foramen ovale is present. A left-to-right shunt across the\ninteratrial septum is seen at rest.\n3. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\n4. Right ventricular chamber size and free wall motion are normal.\n5. The aortic root is moderately dilated at the sinus level. There are complex\n(>4mm) atheroma in the aortic root. The ascending aorta is moderately dilated.\nThere are simple atheroma in the ascending aorta. The descending thoracic\naorta is mildly dilated.\n6. The aortic valve is bicuspid. The aortic valve leaflets are severely\nthickened/deformed. There is moderate aortic valve stenosis (valve area 1.4\ncm2). Moderate to severe (3+) aortic regurgitation is seen. A probable root\nabscess is seen close to the aorto-mitral junction.\n7. Trivial mitral regurgitation is seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine and is being AV paced\n\n1. A well-seated bioprosthetic valve is seen in the aortic position with\nnormal leaflet motion and gradients (mean gradient = 8 mmHg).Trace washing\njets are seen.\n2. Bi ventricular function is unchanged.\n3. Arch and descending aorta appear intact post decannulation.\n4. Other findings are unchanged.\n\nDr. was notified in person of the results\n\n\n"
},
{
"category": "Echo",
"chartdate": "2166-02-10 00:00:00.000",
"description": "Report",
"row_id": 63493,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evauation of Aortic Valve following 4 weeks of abx for Step Viridans Bacteremia.\nHeight: (in) 73\nWeight (lb): 173\nBSA (m2): 2.03 m2\nBP (mm Hg): 116/68\nHR (bpm): 69\nStatus: Outpatient\nDate/Time: at 13:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. Severe AS (area 0.8-1.0cm2). Significant AR, but cannot be\nquantified.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with mild hypokinesis of the basal to mid inferior and\ninferolateral segments. Right ventricular chamber size and free wall motion\nare normal. The aortic root is moderately dilated at the sinus level. The\nascending aorta is moderately dilated. The aortic valve leaflets are severely\nthickened/deformed. No masses or vegetations are seen on the aortic valve, but\ncannot be fully excluded due to suboptimal image quality. There is severe\naortic valve stenosis (valve area 0.8-1.0cm2). Significant aortic\nregurgitation is present, but cannot be quantified. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. No mass or vegetation\nis seen on the mitral valve. Trivial mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Severely thickened aortic valve leaflets. A vegetation cannot be\nexcluded on the basis of this study. Severe aortic stenosis with significant\naortic regurgitation. No abscess seen. Mild inferior and inferolateral\nhypokinesis.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nCompared with the prior study (images reviewed) of , comparison is\ndifficult as the rhythm was atrial fibrillation with rapid ventricular\nresponse on the prior study. The rhythm is sinus on the current study with\nsignificantly lower heart rate. The inferior and inferolateral walls appear\nmildly hypokinetic on the current study. The velocity across the aortic valve\nhas increased, although may have been UNDERestimated on prior study. The\ndegree of aortic regurgitation on the current study is difficult to determine\nbut is likely increased in comparison to the prior.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2166-02-13 00:00:00.000",
"description": "Report",
"row_id": 127275,
"text": "Normal sinus rhythm. Marked left axis deviation at minus 81 degrees. Right\nbundle-branch block with QRS duration of 126 milliseconds. J point elevation in\nleads V4-V6. Compared to the previous tracing of the patient now has\ncomplete right bundle-branch block with secondary ST-T wave changes in the\nright precordial leads but also has ST-T wave changes in lead aVL with a marked\nleftward shift of the frontal plane axis. In addition, the P-R interval is now\nprolonged to 232 milliseconds and was normal on .\n\n"
},
{
"category": "ECG",
"chartdate": "2166-02-11 00:00:00.000",
"description": "Report",
"row_id": 127276,
"text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115742,
"text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\BENTAL PROCEDURE; ASCENDING AORTAHEMI-ARCH REPLACEMENT W/ DEEP CIRCULAR ARREST/MAZE; Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with s/p AVR, asc. ao replacement, LAA ligation, maze, CTs\n d/c'd today\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Status post AVR, chest tubes discontinued today.\n\n FINDINGS: There has been interval removal of the ET tube, Swan-Ganz catheter,\n chest tube, and mediastinal drains. There continues to be moderate\n cardiomegaly. Patient is status post valve replacement and sternotomy. There\n is some mild pulmonary vascular re-distribution but there is no pulmonary\n edema. There is some volume loss in the right mid lung. There are tiny\n bilateral pleural effusions. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-02-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1115447,
"text": " 1:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact # if abnormal-will be in\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\BENTAL PROCEDURE; ASCENDING AORTAHEMI-ARCH REPLACEMENT W/ DEEP CIRCULAR ARREST/MAZE; Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p AVR/ repl. asc. aorta/closure root abscess/res. LAA/ Maze\n REASON FOR THIS EXAMINATION:\n postop film-contact # if abnormal-will be in CVICU approx. 1P:30\n PM-please call first\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 3:39 PM\n PFI: No pneumothorax, all tubes well in place, practically no postoperative\n mediastinal widening. No infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: First postoperative examination, status post aortic valve\n replacement and ascending aorta root abscess treatment.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. There is now status post sternotomy, and the metallic\n components of an aortic valve prosthesis can be identified in place. The\n patient is intubated, the ETT terminates in the trachea some 5 cm above the\n level of the carina. A right internal jugular sheath carries a Swan-Ganz\n catheter, the tip of which reaches the central portion of the right PA. An NG\n tube reaches the fundus of the stomach; however, some further advancement is\n recommended so to enter the side port below the hiatus. Two mediastinal tubes\n and one right-sided chest tube advanced from below are seen. There is no\n pneumothorax on either side. Pulmonary vasculature is normal. No new\n infiltrates have developed in comparison with the next preceding preoperative\n chest examination, and there is practically no postoperative mediastinal\n widening. No pneumothorax on either side.\n\n IMPRESSION: Unremarkable first postoperative chest findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-02-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1115448,
"text": ", C. CSURG CSRU 1:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact # if abnormal-will be in\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\BENTAL PROCEDURE; ASCENDING AORTAHEMI-ARCH REPLACEMENT W/ DEEP CIRCULAR ARREST/MAZE; Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p AVR/ repl. asc. aorta/closure root abscess/res. LAA/ Maze\n REASON FOR THIS EXAMINATION:\n postop film-contact # if abnormal-will be in CVICU approx. 1P:30\n PM-please call first\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax, all tubes well in place, practically no postoperative\n mediastinal widening. No infiltrates.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-02-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1115895,
"text": " 6:21 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for mediastinal widening\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\BENTAL PROCEDURE; ASCENDING AORTAHEMI-ARCH REPLACEMENT W/ DEEP CIRCULAR ARREST/MAZE; Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with s/p cardiac surgery with hct 29->23, +rub on exam\n REASON FOR THIS EXAMINATION:\n evaluate for mediastinal widening\n ______________________________________________________________________________\n WET READ: ENYa 10:29 PM\n Normal mediastinal width. Likely small pleural effusions. Unchanged patchy\n ill-defined opacity projected onto the right lower medial lung, near the right\n cardiophrenic angle, likely residual effect from prior tube placement. No\n PTX.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Cardiac surgery. New rub. Evaluate possible mediastinal widening.\n\n IMPRESSION: PA and lateral chest compared to and 9:\n\n Small left pleural effusion is new and newly apparent. Moderate cardiomegaly\n is unchanged and the mediastinum shows no evidence of bleeding. Upper lungs\n are clear. Right basal atelectasis, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-02-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1116350,
"text": " 9:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\BENTAL PROCEDURE; ASCENDING AORTAHEMI-ARCH REPLACEMENT W/ DEEP CIRCULAR ARREST/MAZE; Mitral Valve Repair/Replace with Concomitant Maze Procedure /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/pmechanical AVR/asc aorta replacement/MAZE/LAA\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: Status post mechanical AVR, ascending aortic replacement, Maze\n and LAA.\n\n FINDINGS: Comparison made to , and multiple priors.\n Postoperative cardiomediastinal contours remain nonenlarged. Small left\n pleural effusion has again increased in size, though it remains small, with\n associated left basilar atelectasis. Right perihilar and basilar opacities,\n likely atelectasis, are not significantly changed. There is no pneumothorax.\n\n IMPRESSION: Continued increase in left pleural effusion.\n\n"
}
] |
76,397 | 184,741 | Given splenic laceration Mr. was admitted to the SICU for close monitoring. Pain was well controlled with PCA, he was started on clear liquids and serial hematocrits remained stable without need for transfusion. CXR did reveal a small pneumothorax which remained stable on follow-up imaging. The patient was transferred to the general surgical on HD2. He remained stable from a neurological standpoint; pain was initially managed with a hydromorphone PCA, which was transitioned to oral oxycodone and acetaminophen with adequate pain control. The patient remained stable from a cardiovascular standpoint; serial hematocrit levels remained stable throughout admission. Additionally, he remained stable from a pulmonary standpoint; deep breathing, incentive spirometry and ambulation were encouraged throughout the patient's hospitalization. The patient's diet was gradually advanced to regular and well tolerated; he was voiding adequately. The patient was evaluated by physical therapy on HD2 with recommendations for ambulation multiple times daily with supervision for safety; please see eval for details. Pt was subsequently able to ambulate without difficulty. Additionally, the patient was evaluated by Social Work in the Emergency Department and again on the general surgical due to trauma, positive opiates on toxicology screen and marijuana use; please see evaluation for details. Additionally, Social work provided resources for ongoing follow-up. On HD4, the patient was discharged to home. He will follow-up in the Acute Care Surgical service clinic in 2 weeks and his primary care provider 2 weeks. | FINDINGS: There is a possible small apical right pneumothorax. Tiny lingular pulmonary contusion. IMPRESSION: Possible small right apical pneumothorax. IMPRESSION: Low lung volumes without evidence for acute process on this single supine view. Minimal bibasilar atelectasis is seen. No definite PTX. Visualized intra-abdominal and pelvic vasculature is within normal limits. No CT evidence for acute intracranial process. No CT evidence for acute intracranial process. TECHNIQUE: Single frontal chest radiograph was obtained portably with the patient in a supine position. Question pneumothorax or other acute process. Normal cardiomediastinal silhouette. There is no left pneumothorax. There is no definite pneumothorax. The collapsed gallbladder, pancreas, adrenal glands, right kidney, stomach, small bowel, and colon are within normal limits. Cardiomediastinal silhouette is unremarkable. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. The appendix is not seen. Small mesenteric lymph nodes do not meet CT size criteria for pathologic enlargement. FINDINGS: There is no pneumothorax. The liver is otherwise unremarkable. No acute fracture is detected. No focal consolidation, pleural effusion, or pneumothorax is evident on this view. IMPRESSION: No evidence for acute cervical spine fracture. PELVIS: The bladder, prostate, seminal vesicles, and rectum are within normal limits. Consider left lateral decubitus radiographs if there is continued suspicion. FINDINGS: There is no evidence for acute fracture or malalignment. No pericardial effusion is seen. There are aerosolized secretions in a left anterior ethmoid air cell; the remainder of the visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. No contraindications for IV contrast FINAL REPORT INDICATION: 19-year-old male with desaturation, tachypnea, hemothorax. No acute soft tissue abnormality is detected. FINDINGS: Lung volumes are low. FINDINGS: Lung volumes are low. There is no free intraperitoneal air. Within the upper pole of the left kidney there is a 13 mm round hypodensity which is incompletely characterized on this study, but most likely represents a cyst. COMPARISONS: Trauma portable chest radiograph from , CT torso from . No pleural effusion or pneumothorax is seen. There is a fracture through the right transverse process of T8. FINDINGS: There is no evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. A small amount of hyperdense fluid is seen in the pelvis, likely layering from the splenic injury. The heart and great vessels are within normal limits. ptx on the R per rads. The visualized portion of the thyroid appears homogeneous. COMPARISON: None available. COMPARISON: None available. COMPARISON: None available. COMPARISON: None available. No mediastinal, axillary, or hilar lymphadenopathy is detected. There is no focal consolidation or pleural effusion. Fracture through the right transverse process of T8. Fracture through the right transverse process of T8. FINDINGS: CHEST: There is a small pulmonary contusion in the lingula. TECHNIQUE: Axial CT images of the cervical spine were acquired without intravenous contrast. There is no pneumothorax. 6:31 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: hemothorox, ptx, other acute process? The visualized portion of the thyroid is homogeneous. REASON FOR THIS EXAMINATION: Please re-assess ptx WET READ: MJMgb FRI 9:31 PM Low lung volumes and atelectasis. There is no prevertebral soft tissue swelling. No other acute fracture is detected. The basal cisterns appear patent. Coronal and sagittal reformatted images were reviewed. Coronal and sagittal reformatted images were reviewed. Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDEMT MEDICAL CONDITION: History: 19M with desat, tachypnea REASON FOR THIS EXAMINATION: hemothorox, ptx, other acute process? IMPRESSION: 1. IMPRESSION: 1. 5:27 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for interval change. Grade III splenic laceration with hemorrhagic ascites adjacent to the spleen, trace around the liver, and small amount in the pelvis. Grade III splenic laceration with hemorrhagic ascites adjacent to the spleen, trace around the liver, and small amount in the pelvis. Grade splenic laceration with small amount of hemorrhagic ascites around the spleen and liver and layering in the pelvis. WET READ VERSION #1 FINAL REPORT CHEST ON HISTORY: Trauma patient with probable pneumothorax. Fracture through the transverse process of T8. ABDOMEN: There is a grade splenic laceration with perisplenic hemorrhagic ascites. Aeroselized secretions in a left anterior ethmoid air cell, which can be indicative of acute sinusitis. Trace hemorrhagic ascites is seen adjacent to the liver. Aerosolized secretions in a left anterior ethmoid air cell, which can be indicative of acute sinusitis. This would be better assessed with the lateral decubitus radiograph if there is continued concern. Please reassess. Coronal, sagittal, and thin slice bone reconstructed images were reviewed. Heart size appears enlarged, likely secondary to low lung volumes and supine positioning. Foci of skin thickening with superficial (Over) 3:03 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: Please evaluate s/p trauma Field of view: 36 Contrast: OMNIPAQUE Amt: 130 FINAL REPORT (Cont) subcutaneous fat stranding along the anterior chest and abdominal walls likely correspond to patient's known ecchymoses. | 7 | [
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1238411,
"text": " 3:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man MVC vs. house\n REASON FOR THIS EXAMINATION:\n Please evaluate s/p trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb FRI 3:25 AM\n 1. No CT evidence for acute intracranial process.\n 2. Aeroselized secretions in a left anterior ethmoid air cell, which can be\n indicative of acute sinusitis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old male status post motor vehicle collision.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast. Coronal, sagittal, and thin slice bone reconstructed images were\n reviewed.\n\n FINDINGS: There is no evidence for acute intracranial hemorrhage, large mass,\n mass effect, edema, or hydrocephalus. The basal cisterns appear patent.\n There is preservation of -white matter differentiation. There are\n aerosolized secretions in a left anterior ethmoid air cell; the remainder of\n the visualized portions of the paranasal sinuses and mastoid air cells appear\n well aerated. No acute fracture is detected.\n\n IMPRESSION:\n 1. No CT evidence for acute intracranial process.\n 2. Aerosolized secretions in a left anterior ethmoid air cell, which can be\n indicative of acute sinusitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1238412,
"text": " 3:02 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Please evaluate status-post trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man MVC vs. house\n REASON FOR THIS EXAMINATION:\n Please evaluate status-post trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb FRI 3:30 AM\n No CT evidence for acute cervical spine fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old male status post motor vehicle collision.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images of the cervical spine were acquired without\n intravenous contrast. Coronal and sagittal reformatted images were reviewed.\n\n FINDINGS: There is no evidence for acute fracture or malalignment. There is\n no prevertebral soft tissue swelling. No acute soft tissue abnormality is\n detected. The visualized portion of the thyroid appears homogeneous. The\n visualized portions of the lung apices are clear.\n\n IMPRESSION: No evidence for acute cervical spine fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1238410,
"text": " 2:58 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: Please evaluate s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man MVC vs. house\n REASON FOR THIS EXAMINATION:\n Please evaluate s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old male status post motor vehicle collision.\n\n COMPARISON: None available.\n\n TECHNIQUE: Single frontal chest radiograph was obtained portably with the\n patient in a supine position.\n\n FINDINGS: Lung volumes are low. No focal consolidation, pleural effusion, or\n pneumothorax is evident on this view. Heart size appears enlarged, likely\n secondary to low lung volumes and supine positioning. Trauma board projects\n under the patient.\n\n IMPRESSION: Low lung volumes without evidence for acute process on this\n single supine view.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1238536,
"text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change. Thanks.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p MVC with splenic laceration, multiple rib fractures.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Splenic laceration and rib fractures, question pneumothorax.\n\n FINDINGS: There is no pneumothorax. There is bibasilar volume\n loss/consolidation which is increased compared to prior studies. The thoracic\n bony fracture at T8 is better visualized on the CT scan. The upper lungs are\n clear. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1238413,
"text": " 3:03 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate s/p trauma\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man MVC vs. house\n REASON FOR THIS EXAMINATION:\n Please evaluate s/p trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb FRI 3:48 AM\n 1. Grade III splenic laceration with hemorrhagic ascites adjacent to the\n spleen, trace around the liver, and small amount in the pelvis.\n 2. Fracture through the right transverse process of T8.\n\n Discussed with Dr. (surgery) in person at 3:40 a.m. and Dr. (ED)\n by phone at 3:46 a.m. on at time of initial review of the study.\n WET READ VERSION #1\n WET READ VERSION #2 EHAb FRI 3:45 AM\n 1. Grade III splenic laceration with hemorrhagic ascites adjacent to the\n spleen, trace around the liver, and small amount in the pelvis.\n 2. Fracture through the transverse process of T8.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old male status post motor vehicle collision.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images through the chest, abdomen, and pelvis were\n acquired after administration of intravenous contrast. Coronal and sagittal\n reformatted images were reviewed.\n\n FINDINGS:\n\n CHEST: There is a small pulmonary contusion in the lingula. No pleural\n effusion or pneumothorax is seen. Minimal bibasilar atelectasis is seen. The\n visualized portion of the thyroid is homogeneous. The heart and great vessels\n are within normal limits. No mediastinal, axillary, or hilar lymphadenopathy\n is detected. No pericardial effusion is seen.\n\n ABDOMEN: There is a grade splenic laceration with perisplenic hemorrhagic\n ascites. Trace hemorrhagic ascites is seen adjacent to the liver. The liver\n is otherwise unremarkable. The collapsed gallbladder, pancreas, adrenal\n glands, right kidney, stomach, small bowel, and colon are within normal\n limits. The appendix is not seen. Within the upper pole of the left kidney\n there is a 13 mm round hypodensity which is incompletely characterized on this\n study, but most likely represents a cyst. There is no free intraperitoneal\n air.\n\n PELVIS: The bladder, prostate, seminal vesicles, and rectum are within normal\n limits. A small amount of hyperdense fluid is seen in the pelvis, likely\n layering from the splenic injury. Foci of skin thickening with superficial\n (Over)\n\n 3:03 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate s/p trauma\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n subcutaneous fat stranding along the anterior chest and abdominal walls likely\n correspond to patient's known ecchymoses.\n\n Visualized intra-abdominal and pelvic vasculature is within normal limits.\n Small mesenteric lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n\n There is a fracture through the right transverse process of T8. No other\n acute fracture is detected.\n\n IMPRESSION:\n 1. Grade splenic laceration with small amount of hemorrhagic ascites\n around the spleen and liver and layering in the pelvis.\n\n 2. Fracture through the right transverse process of T8.\n\n 3. Tiny lingular pulmonary contusion. This finding was reported to Dr.\n by phone by Dr. at approximately 6:30 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1238501,
"text": " 7:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please re-assess ptx\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mvc, polytrauma. ptx on the R per rads.\n REASON FOR THIS EXAMINATION:\n Please re-assess ptx\n ______________________________________________________________________________\n WET READ: MJMgb FRI 9:31 PM\n Low lung volumes and atelectasis. No definite PTX. Consider left lateral\n decubitus radiographs if there is continued suspicion. Normal\n cardiomediastinal silhouette. W/r Masciocchi.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Trauma patient with probable pneumothorax. Please reassess.\n\n FINDINGS: Lung volumes are low. There is no definite pneumothorax. This\n would be better assessed with the lateral decubitus radiograph if there is\n continued concern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1238430,
"text": " 6:31 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: hemothorox, ptx, other acute process?\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDEMT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 19M with desat, tachypnea\n REASON FOR THIS EXAMINATION:\n hemothorox, ptx, other acute process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old male with desaturation, tachypnea, hemothorax.\n Question pneumothorax or other acute process.\n\n COMPARISONS: Trauma portable chest radiograph from , CT torso from\n .\n\n FINDINGS: There is a possible small apical right pneumothorax. There is no\n left pneumothorax. There is no focal consolidation or pleural effusion.\n Cardiomediastinal silhouette is unremarkable. This study is not tailored for\n detection of subtle trauma, but there are no displaced fractures identified.\n\n IMPRESSION: Possible small right apical pneumothorax. Suggest followup PA\n and lateral films in several hours.\n\n These findings were discussed with Dr. by Dr. via\n telephone at 11 a.m.\n\n"
}
] |
66,165 | 131,060 | 67yo M with h/o ESLD, ESRD, CAD admitted with scrotal cellulitis and worsening hepatic and renal failure. Patient evaluated by urology and surgery in the ED who felt pts scrotum not true fournier's, just a scrotal cellulitis. Scrotal ultrasound was obtained and did not show evidence of deep tissue fluid collections or gas. Broad abx coverage initiated with vanc/zosyn. Discussed with family and pt who agreed that he would not want surgical management even if indicated. Similarly, despite worsening renal failure (creatinine to 5.7 from ?baseline 1.7) and poor urine output, patient and family declined dialysis despite electrolyte abnormalities and metabolic acidosis attributed to anuria. He was managed medically with pain control, antibiotics, and IV bicarbonate. His renal function did not improve. Lactulose was continued for his liver disease. Palliative care was very involved regarding goals of care with patient and his family. Patient had been ill for a very long time and did not want aggressive care. On the day prior to discharge patient was made CMO with treatment with oral antibiotics, symptom control, lactulose, and comfort feeding. He was discharged with hospice. | Small right hydrocele otherwise normal testes and epididymides bilaterally. Sinus bradycardia. Sinus bradycardia. There is a small right hydrocele. Diffuse anasarca and bilateral hydroceles. The non-contrast appearance of the spleen, adrenal glands, kidneys, gallbladder are within normal limits. Small right hydrocele. Prolonged Q-T interval. Prolonged Q-T interval. The epididymides demonstrate symmetric echotexture bilaterally. Heart size, mediastinal contours, and pulmonary vascular markings are within normal limits. The prostate and rectum are within normal limits. A Foley catheter is noted within a decompressed bladder. CT OF THE PELVIC WITHOUT CONTRAST: There is a large amount of ascites within the pelvis. The testes demonstrate symmetric homogeneous echotexture and vascularity. Intrapelvic loops of bowel are unremarkable. large amount of ascites. Large amount of ascites. Question of air in the scrotum. FINDINGS: Lungs are well aerated, without consolidation or effusion. IMPRESSION: 1. IMPRESSION: 1. There is massive scrotal edema without evidence of abscess. There is anasarca. Massive scrotal edema consistent with stated diagnosis of cellulitis. There is extensive calcification of the coronary arteries. There are prominent vessels in the left hemiscrotum measuring up to 3 to 4 mm, the significance of which is uncertain in the setting of massive edema. FINDINGS: CT OF THE ABDOMEN WITHOUT CONTRAST: The lung bases are clear. anasarca. TECHNIQUE: Axially acquired images were obtained from the lung bases to the pubic symphysis without contrast. small, nodular liver, consistent with history of chronic liver disease. IMPRESSION: No acute cardiopulmonary disease. Degenerative changes are noted throughout the visualized spine. No abscess. Small foci of air within the decompressed bladder is likely due to recent instrumentation. The liver is small, and demonstrates a nodular contour, consistent with history of chronic liver disease. There are extensive vascular calcifications. 3. 3. Small nodular liver consistent with history of chronic liver disease. The heart size is normal. There is no subcutaneous air overlying the area of the scrotum. 2. 2. Compared to the previous tracingno change.TRACING #2 The patient is status post gastric bypass. Coronal and sagittal reformatted images were also displayed. SCROTAL ULTRASOUND: The right testicle measures 2.2 x 1.7 x 3.2 cm and the left testicle measures 2.0 x 1.7 x 2.8 cm. No previous tracing available forcomparison.TRACING #1 FINAL REPORT INDICATION: 67-year-old male with cellulitis of scrotum. Indication: Pre-op film, end-stage liver disease, and Fournier's gangrene. There is a large amount of ascites throughout the entire abdomen and pelvis. COMPARISON: None. 11:02 AM SCROTAL U.S. No evidence of abscess. Extensive fluid is noted within the soft tissues of the scrotum in addition to hydroceles. There is no free air. (Over) 12:25 AM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: ?air in scrotum Admitting Diagnosis: SCROTAL INFECTION Field of view: 42 FINAL REPORT (Cont) BONE WINDOWS: No concerning osseous lesions are identified. COMPARISON: CT performed earlier the same day. No evidence of air within the scrotum or subcutaneous tissues. FINAL REPORT INDICATION: 67-year-old man with possible Fournier's gangrene and crepitus on exam of scrotum. 12:25 AM CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # Reason: ?air in scrotum Admitting Diagnosis: SCROTAL INFECTION Field of view: 42 MEDICAL CONDITION: 67 year old man with possible fourniers gangrene and crepitus on exam of scrotum REASON FOR THIS EXAMINATION: ?air in scrotum CONTRAINDICATIONS for IV CONTRAST: ARF WET READ: JKSd SUN 2:10 AM no scrotal air or air within the soft tissues. Clip # Reason: CELLULLITIS ,EVAL FOR ABSCESS Admitting Diagnosis: SCROTAL INFECTION MEDICAL CONDITION: 67 year old man with cellulitis of scrotum REASON FOR THIS EXAMINATION: ?drainable abscess WET READ: EAGg SUN 2:00 PM Scrotal wall edema. | 5 | [
{
"category": "Radiology",
"chartdate": "2159-06-03 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1134945,
"text": " 12:25 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: ?air in scrotum\n Admitting Diagnosis: SCROTAL INFECTION\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with possible fourniers gangrene and crepitus on exam of\n scrotum\n REASON FOR THIS EXAMINATION:\n ?air in scrotum\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: JKSd SUN 2:10 AM\n no scrotal air or air within the soft tissues.\n\n large amount of ascites. small, nodular liver, consistent with history of\n chronic liver disease.\n\n anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with possible Fournier's gangrene and crepitus on\n exam of scrotum. Question of air in the scrotum.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially acquired images were obtained from the lung bases to the\n pubic symphysis without contrast. Coronal and sagittal reformatted images\n were also displayed.\n\n FINDINGS:\n CT OF THE ABDOMEN WITHOUT CONTRAST: The lung bases are clear. The heart size\n is normal. There is extensive calcification of the coronary arteries. The\n non-contrast appearance of the spleen, adrenal glands, kidneys, gallbladder\n are within normal limits.\n\n The patient is status post gastric bypass. The liver is small, and\n demonstrates a nodular contour, consistent with history of chronic liver\n disease. There is a large amount of ascites throughout the entire abdomen and\n pelvis. There is no free air.\n\n CT OF THE PELVIC WITHOUT CONTRAST: There is a large amount of ascites within\n the pelvis. A Foley catheter is noted within a decompressed bladder. Small\n foci of air within the decompressed bladder is likely due to recent\n instrumentation. The prostate and rectum are within normal limits.\n Intrapelvic loops of bowel are unremarkable.\n\n There is no subcutaneous air overlying the area of the scrotum. Extensive\n fluid is noted within the soft tissues of the scrotum in addition to\n hydroceles. There is anasarca. There are extensive vascular calcifications.\n\n (Over)\n\n 12:25 AM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: ?air in scrotum\n Admitting Diagnosis: SCROTAL INFECTION\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No concerning osseous lesions are identified. Degenerative\n changes are noted throughout the visualized spine.\n\n IMPRESSION:\n 1. No evidence of air within the scrotum or subcutaneous tissues.\n\n 2. Large amount of ascites. Small nodular liver consistent with history of\n chronic liver disease.\n\n 3. Diffuse anasarca and bilateral hydroceles.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-03 00:00:00.000",
"description": "SCROTAL U.S.",
"row_id": 1134990,
"text": " 11:02 AM\n SCROTAL U.S. Clip # \n Reason: CELLULLITIS ,EVAL FOR ABSCESS\n Admitting Diagnosis: SCROTAL INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cellulitis of scrotum\n REASON FOR THIS EXAMINATION:\n ?drainable abscess\n ______________________________________________________________________________\n WET READ: EAGg SUN 2:00 PM\n Scrotal wall edema. No abscess. Small right hydrocele.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with cellulitis of scrotum.\n\n COMPARISON: CT performed earlier the same day.\n\n SCROTAL ULTRASOUND: The right testicle measures 2.2 x 1.7 x 3.2 cm and the\n left testicle measures 2.0 x 1.7 x 2.8 cm. The testes demonstrate symmetric\n homogeneous echotexture and vascularity. The epididymides demonstrate\n symmetric echotexture bilaterally. There is massive scrotal edema without\n evidence of abscess. There is a small right hydrocele. There are prominent\n vessels in the left hemiscrotum measuring up to 3 to 4 mm, the significance of\n which is uncertain in the setting of massive edema.\n\n IMPRESSION:\n\n 1. No evidence of abscess.\n\n 2. Massive scrotal edema consistent with stated diagnosis of cellulitis.\n\n 3. Small right hydrocele otherwise normal testes and epididymides\n bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1134960,
"text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: preop\n Admitting Diagnosis: SCROTAL INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with h/o tobacco abuse and ESLD with fourniers gangrene\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 04:52.\n\n Indication: Pre-op film, end-stage liver disease, and Fournier's gangrene.\n\n FINDINGS:\n\n Lungs are well aerated, without consolidation or effusion. Heart size,\n mediastinal contours, and pulmonary vascular markings are within normal\n limits.\n\n IMPRESSION: No acute cardiopulmonary disease.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-03 00:00:00.000",
"description": "Report",
"row_id": 301201,
"text": "Sinus bradycardia. Prolonged Q-T interval. Compared to the previous tracing\nno change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-02 00:00:00.000",
"description": "Report",
"row_id": 301202,
"text": "Sinus bradycardia. Prolonged Q-T interval. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
41,803 | 161,409 | The patient with pancreatic adenocarcinoma was admitted to the HPB Surgical Service for elective resection. On , the patient underwent Whipple resection, modified classic, and saphenous vein interposition graft from splenic artery to common hepatic artery, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the ICU, the patient arrived on the floor NPO/NGT, on IV fluids, with a foley catheter, and epidural catheter for pain control. The patient was hemodynamically stable. Neuro: The patient received Hydromorphone/Bupivacaine via epidural, APS service adjusted the rate to achieve an adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. JP amylase was checked on POD # 5, and was low. JP # 1 was removed on POD # 6. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Patient will continue JP #2 at home. HEPATOLOGY: Immediately post op, the patient's LFTs were elevated. LFTs were followed daily and started to downward on POD # 1. The patient spikes fever on POD # 6 and WBC spikes to 32.7. The patient was started on Unasyn empirically. Abdominal CT revealed 6.5 x 9.9 cm hypodense area within segments , and IVb of the liver. The patient's LFTs continue to improve. On POD # 8, repeat CT scan demonstrated increase in size of large area of hypo attenuation within segment and IVb which has a thicker rim than previously. The Hepatology Service was consulted and recommended percutaneous drainage. The patient underwent CT-guided aspiration of the liver fluid collection on POD # 10. Fluid was send for evaluation and grew enterococcus sensitive to Vancomycin. On POD#15 repeat CT showed likely communication of liver collection through abd wall. VASCULAR: On POD # 1, Doppler demonstrated arterial flow within the common hepatic artery and the right hepatic artery. The patient was started on Aspirin PR on POD # 1. On POD # 6, repeat Doppler revealed patent hepatic arteries and saphenous vein interposition graft and high velocities at the graft-hepatic arterial anastomosis. The patient was started on Heparin gtt to prevent possible thrombosis. The patient underwent abdominal CTA/CTV on POD # 7, which demonstrated patent intrahepatic vessels including the portal vein, hepatic veins and hepatic artery, focal high-grade (>70%) narrowing of the left hepatic artery at bifurcation with proper hepatic artery, which was not present previously and distal right hepatic artery is attenuated for several centimeters beyond the bifurcation but patent. Vascular surgery service recommended to discontinue Heparin gtt and continue the patient only on oral Aspirin. GU: The patient has a history of urinary retention. Her Foley was removed on POD # 4. On POD # 5, Foley was placed back s/t 700 cc of residual urine on bladder scan. Despite several attempts to remove patient's Foley, she failed voiding trials. The Foley was replaced on POD # 8 and removed on POD# 12. Pt. has been voiding well since that time with no incontinence. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Liver aspirate grew enterococcus senstive to Vancomycin. On POD#13 drainage was noted from incision site and 6 surgical staples were removed and incision site was allowed to drain. POD#14 5 staples removed from left side of wound and allowed to drain - both samples grew Vanc senstivie enterococcus. Wounds were packed with gauzed and changed . Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. | Flow is visualized within the common hepatic artery and the right hepatic artery, showing prompt systolic upstrokes and antegrade flow in diastole, a normal waveform. Patent hepatic arteries and saphenous vein interposition graft. Mild central intrahepatic biliary ductal dilatation with nondilated common hepatic duct to choledochojejunostomy. TECHNIQUE: Multidetector CT axial images obtained with non-contrast, arterial, portal venous and delayed phase imaging performed. FINDINGS: The patient is status post Whipple procedure. The splenic artery, saphenous vein interposition graft and vein interposition graft anastomoses with the splenic artery and proper hepatic artery are patent. CT on showing concern for hepatic arterial thrombosis. There are postoperative changes in the region of the pancreaticojejunostomy. A linear hypoechoic structure extending laterally from the right lateral aspect of the SMA is noted; query whether this might represent a remnant of the replaced hepatic artery previously arising from this site. 3:42 PM DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Ensure good flow through graft, intrahepatic arteries. Heterogeneous left hepatic lobe, corresponding to region of parenchymal ischemia or necrosis better demonstrated on preceding CT. In comparison to preoperative CTA, the right hepatic artery is attenuated but patent. Distal to this, the common hepatic artery shows preserved flow with sharp systolic upstrokes an antegrade flow throughout diastole, and there is preserved hepatic arterial flow within the right and left hepatic arteries. Interval removal of intra-abdominal drain. Patenc Admitting Diagnosis: PANCREATIC CANCER/SDA Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) left hepatic artery at the bifurcation with the proper hepatic artery, which was not present previously. (Over) 3:42 PM DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Ensure good flow through graft, intrahepatic arteries. 10:06 AM CT ABDOMEN W/O CONTRAST; CT ABDOMEN W/CONTRAST Clip # Reason: Vascular patency? Evaluate for patency of hepatic arteries, interposition graft and portal veins. COMPARISON: Preoperative abdominal CTA from . FINDINGS: Post-Whipple surgical changes are visualized with a small amount of abdominal free fluid. FINAL REPORT INDICATION: Status post Whipple procedure, requiring hepatic artery partial resection due to aberrant anatomy with saphenous vein interposition graft from splenic artery to common hepatic artery. Patency of hepatic arteries, interposition graft, and poral veins. However, the main portal vein appears patent with hepatopetal flow. Since the vein was observed to opacify on the prior CT, this could be due to slow flow or interval thrombosis. No contraindications for IV contrast FINAL REPORT CT ABDOMEN AND PELVIS DATED INDICATION: Status post hepatic arterial reconstruction with Whipple on . COMPARISON: CT abdomen dated . FINDINGS: CT ABDOMEN: There is bibasilar atelectasis within the lung bases. The main, anterior and posterior right portal veins, are patent with antegrade flow. 11:03 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: Liver ultrasound - liver is being fed by interposition graft Admitting Diagnosis: PANCREATIC CANCER/SDA MEDICAL CONDITION: 47F w/ panc adenocarcinoma s/p Whipple and vascular reconstruction REASON FOR THIS EXAMINATION: Liver ultrasound - liver is being fed by interposition graft of vein from splenic artery to common hepatic artery FINAL REPORT INDICATION: Evaluation of patient with history of pancreatic adenocarcinoma status post Whipple with vascular reconstruction, for evaluation of hepatic vasculature with interposition of venous graft between the splenic artery and the common hepatic artery. There are multiple small retroperitoneal, aortocaval and mesenteric nodes, (3B:180, 3B;169). REASON FOR THIS EXAMINATION: Vascular patency? COMPARISON: Abdominal CT of . The intrahepatic portions of the left hepatic artery are patent. IMPRESSION: Successful CT-guided aspiration of 12cc from the left hepatic collection. Evaluate for vascular patency. CTA/CTV: The main, left and right portal veins are patent. * **************************************************************************** MEDICAL CONDITION: 47F s/p Whipple for pancreatic adenocarcinoma, liver hypodensity concerning for fluid collection seen on CT abdomen. However, arterial flow is visualized within the common hepatic artery and the right hepatic artery. The hepatic veins are patent. The intrahepatic vessels are patent including the portal vein, hepatic veins and hepatic artery. There are multiple intraperitoneal foci of air and foci are air within the surgical bed in keeping with recent surgery. (Over) 11:03 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: Liver ultrasound - liver is being fed by interposition graft Admitting Diagnosis: PANCREATIC CANCER/SDA FINAL REPORT (Cont) Please only aspirate, p Admitting Diagnosis: PANCREATIC CANCER/SDA FINAL REPORT (Cont) Coronal and sagittal reformats were obtained. The distal right hepatic artery is attenuated for several centimeters beyond the bifurcation but patent. Admitting Diagnosis: PANCREATIC CANCER/SDA FINAL REPORT (Cont) 2. | 5 | [
{
"category": "Radiology",
"chartdate": "2170-09-04 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1201149,
"text": " 3:42 PM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Ensure good flow through graft, intrahepatic arteries.\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with interposition graft of vein from splenic artery to\n common hepatic artery - CT indicates there may be lack of flow.\n REASON FOR THIS EXAMINATION:\n Ensure good flow through graft, intrahepatic arteries.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Whipple procedure, requiring hepatic artery partial\n resection due to aberrant anatomy with saphenous vein interposition graft from\n splenic artery to common hepatic artery. CT on showing concern\n for hepatic arterial thrombosis. Please assess for flow.\n\n COMPARISON: Abdominal CT of .\n\n TECHNIQUE: Right upper quadrant ultrasound with duplex son evaluation\n of the liver.\n\n FINDINGS: The patient is status post Whipple procedure. The examination is\n difficult due to patient discomfort during scanning and skin incision limiting\n acoustic access. Just posterior to the left lateral segment of the liver, the\n venous interposition graft is identified containing arterial flow. An area of\n focal caliber narrowing and irregularity at the location of the graft-hepatic\n arterial anastomosis shows turbulent, high velocity flow with a peak systolic\n velocity of approximately 322 cm/sec (image 43). This corresponds to the\n region of irregularity and narrowing on the CT of one day prior and could\n relate to anastomotic irregularity, though a small amount of peripheral\n nonocclusive thrombus cannot be excluded by ultrasound as the vessel itself is\n not visualized with sufficient detail. Distal to this, the common hepatic\n artery shows preserved flow with sharp systolic upstrokes an antegrade flow\n throughout diastole, and there is preserved hepatic arterial flow within the\n right and left hepatic arteries.\n\n The main, anterior and posterior right portal veins, are patent with\n antegrade flow. No flow can be detected within the left portal vein although\n imaging is somewhat limited as described above. Since the vein was observed\n to opacify on the prior CT, this could be due to slow flow or interval\n thrombosis.\n\n The parenchymal heterogeneity consistent with ischemia or necrosis which was\n seen on the CT of one day prior is less evident by ultrasound though the left\n lobe parenchyma appears heterogeneous. There is gas within the operative bed\n and pneumobilia.\n\n IMPRESSION:\n 1. Patent hepatic arteries and saphenous vein interposition graft. High\n velocities at the graft-hepatic arterial anastomosis may reflect anastomotic\n site turbulence. Though a nonocclusive thrombus at this location cannot be\n excluded by ultrasound, this is not directly visualized.\n (Over)\n\n 3:42 PM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Ensure good flow through graft, intrahepatic arteries.\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Patent main and right portal veins. No detectable flow in left portal\n vein. This may be due to slow or undetectable flow, or possibly left portal\n vein thrombosis.\n\n 3. Heterogeneous left hepatic lobe, corresponding to region of parenchymal\n ischemia or necrosis better demonstrated on preceding CT.\n\n Results discussed with via telephone by Dr. at 4:40 p.m. on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-29 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1200196,
"text": " 11:03 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Liver ultrasound - liver is being fed by interposition graft\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F w/ panc adenocarcinoma s/p Whipple and vascular reconstruction\n REASON FOR THIS EXAMINATION:\n Liver ultrasound - liver is being fed by interposition graft of vein from\n splenic artery to common hepatic artery\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of pancreatic adenocarcinoma\n status post Whipple with vascular reconstruction, for evaluation of hepatic\n vasculature with interposition of venous graft between the splenic artery and\n the common hepatic artery.\n\n COMPARISON: Preoperative abdominal CTA from .\n\n FINDINGS:\n Post-Whipple surgical changes are visualized with a small amount of abdominal\n free fluid. There is mild central intrahepatic biliary ductal dilatation with\n the common hepatic duct remnant measuring 4 mm. Cholodochojejunostomy site\n appears unremarkable. No focal lesions are visualized throughout the liver and\n the liver is normal in echotexture.\n\n COLOR AND DOPPLER ASSESSMENT: Doppler assessment is limited by overlying\n bandages and patient discomfort. However, the main portal vein appears patent\n with hepatopetal flow. Flow is visualized within the common hepatic artery\n and the right hepatic artery, showing prompt systolic upstrokes and antegrade\n flow in diastole, a normal waveform. The interposed venous graft is not well\n visualized though attempts to image this region were limited by patient\n discomfort. Evaluation of the left hepatic artery was not possible due to\n patient discomfort. The SMA appears patent. A linear hypoechoic structure\n extending laterally from the right lateral aspect of the SMA is noted; query\n whether this might represent a remnant of the replaced hepatic artery\n previously arising from this site.\n\n IMPRESSION:\n 1. Limited exam due to overlying bandages and patient pain. However,\n arterial flow is visualized within the common hepatic artery and the right\n hepatic artery. The left hepatic artery and the venous interposition graft\n were not fully visualized.\n 2. Mild central intrahepatic biliary ductal dilatation with nondilated common\n hepatic duct to choledochojejunostomy.\n 3. Small amount of post-surgical free fluid.\n\n These findings were discussed by Dr. with Dr. at 1:55\n p.m. on .\n (Over)\n\n 11:03 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Liver ultrasound - liver is being fed by interposition graft\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-05 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1201235,
"text": " 10:06 AM\n CT ABDOMEN W/O CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n Reason: Vascular patency? Please do multi-phasic (CTA/CTV). Patenc\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with hepatic arterial reconstruction with Whipple on\n .\n REASON FOR THIS EXAMINATION:\n Vascular patency? Please do multi-phasic (CTA/CTV). Patency of hepatic\n arteries, interposition graft, and poral veins.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS DATED \n\n INDICATION: Status post hepatic arterial reconstruction with Whipple on\n . Evaluate for vascular patency. Please do multiphasic scan.\n Evaluate for patency of hepatic arteries, interposition graft and portal\n veins.\n\n TECHNIQUE: Multidetector CT axial images obtained with non-contrast,\n arterial, portal venous and delayed phase imaging performed. Coronal and\n sagittal reformats were obtained.\n\n COMPARISON: CT abdomen dated .\n\n FINDINGS:\n\n CT ABDOMEN: There is bibasilar atelectasis within the lung bases. Persistent\n large area of hypoattenuation within segments and IVb of the liver which\n has a thicker rim present than previously. This area has increased in size\n from previous CT of and now measures 11.2 cm x 6.8 cm (previously\n 9.9 x 6 cm). There is a 4-mm focus of air within the area of central\n hypoattenuation anteriorly (3:156). There are foci of biliary air which is\n not unexpected following hepaticojejunostomy. The remainder of the liver\n parenchyma appears normal.\n\n There are postoperative changes in the region of the pancreaticojejunostomy.\n There are multiple intraperitoneal foci of air and foci are air within the\n surgical bed in keeping with recent surgery. The residual pancreatic tissue\n is normal in appearance. The spleen, left kidney and both adrenal glands are\n normal. Stable 6-mm cyst within the interpolar region of the right kidney.\n Interval removal of intra-abdominal drain. There are multiple small\n retroperitoneal, aortocaval and mesenteric nodes, (3B:180, 3B;169). The\n visualized small and large bowel are normal in appearance.\n\n CTA/CTV: The main, left and right portal veins are patent. The hepatic veins\n are patent. The splenic artery, saphenous vein interposition graft and vein\n interposition graft anastomoses with the splenic artery and proper hepatic\n artery are patent. In comparison to preoperative CTA, the right hepatic\n artery is attenuated but patent. There is focal high grade narrowing of the\n (Over)\n\n 10:06 AM\n CT ABDOMEN W/O CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n Reason: Vascular patency? Please do multi-phasic (CTA/CTV). Patenc\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left hepatic artery at the bifurcation with the proper hepatic artery, which\n was not present previously. The gastroduodenal artery is not visualized. The\n intrahepatic portions of the left hepatic artery are patent.\n\n OSSEOUS STRUCTURES: Multilevel degenerative disease. No suspicious lytic or\n sclerotic bone lesions identified.\n\n IMPRESSION:\n 1. Increase in size of large area of hypoattenuation within segment and\n IVb which has a thicker rim than previously. The differential includes\n abscess and/or evolving infarction.\n 2. The intrahepatic vessels are patent including the portal vein, hepatic\n veins and hepatic artery. Focal high-grade (>70%) narrowing of the left\n hepatic artery at bifurcation with proper hepatic artery, which was not\n present previously. The distal right hepatic artery is attenuated for several\n centimeters beyond the bifurcation but patent.\n\n Findings were discussed with Dr. at 5:30 on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-07 00:00:00.000",
"description": "CT GUIDED NEEDLE PLACTMENT",
"row_id": 1201579,
"text": " 1:21 PM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # \n MOD SEDATION, FIRST 30 MIN.\n Reason: Drainage of liver fluid collection. Please only aspirate, p\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ********************************* CPT Codes ********************************\n * PUNC ASP ABS HEM BUL CYST CT GUIDED NEEDLE PLACTMENT *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47F s/p Whipple for pancreatic adenocarcinoma, liver hypodensity concerning for\n fluid collection seen on CT abdomen.\n REASON FOR THIS EXAMINATION:\n Drainage of liver fluid collection. Please only aspirate, please do not leave\n a catheter in. Please send aspirate for gram stain, aerobic culture, and\n anaerobic culture.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED LIVER ASPIRATION\n\n INDICATION: 47-year-old status post Whipple procedure for pancreatic\n adenocarcinoma, liver hypodensity concerning for fluid collection seen on CT\n abdomen, for aspiration of liver fluid collection.\n\n PHYSICIANS: Dr. , the attending radiologist, and Dr. \n , radiology fellow, were present throughout the procedure.\n\n PROCEDURE: Written informed consent was obtained following discussion of the\n benefits, risks, and alternatives with the patient. Preprocedure timeout was\n performed using three unique patient identifiers. A directed history and\n physical exam was performed prior to the procedure. Image guidance was\n utilized to select the precise skin entry point just prior to the procedure.\n The skin was prepped and draped in the usual sterile fashion. Approximately 9\n mL of 1% lidocaine was utilized for local anesthesia. Under CT fluoroscopic\n guidance, a 17-gauge, 13.8-cm coaxial needle was introduced into the\n liver. Approximately 10 mL of purulent red-tinged fluid was aspirated and\n sent for Gram stain and culture. The patient tolerated the procedure well.\n There were no immediate complications.\n\n Moderate sedation was provided by administering divided doses of Versed 2 mg\n and fentanyl 150 mcg throughout the total intraservice time of 25 minutes,\n during which the patient's hemodynamic parameters were continuously monitored.\n\n The patient was transferred back to the floor in stable condition.\n\n IMPRESSION: Successful CT-guided aspiration of 12cc from the left hepatic\n collection. A sample was sent for Gram stain and culture. Findings were\n discussed with referring team at 15:20 on .\n (Over)\n\n 1:21 PM\n PUNC ASP ABS HEM BUL CYST; CT GUIDED NEEDLE PLACTMENT Clip # \n MOD SEDATION, FIRST 30 MIN.\n Reason: Drainage of liver fluid collection. Please only aspirate, p\n Admitting Diagnosis: PANCREATIC CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-30 00:00:00.000",
"description": "Report",
"row_id": 248749,
"text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n"
}
] |
13,318 | 113,356 | Diabetic ketoacidosis. The patient was found to be in diabetic ketoacidosis with a serum glucose of 800, bicarbonate less than 3, and anion gap of 41. The patient was given 4 liters of saline in the Emergency Department and given 10 units of insulin IV and started on an insulin drip. Upon admission to the Intensive Care Unit, the patient was repleted with an additional 2 liters of normal saline and then changed over to D5 half normal saline to replace her fluid level losses. The patient's anion gap slowly closed with IV insulin administration. Her electrolytes were monitored every two hours and repleted as needed. The patient quickly improved within 12 to 18 hours with transition over to NPH insulin and a Humalog insulin sliding scale. The patient's diabetic ketoacidosis was found to be secondary to insulin non-compliance. No source of infection was ever found including pulmonary, urinary tract, skin, oral infections, or sinus infections. The patient had one set of cardiac enzymes, which were negative and EKG, which was not concerning for ischemia. The patient was instructed to resume her NPH as an outpatient and to follow- up with her Endocrinologist at the Clinic. Heroin use. The patient admits to almost daily IV heroin use. She states that she uses 50 bags of heroin a day. She denies all other recreational drug use and denies alcohol use. The patient was not interested in detoxification or heroin cessation during this admission. She was placed on methadone during the admission at a dose of 40 mg p.o. b.i.d. to avoid painful withdrawal syndrome. | methadone given as ordered.vss. NPN 0700-1900General: A&Ox3 calm and appropriate until 1600 when pt started c/o leg twitching, general unconfortableness, stated that the temp. Foley cath dc'd per pt request by MD. Plan is to d/c pt if 1730 labs ok.Neuro: A&Ox 3, amb with steady gait.Resp: Lungs CTA, no c/o SOB, O2 sat 99% on RA, pt non-compliant with keeping on O2sat monitor for ongoing assessment, HO aware.CV: T max 99.2, HR 66-72 NSR no ectopy, BP 115/62, +3 Pedal Pulses bilat.GI: BS (+)x 4 quad., abd soft nd/nt, no BM, tolerating regular diet.GU: Voiding clear yellow urine to BSC.Social: Pt spoke with husband over the phone to pick her up.Plan: Monitor FBS, follow-up labs, d/c home. Called, pt given Methadone dose early (see ). MICU NSG ADD:Glucose 286 and Dr. made aware. BP stable. insulin and given 24u NPH early. LS CTA, no cough or SOB noted.GI/GU: Abd. HR 60s-100s SR/ST, no ectopy noted. Glucose 264 at 4am and order for 4u reg. Insulin gtt dc'd FBS 76-270, started on SS insulin with am and pm standing NPH dose. Given 8uNPH at 1200am as ordered and insulin gtt turned off at 2am. also c/o of feeling "jittery" and given am methadone dose early. given 10 u reg. CXR (-).CV: HR 101-105 ST no ectopy, BP's 94-99/37-44, trace edema to lower extremities bilat., 3+ Pedal Pulses bilat.Endo: insulin gtt at 7u/hr, FBS q 1hr.GI: BS (+)x 4 quad., abd soft non-distended, non-tender, no BM, taking ice chips po and tolerating well, clear liquid diet to be started.GU: Dc'd foley cath intact per pt request, using bedpan, voiding clear yellow urine in adequate amts.Social: husband called.Plan: Continue to monitor FBS q 1hr., monitor VS, adm IV flds as ordered. Pt. Pt. Pt. Repleted with MG and Na Phosphate overnight. OOB to commode with assist. RR 16-26, O2 sdat 96-100% RA, no c/o sob, resp even and unlabored. insulin bolus iv in ER arrived on MICU with Insulin gtt at 7u/hr, current FBS 181 and 149. Ordered 8u reg. npnpt to be discharged home when glucose and lytes stabilize.12am K+ 3.5 given po 40 meq kcl at 330am.bs range from 296 to 130. pt received pm dose of 12 nph and 10 units of humalog coverage at 2130pmam labs pending.pt aox3 ambulating in room. Tolerating clear liquid diet. given. R TLC line intact. Sinus tachycardia, rate 114. Scratches noted to UEs. Complaining of sore throat- intern made aware. Bicarb down to 12. To make sure pt. Will continue to monitor glucose.SKIN: Intact. T waves are more upright in the mid-precordium and theQRS axis has shifted more rightward. MICU NPN:NEURO: A&Ox3. Left atrial abnormality/rightatrial abnormality. Compared to the previous tracing of sinustachycardia and criteria for left atrial abnormality and right atrialabnormality are new. IV. repeatedly told to call for assistance secondary to IVs and wires but continually got OOB on own- able to manage with difficulty.CV: Tmax 100.1 po. Intern then ordered to restart gtt and insulin gtt started at 0640 at 2u/hr and to continue with q1hr glucose checks. Skin warm and dry with palpable pedal and radial pulses bilat. NS at 500cc/hr presently infusing x 1L then to be changed to 1/2NS @ 500cc/hr x 1 L see for further details. Vertical heart. soft, non-tender with positive bowel sounds. NPN 1600-1900Pt presented to EW c/o NV and feeling bad, known heroin,adm to MICU with Dx of DKA. Intern aware. Voiding in bedside commode clear yellow urine. 1200 labs: K=3.2 given 40KCL IV and 20KCl po and started on NS with 40KCL at 150cc/hr, Ca=8.1 given 2GM Ca Gluc. No BM. D51/2 NS with 40meq KCL infusing at 250cc/hr and to d/c after this litre.RESP: On RA with O2 Sat >95%. Pt last used heroin this am, husband stated pt had an opiate addiction, to be started on Methadone 40mg po bid.Neuro: A &O x 3 moves self in bed able to void by self into bedpan, MAEW, no noted neuro deficits.Resp: Lungs clear to upper lobes, coarse to lower lobes A&P chest. No nausea or vomitting. no complaints voiced overnight pt has been sleeping / resting most of shift.poan: cont to monitor labs and discharge home when able. clinic in, DKA probably r/t not taking adequate insulin rather then other endogenous stressor. no outbursts behavior has been apporopriate. eats breakfast. was either to hot or cold and was getting in and out of bed pulling off monitoring equip.,then proceeded to yell and throw objects in the room, she stated "I want to go home, I want to get the hell out of here....I want you to leave me alone." | 6 | [
{
"category": "ECG",
"chartdate": "2174-05-05 00:00:00.000",
"description": "Report",
"row_id": 164198,
"text": "Sinus tachycardia, rate 114. Vertical heart. Left atrial abnormality/right\natrial abnormality. Compared to the previous tracing of sinus\ntachycardia and criteria for left atrial abnormality and right atrial\nabnormality are new. T waves are more upright in the mid-precordium and the\nQRS axis has shifted more rightward.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-06 00:00:00.000",
"description": "Report",
"row_id": 1436005,
"text": "MICU NSG ADD:\nGlucose 286 and Dr. made aware. Ordered 8u reg. insulin and given 24u NPH early. Bicarb down to 12. To make sure pt. eats breakfast. Intern then ordered to restart gtt and insulin gtt started at 0640 at 2u/hr and to continue with q1hr glucose checks. Pt. also c/o of feeling \"jittery\" and given am methadone dose early. Intern aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-06 00:00:00.000",
"description": "Report",
"row_id": 1436006,
"text": "NPN 0700-1900\nGeneral: A&Ox3 calm and appropriate until 1600 when pt started c/o leg twitching, general unconfortableness, stated that the temp. was either to hot or cold and was getting in and out of bed pulling off monitoring equip.,then proceeded to yell and throw objects in the room, she stated \"I want to go home, I want to get the hell out of here....I want you to leave me alone.\" Called, pt given Methadone dose early (see ). Insulin gtt dc'd FBS 76-270, started on SS insulin with am and pm standing NPH dose. clinic in, DKA probably r/t not taking adequate insulin rather then other endogenous stressor. 1200 labs: K=3.2 given 40KCL IV and 20KCl po and started on NS with 40KCL at 150cc/hr, Ca=8.1 given 2GM Ca Gluc. IV. Plan is to d/c pt if 1730 labs ok.\n\nNeuro: A&Ox 3, amb with steady gait.\n\nResp: Lungs CTA, no c/o SOB, O2 sat 99% on RA, pt non-compliant with keeping on O2sat monitor for ongoing assessment, HO aware.\n\nCV: T max 99.2, HR 66-72 NSR no ectopy, BP 115/62, +3 Pedal Pulses bilat.\n\nGI: BS (+)x 4 quad., abd soft nd/nt, no BM, tolerating regular diet.\n\nGU: Voiding clear yellow urine to BSC.\n\nSocial: Pt spoke with husband over the phone to pick her up.\n\nPlan: Monitor FBS, follow-up labs, d/c home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-07 00:00:00.000",
"description": "Report",
"row_id": 1436007,
"text": "npn\npt to be discharged home when glucose and lytes stabilize.\n12am K+ 3.5 given po 40 meq kcl at 330am.\nbs range from 296 to 130. pt received pm dose of 12 nph and 10 units of humalog coverage at 2130pm\nam labs pending.\npt aox3 ambulating in room. no outbursts behavior has been apporopriate. methadone given as ordered.\nvss. no complaints voiced overnight pt has been sleeping / resting most of shift.\npoan: cont to monitor labs and discharge home when able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-05 00:00:00.000",
"description": "Report",
"row_id": 1436003,
"text": "NPN 1600-1900\nPt presented to EW c/o NV and feeling bad, known heroin,adm to MICU with Dx of DKA. given 10 u reg. insulin bolus iv in ER arrived on MICU with Insulin gtt at 7u/hr, current FBS 181 and 149. NS at 500cc/hr presently infusing x 1L then to be changed to 1/2NS @ 500cc/hr x 1 L see for further details. Foley cath dc'd per pt request by MD. Pt last used heroin this am, husband stated pt had an opiate addiction, to be started on Methadone 40mg po bid.\n\nNeuro: A &O x 3 moves self in bed able to void by self into bedpan, MAEW, no noted neuro deficits.\n\nResp: Lungs clear to upper lobes, coarse to lower lobes A&P chest. RR 16-26, O2 sdat 96-100% RA, no c/o sob, resp even and unlabored. CXR (-).\n\nCV: HR 101-105 ST no ectopy, BP's 94-99/37-44, trace edema to lower extremities bilat., 3+ Pedal Pulses bilat.\n\nEndo: insulin gtt at 7u/hr, FBS q 1hr.\n\nGI: BS (+)x 4 quad., abd soft non-distended, non-tender, no BM, taking ice chips po and tolerating well, clear liquid diet to be started.\n\nGU: Dc'd foley cath intact per pt request, using bedpan, voiding clear yellow urine in adequate amts.\n\nSocial: husband called.\n\nPlan: Continue to monitor FBS q 1hr., monitor VS, adm IV flds as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-05-06 00:00:00.000",
"description": "Report",
"row_id": 1436004,
"text": "MICU NPN:\nNEURO: A&Ox3. Complaining of sore throat- intern made aware. Pt. stating she can't sleep but appeared to be sleeping frequently throughout night. OOB to commode with assist. Pt. repeatedly told to call for assistance secondary to IVs and wires but continually got OOB on own- able to manage with difficulty.\nCV: Tmax 100.1 po. HR 60s-100s SR/ST, no ectopy noted. Repleted with MG and Na Phosphate overnight. BP stable. Skin warm and dry with palpable pedal and radial pulses bilat. D51/2 NS with 40meq KCL infusing at 250cc/hr and to d/c after this litre.\nRESP: On RA with O2 Sat >95%. LS CTA, no cough or SOB noted.\nGI/GU: Abd. soft, non-tender with positive bowel sounds. Tolerating clear liquid diet. No nausea or vomitting. No BM. Voiding in bedside commode clear yellow urine. Given 8uNPH at 1200am as ordered and insulin gtt turned off at 2am. Glucose 264 at 4am and order for 4u reg. given. Will continue to monitor glucose.\nSKIN: Intact. Scratches noted to UEs. R TLC line intact.\n"
}
] |
63,961 | 180,869 | 67 y/o female s/p ABO incompatible liver transplant with splenectomy on followed by month long post op hospitalization who now presents with shortness of breath. A cardiac echo was obtained on admission showing an EF of > 65%, however there is increased severity of mitral and tricuspid regurgitation and estimated pulmonary artery pressures from the study from of . Cardiology and Renal consults were obtained) Chest xray showed worsening pulmonary edema and she has worsening kidney function, and the patient received hemodialysis. The patient received intermittent hemodialysis until . The patient was also complaining of an increasing amount of abdominal pain. An abdominal CT was obtained on showing increased size of subheaptic fluid collections; differential includes biloma with possible hemorrhage, postoperative seroma and pancreatic pseudocyst. CT guided drainage of the collection returned 1200 cc of dark brown fluid which did not have any organisms or growth on culture. The fluid was also tested for amylase which came back at about , and she underwent an which showed extravasation noted at the tail of the pancreas consistent with pancreatic duct leak. A 7cm by 7FR pancreatic pancreatic stent was placed. This should be removed beginning of . The patient was then noted to have drop in Hct, she was transferred to the ICU and was taken to the OR with Dr for exploratory laparotomy, drainage of intra-abdominal fluid collections and hematoma, interposition iliac artery graft from celiac axis to hepatic artery, Tru-Cut biopsy of the liver for Intra-abdominal bleeding, fluid collection, pancreatic duct leak, hematoma, bleeding from the splenic artery/hepatic artery anastomosis. She received 14 days of Linezolid due to enterococcus growing in her peritoneal fluid. She was not febrile, however white count increased to 26,000. This decreased once infection treated. Another was performed on for persistently elevated Alk Phos. The biliary stent was removed and a small amount of sludge was removed by snare. During , Initial cholangiogram appeared fairly normal and the anastamotic stricture was much improved in appearance. However, on balloon occclusion cholangiogram, evidence of contrast extravasation was noted from small right intrahepatic branches. She underwent successful placement of 9cm x 10Fr biliary stent to facilitate improved biliary drainage. On her hct was noted to drop to 17%, and she was immediately transferred back to the ICU for transfusion and EGD after stooling large amounts of maroon stool. CT of the abdomen did not reveal any issues with the Hepatic artery anastomosis, however the study was limited by lack of contrast. An EGD was performed showing mild esophagitis, but no blood in the stomach or duodenum. She received 5 units of blood on and then another 2 the following day, and Hct was back to 30%. She continued with the bloody/tarry stools, and another EGD was done on with still no evidence of bleeding in the upper GI system. Coloscopy revealed diverticulosis of the transverse colon, descending colon and sigmoid colon with erythema and congestion in the whole colon compatible with portal colopathy. There was blood in the whole colon and Grade 2 external hemorrhoids. During that same time frame she also had a tagged RBC scan which showed blood flow images show normal major vascular flow. Dynamic blood pool images show no gross abnormalities, there was no evidence of intra-abdominal bleeding throughout the total imaging time of 132 minutes, and no definite evidence of intra-abdominal bleeding was found. Over the course of the next few days, the stooling became more normal, she has revceievd 2 units of RBCs over the course of the ensuing two weeks, and there has not been evidence of a re-bleed. The patient was fed via TPN while the GI bleed was ongoing. Once symptoms had resolved and patient was tolerating feeds, a post pyloric feeding tube placed during the upper GI was again utilized. Tube feeds were altered to help with tolerance. Her appetite remains very limited, and weight is 52.5 kg at time of discharge, which is almost 30 kg lost since time of transplant. Her renal function improved with creatinine around 1.5 and approximately 1.5 liters of urine daily. The hemodialysis catheter was removed. All drains have been removed since time of surgery. Immunosuppression was continued during hospitalization, Progral dosing based on daily levels. | CT ABDOMEN WITH AND WITHOUT CONTRAST: There are small bilateral pleural effusions, similar to those seen previously with expected overlying subsegmental atelectasis. PATIENT/TEST INFORMATION:Indication: Tricuspid regurgitation. An oblong curvilinear hyperdense structure is visualized posteriorly in the right hemipelvis, unchanged since and possibly related to a previous urogynecological prolapse repair. Biliary stent is identified as well as surgical drain noted inferior to the right hepatic lobe. There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , a linearthrombus is now suggested in the IVC (area was not visualized on the priorstudy). Left pleural effusion.Conclusions:The left atrium is mildly dilated. The hepatic arterial system remains patent, though a small irregular outpouching of contrast is present near the level of the hepatic arterial anastomosis (4B:240). Doppler assessment of the retrohepatic inferior vena cava, and right, middle, and left hepatic veins as well as main, left, and right portal veins shows patency and appropriate directionality of flow. Notably, there is a small round hypodensity within the distalmost aspect of the left common femoral artery and proximal left superficial femoral artery (4B:340). Anterior ST-T wave changesraise concern for myocardial ischemia. A focused Doppler examination of the hepatic arteries were performed. A central venous catheter terminates in the inferior vena cava. Atrial ectopy has appeared.Followup and clinical correlation are suggested. Now presenting with hematocrit drop and hypotension. FINDINGS: As compared to the previous radiograph, the venous introduction sheath on the right has been removed and replaced by a right internal jugular vein catheter. Noaortic regurgitation is seen. Patent main hepatic artery and left and right branches with normal waveforms and velocities intrahepatically. Patent main hepatic artery and left and right branches with normal waveforms and velocities intrahepatically. Comparedto the previous tracing of atrial fibrillation with rapid ventricularresponse has appeared. Difficulty sampling the hepatic artery surgical anastomosis with a wide range of peak systolic velocities measured. Non-occlusive eccentric filling defect, possibly thrombus seen within the left superficial femoral artery and distal aspect of the left common femoral artery. The left and right brachial arteries are patent with biphasic waveforms. The hepatic veins and portal veins appear patent. Sinus rhythm and frequent atrial ectopy. Sinus rhythm and frequent atrial ectopy. Left atrial abnormality and occasional atrial ectopy. The left hepatic and right hepatic arteries demonstrate normal Doppler waveforms with the left hepatic velocity measuring 74 cm/sec and the right hepatic measuring 69 cm/sec with resistive indices range from 0.8-0.7 cm. Multiple perihepatic organizing fluid collections are identified, though not clearly evaluated and better assessed on the recent abdominal CT. A drain with a left lateral approach is identified within a fluid collection. A slight irregularity of the contour of this pseudoaneurysm near the antero-lateral aspect is noted, possibly related to recent rupture/hemorrhage. Limited CT of the upper abdomen was performed for purposes of procedure planning. The limb leads aremisattached and the precordial leads have been reversed in position. TECHNIQUE: Right upper quadrant ultrasound with Dopplers. A moderate amount of free fluid is seen in the pelvis and note is made of colonic mural thickening, likely related to generalized volume status. Multiple organizing perihepatic fluid collections identified though better assessed on recent CT. There are small bilateral pleural effusions with adjacent compressive atelectasis. A focal area of interposed fat is demonstrated adjacent to the anterior portion of the right hepatic lobe measuring 4.7 cm, similar since CT examination from . The radial arteries are similarly patent with /triphasic waveforms. Fluid collection seen on CT scan , differential biloma versus pseudocyst. S/p liver transplant.Height: (in) 67Weight (lb): 170BSA (m2): 1.89 m2HR (bpm): 130Status: InpatientDate/Time: at 13:54Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINDINGS: The central venous subclavian waveforms have normal cardiac and respirophasicity. Compared to the previous tracingof sinus rhythm has appeared and the T wave abnormalities are similarto those seen on without diagnostic interim change.TRACING #2 Notably, a pigtail drainage catheter has been substantially retracted in the interval, now at the anterior margin, though not definitively within this hemorrhagic collection. The main hepatic artery is patent with appropriate waveforms. Elevated systolic velocities are again noted near the anastomosis which could be related to the presence of the stent; interval difference in these velocities might related to differences in technique. There is moderate pulmonary artery systolichypertension. Central venous catheter traversing the right atrium and ending the IVC. Compared tothe previous tracing of atrial fibrillation is no longer present. As has been seen previously, the pancreas contains numerous hypodensities. The main hepatic artery shows patency and appropriate waveforms. A linear thrombus is suggested in theinferior vena cava> There is mild symmetric left ventricular hypertrophy withnormal cavity size and regional/global systolic function (LVEF>55%). IMPRESSION: Patent central veins. A common bile duct stent is in place. Borderline basilic diameters in the upper arm for access. Elevated systolic velocities are again noted near the anastamosis which could be related to difficulties in angle correction or may be related to the presence of the stent. There is evidence of electrical alternans in leads V1-V3.Consider pericardial effusion. Patent main hepatic artery and left and right branches with normal waveforms (Over) 3:53 PM DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: Please perform a duplex/doppler of the abdomen to evaluate t Admitting Diagnosis: CONGESTIVE HEART FAILURE FINAL REPORT (Cont) and velocities demonstrated intrahepatically. | 16 | [
{
"category": "Radiology",
"chartdate": "2140-09-08 00:00:00.000",
"description": "CT GUIDED NEEDLE PLACTMENT",
"row_id": 1203405,
"text": " 11:49 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n\n Reason: Fluid collection seen on CT scan , differential Biloma v\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDED NEEDLE PLACTMENT *\n * *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n Moderate sedation: Moderate sedation was provided by administering divided\n doses of versed and fentanyl throughout the total intra-service time of 20\n minutes during which the patient's hemodynamic parameters were continuously\n monitored by radiology nursing personnel.\n\n\n\n 11:49 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n\n Reason: Fluid collection seen on CT scan , differential Biloma v\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F s/p liver transplant, s/p ERCP stent placement and sphincterotomy, now with\n increased simple fluid collection per read that is supcapsular. Pt has been\n nauseated and not tolerating diet.\n REASON FOR THIS EXAMINATION:\n Fluid collection seen on CT scan , differential Biloma vs Pseudocyst, looks\n as if fluid collection is subcapsular\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE\n\n DATE: \n\n COMPARISON: CT abdomen and pelvis.\n\n CLINICAL HISTORY: 67-year-old female status post liver transplant, status\n post ERCP, stent placement and sphincterotomy, now with increased simple fluid\n collection that is subcapsular. The patient has been nauseated and not\n tolerating diet. Fluid collection seen on CT scan , differential biloma\n versus pseudocyst. Drainage requested.\n\n PHYSICIAN: . , Dr. .\n\n PROCEDURE: The procedure, risks, benefits and alternatives were discussed\n with the patient and the patient's daughter, , who requested that we\n proceed. Informed consent was obtained from the daughter over the telephone\n with a witness.\n\n The site/side of the procedure was marked with aligned. A directed history\n and physical exam was performed prior to the procedure.\n\n A timeout was performed with assisting personnel just prior to the procedure,\n discussing the planned procedure, confirmed the patient's identity with three\n identifiers and revealing a checklist per protocol.\n\n Limited CT of the upper abdomen was performed for purposes of procedure\n planning. This redemonstrated large subhepatic fluid collections. At least\n two of which are communicating. The right posterior fluid collection is\n questionably communicating. A common bile duct stent is in place. NG tube is\n terminating in the gastric body. There are small bilateral pleural effusions\n with adjacent compressive atelectasis. Post-surgical changes are evident in\n the anterior abdominal wall.\n\n TECHNIQUE:\n\n (Over)\n\n 11:49 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n\n Reason: Fluid collection seen on CT scan , differential Biloma v\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Imaging guidance was utilized to select the precise skin entry point just\n prior to the procedure. The skin was prepped and draped in the usual sterile\n fashion. Approximately 10 mL of 1% lidocaine was utilized for local\n anesthesia.\n\n Under CT fluoroscopic guidance, an 8-French catheter was introduced\n into the perihepatic fluid collections via a left anterior approach. A\n Seldinger technique was utilized with an 18-gauge needle introduced,\n subsequently, guidewire was inserted into the fluid collection. 7 French and\n 8 French dilators were used to dilate the tract. The French catheter was\n placed without complication. Approximately 1200 mL of dark brown fluid was\n removed. A sample was sent for analysis. The catheter was attached to a\n drainage bag and secured to the skin with a Statlock.\n\n The patient tolerated the procedure well. A post-procedure note was placed\n into the medical record and orders were entered into the electronic medical\n record. There is no immediate complication. After the procedure, the\n patient's condition was unchanged. Estimated blood loss was minimal.\n\n Dr. , the attending radiologist, who was present for the entire\n procedure.\n\n IMPRESSION:\n\n CT-guided drainage catheter placement into perihepatic fluid collections, with\n removal of 1200 mL of dark brown fluid. Microbiology pending.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-09 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1203598,
"text": " 5:10 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Duplex, suprahepatic clot seen on echo, Assess IVC/PV/Hepati\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with newly seen IVC thrombus on echo done today\n REASON FOR THIS EXAMINATION:\n Duplex, suprahepatic clot seen on echo, Assess IVC/PV/Hepatic vein clot and\n hepatic artery flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Woman with newly seen IVC thrombus on echocardiogram performed\n the same day. Please evaluate for suprahepatic clot seen on echo as well as\n IVC, portal vein and hepatic veins, and hepatic arterial flow.\n\n COMPARISON: Comparison is made to CT abdomen and pelvis performed and .\n\n FINDINGS: The liver is homogeneous in echotexture without discrete masses or\n lesions. Multiple perihepatic organizing fluid collections are identified,\n though not clearly evaluated and better assessed on the recent abdominal CT.\n A drain with a left lateral approach is identified within a fluid collection.\n A patent biliary stent is also identified. The demonstrated portions of the\n right kidney are without hydronephrosis, mass or stones.\n\n Doppler assessment of the retrohepatic inferior vena cava, and right, middle,\n and left hepatic veins as well as main, left, and right portal veins shows\n patency and appropriate directionality of flow. The main hepatic artery shows\n patency and appropriate waveforms.\n\n IMPRESSION:\n\n 1. No evidence of retrohepatic portal venous or hepatic vein thrombosis. The\n main hepatic artery is patent with appropriate waveforms. The suprahepatic\n inferior vena cava is not assessed via liver Doppler ultrasound.\n 2. Multiple organizing perihepatic fluid collections identified though better\n assessed on recent CT. Drain is noted within a perihepatic fluid collection.\n 3. Patent biliary stent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-14 00:00:00.000",
"description": "CTA PELVIS W&W/O C & RECONS",
"row_id": 1204148,
"text": " 2:18 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F s/p OLT (ABO incompatible) on for HCV cirrhosis, hepatorenal\n syndrome, c/b SOB and CXR c/w fluid overload on HD. Now with pancreatic duct\n leak s/p CT guided drainage and ERCP pancreatic stent placement now\n with HCT drop, hypotension and bloody drainage from abd drain transfer to the\n unit concern for inta abdominal bleed\n REASON FOR THIS EXAMINATION:\n Intraabdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Orthotopic liver transplant on , with presumed\n pancreatic duct leak status post imaging-guided drainage, more recently with\n pancreatic stent placement on . Now presenting with hematocrit drop\n and hypotension.\n\n COMPARISON: , & \n\n TECHNIQUE: Axial CT images are acquired through the abdomen without\n intravenous contrast. Thereafter, images are acquired through the abdomen and\n pelvis at multiple phases following the uneventful intravenous administration\n of 150 cc of Optiray contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: There are small bilateral pleural\n effusions, similar to those seen previously with expected overlying\n subsegmental atelectasis. A central venous catheter terminates in the\n inferior vena cava. An orogastric tube enters the stomach, and terminates\n near the pylorus. Notably, there are areas of intraluminal hyperdensity seen\n within the stomach (4B:207) which are present on pre-contrast images, of\n indeterminate etiology, possibly ingested foreign bodies or tablets. Common\n bile duct and pancreatic ductal stents are present. Finally, there is a\n percutaneously placed pigtail drainage catheter sitting along the anterior\n margin of a large anterior fluid collection, significantly retracted since the\n most recent comparison.\n\n The transplanted liver is heterogeneous in attenuation dural the portal venous\n phase of imaging. There is no portal venous thrombosis. However, the main\n portal vein is now severely attenuated, slit-like in caliber at its\n origin(4B:241). This findings is worsened. The hepatic arterial system\n remains patent, though a small irregular outpouching of contrast is present\n near the level of the hepatic arterial anastomosis (4B:240). This is 6 x 3mm,\n and follows the blood pool on delayed sequences, suggesting a pseudoaneurysm.\n A slight irregularity of the contour of this pseudoaneurysm near the\n antero-lateral aspect is noted, possibly related to recent rupture/hemorrhage.\n\n As has been seen previously, the pancreas contains numerous hypodensities. A\n (Over)\n\n 2:18 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small amount of peripancreatic gas is visualized along the ventral surface of\n the head and neck of the pancreas. There is a large pocket of hyperdense,\n hemorrhagic fluid anterior to the pancreas and posterior to the liver,\n increased from the comparison study. The internal hyperdensity is new,\n indicating interval hemorrhage. The total size of this cavity is difficult to\n measure, approximately 20.1 x 8.6 x 7.3cm. The kidneys enhance and excrete\n contrast in a symmetric fashion. The spleen is absent.\n\n CT PELVIS WITH CONTRAST: The urinary bladder is notable for mural thickening\n and otherwise unremarkable. An oblong curvilinear hyperdense structure is\n visualized posteriorly in the right hemipelvis, unchanged since \n and possibly related to a previous urogynecological prolapse repair. A\n moderate amount of free fluid is seen in the pelvis and note is made of\n colonic mural thickening, likely related to generalized volume status.\n Notably, there is a small round hypodensity within the distalmost aspect of\n the left common femoral artery and proximal left superficial femoral artery\n (4B:340).\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n\n IMPRESSION:\n\n 1. Marked interval expansion of a large hemorrhagic collection anterior to\n the pancreas as described above. Notably, a pigtail drainage catheter has\n been substantially retracted in the interval, now at the anterior margin,\n though not definitively within this hemorrhagic collection.\n\n 2. 6 x 3 mm outpouching adjacent to the level of the hepatic arterial\n anastomosis, concerning for hepatic arterial pseudoaneurysm, suggesting a\n source of the aforementioned hemorrhagic collection although there is no\n evidence for ongoing active extravasation.\n\n 3. Interval increase in attenuation of the portal vein near its origin, with\n now only trace luminal filling visualized. This is likely related to\n extrinsic mass effect from the large adjacent hemorrhagic collection.\n Heterogeneous attenuation within the liver seen most on portal venous phase is\n likely a consequence of this attenuation.\n\n 4. Non-occlusive eccentric filling defect, possibly thrombus seen within the\n left superficial femoral artery and distal aspect of the left common femoral\n artery. It is unclear whether this is related to recent left groin arterial\n puncture.\n\n 5. Small bilateral pleural effusions.\n\n (Over)\n\n 2:18 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Intraabdominal bleeding\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 6. Central venous catheter traversing the right atrium and ending the IVC.\n\n These results were discussed via telephone by Dr. with Dr. \n from Surgery at 10:57 on \n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-22 00:00:00.000",
"description": "ART DUP EXT UP BILAT COMP",
"row_id": 1205269,
"text": " 8:54 AM\n VENOUS DUP UPPER EXT BILATERAL; ART DUP EXT UP BILAT COMP Clip # \n Reason: please do vein mapping\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F s/p ABO incompatible liver transplant and splenectomy for HCV cirrhosis c/b\n perihepatic fluid collection s/p IR drainage now s/p washout, interpos HA graft\n with ARF on HD. Will need tunnelled HD line\n REASON FOR THIS EXAMINATION:\n please do vein mapping\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF STUDY: .\n\n INDICATION: 67-year-old female with end-stage renal failure. Please map arms\n for possible autogenous fistula options.\n\n FINDINGS: The central venous subclavian waveforms have normal cardiac and\n respirophasicity.\n\n The left and right brachial arteries are patent with biphasic waveforms. The\n radial arteries are similarly patent with /triphasic waveforms. No\n significant calcification is noted.\n\n RIGHT ARM: The right arm cephalic vein is small in the forearm with diameters\n mostly less than 2 mm. Near the antecubital fossa there is an isolated\n segment measuring 3.8 mm but the upper cephalic is not seen. The right arm\n basilic vein is less than 2 mm in the forearm with diameters from antecubital\n fossa to upper arm of 2.4, 2.5, 1.8, 2.4 mm, respectively.\n\n LEFT ARM: The left arm cephalic diameters are small ranging from 0.9-1.1 mm\n for the majority with an isolated segment of 2.8 mm at the antecubital fossa.\n The left basilic vein is less than 2 mm in the forearm with diameters in the\n upper arm measuring 2.5 mm.\n\n IMPRESSION: Patent central veins. Patent brachial and radial arteries\n bilaterally without significant calcification. Small cephalic diameters.\n Borderline basilic diameters in the upper arm for access.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-24 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1205588,
"text": " 10:00 AM\n DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n Reason: SP LIVER TRANSPLANT ,EVAL FOR FLOW\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with 67 year old woman s/p liver transplant and take back for\n hepatic interposition graft\n REASON FOR THIS EXAMINATION:\n Eval vessels for flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient status post liver transplant and take back for hepatic\n artery interposition graft. Please evaluate vessels for flow.\n\n COMPARISON: Comparison is made to abdominal ultrasounds performed \n and .\n\n FINDINGS: The liver demonstrates no focal or textural abnormalities. No\n intrahepatic biliary ductal dilatation evident. Fat deposition is again noted\n along the anterior portion of the right hepatic lobe. The gallbladder is\n surgically removed. The common bile duct is not dilated measuring 3 mm.\n Biliary stent is identified as well as surgical drain noted inferior to the\n right hepatic lobe.\n\n Doppler assessment of the portal and hepatic veins show patency and\n appropriate directionality of flow. The left hepatic and right hepatic\n arteries demonstrate normal Doppler waveforms with the left hepatic velocity\n measuring 74 cm/sec and the right hepatic measuring 69 cm/sec with resistive\n indices range from 0.8-0.7 cm. Multiple attempts were made to sample the main\n hepatic artery and anastomosis resulting in multiple measurements of the\n presumed main hepatic artery with a range of 69 to 164 cm/sec. It appears\n that the most reliable measurement is the 69 cm/sec measurement. No ascites\n evident.\n\n IMPRESSION:\n 1. Hepatic and portal venous systems are patent with appropriate waveforms\n and directionality of flow.\n 2. Difficulty sampling the hepatic artery surgical anastomosis with a wide\n range of peak systolic velocities measured. Recommend re-evaluation of main\n hepatic artery anastomosis at no additional charge to patient.\n\n Dr. discussed findings with Dr. at 14:00 hours\n on via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-19 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1204910,
"text": " 3:53 PM\n DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please perform a duplex/doppler of the abdomen to evaluate t\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F s/p ABO incompatible liver transplant and splenectomy for HCV cirrhosis\n here with shortness of breath and perihepatic fluid collection s/p IR drainage\n and pancreatic duct stent now s/p ex lap, washout for HA splenic artery bleed\n with transposition graft\n REASON FOR THIS EXAMINATION:\n Please perform a duplex/doppler of the abdomen to evaluate the patentcy of the\n hepatic vasculature and the patency of the hepatic artery conduit\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 5:40 PM\n PFI: Persistently elevated velocities presumed at the graft anastomosis site\n now with velocities measured up to 1.8 m/sec in this area on this current\n examination. Patent main hepatic artery and left and right branches with\n normal waveforms and velocities intrahepatically.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female status post liver transplantation for HCV\n cirrhosis with transposition graft of the hepatic artery demonstrating high\n velocities previously. For continued evaluation.\n\n EXAMINATION: Liver transplant duplex ultrasound.\n\n COMPARISONS: and CTA from .\n\n FINDINGS:\n\n The liver demonstrates no new focal or textural abnormalities. There is no\n interval development of biliary dilation since recent examinations. A focal\n area of interposed fat is demonstrated adjacent to the anterior portion of the\n right hepatic lobe measuring 4.7 cm, similar since CT examination from . No concerning new focal liver lesions are identified.\n\n The main portal vein remains patent with appropriate hepatopetal flow with\n velocities of the main portal vein measuring approximately 53 cm/sec.\n\n A focused Doppler examination of the hepatic arteries were performed. The\n right hepatic artery demonstrates a normal Doppler waveform and a normal\n velocity measured at 31 cm/sec. The left hepatic artery demonstrates a normal\n Doppler waveform and a normal velocity measured at 53 cm/sec. The resistive\n indices range from 0.68-0.69. The main hepatic artery demonstrates a normal\n waveform and velocity measuring approximately 80 cm/sec. Redemonstrated is\n markedly increased velocities demonstrated in the region of the graft\n anastomosis in today's study ranging up to at least 180 cm/sec.\n\n IMPRESSION: Persistently elevated velocities presumed at the hepatic graft\n anastomosis site now with velocities measured up to 1.8 m/sec in this area.\n Patent main hepatic artery and left and right branches with normal waveforms\n (Over)\n\n 3:53 PM\n DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please perform a duplex/doppler of the abdomen to evaluate t\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and velocities demonstrated intrahepatically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-19 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1204911,
"text": ", W. FA10 3:53 PM\n DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please perform a duplex/doppler of the abdomen to evaluate t\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F s/p ABO incompatible liver transplant and splenectomy for HCV cirrhosis\n here with shortness of breath and perihepatic fluid collection s/p IR drainage\n and pancreatic duct stent now s/p ex lap, washout for HA splenic artery bleed\n with transposition graft\n REASON FOR THIS EXAMINATION:\n Please perform a duplex/doppler of the abdomen to evaluate the patentcy of the\n hepatic vasculature and the patency of the hepatic artery conduit\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistently elevated velocities presumed at the graft anastomosis site\n now with velocities measured up to 1.8 m/sec in this area on this current\n examination. Patent main hepatic artery and left and right branches with\n normal waveforms and velocities intrahepatically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-16 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1204577,
"text": " 5:47 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: is new R IJ in good position?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with line exchange this afternoon\n REASON FOR THIS EXAMINATION:\n is new R IJ in good position?\n ______________________________________________________________________________\n WET READ: DLrc FRI 8:20 PM\n Right approach IJ with tip within the right atrium by 4 cm.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Line exchange.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the venous introduction\n sheath on the right has been removed and replaced by a right internal jugular\n vein catheter. The tip of the catheter projects over the right atrium and\n could be pulled back by approximately 3 to 4 cm. The other monitoring and\n support devices are in correct position. There is no evidence of\n pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2140-09-09 00:00:00.000",
"description": "Report",
"row_id": 90297,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tricuspid regurgitation. Mitral regurgitation. Pulmonary HTN. S/p liver transplant.\nHeight: (in) 67\nWeight (lb): 170\nBSA (m2): 1.89 m2\nHR (bpm): 130\nStatus: Inpatient\nDate/Time: at 13:54\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient. Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. A linear thrombus is suggested in the\ninferior vena cava> There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral leaflets are mildly\nthickened/fibrotic. Trivial mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , a linear\nthrombus is now suggested in the IVC (area was not visualized on the prior\nstudy).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-10 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1208008,
"text": " 3:56 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Duplex US of liver vasculature\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman POD #60 s/p liver transplant and POD #26 s/p hepatic artery\n interposition graft for hematoma, with rising alkaline phosphatase\n REASON FOR THIS EXAMINATION:\n Duplex US of liver vasculature\n ______________________________________________________________________________\n WET READ: SHSf MON 5:51 PM\n Patent hepatic vessels. Elevated systolic velocities are again noted near the\n anastamosis which could be related to difficulties in angle correction or may\n be related to the presence of the stent.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, postop day 26 from hepatic artery\n interposition graft for hematoma with rising alkaline phosphatase. Assess\n liver vasculature.\n\n TECHNIQUE: Right upper quadrant ultrasound with Dopplers.\n\n COMPARISON: Multiple priors, most recently on and CTA of\n the abdomen .\n\n FINDINGS: The liver itself is normal in echotexture without focal lesion,\n intra- or extra-hepatic biliary ductal dilatation. The hepatic veins and\n portal veins appear patent. The hepatic arteries were sampled in multiple\n locations along their course including the interposition graft that courses\n posterior to the left hepatic lobe. Several waveforms demonstrated late\n systolic blunting, but all demonstrated sharp systolic upstrokes. Elevated\n systolic velocities are again noted near the anastomosis which could be\n related to the presence of the stent; interval difference in these velocities\n might related to differences in technique. The imaged aorta and IVC are\n unremarkable. The spleen is mildly enlarged, measuring 12.8 cm.\n\n IMPRESSION:\n 1. Patent vasculature in the transplanted liver.\n 2. Stable mild splenomegaly.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-28 00:00:00.000",
"description": "Report",
"row_id": 238900,
"text": "Sinus rhythm and frequent atrial ectopy. Left atrial abnormality. Compared to\nthe previous tracing of the anterolateral ST-T wave changes have\nresolved somewhat while the rate has increased. Atrial ectopy has appeared.\nFollowup and clinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-13 00:00:00.000",
"description": "Report",
"row_id": 238901,
"text": "Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. Compared to\nthe previous tracing of atrial fibrillation is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-09 00:00:00.000",
"description": "Report",
"row_id": 238902,
"text": "Atrial fibrillation with rapid ventricular response. Anterior ST-T wave changes\nraise concern for myocardial ischemia. Clinical correlation is suggested.\nCompared to the previous tracing of the heart rate is increased\nsubstantially. There is evidence of electrical alternans in leads V1-V3.\nConsider pericardial effusion. The ST-T wave changes were present on prior\ntracing and persist on the current tracing. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-05 00:00:00.000",
"description": "Report",
"row_id": 238903,
"text": "Sinus rhythm. Left atrial abnormality and occasional atrial ectopy. The\nT wave abnormalities previously recorded on persist without diagnostic\ninterim change. The Q-T interval has improved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-05 00:00:00.000",
"description": "Report",
"row_id": 238904,
"text": "Sinus rhythm and frequent atrial ectopy. Compared to the previous tracing\nof sinus rhythm has appeared and the T wave abnormalities are similar\nto those seen on without diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-04 00:00:00.000",
"description": "Report",
"row_id": 238905,
"text": "Atrial fibrillation with rapid ventricular response. The limb leads are\nmisattached and the precordial leads have been reversed in position. Compared\nto the previous tracing of atrial fibrillation with rapid ventricular\nresponse has appeared. The T wave abnormalities have improved somewhat in the\ncontext of the increase in rate and the appearance of atrial fibrillation.\nClinical correlation is suggested and repeat tracing of diagnostic quality.\nTRACING #1\n\n"
}
] |
28,378 | 120,103 | 83 yo male with PMH of afib, high grade glioma who presented with afib/flutter with RVR in the 150s, hemodynamically stable. Cardiovascular) Patient presented with atrial flutter/fibrillation perhaps triggered by hypovolemia. Initially admitted to the ICU overnight then transferred to the medicine service the following day. No evidence of PE, infection, ischemia, medication noncompliance, substance use/withdrawal. The patient's lasix was held. Cardiac enzymes were not elevated. Patient received IV diltiazem with resumption of his outpatient medication regimen with short-acting form of diltiazem 60 mg po qid(on diltiazem SR 240 mg po qd as outpatient) and metoprolol with good rate control throughout the rest of his admission. Since hypovolemia appeared to be a trigger for the patient's a-fib with RVR and since he has poor po intake, on discharge the patient's lasix was decreased from 40 mg po qd to 20 mg po qd. Aspiration PNA- The patient's levaquin/flagyl for question of aspiration pneumonia was completed on Thrombocytopenia-The patient had decreasing platelets since down to 89 on . Keppra had been started on . The patient's keppra was changed to dilantin. HIT antibody came back positive. Since there was now a clear explanation for the patient's thrombocytopenia, the patient's keppra was restarted and dilantin discontinued. Glioma-The patient received 3 treatments of brain XRT on consecutive days before discharge. The patient is to follow-up at radiation oncology clinic at basement Monday through Friday (5 days a week for 28 consecutive treatments) at 2:30 pm. Rehab is to arrange transport for patient. CVA- Hx of CVA-On aspirin, warfarin contraindicated due to glioma. . FEN: Tubefeeds. Speech and swallow evaluated the patient and noted that he is a silent aspiration risk and instructed that the patient not take any meds by mouth. the patient receives his meds via G-tube. IR evaluated the patient's G-tube on day of discharge and noted that it was in good working order and did not need to be replaced. | Moderate mitral annularcalcification. Mild (1+) mitralregurgitation is seen. Mildly dilated ascending aorta. of the mitral chordae (normal variant). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Small hiatal hernia. There are non-pathologically enlarged subcentimeter bilateral axillary lymph nodes. Mild [1+] TR. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Slight decrease in size of bilateral pleural effusions. COMPARISON: CTA chest with and without contrast . Right ventricular chamber size and free wall motion are normal.The ascending aorta is mildly dilated. A small hiatal hernia is identified. MildPA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). RR 12-18.GI/GU: ABD is soft, hypoactive BS. The rhythm appears to beatrial fibrillation.Conclusions:The left atrium is moderately dilated. Stable size and mild mass effect of mass lesions within the left cerebral peduncle and posterior limb of the left internal capsule. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.Height: (in) 67Weight (lb): 173BSA (m2): 1.90 m2BP (mm Hg): 105/57HR (bpm): 108Status: InpatientDate/Time: at 12:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Pt with hemiparesis of right side. Aortic enlargement has caused a slight right tracheal shift. Compared toprevious tracing of no diagnostic change. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Non-specific ST-T wave changes. The right atrium is moderately dilated.The estimated right atrial pressure is 11-15mmHg. No 2D or Doppler evidence ofdistal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The tricuspid valve leaflets are mildly thickened.There is mild pulmonary artery systolic hypertension. TECHNIQUE: Axial non-contrast MDCT images were obtained through the head. TECHNIQUE: Multidetector CT was performed both with and without contrast per PE protocol. Focal calcifications inaortic root. Clinicalcorrelation is suggested.TRACING #1 LS CTA. SINGLE PORTABLE VIEW OF THE CHEST: Lungs volumes are low. A left frontal burr hole is again identified. Compared to previous tracingof ventricular rate is somewhat slower. Slightly heterogeneous mass lesions are identified within the left cerebral peduncle and left posterior limb of the internal capsule. IMPRESSION: 1. IMPRESSION: 1. No c/o pain.CV: HR now 70s-80s, in afib/aflutter. if this is pt's baseline since stroke. The lungs demonstrate sub 4-mm non-calcified pulmonary nodules in the right apex and inferior right upper lobe which have not changed in appearance since the prior study. There is an anterior space which most likely representsa fat pad.Compared with the prior study (images reviewed) of , there is rapidventricular response to atrial fibrillation. NPN 7p-7aPt is a 83y/o with h/o afib, cva, recent dx of high grade glioma. Significant pulmonicregurgitation is seen. Non-specific ST-T wave changes.Compared to previous tracing of no diagnostic change. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Pt has very dry mucous membranes. Again noted are bilateral calcified pleural plaques with upper lobe predominance, likely indicative of prior asbestos exposure. Pt also with slightly slurred speach. The mitral valve leaflets are mildly thickened. No clear pulmonary edema. The paranasal sinuses are well aerated. IMPRESSION: AP chest compared to through 15: Lung volumes are lower due in part to a new small bilateral pleural effusions. Stable appearance of sub 4-mm pulmonary nodules in the right lung. Atrial flutter or coarse atrial fibrillation/flutter with a relatively rapidventricular response. Atrial flutter which may be of the clock-wise variant or fibrillation/flutterwith a mildly rapid ventricular response. The biventricular function andvalvular regurgitation are similar. Calcified pleural plaques consistent with prior asbestos exposure. There is mild symmetric leftventricular hypertrophy with normal cavity size and systolic function(LVEF>55%). Pt was transfered to ED, treated with 10mg IV Dilt x2 with subsequent drop in BP to low 90s. Pt was in route to first XRT when transport noticed pt was tachypneic and had ? Clinical correlation issuggested.TRACING #3 Clinical correlation issuggested.TRACING #2 Small bilateral pleural effusions persist, but are smaller in size. The bony thorax is normal. Oral care provided. History of glioblastoma multiforme. IMPRESSION: No acute cardiopulmonary process. AFIB. Pt received 1L NS with BP up to 100s, HR still 120s-130s. Pt briefly in NSR. Normal IVC diameter(1.5-2.5cm) with <50% decrease during respiration (estimated RAP 11-15mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). No increased mass effect is identified. COMPARISON: . Pt has been afebrile.SOCIAL: No contacts overnight. No AS. There are degenerative changes in the thoracic spine. Mild cardiac enlargement has increased slightly accompanied by more dilatation of pulmonary vasculature consistent with cardiac decompensation. Pt has PEG, clamped for meds. whether it is dependent redness or allergy. COMPARISON: Radiograph . Pt on strict ASP precautions. No resting LVOTgradient. Pt admitted to MICU for tachycardia and borderline BP.In MICU, HR up to 140s in afib/aflutter and given 10mg IV Dilt. Pt is oriented to person only, ? No pneumothorax. start TFs. U/O adequate, foley draining amber clear urine.SKIN: Overall intact. BP has remained stable, 90s-100s. BP 90s-120s, started on PO Dilt and Lopressor with BP tolerating well.RESP: Sats >96% on RA. 4. 3. The imaged portion of the upper abdomen demonstrates a normal-appearing liver, spleen, and other abdominal organs. ? ? Evaluate for pulmonary embolus. Pt has had small mucoid stools, rusty colored and guiac POS. 2. 2. A PEG tube is noted in the stomach. CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage, hydrocephalus, or shift of normally midline structures. There is slightly increased internal hypoattenuation within these lesions, which could represent necrosis. Increased internal hypoattenuation within these lesions could represent interval necrosis. of asp event. No aortic regurgitationis seen. Pt has red rash over back, does not pass flanks. 5. A PEG tube is not changed in position. | 9 | [
{
"category": "Radiology",
"chartdate": "2191-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 982645,
"text": " 1:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for new intracranial pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hx GBM, now with somnolence, confusion\n REASON FOR THIS EXAMINATION:\n Eval for new intracranial pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Glioblastoma multiforme, increased somnolence and confusion.\n\n COMPARISON: .\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalus, or shift of normally midline structures. A left frontal burr\n hole is again identified. Slightly heterogeneous mass lesions are identified\n within the left cerebral peduncle and left posterior limb of the internal\n capsule. There is slightly increased internal hypoattenuation within these\n lesions, which could represent necrosis. No increased mass effect is\n identified. The paranasal sinuses are well aerated.\n\n IMPRESSION:\n 1. No evidence of acute intracranial hemorrhage or mass effect.\n 2. Stable size and mild mass effect of mass lesions within the left cerebral\n peduncle and posterior limb of the left internal capsule. Increased internal\n hypoattenuation within these lesions could represent interval necrosis.\n\n Of note, if further evaluation of the known underlying mass lesions is\n required, an MRI with gadolinium would be recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-11-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 982646,
"text": " 1:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for PE\n Field of view: 45 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute onset SOB, tachycardia. has hx GBM\n\n REASON FOR THIS EXAMINATION:\n Evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc MON 3:01 PM\n No PE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old male with acute shortness of breath, tachycardia.\n History of glioblastoma multiforme. Evaluate for pulmonary embolus.\n\n COMPARISON: CTA chest with and without contrast .\n\n TECHNIQUE: Multidetector CT was performed both with and without contrast per\n PE protocol.\n\n CT CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolus or\n aortic dissection. The lungs demonstrate sub 4-mm non-calcified pulmonary\n nodules in the right apex and inferior right upper lobe which have not changed\n in appearance since the prior study. Small bilateral pleural effusions\n persist, but are smaller in size. Aortic enlargement has caused a slight\n right tracheal shift. Again noted are bilateral calcified pleural plaques\n with upper lobe predominance, likely indicative of prior asbestos exposure.\n There are non-pathologically enlarged subcentimeter bilateral axillary lymph\n nodes. A small hiatal hernia is identified.\n\n The imaged portion of the upper abdomen demonstrates a normal-appearing liver,\n spleen, and other abdominal organs. A PEG tube is noted in the stomach. There\n are degenerative changes in the thoracic spine.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism or aortic dissection.\n 2. Slight decrease in size of bilateral pleural effusions.\n 3. Stable appearance of sub 4-mm pulmonary nodules in the right lung.\n 4. Calcified pleural plaques consistent with prior asbestos exposure.\n 5. Small hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 982714,
"text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change, signs of new intrathoracic process\n Admitting Diagnosis: ATRIAL FIBRILLATION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with with dyspnea, afib\n\n REASON FOR THIS EXAMINATION:\n Interval change, signs of new intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:36 A.M. \n\n HISTORY: Dyspnea. AFIB.\n\n IMPRESSION: AP chest compared to through 15:\n\n Lung volumes are lower due in part to a new small bilateral pleural effusions.\n Mild cardiac enlargement has increased slightly accompanied by more dilatation\n of pulmonary vasculature consistent with cardiac decompensation. No clear\n pulmonary edema. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 982627,
"text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for intrathoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with with dyspnea, afib\n REASON FOR THIS EXAMINATION:\n Evaluate for intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old male with dyspnea and AFIB, evaluate for intrathoracic\n pathology.\n\n COMPARISON: Radiograph .\n\n SINGLE PORTABLE VIEW OF THE CHEST: Lungs volumes are low. There is no\n infiltrate, edema or effusion. A PEG tube is not changed in position. The\n bony thorax is normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-11-22 00:00:00.000",
"description": "Report",
"row_id": 1632674,
"text": "NPN 7p-7a\nPt is a 83y/o with h/o afib, cva, recent dx of high grade glioma. Pt was in route to first XRT when transport noticed pt was tachypneic and had ? of asp event. At XRT, sats 97% on RA but found to be in rapid afib to 150s. Pt was transfered to ED, treated with 10mg IV Dilt x2 with subsequent drop in BP to low 90s. Pt received 1L NS with BP up to 100s, HR still 120s-130s. Pt admitted to MICU for tachycardia and borderline BP.\nIn MICU, HR up to 140s in afib/aflutter and given 10mg IV Dilt. Pt also started on 60mg PO Dilt Q4H. HR trended down to 70s over a few hours. BP has remained stable, 90s-100s. Pt receiving maintanence fluids at 75cc/hr.\n\nNEURO: Pt has slept on/off over night. Pt is oriented to person only, ? if this is pt's baseline since stroke. Pt also with slightly slurred speach. Pt with hemiparesis of right side. Pt given 1000mg IV Dilantin for temporary treatment of glioma. No c/o pain.\n\nCV: HR now 70s-80s, in afib/aflutter. Pt briefly in NSR. BP 90s-120s, started on PO Dilt and Lopressor with BP tolerating well.\n\nRESP: Sats >96% on RA. LS CTA. No cough or sputum. Pt has very dry mucous membranes. Oral care provided. Pt on strict ASP precautions. RR 12-18.\n\nGI/GU: ABD is soft, hypoactive BS. Pt has PEG, clamped for meds. Pt has had small mucoid stools, rusty colored and guiac POS. U/O adequate, foley draining amber clear urine.\n\nSKIN: Overall intact. Pt has red rash over back, does not pass flanks. ? whether it is dependent redness or allergy. Team is aware. Pt also with yeast like rash in groin area, myconazole powder applied.\n\nID: Pt covered on levaquin/flagy for old asp PNA, to be finished . Pt has been afebrile.\n\nSOCIAL: No contacts overnight. wife went home from .\n\nPLAN: ECHO this am. ? start TFs. F/U with pending am labs.\n\n"
},
{
"category": "Echo",
"chartdate": "2191-11-22 00:00:00.000",
"description": "Report",
"row_id": 102448,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 67\nWeight (lb): 173\nBSA (m2): 1.90 m2\nBP (mm Hg): 105/57\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 12:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal IVC diameter\n(1.5-2.5cm) with <50% decrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. No 2D or Doppler evidence of\ndistal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. of the mitral chordae (normal variant). No resting LVOT\ngradient. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThe estimated right atrial pressure is 11-15mmHg. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is an anterior space which most likely represents\na fat pad.\n\nCompared with the prior study (images reviewed) of , there is rapid\nventricular response to atrial fibrillation. The biventricular function and\nvalvular regurgitation are similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2191-11-21 00:00:00.000",
"description": "Report",
"row_id": 295836,
"text": "Atrial flutter or coarse atrial fibrillation/flutter with a relatively rapid\nventricular response. Non-specific ST-T wave changes. Compared to\nprevious tracing of no diagnostic change. Clinical correlation is\nsuggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2191-11-21 00:00:00.000",
"description": "Report",
"row_id": 295834,
"text": "Atrial flutter which may be of the clock-wise variant or fibrillation/flutter\nwith a mildly rapid ventricular response. Compared to previous tracing\nof ventricular rate is somewhat slower. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2191-11-21 00:00:00.000",
"description": "Report",
"row_id": 295835,
"text": "Atrial flutter or coarse atrial fibrillation/flutter with a rapid ventricular\nresponse at about 130 beats per minute. Non-specific ST-T wave changes.\nCompared to previous tracing of no diagnostic change. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
}
] |
24,089 | 101,153 | 1. INFECTIOUS DISEASE/UROLOGY: The Urology Service followed the patient while in the hospital, status post stent placement with return of pus. The stent was kept in place to be removed several weeks after discharge when the patient was more stable. Only one stone was removed. The patient had evidence of more stones. He was monitored for further signs or symptoms of obstruction. The patient was continued on intravenous Levaquin with the consideration of adding gentamicin if his creatinine tolerated this. Vancomycin was discontinued. Escherichia coli in the culture at the outside hospital was pan-sensitive. The patient was continued on aggressive intravenous fluids. Intravenous fluids were discontinued because of evidence of congestive heart failure, and the patient was encouraged to take p.o. hydration. Cultures taken at were negative to date including blood cultures and cultures. Levofloxacin was changed from intravenous to p.o. on . The patient experienced some incontinence, and his Pyridium was changed from p.r.n. to a standing dose. Per the Urology team, he was also discharged on Urised two tablets p.o. q.i.d. times 10 days for his incontinence. Levofloxacin was to be continued for a total of 14 days. 2. CARDIOVASCULAR: Atrial fibrillation with a rapid ventricular rate. The patient was given doses of Lopressor on the floor; a total of 50 mg intravenously. In the Intensive Care Unit, the patient was continued on Lopressor for rate control. He was anticoagulated with heparin, and the plan was to get an echocardiogram on the patient to rule out thrombus. His atrial fibrillation was thought to be triggered by his septic state. The patient's troponin and creatine kinase leak/rise was thought to be ischemia related to sepsis and atrial fibrillation. The patient had no known cardiac history. The patient was anticoagulated with heparin, continued on beta blocker, and continued on aspirin. Creatine kinases and troponins were followed and trended down. The patient remained hemodynamically stable, although with some evidence of congestive heart failure on examination. The patient responded well to diuresis with Lasix. Electrocardiogram which showed ST depressions was repeated with resolution of the ST depressions. The patient was started on captopril 12.5 mg p.o. t.i.d. on . Coumadin was also started that day for atrial fibrillation with a plan to follow up with Cardiology as an outpatient. On , the patient reverted back to sinus rhythm and was well rate controlled with beta blocker. On further consideration, Coumadin was not started, and he was continued on a heparin drip. The patient remained in sinus rhythm for the remainder of his hospital stay. A cardiac echocardiogram was suboptimal secondary to poor echocardiogram windows showing mild symmetric left ventricular hypertrophy, ejection fraction of greater than 55%, 2+ mitral regurgitation, and mild pulmonary hypertension. He heparin drip was discontinued, but he was continued on his Lopressor and captopril. An outpatient exercise tolerance test will be considered. 3. RENAL: The patient with chronic renal insufficiency with a baseline creatinine of 1.2. This may be secondary to hypertension versus old obstruction. It should not increase in the setting of unilateral obstruction alone, but with sepsis and volume depletion this was not unexpected. He was continued on aggressive hydration; although, this was stopped briefly because of signs and symptoms of congestive heart failure. His output was followed as was his creatinine. Medications were renally dosed for a calculated creatinine clearance of 50 cc per minute. The right renal mass seen on CT scan was thought to be chronic, per his primary care physician. electrolytes and FENa were suggestive of prerenal azotemia in the setting of decreased oral intake secondary to nausea, vomiting, and abdominal pain with kidney stone. The patient was to have followup of renal cyst as an outpatient with magnetic resonance imaging or CT with contrast. His renal function improved by the time of discharge with a blood urea nitrogen of 37 and a creatinine of 1.3; almost at his baseline. 4. HEMATOLOGY: The patient with anemia. Guaiac-negative; unknown baseline. Monitored closely on heparin. Coagulations were followed closely on heparin. A decrease in hematocrit may have been secondary to dilution from hydration. On , the patient had a large liquid stool which was occult-blood positive, but his hematocrit remained stable, and he did not require any transfusions. He was continued on Protonix. 5. ONCOLOGY: Leiomyosarcoma without a history of metastatic disease. A head CT in the past was negative for metastatic lesions; though bony lesions were concerning on CT scan. The patient will need further workup of his L3 vertebral body right femoral neck bony lesions. | Moderate (2+) mitral regurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. CT ABDOMEN WITHOUT CONTRAST: There is moderate dependent atelectasis bilaterally in the lung bases. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter.Height: (in) 71Weight (lb): 240BSA (m2): 2.28 m2BP (mm Hg): 150/70Status: InpatientDate/Time: at 09:56Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is mild symmetric left ventricular hypertrophy. Heart size is borderline with some prominence of the LV and tortuosity of the thoracic aorta. There is mild hydroureter extending to the level of the distal third of the ureter, secondary to an 8 mm obstructing ureteral stone. There is mildmitral annular calcification. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. There is slight flattening of the diaphragms. (Over) 1:05 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o renal stone/abscess FINAL REPORT (Cont) IMPRESSION: 1. Moderate (2+) mitralregurgitation is probably present.4. There is mild hydronephrosis, and several paracalyceal stones, the largest of which measures 1.5 x 1.3 cm. There is mild pulmonary artery systolic hypertension. Skin warm and dry with 2+ generalized edema.RESP: 2L O2 NC with O2 Sat > 95%. A linear region of soft tissue density extending from the right inguinal skin to the region of the perineum is noted. The splenic artery is calcified. Overall left ventricular systolic functionis normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is a moderate amount of perinephric fat stranding. HEP GTT REMAINS AT 2050U/HR WITH THERAPEUTIC PTT X36HRS. HR 80s-100s AF with occasional PVCs. There is a small peripapillary calcification and two low attenuation foci in the left kidney which are incompletely evaluated on this noncontrast exam. Remains on Hep gtt at 2050u/hr with therapeutic ptt x2. The aortic valve leaflets are mildly thickened.3. MICU/SICU NPN 0700-1400NO C/O PAIN OR SOB. TECHNIQUE: Noncontrast abdomen and pelvis CT was performed. Denies nausea. Excoriated peri-area noted. He is without abd or flank pain.Resp:on NP o2 4l sats 95%, clr lungs.ID:he is currently lafebrilel on IV levo, he had cx sent this am from the floorA/P:Will rate control with lopressor, ? Mild degenerative changes are seen in the spine. RECONSTRUCTIONS: The large complex right renal cyst and bilateral calcifications are noted. The right ureter is mildly dilated due to a distal third ureteral stone. denies SOB but RR 28-30s and +DOE. Slight splenomegaly. The liver, adrenals, and abdominal bowel loops are normal in appearance for an unenhanced scan. The pelvic bowel loops are normal in caliber. SUPINE AND UPRIGHT ABDOMEN: Supine and upright views of the abdomen demonstrte gas and stool throughout the colon and into the rectum. IVFs dc'd. The leftventricular cavity size is normal. The pancreas is atrophic. The left ventricularcavity size is normal. soft and obese with present bowel sounds. Denies pain.CV: Afeb. Scattered retroperitoneal nodes in the upper abdomen measure less than 8 mm in greatest short axis dimension, which do not attain CT criteria for pathologic enlargement. 12 cm right renal cyst with peripheral calcification is only partially evaluated on this noncontrast exam. BP 130s-160s/60s-80s. No c/o dysuria.SKIN: Intact. atrial fibrillationNonspecific ST-T changes Overall left ventricular systolic function is verydiffiuclt to assess but is probably normal (LVEF>55%).2. The spleen appears slightly enlarged, extending below the costochondral margin. Cholelithiasis without obstruction or cholecystitis. REMAINS IN AF RATE 90S. CURRENTLY >2L NEG. UO ~100cc/hr. 8 mm obstructing stone in the distal third of the right ureter produces mild hydronephrosis. A few prominent gas filled loops of small bowel are seen in the right abdomen. BP ~150/80 w/HR 90-100AF. He was sent to cystoscopy in the am. Lopressor as ordered. The mitral valve leaflets are mildly thickened. Taking POs well. However, in a patient with a complex renal cyst, pathologic lesions cannot be entirely excluded. During night of , pt had eposode of AF rate of 150's.He was given IVF and lopressor and rsp well. Tolerating pos. MAE well.Resp: Lungs clear no resp distress, sats 97-100% in o2 @ 4l n/cCV: Continues to be in a-ffib with no ectopy noted HR over 110 earlier was given extra dose of 50mg of lopressor hr came down to high 80's to high 90's. On the right kidney, there is a large 12 x 9.5 cm exophytic cyst with peripheral calcification, consistent with a type II Bosniak cyst. CT PELVIS WITHOUT CONTRAST: There is a Foley catheter in place. However, pathologic lytic lesions cannot be excluded, in a patient with a complex renal cyst. Linear soft tissue stranding in the right inguinal region is of uncertain etiology or significance. IVAB for sepsis, note fever curve, u/o and BP.Cont IV hydration. MICU/SICU NPN 0700-1900A&O x3. Afebrile. Gets sl dyspneic on extertion but denies SOB and O2sats on RA 96%. He was started on IV heparin for anticoagulation.GI:+bowel sounds noted but pt is NPO except for meds, no pain.GU:urine is sl cloudy but flowing.He cont on IVF with lytes replacement. Given lasix 20mg last pm with good u/o. PTT check at 11:30pm- Bleeding precautions. He is ~1500cc + fluid balance though this does not include lg amt of liq brown,OB +, stool. Pt. Continue to monitor.GI/GU: Abd. Please correlate with physical exam and surgical history to exclude an acute inflammatory process in the right groin. sepsis.PMH:HTN Renal stones-CRI (h/o ARF with CR 1.5-2) h/o RT renal cysts Leiomyosarcoma-orchietomyMeds:Vasotec HytrinAll:Pt had a 2 day c/o N/V,mild dysuria,chills and fever went to OSH and he was found to have UTI with Bilat ureteral stones/obstruction. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2129-04-22 00:00:00.000",
"description": "Report",
"row_id": 1576456,
"text": "Nsg Adm Note\nMr is a 78 yo man adm from PACU after an episode of AF ? sepsis.\nPMH:HTN\n Renal stones-CRI (h/o ARF with CR 1.5-2)\n h/o RT renal cysts\n Leiomyosarcoma-orchietomy\nMeds:Vasotec\n Hytrin\nAll:\nPt had a 2 day c/o N/V,mild dysuria,chills and fever went to OSH and he was found to have UTI with Bilat ureteral stones/obstruction. He was started on Levoquin and transfered to the . He was on the floor being treated for urosepsis(Ecoli-urine,GNR-blood) with vanco and levo. During night of , pt had eposode of AF rate of 150's.He was given IVF and lopressor and rsp well. He was sent to cystoscopy in the am. He had a rt stent placed and pus removed from behind stone. Post- procedure he again was noted to have a run of AF, ?EKG changes and a + tropin leak noted on his am labs.He is adm to the MICU for close monitoring of his CV status and rate control.\nMICU adm course:\nCV:pt cont in AF , given IV lopressor, rate dropped to 90's but back up, so his po dose was increased. He is without c/o CP or SOB. He was started on IV heparin for anticoagulation.\nGI:+bowel sounds noted but pt is NPO except for meds, no pain.\nGU:urine is sl cloudy but flowing.He cont on IVF with lytes replacement. He is without abd or flank pain.\nResp:on NP o2 4l sats 95%, clr lungs.\nID:he is currently lafebrilel on IV levo, he had cx sent this am from the floor\nA/P:Will rate control with lopressor, ? ECHO on monday.\n PTT check at 11:30pm- Bleeding precautions.\n IVAB for sepsis, note fever curve, u/o and BP.Cont IV hydration.\n Asses abd before any further po intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-23 00:00:00.000",
"description": "Report",
"row_id": 1576457,
"text": "MICU NOTE 7P-7A\nNEURO: Alert and orientated x 3. MAE well.\n\nResp: Lungs clear no resp distress, sats 97-100% in o2 @ 4l n/c\n\nCV: Continues to be in a-ffib with no ectopy noted HR over 110 earlier was given extra dose of 50mg of lopressor hr came down to high 80's to high 90's. ? if pt. has had an mi troponin level is ^.\n\nGU/GI: Urine output is 50-100cc/hr urine is yellow /cloudy with sediment, pt has +bs started to eat last evening and tolerated that well.\n\nPlan: To monitor hr and cardiac status status\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-23 00:00:00.000",
"description": "Report",
"row_id": 1576458,
"text": "MICU/SICU NPN 0700-1900\n\nA&O x3. Denies pain. Gets sl dyspneic on extertion but denies SOB and O2sats on RA 96%. New crackles at bases this am. IVFs dc'd. Taking POs well. Remains on Hep gtt at 2050u/hr with therapeutic ptt x2. UO ~100cc/hr. He is ~1500cc + fluid balance though this does not include lg amt of liq brown,OB +, stool. BP ~150/80 w/HR 90-100AF. Lopressor increased to 75mg tid. Afebrile. Plan to transfer to med floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-24 00:00:00.000",
"description": "Report",
"row_id": 1576459,
"text": "MICU NPN:\nNEURO: A&Ox3. MAE. Denies pain.\n\nCV: Afeb. HR 80s-100s AF with occasional PVCs. BP 130s-160s/60s-80s. Lopressor as ordered. Denies CP. Skin warm and dry with 2+ generalized edema.\n\nRESP: 2L O2 NC with O2 Sat > 95%. RA Sat 93-94% Lungs clear with crackles at both bases. Given lasix 20mg last pm with good u/o. Pt. denies SOB but RR 28-30s and +DOE. Continue to monitor.\n\nGI/GU: Abd. soft and obese with present bowel sounds. No BM. Denies nausea. Tolerating pos. Foley intact draining clear yellow urine > 50cc/hr. No c/o dysuria.\n\nSKIN: Intact. Excoriated peri-area noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-24 00:00:00.000",
"description": "Report",
"row_id": 1576460,
"text": "MICU/SICU NPN 0700-1400\n\nNO C/O PAIN OR SOB. STILL W/CRACKLES AT THE BASES. GIVEN 20MG LASIX W/>1L DIURESIS IN 2HRS. CURRENTLY >2L NEG. O2SATS 94% ON RA,97% ON 2L NC. HEP GTT REMAINS AT 2050U/HR WITH THERAPEUTIC PTT X36HRS. REMAINS IN AF RATE 90S. TID LOPRESSOR INCREASED TO 100MG AND HR DOWN SL TO 80S. PLAN TO TRANSFER TO 5SOUTH THIS AFTERNOON.\n"
},
{
"category": "Echo",
"chartdate": "2129-04-26 00:00:00.000",
"description": "Report",
"row_id": 70733,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 71\nWeight (lb): 240\nBSA (m2): 2.28 m2\nBP (mm Hg): 150/70\nStatus: Inpatient\nDate/Time: at 09:56\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is very\ndiffiuclt to assess but is probably normal (LVEF>55%).\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is probably present.\n4. There is mild pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2129-04-21 00:00:00.000",
"description": "Report",
"row_id": 159097,
"text": "atrial fibrillation\nNonspecific ST-T changes\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 755643,
"text": " 4:25 AM\n CHEST (PA & LAT) Clip # \n Reason: Pt with rales at bases\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with urosepsis\n REASON FOR THIS EXAMINATION:\n Pt with rales at bases\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n HISTORY: Urosepsis with rales at lung bases. To evaluate for pneumonia.\n\n Heart size is borderline with some prominence of the LV and tortuosity of the\n thoracic aorta. No evidence for CHF. There is slight flattening of the\n diaphragms. No pulmonary consolidation or pleural effusion.\n\n IMPRESSION: No evidence for pneumonia or CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-21 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 755688,
"text": " 1:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o renal stone/abscess\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with h/o nephrolithiasis, w/ renal colic, ARF, and urosepsis\n REASON FOR THIS EXAMINATION:\n r/o renal stone/abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Nephrolithiasis, renal colic, acute renal failure, urosepsis.\n\n TECHNIQUE:\n Noncontrast abdomen and pelvis CT was performed. Contrast was not administered\n due to the patient's elevated creatinine. Coronal reformations were created.\n\n CT ABDOMEN WITHOUT CONTRAST:\n There is moderate dependent atelectasis bilaterally in the lung bases. The\n liver, adrenals, and abdominal bowel loops are normal in appearance for an\n unenhanced scan. There are innumerable gallstones within the gallbladder,\n without distention or wall thickening to suggest acute cholecystitis. The\n pancreas is atrophic. The splenic artery is calcified. The spleen appears\n slightly enlarged, extending below the costochondral margin. On the right\n kidney, there is a large 12 x 9.5 cm exophytic cyst with peripheral\n calcification, consistent with a type II Bosniak cyst. There is mild\n hydronephrosis, and several paracalyceal stones, the largest of which measures\n 1.5 x 1.3 cm. There is a moderate amount of perinephric fat stranding. There\n is mild hydroureter extending to the level of the distal third of the ureter,\n secondary to an 8 mm obstructing ureteral stone. There is a small\n peripapillary calcification and two low attenuation foci in the left kidney\n which are incompletely evaluated on this noncontrast exam.\n\n CT PELVIS WITHOUT CONTRAST:\n There is a Foley catheter in place. A linear region of soft tissue density\n extending from the right inguinal skin to the region of the perineum is noted.\n Please correlate with physical exam and surgical history to exclude an acute\n inflammatory process in the right groin. The pelvic bowel loops are normal in\n caliber. There is no ascites. Scattered retroperitoneal nodes in the upper\n abdomen measure less than 8 mm in greatest short axis dimension, which do not\n attain CT criteria for pathologic enlargement.\n\n BONE WINDOWS:\n There are several regions of relative bone loss in the right femoral neck and\n in the lumbar vertebrae, right greater than left. As there is not expansile\n quality to these foci, this is likely due to degenerative change. However,\n pathologic lytic lesions cannot be excluded, in a patient with a complex renal\n cyst.\n\n RECONSTRUCTIONS:\n The large complex right renal cyst and bilateral calcifications are noted. The\n right ureter is mildly dilated due to a distal third ureteral stone.\n\n (Over)\n\n 1:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o renal stone/abscess\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. 8 mm obstructing stone in the distal third of the right ureter produces\n mild hydronephrosis. Several other calcifications are noted in the bilateral\n peripapillary regions.\n 2. 12 cm right renal cyst with peripheral calcification is only partially\n evaluated on this noncontrast exam. Due to the patient's renal failure, a\n renal MRI is recommended to exclude a more complex renal mass, when clinically\n indicated.\n 3. Cholelithiasis without obstruction or cholecystitis.\n 4. Slight splenomegaly.\n 5. Linear soft tissue stranding in the right inguinal region is of uncertain\n etiology or significance. Please correlate with physical exam and surgical\n history in this patient presenting with sepsis, to exclude an acute\n inflammatory process.\n 6. Apparent regions of focal bone loss in the L3 vertebral body and right\n femoral neck are likely degenerative in nature. However, in a patient with a\n complex renal cyst, pathologic lesions cannot be entirely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-21 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 755641,
"text": " 12:37 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with see above\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78yr old male with abdominal pain, r/o obstruction.\n\n SUPINE AND UPRIGHT ABDOMEN: Supine and upright views of the abdomen demonstrte\n gas and stool throughout the colon and into the rectum. A few prominent gas\n filled loops of small bowel are seen in the right abdomen. There are no air\n fluid levels and there is no free air beneath the diaphragm. Mild\n degenerative changes are seen in the spine.\n\n IMPRESSION: Nonspecific bowel gas pattern with a few prominent gas filled\n small bowel loops but no evidence of high grade obstruction.\n\n\n"
}
] |
41,318 | 169,995 | This is a 49 year old male with h/o HL, depression, opiate dependence, diazepam dependence, GERD, and recent ankle surgery who presented to hospital after being found minimally responsive by his mother and was found to have MRSA bacteremia and acute hepatitis in the setting of urine tox + for cocaine, benzos, and opiates and a negative tylenol level. . Acute hepatitis: Stable transaminitis with ALT around 3500 and AST around 1200. INR trending down to 1.3. Bili within nl limits during his stay. Given neg tylenol level, tylenol toxicity seems unlikely (will further colaborate with mother) however his mother states that he was taking large amount of percocet that he was prescribed for his ankle surgery 1 week prior to presentation. Tox screen was + for cocaine which can also be hepatotoxic. Ferritin was found to be significantly elevated to 7000 and felt to be an acute phase reactant as Fe wnl, and TIBC/transferrin slightly decreased. AP peaked 1260. ALT peaked at 3953 and AST peaked 2153 and total bili 0.7 on . LFTs downtrending and near normal at time of discharge. His elevated CK's attributed to collapse and hypotension while on floor at home. He was given course of NAC 5g over 4 hrs and then 10g over 16 hrs in the ICU and continued NAC 10g over the next 6hrs. NAC was discontinued at time of transfer to medicine. Pt did not require adminstration of blood products during his stay. RUQ ultrasound with doppler obtained. HIV negative. He did not exhibit any encephalopathy or asterixis. *Home lipitor was held in setting of elevated LFTs and CK. Plan for PCP to monitor labs and restart statin therapy when transaminitis resolves fully. *Pt will also need 2nd and 3rd HBV vaccines in 1mo and 6mo to be arranged by his PCP. . MSSA bacteremia: blood cx + staph aureus at OSH positive for MSSA. Pt was started preliminarily on vancomycin given his history of MRSA bactermia. Final culture data showed oxacillin susceptibility and he was changed to nafcillin 2g Q4 with plan to continue treatment until . ID was consulted and advised on antibiotic course. Pt afebrile and w/o physical stigmata of endocarditis however pt had positive tox screen for cocaine, probable hx of IVDA, and TTE positive for MR2+ but no vegetations. He underwent TEE to rule out endocarditis. TEE attempted but failed pt inability to tolerate probe. TEE retried on with anesthesia and successfully ruled out vegetations. TEE results faxed to PCP dc summary. Surveillance blood cx negative since admission. PICC placed on for planned abx course and pulled upon completion of abx therapy. . Substance abuse: Pt states he does not want interventions and was made DNR/DNI per pt request. Psychiatry consulted and displayed no evidence of major mood disorder, suicidal ideation. It was also felt that there was no indication that pt ingested pills with the intention of hurting or killing himself. No evidence of withdrawal during his admission. Psych encouraged outpt addiction treatment to be considered at time of discharge. Pt's status was reversed to Full Code as he expressed confusion about code status implications. Team confirmed pain medication list with pt' based pain clinic and pharmacy. Pt complained of severe pain however he was able to ambulate w/o difficulty and was able to sleep without additional coverage. Higher doses of opioids were avoided given acute hepatitis. He is agreeable to lowered dose of opioids and will be discharged on current pain medication regimen of Oxycontin 10mg and Oxycodone 5mg Q6 prn for breakthrough. Lidocaine patches applied daily as needed to back. DC summary faxed to pt' pain clinic (Dr. and PCP/Rigaberto . . CK elevation: peaked at 1260, CKMB was 11.4. Likely due to muscle damage from collapse and down status at home however he could also have had a trop leak in setting of cocaine abuse. CK's resolved with IVF and EKGs were negative for any concerning findings. . Acute renal failure: Creatinine 2.5 at OSH which has trended down to 0.8 here after getting 3L IVF at OSH. Admission creatinine wnl on transfer to from outside hospital. Serum creatinine continues to be wnl and stable during his stay. . RLQ pain: Unclear history of hernia however pt states that he has been diagnosed in the past and did not follow up for surgical evaluation. He describes chronic pain at 2cm RLQ site, lateral ventral hernia would be consistent with spigelian hernia if present. Pt expressed interest in f/u w surgery at - was provided with information for appointment scheduling at time of discharge. . HL: Home simvastatin was held on admission for acute hepatitis and CKs w plan to be restarted as an outpatient after resolution of acute hepatitis. This issue to be followed by PCP. | There is no pericardial effusion.IMPRESSION: Moderate mitral regurgitation with normal valve mophology. Mild (1+) mitral regurgitationis seen. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Normal mitral valve leaflets. The estimated pulmonary artery systolic pressure ishigh normal. The proximal aorta is normal in caliber. Noaortic regurgitation is seen. The visualized portions of the intrahepatic IVC has normal ultrasound appearance. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right ventricular chamber size and free wall motion arenormal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. ?EndocarditisHeight: (in) 66Weight (lb): 190BSA (m2): 1.96 m2BP (mm Hg): 139/76HR (bpm): 81Status: InpatientDate/Time: at 15:57Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%decrease during respiration (estimated RA pressure indeterminate).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild mitral annular calcification. Mildly dilated ascendingaorta. Mild [1+] TR. Normal sinus rhythm. Estimated cardiacindex is normal (>=2.5L/min/m2). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The estimated cardiac index is normal(>=2.5L/min/m2). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. The main portal vein, right and left portal veins demonstrate normal patency, wall to wall flow, and expected hepatopetal flow. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 66Weight (lb): 190BSA (m2): 1.96 m2BP (mm Hg): 112/71HR (bpm): 87Status: InpatientDate/Time: at 16:27Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The aortic valve leaflets (3) are mildlythickened. The hepatic arteries have normal arterial flow. Compared to the previous tracing of no diagnostic interim change.TRACING #1 The mitral valve leaflets are structurally normal. Normal Doppler evaluation of the liver vasculature. Normalbiventricular cavity sizes with preserved global and regional biventricularsystolic function. No lower quadrant ascites is seen. The ascending aorta and aortic arch are mildly dilated. Mildly dilated aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There are nonmobileatheroma, some complex, in the aortic arch and descending thoracic aorta to40cm measured from the incisors. Nomass or vegetation is seen on the mitral valve. Heart size normal. The right kidney measures 12.3 cm, without hydronephrosis or calculi. No shadowing gallstones or biliary ductal dilatation. No intrahepatic or extrahepatic biliary ductal dilatation. The mitral valve leaflets are mildly thickened.No mass or vegetation is seen on the mitral valve. Moderate (2+) mitralregurgitation is seen. The cardiac size is normal allowing for projection. No TEE related complications.Conclusions:No atrial septal defect is seen by 2D or color Doppler. Compared to the previous tracing of no diagnostic interim change.TRACING #2 IMPRESSION: AP chest compared to : Tip of the new right PIC is at the presumed superior cavoatrial junction. Normal tracing. Normal tracing. Normal tracing. Tracing is within normal limits. Compared to the previous tracing of no diagnostic interim change.TRACING #3 Trace perihepatic and perisplenic ascites is noted. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 66Weight (lb): 190BSA (m2): 1.96 m2BP (mm Hg): 130/80HR (bpm): 82Status: InpatientDate/Time: at 12:20Test: Portable TEE (Unsuccessful Placement) (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:GENERAL COMMENTS: A TEE was performed in the location listed above. The visualized proximal pancreas is unremarkable. Trace perihepatic and perisplenic ascites. The spleen is normal in size measuring 11.8 cm. Lungs clear. No pleural abnormality or evidence of central adenopathy. No masses orvegetations on aortic valve. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%). The patient was under general anesthesiathroughout the procedure. [Intrinsic LV systolic function likelydepressed given the severity of valvular regurgitation.] No aorticregurgitation is seen. Overall leftventricular systolic function is normal (LVEF>55%). No renal calculi or hydronephrosis. Findings: The liver appears diffusely echogenic, which can represent hepatic steatosis, although other forms of chronic liver disease including cirrhosis and fibrosis cannot be excluded. Sinus rhythm. Sinus rhythm. Sinus rhythm. Dilated thoracic aorta.If clinically indicated, a TEE is suggested to better define the mitral valvemorphology. Right upper quadrant ultrasound with Doppler evaluation was requested to evaluate for portal vein thrombosis. COMPARISON: No prior radiograph available. No shadowing gallstones or sludge. The proximal common duct measures 3 to 4 mm, within normal limits. IMPRESSION: Possible perihilar opacities that may represent acute aspiration. There is no pericardial effusion.No vegetation or abscess seen. 0.2 mg of IV glycopyrrolate was given as anantisialogogue prior to TEE probe insertion. 0.2 mg of IV glycopyrrolate was given as an antisialogogueprior to TEE probe insertion. The distal pancreas is obscured by overlying bowel gas. There is no evidence of effusion. Echogenic liver, can be seen in the setting of hepatic steatosis. I certifyI was present in compliance with HCFA regulations. I certifyI was present in compliance with HCFA regulations. The hepatic veins are patent with expected hepatofugal flow in all three branches. The posterior pharynx was anesthetized with 2%viscous lidocaine. Check position. IMPRESSION: 1. The posterior pharynx was anesthetizedwith 2% viscous lidocaine. Doppler evaluation of the liver vasculature was performed. Although other forms of chronic liver disease, including cirrhosis/fibrosis cannot be excluded. [Intrinsicleft ventricular systolic function is likely more depressed given the severityof valvular regurgitation.] Suboptimalimage quality - poor suprasternal views. No AS. If clinically indicated, atransesophageal echocardiographic examination is recommended.Echocardiographic results were reviewed by telephone with the houseofficercaring for the patient.Conclusions:The left atrium is mildly dilated. PATIENT/TEST INFORMATION:Indication: Bacteremia. No previous tracingavailable for comparison. FINDINGS: Subtle perihilar opacities are suggestive of aspiration and warrant further attention on subsequent radiographs. | 10 | [
{
"category": "Radiology",
"chartdate": "2180-10-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1162652,
"text": " 9:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 48cm R arm\n Admitting Diagnosis: ACUTE LIVER DISEASE; TYLENOL TOXICITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 48cm R arm\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:10 A.M, \n\n HISTORY: New right arm PIC. Check position.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new right PIC is at the presumed superior cavoatrial junction.\n Findings reported to IV nurse. Lungs clear. Heart size normal. No pleural\n abnormality or evidence of central adenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-16 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1161878,
"text": " 8:40 AM\n DUPLEX DOPP ABD/PEL; ABDOMEN U.S. (COMPLETE STUDY) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: RUQ with doppler to eval for thrombosis\n Admitting Diagnosis: ACUTE LIVER DISEASE; TYLENOL TOXICITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with acute hepatitis\n REASON FOR THIS EXAMINATION:\n RUQ with doppler to eval for thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n Abdominal ultrasound with liver doppler evaluation.\n\n INDICATION: 49-year-old male with acute hepatitis. Right upper quadrant\n ultrasound with Doppler evaluation was requested to evaluate for portal vein\n thrombosis.\n\n No priors are available for comparison.\n\n Findings:\n\n The liver appears diffusely echogenic, which can represent hepatic steatosis,\n although other forms of chronic liver disease including cirrhosis and fibrosis\n cannot be excluded. No intrahepatic or extrahepatic biliary ductal\n dilatation. The proximal common duct measures 3 to 4 mm, within normal\n limits. The gallbladder demonstrates extensive diffuse gallbladder wall\n thickening and pericholecystic fluid, which is most commonly seen in the\n setting of severe chronic liver disease or hypoalbuminemic states. Negative\n son sign. No shadowing gallstones or sludge. The visualized\n proximal pancreas is unremarkable. The distal pancreas is obscured by\n overlying bowel gas. Trace perihepatic and perisplenic ascites is noted. The\n spleen is normal in size measuring 11.8 cm.\n\n The right kidney measures 12.3 cm, without hydronephrosis or calculi. The\n left kidney is slightly larger in size, measuring 13.7 cm. No renal calculi\n or hydronephrosis.\n\n Doppler evaluation of the liver vasculature was performed. The main portal\n vein, right and left portal veins demonstrate normal patency, wall to wall\n flow, and expected hepatopetal flow. The hepatic arteries have normal\n arterial flow. The hepatic veins are patent with expected hepatofugal flow in\n all three branches. The visualized portions of the intrahepatic IVC has\n normal ultrasound appearance. The proximal aorta is normal in caliber.\n\n No lower quadrant ascites is seen.\n\n IMPRESSION:\n\n 1. Echogenic liver, can be seen in the setting of hepatic steatosis. Although\n other forms of chronic liver disease, including cirrhosis/fibrosis cannot be\n excluded.\n\n (Over)\n\n 8:40 AM\n DUPLEX DOPP ABD/PEL; ABDOMEN U.S. (COMPLETE STUDY) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: RUQ with doppler to eval for thrombosis\n Admitting Diagnosis: ACUTE LIVER DISEASE; TYLENOL TOXICITY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Trace perihepatic and perisplenic ascites.\n\n 3. Normal Doppler evaluation of the liver vasculature.\n\n 4. Marked pericholecystic fluid and gallbladder wall thickening can be seen\n in the setting of severe liver disease and hypoalbuminemic states. Negative\n son sign. No shadowing gallstones or biliary ductal\n dilatation. Clinical correlation would be useful to further assess the\n findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1161825,
"text": " 6:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: any evidence of infitrate or aspiration\n Admitting Diagnosis: ACUTE LIVER DISEASE; TYLENOL TOXICITY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 yo male with chest congestion\n REASON FOR THIS EXAMINATION:\n any evidence of infitrate or aspiration\n ______________________________________________________________________________\n WET READ: JBRe SUN 8:24 PM\n Bibasilar opacities might represent aspiration, atelectasis or less likely\n multifocal pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for pneumonia or aspiration.\n\n COMPARISON: No prior radiograph available.\n\n FINDINGS: Subtle perihilar opacities are suggestive of aspiration and warrant\n further attention on subsequent radiographs. The cardiac size is normal\n allowing for projection. There is no evidence of effusion.\n\n IMPRESSION: Possible perihilar opacities that may represent acute aspiration.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-18 00:00:00.000",
"description": "Report",
"row_id": 67813,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 190\nBSA (m2): 1.96 m2\nBP (mm Hg): 130/80\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 12:20\nTest: Portable TEE (Unsuccessful Placement) (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. No TEE related complications.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe procedure was unsuccessful and was aborted after 3 attempts, due to\nsignificant patient discomfort and safety issues with excessive gagging. Prior\nto the procedure he had received 3 benzocaine sprays as well as a viscous\nlidocaine swish and swallow, and IV glycopyrrolate, versed and fentanyl. On\neach of 3 attempts, the probe was successful passed into the esophagus but had\nto be withdrawn very shortly afterwards due to the patient's inability to\ntolerate the probe. Dr. was notified by telephone at 12:15pm, and if\nclinically indicated, TEE can be reattempted with anesthesiology present and\nadministration of propofol.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-19 00:00:00.000",
"description": "Report",
"row_id": 68268,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 190\nBSA (m2): 1.96 m2\nBP (mm Hg): 112/71\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 16:27\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was under general anesthesia\nthroughout the procedure. The posterior pharynx was anesthetized with 2%\nviscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. No TEE related complications.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). There are nonmobile\natheroma, some complex, in the aortic arch and descending thoracic aorta to\n40cm measured from the incisors. The aortic valve leaflets (3) are mildly\nthickened. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. No\nmass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion.\n\nNo vegetation or abscess seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-16 00:00:00.000",
"description": "Report",
"row_id": 68269,
"text": "PATIENT/TEST INFORMATION:\nIndication: Bacteremia. ?Endocarditis\nHeight: (in) 66\nWeight (lb): 190\nBSA (m2): 1.96 m2\nBP (mm Hg): 139/76\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 15:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] Estimated cardiac\nindex is normal (>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild mitral annular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. If clinically indicated, a\ntransesophageal echocardiographic examination is recommended.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.] The estimated cardiac index is normal\n(>=2.5L/min/m2). Right ventricular chamber size and free wall motion are\nnormal. The ascending aorta and aortic arch are mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mass or vegetation is seen on the mitral valve. Moderate (2+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nhigh normal. There is no pericardial effusion.\n\nIMPRESSION: Moderate mitral regurgitation with normal valve mophology. Normal\nbiventricular cavity sizes with preserved global and regional biventricular\nsystolic function. Dilated thoracic aorta.\nIf clinically indicated, a TEE is suggested to better define the mitral valve\nmorphology.:\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-17 00:00:00.000",
"description": "Report",
"row_id": 164439,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-15 00:00:00.000",
"description": "Report",
"row_id": 164440,
"text": "Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-19 00:00:00.000",
"description": "Report",
"row_id": 164437,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno diagnostic interim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-18 00:00:00.000",
"description": "Report",
"row_id": 164438,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno diagnostic interim change.\nTRACING #2\n\n"
}
] |
2,452 | 199,951 | The patient was admitted to the Service where he was continued on his Levaquin and had sputum cultures sent for his pneumonia. The patient was diuresed, given the possibility of CHF in addition to his pneumonia. The patient continued to have a very high oxygen requirement with 02 saturations running 93% on 100% nonrebreather. The patient was electively sent to the MICU during which time he was diuresed and followed very closely by Pulmonology and Nephrology. The nephrologist believed that the patient was euvolemic at the time of discharge from the MICU and advised no further Lasix use. The pulmonologist believed that the patient was possibly mucous plugging and the patient had two serial chest x-rays which revealed the loculated pleural effusion. The pulmonologists were quite concerned that given his recurrent pneumoniae and the chest x-ray that this may actually have been due to postobstructive pneumonia secondary to a mass. The patient was discharged from the MICU and sent to the floor. The patient remained quite tachypneic with a high 02 saturation on 93% on liters 02 by nasal cannula. The patient was seen again by Pulmonary who advised a noncontrast CT given the patient's poor renal function. After the CT, the pulmonologist recommended a tap of the loculated pleural effusion. The patient had 1.7 liters of fluid removed from the left side. Once the fluid was removed, the patient's tachypnea and 02 saturation improved dramatically. The patient's 02 requirement decreased to 3 liters by nasal cannula. The patient's BUN continued to rise to 136 and his creatinine continued to rise to 6.6. The patient was not thought to be uremic at that time since his mental status continued to be clear, but the Renal Team believed that it would beneficial to place a Perma-Cath on and hemodialyze the patient. The patient was to have a peritoneal dialysis catheter placed on the upcoming Friday since the patient's wish was to continue peritoneal dialysis. The patient was to have a repeat chest CT at the time of this dictation. After the result of the chest CT, the patient was possibly to have a bronchoscopy and a tissue biopsy that would be sent for analysis to see if this was in fact a malignancy. There was also discussion about a repeat pleural effusion drainage by Pulmonary. This issue had not been resolved at the end of this dictation. This dictation covers the dates including and up to . The co-intern picking up the service after me will dictate from onwards. My pager number is 39-529. If you have any questions, please feel free to page me. , M.D. Dictated By: MEDQUIST36 D: 00:00 T: 05:48 JOB#: | CT OF THE CHEST WITHOUT CONTRAST: There has been a slight interval decrease in the size of the right pleural effusion and significant decrease in size of the left pleural effusion. Respiratory motion artifact degrades the remainder of the angiographic portion of the examination, but there appears to be moderate stenosis 1 cm distal to the origin of the celiac axis. Bilateral pleural effusions and mild CHF. CHEST, PA AND LATERAL: Patchy bibasilar and lingular lung consolidations are present. There is a small outpouching seen in the right-sided oropharynx. IMPRESSION: 1) Moderate CHF with large bilateral pleural effusions and bibasilar atelectasis. Biapical scarring and/or atelectasis remains. COMPARISON: CHEST CT WITHOUT CONTRAST: There are large bilateral pleural effusions with associated passive atelectasis at the left base. There has been partial resolution of the ill-defined patchy pulmonary infiltrate at both lung bases with residual changes mainly in the left lower zone. IMPRESSION: Interval reduction in size of the bilateral pleural effusions and associated bibasilar collapse/consolidation. A right pleural effusion has decreased in size. A coarse calcification is present within the spleen likely vascular in etiology. Small mediastinal lymph nodes are again noted, unchanged from prior study. Compared to the film from prior day, there is worsening bilateral lower lobe fluffy alveolar infiltrates with pulmonary vascular redistribution. The patchy areas of opacity seen within the upper lobes bilaterally on the previous study have almost completely resolved in the interval. New, patchy areas of opacity are seen in the upper lobes bilaterally. There is normal epiglottic deflection and laryngeal elevation. The findings are consistent with worsening chf with and without superimposed infection. 2) Moderate stenosis celiac axis. There has been interval decrease in size in the areas of consolidation with air bronchograms in both the left and right lower lobes. Note is made of absent signal within the region of the distal common bile duct which may represent small stones/biliary sludge. The pleural effusions have slightly decreased. Residual loculated right effusion. The pulmonary vascularity appears slightly engorged and is indistinct. Review of lung windows demonstrate evidence of intralobular septal thickening, most likely related to pulmonary edema. In comparison to a more recent chest X-ray of , slightly different areas of the lung bases appear to be involved with interval clearing of left retrocardiac density, but with an overall increase in opacification of the left lower lobe. (Over) 11:11 AM MRA ABD W&W/O CONTRAST; MR ABDOMEN W&W/O CONTRAST Clip # MR RECONSTRUCTION IMAGING; MR DOUBLE DOSE CONTRAST Reason: Please evaluate for renal artery stenosis Contrast: MAGNEVIST Amt: 40CC FINAL REPORT (Cont) 4) Otherwise, unremarkable but significantly limited abdominal MRI/MRA. Left ventricular function.Height: (in) 74Weight (lb): 144BSA (m2): 1.89 m2BP (mm Hg): 167/78HR (bpm): 71Status: InpatientDate/Time: at 12:40Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. Mild(1+) aortic regurgitation is seen. Mild tricuspid [1+]regurgitation is seen. Aleft-to-right shunt across the interatrial septum is seen at rest.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anterior - hypokinetic; mid anterior -hypokinetic; basal inferolateral - hypokinetic; mid inferolateral -hypokinetic; mid anterolateral - hypokinetic; anterior apex - hypokinetic;septal apex - hypokinetic; inferior apex - hypokinetic; lateral apex -hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Mild (1+)aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. 11:03 AM GUIDANCE FOR /ABD/PARA CENTESIS US; PLEURAL ASP BY RADIOLOGISTClip # Reason: PLEURAL EFFUSION FINAL REPORT INDICATION: Large left pleural effusion. 3 cc 1% subcutaneous Lidocaine. There is moderate pulmonary artery systolichypertension.GENERAL COMMENTS: A left pleural effusion is present.Conclusions:The left atrium is mildly dilated. Overall left ventricular systolic function appears similaralthough distribution of hypokinesis is now more segmental than previously(previously more diffuse/global).Report modified on to note that color Doppler study is suggestive ofa small secundum-type atrial septal defect. Ultrasonography demonstrates the right internal jugular vein to be patent and compressible. The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild to moderate(+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Under ultrasound guidance, needle was introduced into the left pleural space and 1.7 liters of - colored, clear fluid was aspirated. 6, 8, 10 and 12 FR serial dilators are exchanged over a 0.035 wire, with wire tip demonstrated to be in the IVC under fluoroscopic guidance. Sinus rhythmPossible left atrial abnormalityMarked left axis deviationProbable Left ventricular hypertrophy with ST-T changeSince last ECG, no significant change Mild to moderate (+) mitral regurgitation is seen. There ismoderate pulmonary artery systolic hypertension.Compared with the prior study of , aortic and mitral regurgitation arenow more prominent. There is mild symmetric left ventricularhypertrophy. CONCLUSION: Successful left thoracentesis. Lopressor 5mg also given IVP and PO.RESP: O2 on at 100% cool mist titrated to 4LNC. (Over) 1:27 PM TUNNEDLED DIALYSIS CATH PLACE Clip # Reason: please place tunneled dialysis catheter FINAL REPORT (Cont) | 22 | [
{
"category": "Radiology",
"chartdate": "2111-10-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 773743,
"text": " 11:13 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with sob\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Shortness of breath.\n\n CHEST, PA AND LATERAL: Patchy bibasilar and lingular lung consolidations are\n present. A small locule of pleural fluid is seen at the lateral right base.\n Some pleural fluid is seen within the major fissures. These findings are new\n in comparison to prior PA and lateral chest X-ray of . In comparison\n to a more recent chest X-ray of , slightly different areas of the lung\n bases appear to be involved with interval clearing of left retrocardiac\n density, but with an overall increase in opacification of the left lower lobe.\n A right pleural effusion has decreased in size. No pulmonary vascular\n redistribution is seen. The cardiac and mediastinal contours are stable.\n\n IMPRESSION: Bibasilar parenchymal opacities, with marked increase in\n consolidation of the left lower lobe . Residual loculated\n right effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 773790,
"text": " 9:29 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval changes.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with sob, known pnueomia and mild chf on previous CXR. Please\n call trusitn # with questions.\n REASON FOR THIS EXAMINATION:\n please assess for interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, TWO VIEWS:\n\n HISTORY: F/U pneumonia and chf.\n\n Reference exam, .\n\n Compared to the film from prior day, there is worsening bilateral lower lobe\n fluffy alveolar infiltrates with pulmonary vascular redistribution. The\n amount of effusion is also increased. Cardiac silhouette can't be assessed\n due to the opacity of both lower lobes. The findings are consistent with\n worsening chf with and without superimposed infection.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 774157,
"text": " 2:51 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: HX PNEUMONIA, EVAL FOR BOOP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for pneumonia or BOOP.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the thoracic inlet without contrast using 5 mm collimation.\n\n COMPARISON: \n\n CHEST CT WITHOUT CONTRAST: There are large bilateral pleural effusions with\n associated passive atelectasis at the left base. Numerous small mediastinal\n lymph nodes are present, overall not significantly changed in size when\n compared to the previous exam. There are coronary artery calcifications.\n There is mild cardiomegaly.\n\n Review of lung windows demonstrate evidence of intralobular septal thickening,\n most likely related to pulmonary edema. Again seen is an area of\n consolidation with air bronchograms in the right upper lobe medially, slightly\n improved since the exam from . There is also an area of\n consolidation with air bronchograms in the left lower lobe which is increased\n since the previous examination. New, patchy areas of opacity are seen in the\n upper lobes bilaterally.\n\n In the imaged portion of the upper abdomen, the unenhanced liver, spleen,\n adrenal glands, and upper poles of the kidneys are unremarkable. No suspicious\n osseous lesions are seen.\n\n IMPRESSION:\n 1) Moderate CHF with large bilateral pleural effusions and bibasilar\n atelectasis.\n 2) Slight interval improvement in the degree of consolidation in the right\n upper lobe, however there has been interval increase in the extent of left\n lower lobe consolidation. There are also new patchy areas of opacity in the\n upper lobes bilaterally. Differential diagnostic possibilities for these\n opacities continue to include chronic infection, vasculitis, BOOP, lymphoma,\n or BAC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-02 00:00:00.000",
"description": "MRA ABD W&W/O CONTRAST",
"row_id": 773863,
"text": " 11:11 AM\n MRA ABD W&W/O CONTRAST; MR ABDOMEN W&W/O CONTRAST Clip # \n MR RECONSTRUCTION IMAGING; MR DOUBLE DOSE CONTRAST\n Reason: Please evaluate for renal artery stenosis\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old male with DM, CRI, with increasing Cr\n REASON FOR THIS EXAMINATION:\n Please evaluate for renal artery stenosis\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRA of abdomen with and without contrast.\n\n INDICATION: 57 year old male with diabetes, chronic renal insufficiency;\n please evaluate for renal artery stenosis.\n\n COMPARISONS: None.\n\n TECHNIQUE: Multiplanar multisequence MR imaging of the abdomen was performed\n both before and after administration of intravenous contrast, including T1\n axial in- and out-of-phase, coronal and axial dynamic VIBE, axial STIR,\n coronal and axial HASTE. Multiplanar reformats were generated and evaluated\n at the workstation.\n\n Please note that this patient was a poor breath holder and as a consequence\n the examination of the remainder of the abdomen is degraded. However, the\n renal artery portion of the examination is of diagnostic quality.\n\n FINDINGS:\n\n MRA OF RENAL ARTERIES: There are single renal arteries bilaterally without\n evidence of stenosis or filling defects. Respiratory motion artifact degrades\n the remainder of the angiographic portion of the examination, but there\n appears to be moderate stenosis 1 cm distal to the origin of the celiac axis.\n The SMA and are patent.\n\n ABDOMEN: No gross abnormalities of the liver, gallbladder, kidneys, adrenal\n glands, spleen, or pancreas are identified. However, as previously stated,\n respiratory motion artifact significantly degrades image quality and if there\n is concern for additional abdominal pathology, further examination with a\n repeat MRI of abdomen may be useful, if clinically indicated. Note is made of\n absent signal within the region of the distal common bile duct which may\n represent small stones/biliary sludge. However, no significant intra- or\n extrahepatic biliary ductal dilatation is present.\n\n IMPRESSION:\n\n 1) No renal artery stenosis.\n\n 2) Moderate stenosis celiac axis.\n\n 3) Possible biliary sludge/small stones distal common bile duct.\n (Over)\n\n 11:11 AM\n MRA ABD W&W/O CONTRAST; MR ABDOMEN W&W/O CONTRAST Clip # \n MR RECONSTRUCTION IMAGING; MR DOUBLE DOSE CONTRAST\n Reason: Please evaluate for renal artery stenosis\n Contrast: MAGNEVIST Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4) Otherwise, unremarkable but significantly limited abdominal MRI/MRA. If\n there is concern for pathology in the remainder of the abdomen, a repeat\n examination once the patient is clinically able may be useful.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 774551,
"text": " 9:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for mass, BOOP, PNA. Please compare to CT d\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with b/l PNA and b/l effusions\n REASON FOR THIS EXAMINATION:\n Please evaluate for mass, BOOP, PNA. Please compare to CT done on and\n please so same exact type of CT please. Please do CT on as he may go\n for broncoscopy on .\n CONTRAINDICATIONS for IV CONTRAST:\n CRF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 year old man with bilateral pneumonia and bilateral effusions.\n\n CT OF THE CHEST WITHOUT CONTRAST.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous serial axial images were obtained through the chest\n with 5 mm collimation without intravenous contrast.\n\n CT OF THE CHEST WITHOUT CONTRAST: There has been a slight interval decrease\n in the size of the right pleural effusion and significant decrease in size of\n the left pleural effusion. There has been interval decrease in size in the\n areas of consolidation with air bronchograms in both the left and right lower\n lobes. The area of consolidation within the medial right upper lobe is also\n decreased in size. The patchy areas of opacity seen within the upper lobes\n bilaterally on the previous study have almost completely resolved in the\n interval. Biapical scarring and/or atelectasis remains. Small mediastinal\n lymph nodes are again noted, unchanged from prior study.\n\n There are dense coronary artery calcifications and scattered aortic\n calcifications. Noncontrast evaluation of the incompletely visualized liver,\n adrenals and kidneys are unremarkable. A coarse calcification is present\n within the spleen likely vascular in etiology.\n\n BONE WINDOWS: Osseous structures reveal degenerative change but are otherwise\n unremarkable. A central venous line is present with its tip extending into\n the right atrium.\n\n IMPRESSION: Interval reduction in size of the bilateral pleural effusions and\n associated bibasilar collapse/consolidation. There has been interval decrease\n in size in the medial right upper lobe consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-12 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 774635,
"text": " 10:11 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: NAUSEA, PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with nausea and no BM for 4 days. H/o DM, recurrent PNA, ESRD\n on HD\n REASON FOR THIS EXAMINATION:\n Please assess for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN 2 VIEWS SUPINE & UPRIGHT:\n\n HISTORY: Nausea and absence of bowel movements in diabetic. To evaluate for\n obstruction.\n\n Gas and fecal residue are present throughout the colon and there is no\n evidence for intestinal obstruction. No free intraperitoneal gas. No soft\n tissue masses or radiopaque calculi. Bibasilar atelectases.\n\n IMPRESSION: No evidence for intestinal obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773936,
"text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleas eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old male hx of CHF (EF of 30%) and multiple PNA admitted with hypoxia\n - previous CXR show CHF exacerbation and question of PNA\n\n REASON FOR THIS EXAMINATION:\n Pleas eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Hypoxia.\n\n COMPARISONS: AP chest radiograph from .\n\n AP CHEST RADIOGRAPH: The heart size, mediastinal contours, and pulmonary\n vasculature are unchanged. There is no evidence of failure. There is\n increase in both intensity and extent of the bibasilar opacities, suggesting\n progression of disease. The osseous structures are unchanged.\n\n IMPRESSION: Increase in extent and intensity of bibasilar opacities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-13 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 774694,
"text": " 2:11 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please assess for silent aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with recurrent PNAs, DM, h/o CVA, and ESRD on HD\n REASON FOR THIS EXAMINATION:\n Please assess for silent aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recurrent pneumonias and history of CVA.\n\n TECHNIQUE: The study was performed in conjunction with the speech therapist.\n Various conistencies of barium were administered orally.\n\n FINDINGS: There is normal chewing and bolus formation with minimal premature\n spillage. There is normal epiglottic deflection and laryngeal elevation.\n There is no penetration or aspiration seen. There is a small outpouching seen\n in the right-sided oropharynx. On AP views there was smooth bolus passage.\n There is no cricopharyngeal enlargement.\n\n IMPRESSION: No penetration or aspiration. Please see Speech and Swallowing\n report for detailed description of the findings and recommendations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 773841,
"text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out bilateral renal artery stenosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with Dm and increasing creatinine with improved blood pressure\n control.\n REASON FOR THIS EXAMINATION:\n rule out bilateral renal artery stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW:\n\n HISTORY: Diabetes, increasing creatinine, SOB.\n\n Compared to the film from the prior day there has been no significant interval\n change in bilateral lower lung lung alveolar infiltrates. The pleural\n effusions have slightly decreased. Volume loss in the lower lobes is likely\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774101,
"text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF VS PNUEMONIA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Respiratory difficulties. Clinical suspicion of\n congestive heart failure or pneumonia.\n\n Re-dictation from a previously lost report.\n\n The heart size cannot be assessed due to obscuration of both heart borders by\n adjacent consolidation. The pulmonary vascularity appears slightly engorged\n and is indistinct. Again demonstrated is a pattern of alveolar consolidation,\n which is most pronounced in the mid and lower lung zones. This shows slight\n improvement, particularly in the right lung. Note is also made of bilateral\n pleural effusions, moderate on the left and small to moderate on the right.\n\n IMPRESSION:\n\n 1. Persistent bilateral alveolar pattern, predominantly in the mid and lower\n lung zones. Diagnostic considerations include multifocal pneumonia versus an\n asymmetric distribution of pulmonary edema.\n\n 2. Bilateral pleural effusions, left greater than right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 774525,
"text": " 4:09 PM\n CHEST (PA & LAT); CHEST (LAT DECUB ONLY) Clip # \n Reason: Please assess status of right effusion and consolidations\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with h/o bilat PNAs, and bilat pleural effusions and mild\n chf, s/p L thoracentesis.Please call # with questions. Please\n do exam today after dialysis on at around 11-11:30 am.\n REASON FOR THIS EXAMINATION:\n Please assess status of right effusion and consolidations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of bilateral pneumonia. Bilateral pleural effusions and\n mild CHF. Status post left thoracentesis. Patient on dialysis.\n\n FINDINGS: Standard PA and left lateral views. Comparison study dated\n . There has been partial resolution of the ill-defined patchy\n pulmonary infiltrate at both lung bases with residual changes mainly in the\n left lower zone. There is also an associated reduction in size of the right\n pleural effusion. The lungs appear better inflated. A new right IJ dialysis\n catheter is noted, its distal end well positioned at the SVC-right atrial\n junction. The heart shows slight LV enlargement. The pulmonary vessels are\n unremarkable and do not indicate cardiac failure at this time.\n\n IMPRESSION: Improving bibasilar pulmonary infiltrates and effusions.\n Satisfactory placement of dialysis catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 774286,
"text": " 9:03 PM\n CHEST (PA & LAT); CHEST (LAT DECUB ONLY) Clip # \n Reason: S/P THORACENTESIS\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: S/P thoracentesis.\n\n PA AND LATERAL CHEST: There has been marked interval reduction in size of a\n left pleural effusion with only a small pleural effusions remaining. There is\n a moderate sized, freely layering right pleural effusion. The left pleural\n effusion also demonstrates layering.\n\n The heart is upper limits of normal in size. The mediastinal contours are\n normal. The lungs reveal a bilateral interstitial pattern with numerous\n thickened septal lines, predominantly in the lower lung zones.\n\n No pneumothorax is identified.\n\n IMPRESSION:\n\n 1. Marked interval decrease in size of left pleural effusion, likely\n corresponding to interval thoracentesis.\n\n 2. Moderate sized right pleural effusion, freely layering on decubitus view.\n\n 3. Numerous thickened septal lines in the mid and lower lung zones.\n Differential diagnosis includes interstitial edema, interstitial infection, if\n the patient has a history of primary neoplasm, lymphangetic carcinomatosis.\n\n 4. Additional patchy parenchymal opacities at the lung bases may be related\n to patchy atelectasis or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-09 00:00:00.000",
"description": "IMPLANT VENOUS ACCESS PORT",
"row_id": 774327,
"text": " 1:27 PM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place tunneled dialysis catheter\n ********************************* CPT Codes ********************************\n * IMPLANT VENOUS ACCESS UD GUID FOR NEEDLE PLACMENT *\n * FLUORO 1 HR W/RADIOLOGIST C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESRD from DM has worsening BUN/CR in setting of CHF and\n pnemonia with pleural effusions. has been afebrile since , all blood cx\n neg.\n REASON FOR THIS EXAMINATION:\n please place tunneled dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, DM, worsening creatinine, CHF, recent\n pneumonia, afebrile since , blood cultures negative.\n\n RADIOLOGISTS: Procedure performed by Drs. and , \n radiologist supervising entire procedure.\n\n MEDICATION AND CONTRAST: 0.5 mg Versed, 25 mcg Fentanyl, administered\n intravenously in divided doses under constant hemodynamic monitoring. 3 cc 1%\n subcutaneous Lidocaine.\n\n TECHNIQUE/PROCEDURE: The patient was informed of the details and associated\n risks of the procedure and written consent was obtained. The patient was\n placed supine on the angiographic table and the right neck was sterilely\n prepped and draped in the usual fashion. Ultrasonography demonstrates the\n right internal jugular vein to be patent and compressible. A 19 gauge\n micropuncture needle was used to gain access to the right internal jugular\n vein under ultrasonographic guidance. 6, 8, 10 and 12 FR serial dilators are\n exchanged over a 0.035 wire, with wire tip demonstrated to be in the\n IVC under fluoroscopic guidance. Finally, a 14.5 FR peel away sheath was\n advanced over the guidewire. The right chest wall was also sterilely prepped\n and draped in the usual fashion. The guidewire was measured that was\n determined at a 23 cm cuff to tip 14.5 FR tunneled hemodialysis catheter would\n be an appropriate length. The subcutaneous tissues of the right chest wall\n were tunneled following the administration of subcutaneous Lidocaine. The\n 14.5 FR 23 cm (cuff to tip) tunneled catheter was then pulled through the\n subcutaneous tunnel and advanced through the peel away sheath under\n fluoroscopic guidance so that the tip was within the proximal right atrium.\n The neck incision was closed with 4-0 Vicryl and the hemodialysis catheter\n secured to the chest wall with O Prolene. Both ports flushed and withdrew\n well and were capped and flushed with heparin. There were no immediate\n complications and the patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of 14.5 FR 23 cm (cuff to tip) tunneled\n hemodialysis catheter via right internal jugular vein with tip in proximal\n right atrium, ready for use.\n (Over)\n\n 1:27 PM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place tunneled dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-11-06 00:00:00.000",
"description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US",
"row_id": 1260654,
"text": " 11:03 AM\n GUIDANCE FOR /ABD/PARA CENTESIS US; PLEURAL ASP BY RADIOLOGISTClip # \n Reason: PLEURAL EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large left pleural effusion.\n\n TECHNIQUE/FINDINGS: The procedure was fully explained to the patient and\n informed signed consent was obtained. Under ultrasound guidance, \n needle was introduced into the left pleural space and 1.7 liters of -\n colored, clear fluid was aspirated. Fluid was sent to Microbiology and\n Chemistry for analysis per house staff. The patient tolerated the procedure\n without any immediate complication. Dr. , staff radiologist, was present\n throughout the entire procedure.\n\n CONCLUSION: Successful left thoracentesis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2111-11-03 00:00:00.000",
"description": "Report",
"row_id": 92984,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function.\nHeight: (in) 74\nWeight (lb): 144\nBSA (m2): 1.89 m2\nBP (mm Hg): 167/78\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 12:40\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\nleft-to-right shunt across the interatrial septum is seen at rest.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - hypokinetic; mid anterior -\nhypokinetic; basal inferolateral - hypokinetic; mid inferolateral -\nhypokinetic; mid anterolateral - hypokinetic; anterior apex - hypokinetic;\nseptal apex - hypokinetic; inferior apex - hypokinetic; lateral apex -\nhypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nGENERAL COMMENTS: A left pleural effusion is present.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. Resting regional wall motion abnormalities include lateral,\nanterior and apical hypokinesis. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension.\n\nCompared with the prior study of , aortic and mitral regurgitation are\nnow more prominent. Overall left ventricular systolic function appears similar\nalthough distribution of hypokinesis is now more segmental than previously\n(previously more diffuse/global).\n\nReport modified on to note that color Doppler study is suggestive of\na small secundum-type atrial septal defect.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-11-04 00:00:00.000",
"description": "Report",
"row_id": 244163,
"text": "Sinus rhythm\nPossible left atrial abnormality\nLeft axis deviation\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-11-03 00:00:00.000",
"description": "Report",
"row_id": 244164,
"text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave abnormalities. Since\nthe previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2111-10-31 00:00:00.000",
"description": "Report",
"row_id": 244165,
"text": "Sinus rhythm\nPossible left atrial abnormality\nMarked left axis deviation\nProbable Left ventricular hypertrophy with ST-T change\nSince last ECG, no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-02 00:00:00.000",
"description": "Report",
"row_id": 1294018,
"text": "NPN\n\nCV: Remains on NTG, SBP was maintained ~ 110-120, u/o poor, there was some thought to starting him on nitrecor but his u/o started to increase, the NTG was decreased to increase his systemic BP to increase perfusion to his kidneys. U/O has been ~ 100cc/hr for the last ~ 4 hrs, LS still rales. Dilt has been d/ced.\n\nResp: Pt on CPAP, woke at 1 am suddenly and was confused, he was taken off CPAP and put on vent mask in case he was retaining - he was not. He is presently on a cool neb at 100%, his SATs have been in the mid to upper 90s execpt for one period when he was 70%, after waking him up - he denied SOB, and sitting him up his SATs went up to the mid 90s again.\n\nGI: Having water and juice with his pills, he states that he has not eaten in at least 48 hrs due to n/v.\n\nGU: U/O poor initally as above but has picked up, he was given 40mg of lasix this morning\n\nNeuro: Period of confusion - unknown etiology. MAE, appropriate\n\nEndo: BS high, 382 at 11 pm, given 10 units - after giving it to him he said that it is too much insulin for him, BS slowly comming down, ? need for gtt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-02 00:00:00.000",
"description": "Report",
"row_id": 1294019,
"text": "NURSING NOTE 7A-7P\nNEURO: Awake alert and oriented X3. , follows commands well. No periods of confusion noted.\nC/V: SR rate in the 70's. SBP 120-170, Nitro titrated up to 4mcg/kg/min. Lopressor 5mg also given IVP and PO.\nRESP: O2 on at 100% cool mist titrated to 4LNC. O2 Sat 88-98%. Lungs sounds clear upper and diminished lower airway.\nGU/GI: Foley patent draining clear yellow urine 80-150cc/hour. Transported to MRI accompanied by nurse, tol procedure well. Results pending. Diet taken po tol well, no c/o nausea or vomiting. BS present.\nENDO: NPH insulin restarted in AM. FS 236 covered with 4 units Reg insulin.\nSOCIAL: Wife into visit, emotional support provided.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-03 00:00:00.000",
"description": "Report",
"row_id": 1294020,
"text": "NPN\n\nCV: SBP 170-140s per aline, ~ 20 points lower with oscultation. NTG cont until 4 am when it was d/ced for SBP 150s - they would like him less than 160 for a SBP. He has been tolerating his cardiac meds, he is not up to his doses that he takes at home.\n\nResp: LS rales at bases on the evening, clear at MN, SATs high 90s on 100% CN flooded 02, when he was decreased to 70% he decreased to 92%.\n\nGI: Very sm hard stool\n\nGU: Conts to urinate, he was 1500 neg at MN\n\nNeuro: Alert and oriented, no periods of orientation, has not slept as well as last night.\n\nEndo: Rec 4 units of reg insulin at MN\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-11-01 00:00:00.000",
"description": "Report",
"row_id": 1294017,
"text": "NURSING NOTE:7A-7P\nPt Adm to MICU from CC7 at 1630. Wife accompanied patient. NEURO: Very sleepy arouses to voice. Alert and oriented, PERL, MAE. C/V: SB no ectopy noted, rate in the 50's. Nitro started at 1mcg/kg/min and titrated up to 3mcg/kg/min to maintain SBP 110-120. RESP: Arrived on unit with 100%NRB on Sat in the low 90's. Started on Bipap 40% with 5/5. ABG done and reported, no changes made. Lung sounds GU: Foley patent draining small amts clear yellow urine, Lasix 60 mg given this evening no response yet. Rt arm no BP or venopunctures site saved for future fistula for pt to start HD. GI: positive BS taking meds PO with sips of H2O. LINES: Rt radial Aline started good wave form, Two peripheral #18 started Left arm. SOCIAL: Wife into visit emotional support offered. Will call tonite for update.\n"
}
] |
52,641 | 131,760 | ACTIVE ISSUES: # Congestive heart failure: Acute on chronic systolic congestive heart failure, with most recent EF 35%. Mr. was admitted and diuresed with IV Lasix with milrinone for blood pressure support. He underwent a left sided thoracentesis by the Interventional Pulmonology service on for a yield of 1600cc of fluid. Right sided thoracentesis on yielded 1600cc of fluid. It was attempted to transition back to PO torsemide however he was not effectively diuresing with this regimen so he was restarted on a lasix drip with dopamine for pressure support. He did well with this and was transferred to the floor on PO furosemide. He was felt to be euvolemic and ready for discharge. ACEI should be restarted as an outpatient. Carvedilol was resumed at 3.125 mg at discharge. . #Sepsis: After Mr was transferred back to the floor he had an episode of hypotension with SBPs in the 80s as well as abdominal pain, diarrhea and fever, he was taken back to the CCU where pressors were re-initiated. He was started on vancomycin and zosyn. Blood and urine cultures were negative however his midline catheter tip grew coagulase negative staph. He was treated with vanc/zosyn for one week. His stool studies were negative and his diarrhea slowly resolved. . # Acute kidney injury: His creatinine has been rising over the past two months secondary to diuresis for repeat acute episodes of heart failure. At the time of admission, his creatinine had been 2.3, rose to a peak of 2.9, and was 2.4 at the time of transfer to the CCU. Dopamine was used to increase kidney perfusion. With successful diuresis, the patient's creatinine improved to 1.0 on discharge. . # Diabetes mellitus, type 2: The patient's blood glucose was initially poorly controlled, ranging up to 300 upon transfer to the CCU. He was followed by the consulting team who adjusted his standing and sliding scale doses of insulin with resulting better blood gluocose control. At the time of discharge, his regimen included glargine and HISS . # BPH: Has had difficulty voiding while in the hospital. Because he had been hypotensive his tamsulosin had been held and later restarted. On the day of discharge he had succesfully urinated without a foley catheter. . CHRONIC ISSUES: # Rhythm: The patient is AV- and V-paced at 85 bpm. He was monitored on telemtry during this admission without any issues. . # Hypertension: During this admission, the patient was hypotensive from aggressive diurese, so his home antihypertensives (hydralazine and isosorbide) were held accordingly. . # Hyperlipidemia: Documented history of this problem, for which the patient was continued on his home atorvastatin. . # CAD: s/p 3-vessel CABG , with moderately decreased LV systolic function (EF 35%). The patient was chest pain-free during this admission, and continued on his aspirin adn atorvastatin. His beta blocker and ACEi were initially held secondary to hypotension. At the time of discharge, he was restarted on carvedilol 3.125 mg . ACEI should be resumed as an outpatient . # Inflammatory bowel disease: Documented history of this problem, for which the patient was continued on his mesalamine 800 mg PO QID. . | Small amount of right upper quadrant ascites and right pleural effusion. Small amount of right upper quadrant ascites and right pleural effusion. Small amount of right upper quadrant ascites and right pleural effusion. Abnormal diastolic septal motion/position consistent with RVvolume overload.AORTA: Normal aortic diameter at the sinus level. A small amount of right upper quadrant ascites and right pleural fluid is demonstrated. The right ventricular cavity is moderately dilated with mild globalfree wall hypokinesis. Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. Moderate mitral annular calcification. There is moderatepulmonary artery systolic hypertension. Trivial mitral regurgitation is seen. Trivial mitral regurgitation is seen. Normally functioning aortic bioprosthesis.Compared with the prior study (images reviewed) of , the rightventricle appears more dilated/hypokinetic. There is at least mild LV systolicdysfunction. There is mild symmetric left ventricularhypertrophy with normal cavity size. Well-seated, normallyfunctioning mitral valve annuloplasty ring. Well-seated mitral annular ring with normal gradient.Moderate mitral annular calcification. Mild tricuspidannular calcification. The pre-existing right pleural effusion has minimally decreased. Mild cardiomegaly and venous congestion. Trace aorticregurgitation is seen. Unchanged cardiomegaly with mild fluid overload. Mild thickening of mitral valvechordae. Normal left ventricular cavity size withmoderately depressed left ventricular systolic function and regional wallmotion abnormalities as described above. Right ventricular chamber sizeis normal with moderate global free wall hypokinesis. Normally functioning bioprostheticaortic valve with trace aortic regurgitation. The mitral annular ring appearswell seated with normal gradient. There is abnormaldiastolic septal motion/position consistent with right ventricular volumeoverload. Trace aortic regurgitationis seen. Dilated and hypokinetic rightventricle with moderate tricuspid regurgitation and moderate pulmonary arteryhypertension. Moderate [2+] tricuspidregurgitation is seen. Right central catheter has been removed. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Bilateral pleural effusions.Conclusions:The left atrium is mildly dilated. Thereis moderate pulmonary artery systolic hypertension. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. ]TRICUSPID VALVE: Normal tricuspid valve leaflets. ]Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. The right atrium is moderately dilated. porcine aortic valve and mitral valve annuloplasty ring).Height: (in) 68Weight (lb): 186BSA (m2): 1.98 m2BP (mm Hg): 110/66HR (bpm): 102Status: InpatientDate/Time: at 14:07Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. IMPRESSION: Interval decrease in bilateral pleural effusions. Small right renal cyst. Small right renal cyst. Small right renal cyst. Unchanged bilateral pleural effusions. A right IJ catheter tip is in the region of the main pulmonary artery, stable. Bilateral pleural effusions are moderately decreased. No resting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Right subclavian catheter is present with the tip reaching at least the distal superior vena cava. Mild pulmonary venous congestion remains. FINDINGS: As compared to the previous radiograph, the right-sided chest tube is in unchanged position. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. SG cath has been removed from right IJ sheath. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is moderate thickening of the mitral valvechordae. AP UPRIGHT VIEW OF THE CHEST: The trace right effusion has decreased substantially. Cardiomediastinal silhouette is unchanged as well as the position of the pacemaker leads and replaced most likely mitral valve. The right-sided pleural effusion is unchanged. Right internal jugular line has been replaced by the Swan-Ganz catheter. FINDINGS: In comparison with the earlier study of this date, the new left basilar pigtail catheter has been placed with decrease in the pleural effusion on that side. Right hepatic hemangioma. Since the prior chest x-ray of a new right-sided PICC line terminates at the atriocaval junction. There is perihilar haziness with vascular indistinctness compatible with mild congestive heart failure. There is perihilar haziness with vascular indistinctness compatible with mild congestive heart failure. Moderate right pleural effusion has decreased in size. Rule out pneumothorax. Question pneumothorax and resolution of effusion. Bilateral pleural effusions with compressive atelectasis. FINDINGS: In comparison with the study of , there has been placement of a right IJ catheter that extends to the mid-to-lower portion of the SVC. FINDINGS: In comparison to prior chest radiograph a new right-sided PICC line is seen with its tip at the atriocaval junction. There is a left basal pleural catheter. FINDINGS: One frontal view of the abdomen was obtained. No acute osseous abnormalities are seen, though degenerative changes of the right glenohumeral joint are noted. Moderate right effusion and bibasilar atelectasis unchanged, as is the cardiomegaly and monitoring of support devices. Right internal jugular line tip is at the level of mid SVC. IMPRESSION: PA and lateral chest compared to and 29: Previous substantial right pleural effusion has not recurred, but there is new mild bibasilar pulmonary edema and mild decrease in lung volume since . Small-to-moderate bilateral pleural effusions are stable when compared to the prior chest radiograph. Note is made of bilateral pleural effusions. Patchy opacities at both lung bases likely represent bilateral atelectases. Evaluate pleural effusions. Since the prior study, there is interval improvement in congestive heart failure with only minimal interstitial edema currently seen associated with bilateral pleural effusions, small to moderate, as well as cardiomegaly. There is a left pleural effusion. FINDINGS: In comparison with study of , there again are relatively low lung volumes with enlargement of the cardiac silhouette and probable elevation of pulmonary venous pressure in a patient with a pacemaker device in place. 11:45 AM CHEST (PORTABLE AP) Clip # Reason: evidence of worsening CHF? Compared to the previous tracing of no diagnostic change. The intrahepatic portion of the IVC is minimally visualized and is unremarkable. 1:17 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ? | 33 | [
{
"category": "Echo",
"chartdate": "2121-10-29 00:00:00.000",
"description": "Report",
"row_id": 67431,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. AVR with size 25 bioprosthetic AVR on , mitral annuloplasty with 28 CG band.\nHeight: (in) 68\nWeight (lb): 183\nBSA (m2): 1.97 m2\nBP (mm Hg): 100/52\nStatus: Inpatient\nDate/Time: at 10:49\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mildly depressed\nLVEF. Diastolic function could not be assessed. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR\ngradient. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Moderate mitral annular calcification. Moderate thickening\nof mitral valve chordae. Calcified tips of papillary muscles. Trivial MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild tricuspid\nannular calcification. Moderate [2+] TR. [Due to acoustic shadowing, the\nseverity of tricuspid regurgitation may be significantly UNDERestimated.]\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Bilateral pleural effusions.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Overall left ventricular systolic\nfunction is mildly depressed (LVEF= XX %). Diastolic function could not be\nassessed. The right ventricular cavity is moderately dilated with mild global\nfree wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The\ntransaortic gradient is normal for this prosthesis. Trace aortic regurgitation\nis seen. The mitral valve leaflets are moderately thickened. A mitral valve\nannuloplasty ring is present. There is moderate thickening of the mitral valve\nchordae. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] The\ntricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid\nregurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid\nregurgitation may be significantly UNDERestimated.] There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric LVH. There is at least mild LV systolic\ndysfunction. There appears to be significant dyssynchrony present - as a\nresult LV cardiac ouput is further impaired. Dilated and hypokinetic right\nventricle with moderate tricuspid regurgitation and moderate pulmonary artery\nhypertension. Normally functioning aortic bioprosthesis.\n\nCompared with the prior study (images reviewed) of , the right\nventricle appears more dilated/hypokinetic. There is probably increased\ndyssynchrony present.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2121-10-09 00:00:00.000",
"description": "Report",
"row_id": 67432,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease (s/p . porcine aortic valve and mitral valve annuloplasty ring).\nHeight: (in) 68\nWeight (lb): 186\nBSA (m2): 1.98 m2\nBP (mm Hg): 110/66\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 14:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. No ASD by 2D or color\nDoppler. Normal IVC diameter (>2.1cm) with <50% decrease with sniff (estimated\nRA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderately depressed\nLVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis. Abnormal diastolic septal motion/position consistent with RV\nvolume overload.\n\nAORTA: Normal aortic diameter at the sinus level. No 2D or Doppler evidence of\ndistal arch coarctation.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move\nnormally. Normal AVR gradient. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Well-seated mitral annular ring with normal gradient.\nModerate mitral annular calcification. Mild thickening of mitral valve\nchordae. Calcified tips of papillary muscles. Trivial MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Eccentric\nTR jet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. Suboptimal image quality - body\nhabitus. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. The estimated right\natrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is\nmoderately depressed (LVEF= 35 %) with akinesis of the basal and mid inferior\nand inferolateral segments. Due to suboptimal image quality additional wall\nmotion abnormalities cannot be fully excluded. Right ventricular chamber size\nis normal with moderate global free wall hypokinesis. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload. A bioprosthetic aortic valve prosthesis is present. The aortic valve\nprosthesis leaflets appear to move normally. The transaortic gradient is\nnormal for this prosthesis. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. A\nmitral valve annuloplasty ring is present. The mitral annular ring appears\nwell seated with normal gradient. Trivial mitral regurgitation is seen. [Due\nto acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.\nThe tricuspid regurgitation jet is eccentric and may be underestimated. There\nis moderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Biatrial enlargment. Normal left ventricular cavity size with\nmoderately depressed left ventricular systolic function and regional wall\nmotion abnormalities as described above. Normally functioning bioprosthetic\naortic valve with trace aortic regurgitation. Well-seated, normally\nfunctioning mitral valve annuloplasty ring. Moderate tricuspid regurgitation.\nModerate pulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , the pulmonary\nartery systolic pressure has increased from 38 mmHg to at least 44 mmHg. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210215,
"text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess effusions\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p avr recurrent effusions\n REASON FOR THIS EXAMINATION:\n assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR with recurrent effusions.\n\n FINDINGS: In comparison with the study of , there is little change.\n Monitoring and support devices remain in place. Continued layering pleural\n effusion on the right with bibasilar atelectasis, enlargement of the cardiac\n silhouette, and probably mild elevation of pulmonary venous pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1212030,
"text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Are there infiltrates or pleural effusions?\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old gentleman with history of DM2, HTN, PVD, s/p PPM placement for\n complete heart block, and CAD who is s/p 3-vesel CABG with AV replacement and\n MV repair on , who has been readmitted for decompensated systolic heart\n failure and acute kidney injury, now undergoing continued diuresis with\n dopamine for blood pressure support.\n REASON FOR THIS EXAMINATION:\n Are there infiltrates or pleural effusions?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pacemaker placement.\n\n FINDINGS: In comparison with study of , there has been placement of\n pacemaker device. The leads are extremely difficult to visualize due to\n underpenetration of the abdomen, though they appear to be in the general area\n of the apex of the right ventricle and right atrium.\n\n There are decreasing lung volumes. Bibasilar opacification most likely\n reflects atelectasis and effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1210631,
"text": " 5:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please read for 41cm right brachial PICCThanks! #95\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with need for central access.\n REASON FOR THIS EXAMINATION:\n Please read for 41cm right brachial PICCThanks! #\n ______________________________________________________________________________\n WET READ: NATg FRI 6:00 PM\n rue picc is at cavoatrial jct. SG cath has been removed from right IJ sheath.\n O/W unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Right PICC line placed.\n\n COMPARISON: at 0748 hours.\n\n FINDINGS: Swan-Ganz catheter has been removed. A right PICC line is at the\n cavoatrial junction. There has been no change in the bilateral pleural\n effusions and mild vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210378,
"text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Followup effusion after CT\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CHF\n REASON FOR THIS EXAMINATION:\n Followup effusion after CT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chronic heart failure, followup after chest tube.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the right-sided chest tube\n is in unchanged position. The course of the tube is also unchanged. The\n pre-existing right pleural effusion has minimally decreased. There is no\n evidence of pneumothorax or other complication. There is an unchanged small\n left pleural effusion, the left chest drain is in unchanged position.\n Unchanged cardiomegaly with mild fluid overload. Unchanged left pectoral\n pacemaker with leads.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209834,
"text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for voluem overload\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n eval for voluem overload\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory distress, volume overload.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n There is no substantial change in the bilateral pleural effusions and bibasal\n atelectasis but the degree of pulmonary edema can be potentially slightly less\n severe. Cardiomediastinal silhouette, tubes and lines are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-12 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1209856,
"text": " 12:55 PM\n RENAL U.S. PORT Clip # \n Reason: evaluate including doppler flows for renal flow due to renal\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p cabg with acute renal failure\n REASON FOR THIS EXAMINATION:\n evaluate including doppler flows for renal flow due to renal failure - please\n do as portable due to hemodynamic instability and hypoxia - if questions please\n page \n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh SUN 4:39 PM\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Small right renal cyst.\n 3. Small amount of right upper quadrant ascites and right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old male with acute renal failure.\n\n STUDY: Renal ultrasound; discussion with the clinical team confirmed that a\n Doppler study was not necessary even though one was ordered.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 11.3 cm in its long axis. In the mid\n pole of right kidney is a 1.8 x 0.9 x 1.2 cm, anechoic, well-circumscribed\n region compatible with a simple cyst. The left kidney measures 12.1 cm in its\n long axis. Neither kidney demonstrates stones or hydronephrosis. Both\n kidneys demonstrate global color Doppler flow.\n\n Transverse and sagittal views of the bladder demonstrate it to be decompressed\n around a Foley balloon.\n\n There is no ascites seen in the lower quadrants. A small amount of right\n upper quadrant ascites and right pleural fluid is demonstrated.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Small right renal cyst.\n 3. Small amount of right upper quadrant ascites and right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-12 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1209857,
"text": ", CSURG CSRU 12:55 PM\n RENAL U.S. PORT Clip # \n Reason: evaluate including doppler flows for renal flow due to renal\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p cabg with acute renal failure\n REASON FOR THIS EXAMINATION:\n evaluate including doppler flows for renal flow due to renal failure - please\n do as portable due to hemodynamic instability and hypoxia - if questions please\n page \n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Small right renal cyst.\n 3. Small amount of right upper quadrant ascites and right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210679,
"text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: frolowup effusions after drainage\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with ht fsailure\n REASON FOR THIS EXAMINATION:\n frolowup effusions after drainage\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Followup pleural effusions after drainage.\n\n COMPARISON: , 1731 hours.\n\n Right chest tube remains in good position. Right subclavian catheter is\n present with the tip reaching at least the distal superior vena cava. Heart\n remains enlarged with mild vascular congestion improved. Bilateral pleural\n effusions are moderately decreased. There is no evidence of pneumothorax.\n\n IMPRESSION: Interval decrease in bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210940,
"text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p L pigtail d/c\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with avr/mvr/cabg\n REASON FOR THIS EXAMINATION:\n s/p L pigtail d/c\n ______________________________________________________________________________\n WET READ: MLHh MON 8:12 PM\n No PTX s/p L CT removal. Mild cardiomegaly and venous congestion. Tiny\n residual bilat effusions. LLL atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Removal of pigtail catheter.\n\n FINDINGS: In comparison with the study of , the pigtail catheter on the\n right has been almost withdrawn. No pneumothorax is seen on either side.\n Right central catheter has been removed.\n\n Continued enlargement of the cardiac silhouette with some venous congestion\n that appears to be less than on the prior study. Bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1211093,
"text": " 5:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for chf/effusions/infiltrates\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p AVR-chest tube removal-hypoxia\n REASON FOR THIS EXAMINATION:\n assess for chf/effusions/infiltrates\n ______________________________________________________________________________\n WET READ: LLTc TUE 6:11 PM\n Interval removal of a right thoracostomy tube. Persistent central vascular\n congestion but improved mild interstitial edema. Unchanged bilateral pleural\n effusions. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:48 P.M., \n\n HISTORY: Status post AVR. Chest tube removed.\n\n IMPRESSION: AP chest compared to through 11 at 7:27 a.m.:\n\n Right pleural drain has been removed. There is no pneumothorax. Moderate\n right pleural effusion is smaller, moderate cardiomegaly is stable, but\n previous mild pulmonary edema has improved. Small to moderate left pleural\n effusion has increased slightly over the course of the day. Tip of the left\n PIC line is still extrathoracic. Venous pacer leads cannot be fully traced,\n but do not appear to have migrated since the earlier examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210976,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check R effusion\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with avr/mvr/cabg\n REASON FOR THIS EXAMINATION:\n check R effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery, to check for effusions.\n\n FINDINGS: In comparison with the study of , there is some increasing\n hazy opacification at both bases consistent with bilateral effusions in a\n patient with cardiac enlargement and vascular congestion and evidence of a\n previous cardiac surgery and dual-channel pacemaker device in place. No\n evidence of pneumothorax with the right pigtail catheter remaining in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210783,
"text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u effusions\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CHF\n REASON FOR THIS EXAMINATION:\n f/u effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Congestive heart failure.\n\n COMPARISON: at 0759.\n\n FINDINGS: Right chest tube and right subclavian catheters remain in good\n position. The heart is enlarged. Mild pulmonary venous congestion remains.\n No definite edema. Bilateral pleural effusions, right greater than left are\n slightly improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209923,
"text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural eff.\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p AVR/MVr/CABG on \n REASON FOR THIS EXAMINATION:\n Pleural eff.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AVR, MVR and CABG on . Evaluate for pleural\n effusion.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: .\n\n FINDINGS: A pacer device overlying the left chest with three leads appears\n stable. A right IJ catheter tip is in the region of the main pulmonary\n artery, stable. Sternal wires remain intact. A mitral valve replacement\n appears stable.\n\n Lung volumes remain quite low and there is increased pulmonary vascular\n markings. Bibasilar pleural effusions are present. No pneumothorax is\n present. The cardiac silhouette appears enlarged but stable.\n\n IMPRESSION:\n\n Low lung volumes with pulmonary vascular congestion and bibasilar bilateral\n pleural effusions, progressed. Stable appearance to multiple support devices.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-21 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1211035,
"text": " 12:59 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place double lumen PICC\n Admitting Diagnosis: HEART FAILURE\n Contrast: VISAPAQUE Amt: 15\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p MVR/AVR/CABG\n REASON FOR THIS EXAMINATION:\n place double lumen PICC\n ______________________________________________________________________________\n WET READ: IPf TUE 6:54 PM\n 1. Uncomplicated fluoroscopically guided midline line exchange for a new\n double-lumen line. Final length is 35 cm (1.5 cm outside), with the tip\n positioned in the mid left subcalvian vein (midline). The line is ready to\n use.\n 2. Occlusion at the level of the mid left subclavian vein with multiple\n collaterals.\n\n Note: Use of 15 cc iv contrast was communicated with NP, at\n 3:30 p.m. on . Hydration was recommended to prevent\n nephrotoxicity from administrated iv contrast if patient baseline condition\n allowed. Consideration for attempt on the right side was recommended, as\n clinically warranted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Malposition of indwelling PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. (resident), Dr. (fellow), and Dr.\n (attending) performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling left arm PICC line under fluoroscopic\n guidance. The old PICC line was then removed and a peel-away sheath was then\n placed over the guidewire.\n\n Due to resistance in the vessel at the mid left subclavian vein, hand\n injection venogram was performed with 15 cc Visipaque. Venogram demonstrated\n occlusion at the level of the mid left subclavian vein with multiple\n collaterals. Attempt was made to pass the wire through a collateral; however,\n was unsuccessful.\n\n A new double-lumen line measuring 35 cm in length was then placed through the\n peel-away sheath with its tip positioned in the mid left subclavian vein under\n fluoroscopic guidance (midline). Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n (Over)\n\n 12:59 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place double lumen PICC\n Admitting Diagnosis: HEART FAILURE\n Contrast: VISAPAQUE Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION:\n\n 1. Uncomplicated fluoroscopically guided midline line exchange for a new\n double-lumen line. Final length is 35 cm (1.5 cm outside), with the tip\n positioned in the mid left subcalvian vein (midline). The line is ready to\n use.\n 2. Occlusion at the level of the mid left subclavian vein with multiple\n collaterals.\n\n Note: Use of 15 cc iv contrast was communicated with NP, at\n 3:30 p.m. on . Hydration was recommended to prevent\n nephrotoxicity from administrated iv contrast if patient baseline condition\n allowed. Consideration for attempt on the right side was recommended, as\n clinically warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-30 00:00:00.000",
"description": "UNILAT LOWER EXT VEINS",
"row_id": 1212370,
"text": " 10:25 AM\n UNILAT LOWER EXT VEINS Clip # \n Reason: Please evaluate for DVT\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with history of DM2, HTN, PVD, s/p PPM placement for complete\n heart block, and CAD who is s/p 3-vesel CABG with AV replacement and MV repair\n on , who has been readmitted for decompensated systolic heart failure\n and acute kidney injury, in the CCU for continued diuresis with pressors for\n blood pressure support, with new onset LLE swelling.\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with new onset of left lower extremity swelling,\n evaluate for DVT.\n\n COMPARISON: Vein mapping, .\n\n FINDINGS: Grayscale, color and Doppler images were obtained of the left\n common femoral, superficial femoral, popliteal and tibial veins. Normal flow,\n compression and augmentation is seen in all of the vessels.\n\n There is an elongated complex fluid collection which extends from the left\n popliteal fossa region upward to the lower third of the medial left thigh.\n This structure could represent a hematoma from the patient's recent saphenous\n vein harvest site.\n\n IMPRESSION:\n 1. No deep vein thrombosis seen in the left leg.\n 2. Avascular complex fluid collection in the medial left distal thigh and \n fossa could represent a hematoma from recent saphenous vein harvest site.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1210017,
"text": " 6:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX/Pleural eff.\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p pigtail placement\n REASON FOR THIS EXAMINATION:\n PTX/Pleural eff.\n ______________________________________________________________________________\n WET READ: SHSf MON 7:35 PM\n New left pigtail catheter with decreased left effusion. No pneumothorax.\n Moderate right effusion and atelectasis, cardiomegaly and support devices are\n unchanged.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pigtail placement, to assess for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, the new left\n basilar pigtail catheter has been placed with decrease in the pleural effusion\n on that side. Moderate right effusion and bibasilar atelectasis unchanged, as\n is the cardiomegaly and monitoring of support devices.\n\n Specifically, no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210320,
"text": " 4:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx-assess effusion\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p pigtail placement\n REASON FOR THIS EXAMINATION:\n r/o ptx-assess effusion\n ______________________________________________________________________________\n WET READ: NATg WED 8:35 PM\n new b/l pleural pigtails, no pneumothorax. bibasilar opacities slightly\n improved, SG tip in MPA.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess pigtail placement.\n\n Comparison is made with prior study performed 10 hours earlier.\n\n There is a new right upper pigtail catheter. Moderate right pleural effusion\n has decreased in size. Cardiomegaly is stable. Transvenous pacemaker leads\n are in a standard position. There is a left basal pleural catheter. There is\n no evident pneumothorax. Bibasilar opacities consistent with atelectasis have\n improved. Sternal wires are aligned. Swan-Ganz catheter tip is in the main\n pulmonary artery. There is mild stable vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-05 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1213180,
"text": " 11:10 AM\n PORTABLE ABDOMEN Clip # \n Reason: acute process\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with abd pain and diarrhea\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n WET READ: PRib WED 3:27 PM\n No evidence of obstruction or ileus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain and diarrhea, assess for acute process.\n\n COMPARISON: .\n\n FINDINGS: One frontal view of the abdomen was obtained. There is an overall\n paucity of bowel gas; however, there is some air seen in the small bowel and\n rectum. There is no evidence small or large bowel dilatation. There are\n degenerative changes of the lower lumbar spine and hips. Again seen are the\n vascular calcifications.\n\n IMPRESSION: No evidence of obstruction or ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1212957,
"text": " 12:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new right IJ\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: DLrc TUE 1:39 AM\n RIJ terminates in the upper SVC. No evidence of pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n a right IJ catheter that extends to the mid-to-lower portion of the SVC. No\n evidence of pneumothorax. Little overall change in the appearance of the\n heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1209762,
"text": " 1:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for new R IJ cordis position\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new R IJ cordis\n REASON FOR THIS EXAMINATION:\n eval for new R IJ cordis position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New right internal jugular line placement.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n New right internal jugular line has been inserted with its tip at the level of\n superior SVC/ junction of the jugular vein and brachiocephalic vein. The\n right PICC line tip is at the level of the mid SVC.\n\n There is an interval substantial progression of right mid and lower lobe\n consolidation as well as left lower lobe consolidation in conjunction with\n pulmonary edema. The pulmonary edema may potentially explain this worsening\n of the basal aeration but correlation with post-diuresis radiograph to exclude\n the possibility of aspiration or developing infection is recommended.\n\n Cardiomediastinal silhouette is unchanged as well as the position of the\n pacemaker leads and replaced most likely mitral valve.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-04 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1212987,
"text": " 8:18 AM\n PORTABLE ABDOMEN Clip # \n Reason: KUB to assess for dilation, obstruction, ileus\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with HTN, DM, CAD s/p CABG who now has fevers, on pressors,\n with abdominal distension\n REASON FOR THIS EXAMINATION:\n KUB to assess for dilation, obstruction, ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension, diabetes, CAD, status post CABG, now with fevers\n and abdominal distention. Assess for dilation, obstruction or ileus.\n\n COMPARISON: None.\n\n FINDINGS: Two frontal views of the abdomen were obtained. There is\n nonspecific gas pattern with a relative paucity of small bowel gas. There are\n scattered air-fluid levels. There is no small or large bowel dilatation.\n There is no free air. There is a left pleural effusion. The sternotomy wires\n are in place. There are vascular calcifications in a branch of the internal\n iliac arteries bilaterally, SFAs bilaterally, and splenic artery. There are\n degenerative changes of the hips.\n\n IMPRESSION: No evidence of obstruction or ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1209765,
"text": " 2:57 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: is cordis in position\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with oliguria/PICC/Permanent pacer\n REASON FOR THIS EXAMINATION:\n is cordis in position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with oliguria.\n\n Portable AP radiograph of the chest was reviewed in comparison to at 1:18 p.m.\n\n Current study redemonstrates bilateral pulmonary opacities consistent with\n pulmonary edema with bilateral pleural effusions. The cardiomediastinal\n silhouette is unchanged.\n\n Right internal jugular line has been replaced by the Swan-Ganz catheter. No\n pneumothorax is present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-04 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1212983,
"text": " 7:55 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ? cholecystitis, abdominal pathology\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with DM, HTN, UC, CAD s/p CABG who spiked a fever and now with\n RUQ pain\n REASON FOR THIS EXAMINATION:\n ? cholecystitis, abdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with fever and right upper quadrant pain.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The hepatic architecture is unremarkable. A sharply marginated\n echogenic avascular lesion is seen in the right lobe of the liver consistent\n with a hemangioma. This lesion measures 1.2 x 1.5 x 1.5 cm and is located in\n segment VI. No additional liver lesion is identified.\n\n No biliary dilatation is seen and the common duct measures 0.4 cm. A tiny\n polyp measuring 2 mm is seen within the lumen of the gallbladder. There are\n no gallstones. No pericholecystic fluid or gallbladder wall edema is\n identified and the gallbladder is not distended. The pancreas is not\n visualized due to overlying bowel gas. The spleen is unremarkable and\n measures 10.6 cm. No hydronephrosis is seen. The right kidney measures 11.3\n cm and the left kidney measures 11.2 cm. The aorta is obscured from view.\n The intrahepatic portion of the IVC is minimally visualized and is\n unremarkable. Note is made of bilateral pleural effusions.\n\n IMPRESSION:\n 1. No evidence of cholecystitis.\n 2. Right hepatic hemangioma.\n 3. Bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1209620,
"text": " 10:48 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p AVR/MV repair/CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: AVR and MVR. CABG. Evaluate pleural effusions.\n\n IMPRESSION: PA and lateral chest compared to and 29:\n\n Previous substantial right pleural effusion has not recurred, but there is new\n mild bibasilar pulmonary edema and mild decrease in lung volume since\n . There is no pneumothorax. Lateral view suggests either right\n hilar adenopathy or dense perihilar consolidation, less readily recognized on\n the frontal view, but should be considered pneumonia until proved otherwise.\n\n Findings were discussed over the telephone with the house officer caring for\n this patient at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1212937,
"text": " 5:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary source\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with DM2, HTN, PVD, s/p PPM for complete heart block, CAD s/p\n CABG with AVR, MV repair who just spiked temp\n REASON FOR THIS EXAMINATION:\n ? pulmonary source\n ______________________________________________________________________________\n WET READ: OXZa MON 6:10 PM\n low lung volumes. bibasilar and left hilar opacities could be explained by\n effusion and atelectasis though infection cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes, hypertension, and pacemaker with temperature.\n\n FINDINGS: In comparison with study of , there again are relatively low\n lung volumes with enlargement of the cardiac silhouette and probable elevation\n of pulmonary venous pressure in a patient with a pacemaker device in place.\n Bilateral pleural effusions with compressive atelectasis.\n\n The possibility of supervening pneumonia cannot be definitely excluded in the\n appropriate clinical setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209364,
"text": " 1:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? PTX, ? residual effusion on L\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with bilateral pleural effusions s/ with 1600cc out on\n the L.\n REASON FOR THIS EXAMINATION:\n ? PTX, ? residual effusion on L\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 80-year-old man with bilateral effusions, status post\n thoracentesis. Question pneumothorax and resolution of effusion.\n\n COMPARISON: at 9:20 a.m.\n\n FINDINGS: Comparison with the chest radiograph from earlier this morning,\n there is no evidence of pneumothorax bilaterally. The left-sided pleural\n effusion has decreased in size but a small amount remains. The right-sided\n pleural effusion is unchanged. Opacification of bilateral lung bases likely\n represents atelectasis. Remainder of the examination is unchanged from\n earlier this a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209483,
"text": " 11:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out pnuemothorax right sided\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with bilateral pleural effusion s/p right thoracentesis now.\n REASON FOR THIS EXAMINATION:\n rule out pnuemothorax right sided\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with bilateral pleural effusions, status post\n thoracentesis. Rule out pneumothorax.\n\n COMPARISON: .\n\n AP UPRIGHT VIEW OF THE CHEST: The trace right effusion has decreased\n substantially. There is possible small left effusion with basilar\n atelectasis. There is no pneumothorax. The heart size is moderately enlarged\n as before. There is mild edema which may in part be due re-expansion on the\n right.\n\n Three leads follow a normal course from the left-sided battery pack\n terminating in the expected region of the right atrium and two in the right\n ventricle. Multiple sternal wires are intact. Metallic component of a valve\n prosthesis is noted. The distal tip of the right PICC cannot be assessed due\n to obscuration by the pacer wires.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1209316,
"text": " 9:24 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 47cm iv \n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with picc\n REASON FOR THIS EXAMINATION:\n r picc 47cm iv \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New right-sided PICC line.\n\n COMPARISON: .\n\n FINDINGS: In comparison to prior chest radiograph a new right-sided PICC line\n is seen with its tip at the atriocaval junction.\n\n The patient is status post median sternotomy and CABG and dual-chamber\n left-sided pacemaker with leads terminating in the regions of the right atrium\n and right ventricle. The heart size is moderately enlarged. There is\n perihilar haziness with vascular indistinctness compatible with mild\n congestive heart failure. Small-to-moderate bilateral pleural effusions are\n stable when compared to the prior chest radiograph. Patchy opacities at both\n lung bases likely represent bilateral atelectases.\n\n IMPRESSION:\n 1. Since the prior chest x-ray of a new right-sided PICC\n line terminates at the atriocaval junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209226,
"text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with chf\n REASON FOR THIS EXAMINATION:\n r/o effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy, CABG,\n and left-sided dual-chamber pacemaker with leads terminating in the regions of\n the right atrium and right ventricle. Heart size is moderately enlarged.\n There is perihilar haziness with vascular indistinctness compatible with mild\n congestive heart failure. Additionally, small to moderate sized bilateral\n pleural effusions are increased when compared to the prior exam with patchy\n opacities in the lung bases, which may reflect atelectasis. No pneumothorax\n is identified. No acute osseous abnormalities are seen, though degenerative\n changes of the right glenohumeral joint are noted.\n\n IMPRESSION: Mild congestive heart failure, worse in the interval, with\n increased size of small to moderate sized bilateral pleural effusions.\n Bibasilar airspace opacities may reflect atelectasis though infection cannot\n be excluded.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1213935,
"text": " 11:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of worsening CHF?\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with chronic CHF and no diuretics for 48 hours.\n REASON FOR THIS EXAMINATION:\n evidence of worsening CHF?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Known chronic congestive heart failure and no\n diuresis for 48 hours, status of congestive heart failure.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Since the prior study, there is interval improvement in congestive heart\n failure with only minimal interstitial edema currently seen associated with\n bilateral pleural effusions, small to moderate, as well as cardiomegaly. Note\n is made that there is slightly different configuration of the cardiac\n silhouette, which potentially may be due to different patient position, but\n interval development of pericardial effusion cannot be excluded. If\n clinically warranted, correlation with echocardiography to exclude the\n possibility of pericardial effusion is recommended.\n\n Right internal jugular line tip is at the level of mid SVC.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-11-03 00:00:00.000",
"description": "Report",
"row_id": 144400,
"text": "A-V sequential paced rhythm. Compared to the previous tracing of \nno diagnostic change.\n\n"
}
] |
9,849 | 156,939 | 1. Pulmonary: She remained in the Intensive Care Unit for one day where she received 60 mg intravenous q. six hours of Solu-Medrol. She was stable on four liters of O2 and was transferred to the Floor where intravenous steroids were discontinued and she was started on 60 mg p.o. q. day of Prednisone with Prednisone taper. She was comfortable at this setting, although she continued to complain of severe dyspnea which she stated was her baseline. She was coughing frequently and was given Robitussin DM as well as Robitussin with codeine for symptomatic relief of her cough. She was started on Azithromycin while in the Emergency Department and will finish up a five-day course of Azithromycin. She also received Albuterol and Atrovent nebulizer treatments although she did not have evidence of bronchospasm on examination. On further discussion, the patient states that her baseline exercise tolerance is so poor that she is unable to perform basic functions such as getting from her bed at home to her bathroom without becoming extremely dyspneic. Given the patient's extremely poor prognosis, she requested that she be made a home Hospice candidate. 2. Hematologic: She has a persistently elevated white blood cell count often to the low 20s, in the past. Most likely, this represents and effects both of the steroids that she is taking and of a possible myelodysplastic syndrome. Given that myelodysplastic syndrome is treated only symptomatically with blood transfusions, no further work-up is necessary at this time. | Febrile to 100.4. Pt given treatment tol well. The left costophrenic angle is excluded. BS'S DIMINISHED THROUGHOUT. SHE IS DNR/DNI. Non-porductive. The heart size and mediastinal contour are within normal limits. RR IN TEENS, REG, NONLABORED AT REST. Low normal voltage. + OCC COUGH. There is a rounded density at the right base which likely relates to diaphragm. Pt in NARD on 4LPM N/C. Lung sounds DIM but no wheezing noted. SATS IN LOW 90'S. ATE A REG DIET AND TOL WELL. Pt ordered for Alb nebs Q2 W/A. Sinus rhythm. Otherwise normal. NO FEVER. Opacity at the right base likely relates to the diaphragm and may represent focal eventration. Resp Care Note:Pt received from ER admitted for COPD flare. Starting steroid taper.. A. COPD flare...stable 24hrs...sats 88-92\ P. Antibiotics..steriods..ready for transfer to floor. The left costophrenic angle is excluded and cannot be assessed. Cough and shortness of breath x three days. No previous tracingavailable for comparison. IMPRESSION: No evidence of acute pathologic cardiopulmonary process. The lungs are otherwise clear. PORTABLE AP VIEW OF CHEST: Comparison is made with prior study performed . 4 ICU nursing progress note: Altered Respiratory:Remains on 4l nc..rr 22-30..increase dypsnia with excertion...c/o cough..though says she has this at home till 12n. PRESENTED LAST EVE TO EW WHO PUT HER ON BIPAP, BUT TRANSFERRED HER EAST OFF OF IT. The aorta is tortuous. NPN (NOC): PT IS A 77 Y/O WF W/ PMHX OF COPD AND CHRON'S DZ WHO USES O2 AT HOME AT 3 LITERS AND HAS 4 DAY HX OF COUGH. FOLEY D/C'D AT 6AM AT HER REQUEST. WHEN SHE ARRIVED HERE, SHE TOLD US THAT SHE DID NOT FEEL THAT SHE NEEDED BIPAP ANY LONGER, SO SHE HAS GONE ALL NIGHT ON 4 LITERS NC AND HAS DONE VERY WELL. | 5 | [
{
"category": "ECG",
"chartdate": "2145-02-28 00:00:00.000",
"description": "Report",
"row_id": 115388,
"text": "Sinus rhythm. Low normal voltage. Otherwise normal. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-01 00:00:00.000",
"description": "Report",
"row_id": 1392229,
"text": "NPN (NOC): PT IS A 77 Y/O WF W/ PMHX OF COPD AND CHRON'S DZ WHO USES O2 AT HOME AT 3 LITERS AND HAS 4 DAY HX OF COUGH. PRESENTED LAST EVE TO EW WHO PUT HER ON BIPAP, BUT TRANSFERRED HER EAST OFF OF IT. WHEN SHE ARRIVED HERE, SHE TOLD US THAT SHE DID NOT FEEL THAT SHE NEEDED BIPAP ANY LONGER, SO SHE HAS GONE ALL NIGHT ON 4 LITERS NC AND HAS DONE VERY WELL. SHE IS DNR/DNI. RR IN TEENS, REG, NONLABORED AT REST. SATS IN LOW 90'S. BS'S DIMINISHED THROUGHOUT. + OCC COUGH. NO FEVER. ATE A REG DIET AND TOL WELL. FOLEY D/C'D AT 6AM AT HER REQUEST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-01 00:00:00.000",
"description": "Report",
"row_id": 1392230,
"text": " 4 ICU nursing progress note:\n Altered Respiratory:\nRemains on 4l nc..rr 22-30..increase dypsnia with excertion...c/o cough..though says she has this at home till 12n. Non-porductive. Starting steroid taper..\n A. COPD flare...stable 24hrs...sats 88-92\\\n P. Antibiotics..steriods..ready for transfer to floor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-03-01 00:00:00.000",
"description": "Report",
"row_id": 1392228,
"text": "Resp Care Note:\n\nPt received from ER admitted for COPD flare. Pt ordered for Alb nebs Q2 W/A. Pt given treatment tol well. Lung sounds DIM but no wheezing noted. Pt in NARD on 4LPM N/C.\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 750839,
"text": " 4:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, cough\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hx copd, febrile too 100.4 cough sob x 3 days\n REASON FOR THIS EXAMINATION:\n sob, cough\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 year old woman with history of COPD. Febrile to 100.4. Cough\n and shortness of breath x three days.\n\n PORTABLE AP VIEW OF CHEST: Comparison is made with prior study performed\n . The heart size and mediastinal contour are within normal limits. The\n aorta is tortuous. The left costophrenic angle is excluded and cannot be\n assessed. There is a rounded density at the right base which likely relates\n to diaphragm. The lungs are otherwise clear.\n\n IMPRESSION: No evidence of acute pathologic cardiopulmonary process. The left\n costophrenic angle is excluded. Opacity at the right base likely relates to\n the diaphragm and may represent focal eventration.\n\n"
}
] |
74,016 | 112,955 | MICU COURSE: # Fevers/elevated WBC: CXR clear at presentation. Urine clear except for high glucose. Abdomen was soft and non-tender with no rebound at presentation. No signs of RUQ pathology/cholecystitis on LFTs. History of seizures raised suspicion for CNS infection, although no signs of meningismus on exam; family refused LP to conclusively rule out meningitis. Regardless, patient was treated empirically in first 24 hours with Acyclovir, Vancomycin, Ampicillin, and Ceftriaxone at meningitis dosing. On morning of , culture data and clinical signs remained unrevealing, and with no specific source of infection identified, on , ceftriaxone was stopped as well. | CKs were elevated, likely to renal failure, trops were flat. # constipation- pt without BM since admission and evidence of stool-filled colon on CXR. Now resolved at 0.7, was likely prerenal. # HTN: currently normotensive, dry, and infected, so will hold antihypertensives . # HTN: currently normotensive, dry, and infected, so will hold antihypertensives . # HTN: currently normotensive, dry, and infected, so will hold antihypertensives . Hyperglycemia now resolved. -trend # HTN: Was normotensive on admission and antihypertensives were held, now hypertensive to 160 - restart anti-hypertensive medication today start one at time . # acute renal failure: unknown baseline, but elevated at 2.1. # acute renal failure: unknown baseline, but elevated at 2.1. Plan: # fevers/elevated WBC: CXR clear. Plan: # fevers/elevated WBC: CXR clear. Plan: # fevers/elevated WBC: CXR clear. Plan: # Fevers/elevated WBC: CXR clear. Check renal U/S if does not resolve. Initially was on meningitis dosing of abx (vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover Listeria, and acyclovir 10mg/kg q12h) which has since been cut back to ceftriaxone only as low concern for meningitis, afebrile WBC down to 7.4. Hypernatremia -- significant free water deficit remains. ARF--pre-renal etiology, possibly with ATN component. - lytes check # Acute renal failure: On admission elevated at 2.1, unknown baseline. ACUTE RENAL FAILURE -- improving with iv hydration. Na coming down appropriately (goal is decr 12 mEQ/ 24 hrs) - d/c insulin gtt, IVF -Cont TF and 250cc free water flushes Q 6hrs - Lantus 5 u plus HISS - C/S -Q 6 hr lytes. Also febrile to 102.6 on arrival. Also febrile to 102.6 on arrival. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. on colace, lactulose NEURO: pt probably at baseline. on colace, lactulose NEURO: pt probably at baseline. on colace, lactulose NEURO: pt probably at baseline. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Action: Continued monitoring , had received motrin & Tylenol in ED. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Hydration changed to D51/2 NS. Has received 3L NS (hypotonic relative to pt), will recheck labs and likely change to 1/2NS for IVF for both free water repletion and volume expansion. Response: Urine output okay, na coming down slowly Plan: Check electrolytes in am, replete K as needed. Plan: # fevers/elevated WBC: CXR clear. Plan: # fevers/elevated WBC: CXR clear. Monitor UO, BUN, creatinine. # HTN: currently normotensive, dry, and infected, so will hold antihypertensives . # HTN: currently normotensive, dry, and infected, so will hold antihypertensives . Response: Decreasing WBC Plan: Continue IV antibx for 2 wks, check regarding droplet precautions in am. Known sz d/o, Dilantin reloaded and dose adjusted since admit. - Dilantin dose adjustedfollow levels. # Hyperglycemia---Most c/w HHS on presentation, s/p adequate volume resus. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. Also febrile to 101--> sent to ED. - Reloaded with dilantin. febrile to 101--> sent to ED at . Sodium 158 (169 corrected for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Reloaded with dilantin. Action: Continued monitoring , had received motrin & Tylenol in ED. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. Hyperglycemic to 774-->insulin gtt and fluids given. # Fevers/leukocytosis--no obvious source on initial presentation and cxd have returned neg. # Hyperglycemia---Most c/w HHS on presentation, adeuqtely volume resus. CKs were elevated, likely to renal failure, trops were flat. Has received 3L NS (hypotonic relative to pt), will recheck labs and likely change to 1/2NS for IVF for both free water repletion and volume expansion. Per EMS--> had 1-2 min witnessed tonic clonic sz which broke upon IV placement. Plan: # fevers/elevated WBC: CXR clear. Plan: # fevers/elevated WBC: CXR clear. Plan: # Fevers/elevated WBC: CXR clear. #ARF--pre-renal etiology, possibly with ATN component. # ARF--pre-renal etiology, possibly with ATN component. # ARF--pre-renal etiology, possibly with ATN component. # ARF--pre-renal etiology, possibly with ATN component. Trop mildly elevated in setting of renal failure. Trop mildly elevated in setting of renal failure. Trop mildly elevated in setting of renal failure. Trop mildly elevated in setting of renal failure. | 45 | [
{
"category": "Physician ",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652450,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Discontinued ampicillin and vancomycin\n - Discontinued IVF\n - Patient's insulin drip was stopped and glarine + HISS was started\n - Attempted consult; however, they were not reachable\n - Sodium check at 1700 was 150 (was 162 24 hours prior)\n - Sodium check at 2300 was 149\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Ceftriaxone - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 98 (81 - 98) bpm\n BP: 164/79(99) {123/56(76) - 164/103(143)} mmHg\n RR: 19 (16 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,674 mL\n 695 mL\n PO:\n TF:\n 810 mL\n 69 mL\n IVF:\n 3,254 mL\n 125 mL\n Blood products:\n Total out:\n 1,905 mL\n 360 mL\n Urine:\n 1,905 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,769 mL\n 335 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, mask\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 71 K/uL\n 10.9 g/dL\n 203 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 116 mEq/L\n 148 mEq/L\n 33.0 %\n 7.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n 05:27 PM\n 10:00 PM\n 11:29 PM\n 05:08 AM\n WBC\n 16.0\n 12.7\n 7.4\n Hct\n 46.4\n 35.1\n 33.0\n Plt\n 151\n 94\n 71\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n \n 257\n 218\n 203\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:8.5 mg/dL, Mg++:2.1\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assesment: 73M with h/o R sided strokes, seizure disorder, dementia,\n now with new onset diabetes and hyperglycemia/HHS, fevers, elevated\n WBC, and witnessed seizure, and hypernatremia.\n .\n Plan:\n # Fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raised suspicion for CNS infection,\n although no signs of meningismus on exam. LP not done as family\n refused. Initially was on meningitis dosing of abx (vanc 1gm q24\n (renally adjusted dose), ampicillin 2gm Q6h to cover Listeria, and\n acyclovir 10mg/kg q12h) which has since been cut back to ceftriaxone\n only as low concern for meningitis, afebrile WBC down to 7.4. C. diff\n negative x1, urine cx negative\n - bld cultures pending\n - continue CTX for 2 weeks\n - can d/c droplet precautions as has been on treatment for 48 hours\n # Hyperglycemia: On admission markedly elevated glucose in a patient\n with no known history of diabetes and active infection as evidenced by\n fever, WBC. Anion gap 18 (not correcting for glc) with bicarb 20, but\n no ketones in urine, so more c/w HHS than with DKA. Glucose this\n 203. Off insulin gtt, started on sliding scale and 5 of lantus\n - qid fingersticks\n - add D5 to fluids now that sugars less than 250\n - check A1c\n # Hypernatremia: On admission Na 158 on chem7, but after correcting for\n Glc 774, Na is 169. Has received 3L NS (hypotonic relative to pt). Na\n trending down slowly to 148 this morning with correction of half of\n goal in first 12 hours.\n - lytes check\n # Acute renal failure: On admission elevated at 2.1, unknown baseline.\n Now resolved at 0.7, was likely prerenal.\n -trend\n # HTN: Was normotensive on admission and antihypertensives were held,\n now hypertensive to 160\n - restart anti-hypertensive medication today\n start one at time\n .\n # EKG changes: On admission has nonspecific distribution of ST\n depressions that was more consistent with demand than plaque rupture\n physiology. CK\ns were elevated, likely to renal failure, trops were\n flat. CK nadir at 6700, now trending down to 5800.\n - continue to trend CK\ns, expect continued decrease as ARF has resolved\n # Seizure Disorder: Has history of seizures and had seizure on day of\n admission in setting of fever and dilantin level of 3.8; not clear when\n last seizure was. LP not done as above as above. Reloaded with 500mg\n dilantin IV and increase maintenance dose to 50mg from 25mg .\n Last dilantin level was supratherapeutic at 28 yesterday am, this\n morning\ns level is pending.\n # FEN: has PEG, replete lytes prn\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 10:54 PM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: none\n VAP:\n Comments:\n Communication: notes list as daughter\n and HCP: . Spoke with her, who provided some details of\n history and said that although he would not want CPR/shocks or\n intubation, everything else should be done.\n Code status: DNR / DNI\n Disposition: call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652035,
"text": "Chief Complaint: 73 yo M with CVA, HTN, PEG who presents with\n hypernatremia, hyperglycemia/HHS, fevers with seizures, and acute renal\n failure.\n 24 Hour Events:\n -K remained low at 2.9, repleted with K through PEG, will likely need K\n added to IVFs\n -Na, Cre improved with IVFs\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n Tylenol\n Insulin gtt\n Colace\n Heparin\n Phenytoin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 103 (101 - 116) bpm\n BP: 121/65(80) {100/61(71) - 138/76(90)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,545 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,645 mL\n Blood products:\n Total out:\n 0 mL\n 525 mL\n Urine:\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,020 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 2.9 mEq/L\n 44 mg/dL\n 136 mEq/L\n 167 mEq/L\n 46.4 %\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments: Not indicated\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: in ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652036,
"text": "Chief Complaint: 73 yo M with CVA, HTN, PEG who presents with\n hypernatremia, hyperglycemia/HHS, fevers with seizures, and acute renal\n failure.\n 24 Hour Events:\n -K remained low at 2.9, repleted with K through PEG, will likely need K\n added to IVFs\n -Na, Cre improved with IVFs\n - Insulin gtt decreased to 10 U/hr\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n Tylenol\n Insulin gtt\n Colace\n Heparin\n Phenytoin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 103 (101 - 116) bpm\n BP: 121/65(80) {100/61(71) - 138/76(90)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,545 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,645 mL\n Blood products:\n Total out:\n 0 mL\n 525 mL\n Urine:\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,020 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 2.9 mEq/L\n 44 mg/dL\n 136 mEq/L\n 167 mEq/L\n 46.4 %\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n .\n # hyperglycemia: markedly elevated glucose in a patient with no known\n history of diabetes and active infection as evidenced by fever, WBC.\n Anion gap 18 (not correcting for glc) with bicarb 20, but no ketones in\n urine, so more c/w HHS than with DKA.\n - check plasma acetone\n - insulin gtt\n - Q1h fingersticks\n - add D5 to fluids once blood sugar less than 250\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Has received 3L NS (hypotonic relative to pt), will recheck\n labs and likely change to 1/2NS for IVF for both free water repletion\n and volume expansion.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reload with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n .\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments: Not indicated\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: in ICU\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1054579,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: =PICC line placement=55 cm Picc placed in left brachial vein\n Admitting Diagnosis: EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n =PICC line placement=55 cm Picc placed in left brachial vein, need Picc tip\n placement. Pt pulled a few inches out.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement, evaluate.\n\n Portable supine AP view of the chest performed and compared to . Again seen is a left-sided PICC with tip has been pulled back and is at\n the junction of the right and left brachiocephalic vein. Lung volumes are\n decreased but without pulmonary edema or focal opacity. There appears to be a\n small left effusion. The mediastinum and pericardial silhouettes are\n unchanged.\n\n IMPRESSION: Left PICC line with tip at the junction of the left\n brachiocephalic vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1054044,
"text": " 10:00 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 55 cm Picc placed in left brachial vein, need Picc tip place\n Admitting Diagnosis: EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 55 cm Picc placed in left brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post left brachial PICC line placed.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: A new left PICC terminates in the lower SVC. Low\n inspiratory volumes and motion limit lung evaluation, although the pulmonary\n vessels are prominent and there is likely an element of interstitial edema.\n Heart size is normal. There are no pleural effusions or pneumothorax.\n Dextroconvex scoliosis is stable.\n\n IMPRESSION:\n\n 1. Left PICC terminates in the lower SVC.\n\n 2. Probable interstitial edema, although exam is limited by motion and low\n lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1054219,
"text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new infiltrate?\n Admitting Diagnosis: EDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fever, leukocytosis. Unsure of source but desaturations\n this am to 70\n REASON FOR THIS EXAMINATION:\n ? new infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever, leukocytosis.\n\n CHEST\n\n Low lung volumes. The tip of the PICC line remains unchanged. No failure or\n infiltrates are seen.\n\n IMPRESSION: No pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053915,
"text": " 7:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for effusion / consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with altered mental status, elevated blood sugar\n REASON FOR THIS EXAMINATION:\n please eval for effusion / consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status with elevated blood sugar.\n\n COMPARISON: None.\n\n UPRIGHT AP VIEW OF THE CHEST: The heart size is normal. The aorta is mildly\n unfolded. Pulmonary vascularity is normal. Hilar contours are within normal\n limits. The lungs demonstrate low inspiratory volumes, but otherwise are\n clear. No pleural effusions or pneumothorax. Thoracic scoliosis convex to\n the right is again demonstrated.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1053916,
"text": " 7:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with altered mental status, elevated blood sugar, seizure, and\n sluggish left pupil\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg TUE 9:51 PM\n no hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with altered mental status, elevated blood\n sugar, seizure. Evaluate for bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the brain.\n\n FINDINGS: There is no hemorrhage, hydrocephalus, shift of normally midline\n structures, or evidence of acute major vascular territorial infarct. The\n -white matter differentiation is preserved. Hypodensities in the\n periventricular and subcortical white matter reflect chronic microvascular\n ischemic change. Right frontal and left parieto-occipital lobe\n encephalomalacia is compatible with old infarcts. Tiny hypodensities in the\n right subinsular region is consistent with lacunes. The ventricles and sulci\n are prominent, compatible with age- related involutional change. There has\n been a right frontal craniotomy. The visualized paranasal sinuses and mastoid\n air cells are normally aerated. The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No intracranial hemorrhage.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-01-19 00:00:00.000",
"description": "Report",
"row_id": 184806,
"text": "Sinus tachycardia. Left atrial enlargement. Left ventricular hypertrophy.\nST segment depression in leads II, III, aVF and V3-V6 which may represent\ninferolateral ischemia. No previous tracing available for comparison.\nFollowup and clinical correlation are suggested.\n\n"
},
{
"category": "Case Management ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 652243,
"text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance: MASSHEALTH/SECONDARY TO MEDICARE\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: Pt. is a resident at \n DME / Home O[2]:\n Functional Status / Home / Family Assessment:\n Pt. is a resident at . He is followed by Urban Med. He is\n dependent for all ADL's. He has contractures due to a cva, is withdrawn\n and confused . He has g-tube for tube feeds.\n Primary Contact(s): (dtr) (\n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended:\n Current plan: Rehab\n Return to . Pt. has a 10 day bed hold. Case Management\n will follow for DC needs\n Patient (s) to Discharge:\n Medically unstable\n Patient discussed with multidisciplinary team: Yes\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652258,
"text": "Chief Complaint: Hypernatremia, seizure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:24 AM\n Dilantin initiated.\n History obtained from Medical records\n Patient unable to provide history: Non-communicative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 01:28 AM\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Dextrose 50% - 11:22 PM\n Dilantin - 03:03 AM\n Heparin Sodium (Prophylaxis) - 03:54 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.8\nC (98.2\n HR: 95 (79 - 100) bpm\n BP: 123/60(76) {104/59(72) - 167/92(102)} mmHg\n RR: 26 (14 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 10,250 mL\n 3,750 mL\n PO:\n TF:\n 120 mL\n 265 mL\n IVF:\n 6,350 mL\n 2,706 mL\n Blood products:\n Total out:\n 1,300 mL\n 745 mL\n Urine:\n 900 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,950 mL\n 3,005 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal, Dense left hemiplegia\n Labs / Radiology\n 11.0 g/dL\n 94 K/uL\n 173 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 127 mEq/L\n 158 mEq/L\n 35.1 %\n 12.7 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n WBC\n 16.0\n 12.7\n Hct\n 46.4\n 35.1\n Plt\n 151\n 94\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n 213\n 173\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:7.5 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n FEVERS & LEUKOCYTOSIS -- no obvious source on initial presentation.\n Concern for possible meningitis or encephalitis, although no meningeal\n signs on presentation, and altered mental status may be attributed to\n hypernatremia.\n Hypernatremia -- significant free water deficit remains. Likely a\n subacute process in setting of HHS. Monitor Na q6h. Free H2O via PEG.\n Hyperglycemia -- Most c/w HHS, with significant volume depletion on\n admission. No gap acidosis. Glucose improved. Continue current\n regimen. Insulin requirement may change when Free H2O is corrected,\n and D5W discontinued.\n ARF--pre-renal etiology, possibly with ATN component. Cr improving with\n hydration but still with poor urine outpt.\n SEIZURE IDSORDER -- witnessed seizuire by EMS. Now controlled. Follow\n Dilantin level. Consider repeat EEG.\n CPK ELEVATION -- suspect related to seizures. Doubt rhabdomyalasis.\n Monitor CPK.\n ACUTE RENAL FAILURE -- improving with iv hydration. Monitor UO, BUN,\n creatinine.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652262,
"text": "Chief Complaint: Hypernatremia\n 24 Hour Events:\n PICC LINE - START 11:24 AM\n - Urine and blood cultures pending\n - Family refused LP\n - C diff ordered\n - CXR with ? interstitial edema\n - 6p Na 162 from 169 at 1a- correcting w/ 250 cc Q 4 plus\n - D5 1/2 NS plus 40 K at 200cc/hr for the night\n - Phenytoin level 7.9 ( therapeutic at 6p)\n - CK continueds to trend up to 6733 in evening. Trop flat\n -Fingersticks trended down to nadir 47 then fluids back to D5 1/2 NS\n from 1/2 NS at midnight\n -PICC successfully placed\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:20 AM\n Ceftriaxone - 01:28 AM\n Ampicillin - 03:54 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Dextrose 50% - 11:22 PM\n Dilantin - 03:03 AM\n Heparin Sodium (Prophylaxis) - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.5\n HR: 88 (79 - 108) bpm\n BP: 123/92(100) {104/59(72) - 167/92(117)} mmHg\n RR: 22 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 10,250 mL\n 2,329 mL\n PO:\n TF:\n 120 mL\n 142 mL\n IVF:\n 6,350 mL\n 1,688 mL\n Blood products:\n Total out:\n 1,300 mL\n 375 mL\n Urine:\n 900 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,950 mL\n 1,954 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: surgical pupils\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, No(t) Sedated, Tone: Not\n assessed\n Labs / Radiology\n 94 K/uL\n 11.0 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 127 mEq/L\n 158 mEq/L\n 35.1 %\n 12.7 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n WBC\n 16.0\n 12.7\n Hct\n 46.4\n 35.1\n Plt\n 151\n 94\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n 213\n 173\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:7.5 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam. No signs of RUQ\n pathology/cholecystitis on LFTs.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n - check C. diff\n - repeat CXR.\n .\n # hyperglycemia: Likely HHS (no ketones in urine, so unlikely DKA).\n Stimulant likely infectious process. Total Free water deficit 8.7 L.\n Would like to decrease Na by 12 mEq over 24 hours (0.5 mEq/hr), so\n amount of free water needed to correct this is 3.2 L.\n - continue insulin gtt ( to 5 U/hr)\n - Q1h fingersticks\n - change fluids to 40 meq K D5\n NS @ 250 ccs/hr\n - free H2O boluses at 150 q4H through PEG\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Changed IVFs from NS in ED to 1/2NS for IVF for both free water\n repletion and volume expansion. Likely chronic process.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n Check renal U/S if does not resolve.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reloaded with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n . Re-Check dilantin level in PM prior to PM dose.\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652264,
"text": "Chief Complaint: Hypernatremia\n 24 Hour Events:\n PICC LINE - START 11:24 AM\n - Urine and blood cultures pending\n - Family refused LP\n - C diff ordered\n - CXR with ? interstitial edema\n - 6p Na 162 from 169 at 1a- correcting w/ 250 cc Q 4 plus\n - D5 1/2 NS plus 40 K at 200cc/hr for the night\n - Phenytoin level 7.9 ( therapeutic at 6p)\n - CK continueds to trend up to 6733 in evening. Trop flat\n -Fingersticks trended down to nadir 47 then fluids back to D5 1/2 NS\n from 1/2 NS at midnight\n -PICC successfully placed\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:20 AM\n Ceftriaxone - 01:28 AM\n Ampicillin - 03:54 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Dextrose 50% - 11:22 PM\n Dilantin - 03:03 AM\n Heparin Sodium (Prophylaxis) - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.5\n HR: 88 (79 - 108) bpm\n BP: 123/92(100) {104/59(72) - 167/92(117)} mmHg\n RR: 22 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 10,250 mL\n 2,329 mL\n PO:\n TF:\n 120 mL\n 142 mL\n IVF:\n 6,350 mL\n 1,688 mL\n Blood products:\n Total out:\n 1,300 mL\n 375 mL\n Urine:\n 900 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,950 mL\n 1,954 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: surgical pupils\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, No(t) Sedated, Tone: Not\n assessed\n Labs / Radiology\n 94 K/uL\n 11.0 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 127 mEq/L\n 158 mEq/L\n 35.1 %\n 12.7 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n WBC\n 16.0\n 12.7\n Hct\n 46.4\n 35.1\n Plt\n 151\n 94\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n 213\n 173\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:7.5 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam. No signs of RUQ\n pathology/cholecystitis on LFTs. WBC trending down today to 12.7 from\n 16 and pt now afebrile but still no definitive source of infxn\n - f/u bld, urine cultures\n - cont to empirically treat for meningitis with CTX 2gm daily for 14\n days\n - check C. diff\n .\n # HHS: Likely HHS (no ketones in urine, so unlikely DKA). Stimulant\n likely infectious process. Hyperglycemia now resolved. Na coming down\n appropriately (goal is decr 12 mEQ/ 24 hrs)\n - d/c insulin gtt, IVF\n -Cont TF and 250cc free water flushes Q 6hrs\n - Lantus 5 u plus HISS\n - C/S\n -Q 6 hr lytes.\n -\n .\n # acute renal failure: Cr from 1.8 on arrival to ICU to 0.7 now .\n Likely was prerenal.\n -Renally dose meds, avoid nephrotoxins.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # seizure do: has history of seizures and on admission had seizure in\n setting of fever and dilantin level of 3.8; not clear when last seizure\n was. Still unsure if meningitis was present but without LP cannot know\n this. Reloaded with 500mg dilantin IV x2 and am level today after\n second dose supratherapeutic at 28.\n -recheck dilantin level in am and start daily dose\n -chk EEG\n .\n # constipation- pt without BM since admission and evidence of\n stool-filled colon on CXR. Ordered lactulose today for constipation\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI- daughters refuses invasive tx incl LP\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Generic Note",
"row_id": 651976,
"text": "TITLE:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n hanging now. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Generic Note",
"row_id": 651977,
"text": "TITLE:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n given in ed. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 651964,
"text": "Chief Complaint: lethargy; hyperglycemia, hypernatremia, and fevers at\n nursing home\n HPI:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n hanging now. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive, dementia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 15 units/hour\n Other ICU medications:\n Other medications:\n lisinopril 40mg daily\n metoprolol 100mg \n hydralazine 50mg qid\n milk of magnesia\n dilantin 25mg \n colace liquid 100mg \n Past medical history:\n Family history:\n Social History:\n strokes from ruptured intracerebral aneurysms in and or \n with residual left sided deficits (has not been able to walk since\n stroke in ') and aphasia, PEG for dysphagia\n h/o seizure do\n dementia\n HTN\n h/o HepC hepatitis, apparently not active\n h/o neurosyphilis, treated in \n hypothyroidism\n noncontributory\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: nursing home resident for ~10 years\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: Tube feeds\n Neurologic: Seizure\n Flowsheet Data as of 02:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 113 (113 - 116) bpm\n BP: 113/66(74) {113/64(74) - 122/66(77)} mmHg\n RR: 27 (23 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 3,182 mL\n PO:\n TF:\n IVF:\n 16 mL\n 282 mL\n Blood products:\n Total out:\n 0 mL\n 475 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 2,707 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, elderly, chronically ill\n Eyes / Conjunctiva: Pupils dilated, rightward gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, neck supple,\n no signs of meningismus\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, G tube site clean, without erythema\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Increased\n Labs / Radiology\n 290 mg/dL\n 1.8 mg/dL\n 45 mg/dL\n 21 mEq/L\n 135 mEq/L\n 2.4 mEq/L\n 169 mEq/L\n [image002.jpg]\n \n 2:33 A12/31/ 01:00 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.8\n Glucose\n 290\n Other labs: CK / CKMB / Troponin-T:1754//, ALT / AST:49/53, Alk Phos /\n T Bili:114/0.7, Lactic Acid:5.3 mmol/L, Ca++:9.4 mg/dL, Mg++:2.5 mg/dL,\n PO4:1.6 mg/dL\n Imaging: UPRIGHT AP VIEW OF THE CHEST: The heart size is normal. The\n aorta is mildly unfolded. Pulmonary vascularity is normal. Hilar\n contours are within normal limits. The lungs demonstrate low\n inspiratory volumes, but otherwise are clear. No pleural effusions or\n pneumothorax. Thoracic scoliosis convex to the right is again\n demonstrated.\n IMPRESSION: No acute cardiopulmonary abnormality.\n CT Head: no ICH.\n ECG: ST 137, nml axis. 1-2mm ST depresions in II, III, aVF, V3-V5.\n Assessment and Plan\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n .\n # hyperglycemia: markedly elevated glucose in a patient with no known\n history of diabetes and active infection as evidenced by fever, WBC.\n Anion gap 18 (not correcting for glc) with bicarb 20, but no ketones in\n urine, so more c/w HHS than with DKA.\n - check plasma acetone\n - insulin gtt\n - Q1h fingersticks\n - add D5 to fluids once blood sugar less than 250\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Has received 3L NS (hypotonic relative to pt), will recheck\n labs and likely change to 1/2NS for IVF for both free water repletion\n and volume expansion.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reload with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n .\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n .\n # Comm: notes list as daughter and HCP:\n . Spoke with her, who provided some details of history and\n said that although he would not want CPR/shocks or intubation,\n everything else should be done.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: ICU\n consent obtained over the phone\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Generic Note",
"row_id": 651992,
"text": "TITLE:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n given in ed. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n Critically high Blood sugars with negative urine Ketones.\n Assessment:\n FS 429 when admitted to MIcu, . Lactate reduced to 5 from 9.0\n Action:\n Continued on IV Regular Insulin 15 units/hr & 0.4 NS @ 150 mls/hr.\n Response:\n FS reduced to 239, started on D51/2 NS @ 150 mls/hr then increased to\n 250 mls/hr as urine output remained low. AT 4am FS 181 , insulin drip\n @ 11 units/hr\n Plan:\n Continue FS monitoring.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia) ? Meningitis.\n Assessment:\n Pt afebrile on admission to MICU.\n Action:\n Continued monitoring , had received motrin & Tylenol in ED. Cultures\n were sent in ED. Started on IV Anbx- ceftriaxone 1 dose given, IV Vanco\n 1 gram q 24 hrs, iv ampicillin q 6hrs,.\n Response:\n Cultures pending.\n Plan:\n ? LP. Monitor temp curve, Follow up on cultures.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n H?O stoke with left sided deficits. Unresponsive at baseline as per\n Nursing home. Patient opens eye spontaneously, does not follow command,\n does not track. Non purposeful movements noted to his right hand\n Action:\n Received iv dilantin 500 mgs one time dose & has orders for po\n phenytoin BD.\n Response:\n No seizures noted in MICU..\n Plan:\n Continue phenytoin, monitor for seizures.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Unknown baseline. Creatinine elevated at 2.1? prerenal. Urine output\n has been inadequate.\n Action:\n Meds are renally dosed. IV Fluids increased to 250 mls/hr.\n Response:\n Urine output remains low.\n Plan:\n Continue monitoring u/o, continue fluids, Monitor lytes.\n Electrolyte & fluid disorder, other\n Assessment:\n K+ 2.4 in MICU, Na 168\n Action:\n K-Dur 40 meq given via Peg tube.\n Response:\n AM labs\n Plan:\n Continue monitoring labs.\n Skin Impairment\n Assessment:\n Patient came in from Nursing Home via ED with pressure ulcer with had\n a dressing on it.\n Action:\n Site examined, cleaned with NS, alevyn dressing applied. Has foam\n multipodus boots on bilaterally.\n Response:\n Unchanged.\n Plan:\n Continue skin care & frequent positioning.\n Daughter is the HCP.\n is a DNR/DNI\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652174,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Remains on Insulin gtt at 10 units hour, IVF changed,\n NS with 40\n meq KCL @ 200 cc/hr, insulin gtt decreased to 4 units hour, FS 120-150\n range. FS dropped to 42\n one amp d50 given x 1, fluid changed to\n D5\n NS with 40 meq KCL @ 200 cc/hr, FS range 150\n remains on Insulin\n gtt at 3 units/hr K 3.1 Na 162 urine output 30-50 cc/hr\n Action:\n Current IVF d51/2 NS with 40 meq KCL @ 200 cc/hr x 2 liters. 40\n meq kcl per peg tube given x 1.\n Response:\n Urine output okay, na coming down slowly\n Plan:\n Check electrolytes in am, replete K as needed. Adjust IVF\n accordingly.\n Seizure, without status epilepticus\n Assessment:\n Pt is nonverbal, but when name called opens his eyes, with pm care,\n pt moves head away, stiffens up, no sz acitivity noted. Dilantin\n level 7.9\n Action:\n 500 mg IV Dilantin given x 1\n Response:\n No seizure activity noted,\n Plan:\n Continue to monitor\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile, wBC 16.0\n Action:\n Pt remains on Ampicillin, Vanco, Ceftriaxone\n Response:\n Afebrile\n Plan:\n Check cultures, follow WBC, temp, continue antibx.\n Alteration in Nutrition\n Assessment:\n Tube feeds FS Nutren Pulmonary FS @ 30 cc/hr, (goal 50 cc/hr) flush\n with 250 cc\ns water q 4 hrs. belly soft, no stool\n Action:\n Tubed feeds continue via peg\n Response:\n Tolerating tube feeds, no stool\n Plan:\n Goal is 50 cc/hr, check for stool\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652229,
"text": "Chief Complaint: Hypernatremia\n 24 Hour Events:\n PICC LINE - START 11:24 AM\n - Urine and blood cultures pending\n - Family refused LP\n - C diff ordered\n - CXR with ? interstitial edema\n - 6p Na 162 from 169 at 1a- correcting w/ 250 cc Q 4 plus\n - D5 1/2 NS plus 40 K at 200cc/hr for the night\n - Phenytoin level 7.9 ( therapeutic at 6p)\n - CK continueds to trend up to 6733 in evening. Trop flat\n -Fingersticks trended down to nadir 47 then fluids back to D5 1/2 NS\n from 1/2 NS at midnight\n -PICC successfully placed\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:20 AM\n Ceftriaxone - 01:28 AM\n Ampicillin - 03:54 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Dextrose 50% - 11:22 PM\n Dilantin - 03:03 AM\n Heparin Sodium (Prophylaxis) - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.5\n HR: 88 (79 - 108) bpm\n BP: 123/92(100) {104/59(72) - 167/92(117)} mmHg\n RR: 22 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 10,250 mL\n 2,329 mL\n PO:\n TF:\n 120 mL\n 142 mL\n IVF:\n 6,350 mL\n 1,688 mL\n Blood products:\n Total out:\n 1,300 mL\n 375 mL\n Urine:\n 900 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,950 mL\n 1,954 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: surgical pupils\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, No(t) Sedated, Tone: Not\n assessed\n Labs / Radiology\n 94 K/uL\n 11.0 g/dL\n 173 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 127 mEq/L\n 158 mEq/L\n 35.1 %\n 12.7 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n WBC\n 16.0\n 12.7\n Hct\n 46.4\n 35.1\n Plt\n 151\n 94\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n 213\n 173\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:7.5 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam. No signs of RUQ\n pathology/cholecystitis on LFTs.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n - check C. diff\n - repeat CXR.\n .\n # hyperglycemia: Likely HHS (no ketones in urine, so unlikely DKA).\n Stimulant likely infectious process. Total Free water deficit 8.7 L.\n Would like to decrease Na by 12 mEq over 24 hours (0.5 mEq/hr), so\n amount of free water needed to correct this is 3.2 L.\n - continue insulin gtt ( to 5 U/hr)\n - Q1h fingersticks\n - change fluids to 40 meq K D5\n NS @ 250 ccs/hr\n - free H2O boluses at 150 q4H through PEG\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Changed IVFs from NS in ED to 1/2NS for IVF for both free water\n repletion and volume expansion. Likely chronic process.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n Check renal U/S if does not resolve.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reloaded with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n . Re-Check dilantin level in PM prior to PM dose.\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652304,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Alteration in Nutrition\n Assessment:\n Pt is tol TF and on hi s way to goal rate, no stool as yet\n Action:\n TF increased, lactolose added\n Response:\n No PEG residuals noted, no stool as yet + flatus\n Plan:\n Goal rate at 50cc/hr at 8pm tonight, lactolose q8 till stooling\n Electrolyte & fluid disorder, other\n Assessment:\n Pt\ns lytes correcting nicely\n Action:\n Backing off of IVF, cont t follow labs, water boluses\n Response:\n NA down to 153, u/o now up to70-80cc/hr, CR NL\n Plan:\n Check lytes q6hrs\n Seizure, without status epilepticus\n Assessment:\n Pt more alert attempting to say some words but it is very garbled\n Action:\n Dilantin level supratherapeutic , to get and EEG today\n Response:\n More awake\n Plan:\n Hold pm dilantin and recheck dilantin level in am\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile\n Action:\n IVAB trimmed to just ceftriaxone for meningitis coverage for 2 week\n course\n Response:\n Decreasing WBC ct , neg cx\n Plan:\n Cont IV AB for 2 weeks , check about Precautions tomorrow after 48\n hours of treatment\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt doing well , tol TF and NA improved so will transition to SQ insulin\n Action:\n Taken off IV insulin at 12 and started on Lantus and humalog insulin,\n OFF IVF also\n Response:\n Pnd\n Plan:\n Will follow rsp to SQ insulin to keep BS 150-200\n Wheezing\n Assessment:\n Pt with some upper airway forced wheezing this am, RR up to 28, sats\n 90, he had an increased cough\n Action:\n Albuterol neb given , CXR, oral sx , Pt put up to 4l NP O2\n Response:\n Much less coughing , sats back to 98%, CXR still neg for infiltrate\n Plan:\n Follow O2 sats , nebs as needed, lung exam\n Social: daughter called and updated by Nsg\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652125,
"text": "Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652131,
"text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt has been rsp slowly to electrolytes repletion\n Action:\n IVF have been adjusted to replaced lytes slowly, water boluses have\n been added\n Response:\n NA++ and K+ are improving , u/o is up to 50cc/hr , CR down\n Plan:\n Will cont to follow labs q6hrs and replace slowly\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Blood sugars still very labile despite aggressive rcorrection\n Action:\n Cont on IV Reg Insulin titrated to keep BS 150-200\n Response:\n Lablie\n Plan:\n Cont IV Insulin until lytes are corrected\n Tachycardia, Other\n Assessment:\n HR has dropped nicely as IVF and hydration have improved\n Action:\n IVF given Cardiac meds still being held,\n Response:\n HR in the 80-90\ns, TRopins are neg BP 120-150\ns/60-70\n Plan:\n Finish with r/o MI Follow for HTN\n Seizure, without status epilepticus\n Assessment:\n Pt is nonverbal but when name called her opens eyes, when care\n attempted, he clamps mouth shut or moves head away, no SZ activity\n noted . Per daughter, he looked same to her at 12n\n Action:\n Hydrations as noted, lytes corrected and feedings begun, Dilantin load\n given and level pnd from 6pm\n Response:\n NO SZ activity noted, pt brighter, still awaiting daughters decision on\n LP from family\n Plan:\n Will cont to follow and noted Dilantin level\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with low grade fever, cx pn\n Action:\n PICC placed for vanco and IV antibiotics\n Response:\n Only low grade fever\n Plan:\n Await cx, cont IVAB\n Alteration in Nutrition\n Assessment:\n Pt with no PEG tube residuals,+ Bowel sounds, restarted on TF\n Action:\n Started on Nutren Pulmonary\n Response:\n +flatus, no stool\n Plan:\n Adv TF to goal of 50cc ate rate of 10cc q8hrs\n Social: pt\ns family updated by house staff and NSg. They report he is\n not far from his baseline now. They are concerned about doing to much\n if it is not needed; they are to get back to HO on the LPdecision\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652132,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt has been rsp slowly to electrolytes repletion\n Action:\n IVF have been adjusted to replaced lytes slowly, water boluses have\n been added\n Response:\n NA++ and K+ are improving , u/o is up to 50cc/hr , CR down\n Plan:\n Will cont to follow labs q6hrs and replace slowly\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Blood sugars still very labile despite aggressive rcorrection\n Action:\n Cont on IV Reg Insulin titrated to keep BS 150-200\n Response:\n Labile\n Plan:\n Cont IV Insulin until lytes are corrected ,FSq1hr\n Tachycardia, Other\n Assessment:\n HR has dropped nicely as IVF and hydration have improved\n Action:\n IVF given Cardiac meds still being held,\n Response:\n HR in the 80-90\ns, TRopins are neg BP 120-150\ns/60-70\n Plan:\n Finish with r/o MI Follow for HTN\n Seizure, without status epilepticus\n Assessment:\n Pt is nonverbal but when name called her opens eyes, when care\n attempted, he clamps mouth shut or moves head away, no SZ activity\n noted . Per daughter, he looked same to her at 12n\n Action:\n Hydrations as noted, lytes corrected and feedings begun, Dilantin load\n given and level pnd from 6pm\n Response:\n NO SZ activity noted, pt brighter, still awaiting daughters decision on\n LP from family\n Plan:\n Will cont to follow and noted Dilantin level\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with low grade fever, cx pn\n Action:\n PICC placed for vanco and IV antibiotics\n Response:\n Only low grade fever\n Plan:\n Await cx, cont IVAB\n Alteration in Nutrition\n Assessment:\n Pt with no PEG tube residuals,+ Bowel sounds, restarted on TF\n Action:\n Started on Nutren Pulmonary\n Response:\n +flatus, no stool\n Plan:\n Adv TF to goal of 50cc at rate of 10cc q8hrs\n Social: pt\ns family updated by house staff and NSg. They report he is\n not far from his baseline now. They are concerned about doing to much\n if it is not needed; they are to get back to HO on the LP decision\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652358,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652300,
"text": "Alteration in Nutrition\n Assessment:\n Pt is tol TF and on hi s way to goal rate, no stool as yet\n Action:\n TF increased, lactolose added\n Response:\n No PEG residuals noted, no stool as yet + flatus\n Plan:\n Goal rate at 50cc/hr, lactolose q8 till stooling\n Electrolyte & fluid disorder, other\n Assessment:\n Pt\ns lytes correcting nicely\n Action:\n Backing off of IVF, cont t follow labs, water boluses\n Response:\n NA down to 153, u/o now up to70-80cc/hr, CR NL\n Plan:\n Check lytes q6hrs\n Seizure, without status epilepticus\n Assessment:\n Pt more alert attempting to say some words but it is very garbled\n Action:\n Dilantin level supratherapeutic , to get and EEG today\n Response:\n More awake\n Plan:\n Hold pm dilantin and recheck dilantin level in am\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile\n Action:\n IVAB trimmed to just ceftriaxone for meningitis coverage for 2 week\n course\n Response:\n Decreasing WBC ct , neg cx\n Plan:\n Cont IV AB for 2 weeks , check about Precautions\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt doing well , tol TF and NA improved so will transition to SQ insulin\n Action:\n Taken off IV insulin at 12 and started on Lantus and humalog insulin,\n OFF IVF also\n Response:\n Pnd\n Plan:\n Will follow rsp to SQ insulin to keep BS <150\n Wheezing\n Assessment:\n Pt with some upper airway forced wheezing this am, RR up to 28, sats\n 90, he had an increased cough\n Action:\n Albuterol neb given , CXR, oral sx , Pt put up to 4l NP O2\n Response:\n Much less coughing , sats back to 98%, CXR still neg for infiltrate\n Plan:\n Follow O2 sats , nebs as needed, lung exam\n Social: daughter called and updated by Nsg\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652297,
"text": "Alteration in Nutrition\n Assessment:\n Pt is tol TF and on hi s way to goal rate, no stool as yet\n Action:\n TF increased, lactolose added\n Response:\n No PEG residuals noted, no stool as yet + flatus\n Plan:\n Goal rate at 50cc/hr, lactolose q8 till stooling\n Electrolyte & fluid disorder, other\n Assessment:\n Pt\ns lytes correcting nicely\n Action:\n Backing off of IVF, cont t follow labs, water boluses\n Response:\n NA down to 153, u/o now up to70-80cc/hr, CR NL\n Plan:\n Check lytes q6hrs\n Seizure, without status epilepticus\n Assessment:\n Pt more alert attempting to say some words but it is very garbled\n Action:\n Dilantin level supratherapeutic , to get and EEG today\n Response:\n More awake\n Plan:\n Hold pm dilantin and recheck dilantin level in am\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile\n Action:\n IVAB trimmed to just ceftriaxone for meningitis coverage for 2 week\n course\n Response:\n Decreading WBC ct , neg cx\n Plan:\n Cont IV AB for 2 weeks , check about Precautions\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt doing well , tol TF and NA improved so will transition to SQ insulin\n Action:\n Taken off IV insulin at 12 and started on Lantus and humalog insulin,\n OFF IVF also\n Response:\n Pnd\n Plan:\n Will follow rsp to SQ insulin to keep BS <150\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652299,
"text": "Chief Complaint: Hypernatremia, seizure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:24 AM\n Dilantin initiated.\n History obtained from Medical records\n Patient unable to provide history: Non-communicative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 01:28 AM\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Dextrose 50% - 11:22 PM\n Dilantin - 03:03 AM\n Heparin Sodium (Prophylaxis) - 03:54 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.8\nC (98.2\n HR: 95 (79 - 100) bpm\n BP: 123/60(76) {104/59(72) - 167/92(102)} mmHg\n RR: 26 (14 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 10,250 mL\n 3,750 mL\n PO:\n TF:\n 120 mL\n 265 mL\n IVF:\n 6,350 mL\n 2,706 mL\n Blood products:\n Total out:\n 1,300 mL\n 745 mL\n Urine:\n 900 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,950 mL\n 3,005 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal, Dense left hemiplegia\n Labs / Radiology\n 11.0 g/dL\n 94 K/uL\n 173 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 127 mEq/L\n 158 mEq/L\n 35.1 %\n 12.7 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n WBC\n 16.0\n 12.7\n Hct\n 46.4\n 35.1\n Plt\n 151\n 94\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n 213\n 173\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:7.5 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n SEPSIS -- fever and leukocytosis suggest infection, but no obvious\n source on initial presentation. Concern for possible meningitis or\n encephalitis, although no meningeal signs on presentation, and altered\n mental status may be attributed to hypernatremia.\n Hypernatremia -- significant free water deficit remains. Likely a\n subacute process in setting of HHS. Monitor Na q6h. Free H2O via PEG.\n Hyperglycemia -- Most c/w HHS, with significant volume depletion on\n admission. No gap acidosis. Glucose improved. Continue current\n regimen. Insulin requirement may change when Free H2O is corrected,\n and D5W discontinued.\n ARF--pre-renal etiology, possibly with ATN component. Creatinine\n improving with hydration but still with poor urine output.\n SEIZURE IDSORDER -- witnessed seizuire by EMS. Now controlled. Follow\n Dilantin level. Consider repeat EEG.\n CPK ELEVATION -- suspect related to seizures. Doubt rhabdomyalasis.\n Monitor CPK to observe clearing.\n ACUTE RENAL FAILURE -- improving with iv hydration. Monitor UO, BUN,\n creatinine.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652401,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt off insulin gtt, FS range 250- tube feeds FS Nutren Pulmonary\n increased to goal ~ 50 cc/hr\n Action:\n Pt on sliding scale Humalog receiving 6 units Humalog x 2. also 5\n units Glargine in the am.\n Response:\n Need to increase sliding scale\n Plan:\n Continue to monitor FS qid, increase sliding scale as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile WBC 12.7 VSS bp 145/90\n Action:\n Pt just on Ceftriaxone for meningitis coverage for 2 wks.\n Response:\n Decreasing WBC\n Plan:\n Continue IV antibx for 2 wks, check regarding droplet precautions in\n am.\n SKIN: pt with long fingernails, scratched his scrotom\n skin\n bleeding. Also pt pulling at foley, and pulling at his\n Peg. Wrists retrained for safety. Restraints ordered\n. Pt\n turned freq.\n GI: passed small stool ob neg. on colace, lactulose\n NEURO: pt probably at baseline. Pt pulls away at you with pm care.\n Need 2 people to turn. Pt more alert tonight, words\n Garbled. Hold dilantin till level checked\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 652504,
"text": "Briefly this is 73 y/o M w/ a PMH significant for CVA's, baseline\n dysphagia/(receptive & expressive aphasia), L hemiplegia, seizure\n disorder, who presented w/ multiple electrolyte abnormalities in\n setting of severe dehydration/HHS with fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt off insulin gtt, FS range 250- tube feeds FS Nutren Pulmonary\n increased to goal ~ 50 cc/hr\n Action:\n Pt on sliding scale Humalog receiving 6 units Humalog x 2. also 5\n units Glargine in the am.\n Response:\n Need to increase sliding scale\n Plan:\n Continue to monitor FS qid, increase sliding scale as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile WBC 12.7 VSS bp 145/90\n Action:\n Pt just on Ceftriaxone for meningitis coverage for 2 wks.\n Response:\n Decreasing WBC\n Plan:\n Continue IV antibx for 2 wks, check regarding droplet precautions in\n am.\n SKIN: pt with long fingernails, scratched his scrotom\n skin\n bleeding. Also pt pulling at foley, and pulling at his\n Peg. Wrists retrained for safety. Restraints ordered\n. Pt\n turned freq.\n GI: passed small stool ob neg. on colace, lactulose\n NEURO: pt probably at baseline. Pt pulls away at you with pm care.\n Need 2 people to turn. Pt more alert tonight, words\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 652505,
"text": "Briefly this is 73 y/o M w/ a PMH significant for dementia, CVA,\n (receptive & expressive aphasia @ baseline), dysphagia, L hemiplegia,\n seizure disorder, who presented from a Long term care facility febrile\n to 101 w/ multiple electrolyte abnormalities in setting of severe\n dehydration (hypernatrimic to 160\ns/ serum glucose 774).\n .\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt off insulin gtt, FS range 250- tube feeds FS Nutren Pulmonary\n increased to goal ~ 50 cc/hr\n Action:\n Pt on sliding scale Humalog receiving 6 units Humalog x 2. also 5\n units Glargine in the am.\n Response:\n Need to increase sliding scale\n Plan:\n Continue to monitor FS qid, increase sliding scale as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile WBC 12.7 VSS bp 145/90\n Action:\n Pt just on Ceftriaxone for meningitis coverage for 2 wks.\n Response:\n Decreasing WBC\n Plan:\n Continue IV antibx for 2 wks, check regarding droplet precautions in\n am.\n SKIN: pt with long fingernails, scratched his scrotom\n skin\n bleeding. Also pt pulling at foley, and pulling at his\n Peg. Wrists retrained for safety. Restraints ordered\n. Pt\n turned freq.\n GI: passed small stool ob neg. on colace, lactulose\n NEURO: pt probably at baseline. Pt pulls away at you with pm care.\n Need 2 people to turn. Pt more alert tonight, words\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652506,
"text": "Chief Complaint: ARF, HHS, hypernatremia, sz\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 73 yo M NH resident with h/o multiple prior CVAs, htn, sz d/o\n presents with fevers, leukocytosis, severe hypernatremia, sz, and\n hyperglycemia (HHS).\n 24 Hour Events:\n STOOL CULTURE - At 06:38 AM\n Family declined LP\n Amp/vanco d/c'd given low clinical suspicion for CNS infection.\n Insulin gtt stopped yesterday--> transitioned to glargine and SSI\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Ceftriaxone - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:33 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 98 (81 - 98) bpm\n BP: 156/70(90) {123/56(76) - 164/103(143)} mmHg\n RR: 16 (16 - 26) insp/min\n SpO2: 98% FM\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,677 mL\n 1,092 mL\n PO:\n TF:\n 813 mL\n 452 mL\n IVF:\n 3,254 mL\n 140 mL\n Blood products:\n Total out:\n 1,905 mL\n 360 mL\n Urine:\n 1,905 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,772 mL\n 733 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Thin, MS , awake,\n nonconversant\n Eyes / Conjunctiva: No(t) PERRL, MMM\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, no jvd\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:good AM,\n CTA without wheeze: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, no rash\n Neurologic: Responds to: Verbal stimuli, Oriented (to): at ,\n Movement: spont,\n Labs / Radiology\n 10.9 g/dL\n 71 K/uL\n 203 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 116 mEq/L\n 148 mEq/L\n 33.0 %\n 7.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n 05:27 PM\n 10:00 PM\n 11:29 PM\n 05:08 AM\n WBC\n 16.0\n 12.7\n 7.4\n Hct\n 46.4\n 35.1\n 33.0\n Plt\n 151\n 94\n 71\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n \n 257\n 218\n 203\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB / Troponin-T:5812\n (decreasing) /10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:8.5 mg/dL, Mg++:2.1\n mg/dL, PO4:2.6 mg/dL\n Imaging: CXR--no new imaging\n Microbiology: mciro--c diff neg, urine cx neg, bl ngtd\n Assessment and Plan\n WHEEZING\n ALTERATION IN NUTRITION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73 yo M NH resident with h/o multiple prior CVAs, htn, sz d/o presents\n with fevers, leukocytosis, severe hypernatremia, sz, and hyperglycemia\n (HHS).\n # Fevers/leukocytosis--no obvious infectious source on initial\n presentation and cx\ns have returned neg. Had no indwelling lines or\n catheters on admission. O2 sats have remained stable throughout course\n with no infiltrate on chest imaging. Given sz initially covered for\n possible CNS infection\nbut have had low clinical suspicion for\n meningitis, family declined LP.\n Has been AF and WBC normalized.\n - Majority of antibx d/c\nd yesterday. As all cxs neg and\n given low suspicion for CNS infection will d/c ctx today.\n - F/u final cx results.\n # Hyperglycemia---Most c/w HHS on presentation, s/p adequate volume\n resus.\n - Continue close electrolyte monitoring, repleting K.\n - Converted from gtt insulin to glargine and ssi. \n c/s. Will increase glargine. As pt receives cycling TFs at NH will\n change to this regimen from continuous\nwill likely need to adjust\n insulin accordingly.\n # Hypernatremia--significant free water deficit on admit. Likely a\n subacute process. Much improved.\n - Give free water via peg\n - Monitor sodium Q 12 hrs.\n # ARF--pre-renal etiology, possibly with ATN component. Cr now\n normalized. U/o adequate\n # sz d/o--witnessed sz by ems. Known sz d/o, Dilantin reloaded and\n dose adjusted since admit.\n - follow levels\n - EEG ordered\n # Elevated CPK--likely elevated in setting of witnessed sz. Trop\n mildly elevated in setting of renal failure.\n - CKs peaked and now trending down.\n # thrombocytopenia\ndeveloped during hospitalization. Likely dilutional\n component. ? med related. Have very low suspicion for HIT.\n - Will moniior.\n # AMS\nappears back to .\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 01:19 AM 50 mL/hour\nwould resume\n cycling TFs as pt receives at NH.\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: sq hep\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition : stable for floor transfer\n Total time spent: 40\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652519,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Discontinued ampicillin and vancomycin\n - Discontinued IVF\n - Patient's insulin drip was stopped and glarine + HISS was started\n - Attempted consult; however, they were not reachable\n - Sodium check at 1700 was 150 (was 162 24 hours prior)\n - Sodium check at 2300 was 149\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Ceftriaxone - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 98 (81 - 98) bpm\n BP: 164/79(99) {123/56(76) - 164/103(143)} mmHg\n RR: 19 (16 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,674 mL\n 695 mL\n PO:\n TF:\n 810 mL\n 69 mL\n IVF:\n 3,254 mL\n 125 mL\n Blood products:\n Total out:\n 1,905 mL\n 360 mL\n Urine:\n 1,905 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,769 mL\n 335 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, O2 mask on face\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: 2+ DP and radial pulses\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+ \n Skin: Warm\n Neurologic: Responds to: Verbal stimuli\n Labs / Radiology\n 71 K/uL\n 10.9 g/dL\n 203 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 116 mEq/L\n 148 mEq/L\n 33.0 %\n 7.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n 05:27 PM\n 10:00 PM\n 11:29 PM\n 05:08 AM\n WBC\n 16.0\n 12.7\n 7.4\n Hct\n 46.4\n 35.1\n 33.0\n Plt\n 151\n 94\n 71\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n \n 257\n 218\n 203\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB /\n Troponin-T:5812/10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:8.5 mg/dL, Mg++:2.1\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assesment: 73M with h/o R sided strokes, seizure disorder, dementia,\n now with new onset diabetes and hyperglycemia/HHS, fevers, elevated\n WBC, and witnessed seizure, and hypernatremia.\n .\n Plan:\n # Fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raised suspicion for CNS infection,\n although no signs of meningismus on exam. LP not done as family\n refused. Initially was on meningitis dosing of abx (vanc 1gm q24\n (renally adjusted dose), ampicillin 2gm Q6h to cover Listeria, and\n acyclovir 10mg/kg q12h) which has since been cut back to ceftriaxone\n only as low concern for meningitis, afebrile WBC down to 7.4. C. diff\n negative x1, urine cx negative\n - bld cultures pending\n - will d/c CTX as no evidence of meningitis clinically and low concern\n initially\n - d/c droplet precautions\n - recheck c. diff\n # Hyperglycemic Hyperosmolar Syndrome: On admission markedly elevated\n glucose in a patient with no known history of diabetes and active\n infection as evidenced by fever, WBC. Anion gap 18 (not correcting for\n glc) with bicarb 20, but no ketones in urine, so more c/w HHS than with\n DKA. Glucose this 203. Off insulin gtt, started on sliding\n scale and 5 of lantus\n - qid fingersticks\n - check A1c\n - c/s placed, appreciate recs\n # Hypernatremia: On admission Na 158 on chem7, but after correcting for\n Glc 774, Na is 169. Has received 3L NS (hypotonic relative to pt). Na\n trending down slowly to 148 this morning with correction of half of\n goal in first 24 hours.\n - lytes check\n - free H2O boluses through feeding tube\n 250cc q6h\n # Acute renal failure: On admission elevated at 2.1, unknown baseline.\n Now resolved at 0.7, was likely prerenal.\n -trend\n -renally dose meds, avoid nephrotoxic agents\n # HTN: Was normotensive on admission and antihypertensives were held,\n now hypertensive to 160\n - restart metprolol at 50mg (on 100mg at home)\n - continue lisinopril 5mg qd (on 40mg at home)\n -titrate up home agents prn\n .\n # EKG changes: On admission has nonspecific distribution of ST\n depressions that was more consistent with demand than plaque rupture\n physiology. CK\ns were elevated, likely to renal failure, trops were\n flat. CK nadir at 6700, now trending down to 5800.\n - continue to trend CK\ns, expect continued decrease as ARF has resolved\n # Seizure Disorder: Has history of seizures and had seizure on day of\n admission in setting of fever and dilantin level of 3.8; not clear when\n last seizure was. LP not done as above as above. Reloaded with 500mg\n dilantin IV and increase maintenance dose to 50mg from 25mg .\n Last dilantin level was supratherapeutic at 28 yesterday am, this\n morning\ns level is 13.8\n goal ..\n - EEG ordered, not done yet\n - continue dilatin 300mg tid\n # FEN: has PEG, replete lytes prn, TF and free water flushes as above\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 10:54 PM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: none\n VAP:\n Comments:\n Communication: notes list as daughter\n and HCP: . Spoke with her, who provided some details of\n history and said that although he would not want CPR/shocks or\n intubation, everything else should be done.\n Code status: DNR / DNI\n Disposition: call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 652110,
"text": "Chief Complaint: hyperglycemia (HHS), hypernatremia, fevers and\n leukocytosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Patient admitted from: ER\n History obtained from Family / Medical records, Nh, HO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n per (reviewed)\n Past medical history:\n Family history:\n Social History:\n Multiple prior cva's\n ruptured cerebral aneurysms\n Nh resident since \n seizure d/o\n hep c\n h/o neurosyphillls\ns/p treatment in 's\n hypothyroidism (not on replacement medication)\n htn\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives in \n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Flowsheet Data as of 09:10 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 108 (101 - 116) bpm\n BP: 145/76(88) {100/61(71) - 145/76(98)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,797 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,897 mL\n Blood products:\n Total out:\n 0 mL\n 575 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,222 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: r-sided gaze, fixed gazed, cataracts/nonreactive\n Head, Ears, Nose, Throat: Normocephalic, dry MM\n Lymphatic: Cervical WNL, supple neck, no mennengismus\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse:present), (Left radial pulse:\n present), (Right DP pulse:present, decreased), (Left DP pulse:\n decreased)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, peg site c/d/i\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal:+ Muscle wasting\n Skin: Warm, dry\n Neurologic: Responds to voice, nonverbal (at baseline),\n Movement:spontaneous,\n Labs / Radiology\n 151 K/uL\n 46.4 %\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 44 mg/dL\n 21 mEq/L\n 136 mEq/L\n 2.9 mEq/L\n 167 mEq/L\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Imaging: head ct--old cva's, lacunar infarcts, no acute changes\n cxr--tort aorta, no focal findings\n ECG: sinus tach 130's, 1-2 mm std--no old for comparison\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73 yo M NH resident with h/o multiple prior CVAs, htn, sz d/o presents\n with fevers, leukocytosis, severe hypernatremia and hyperglycemia\n (HHS).\n # Fevers/leukocytosis--no obvious source on initial presentation. Has\n no indwelling lines or catheters. O2 sats stable and in no resp\n distress though possibility of pna which might blossom with hydration\n remains. Given sz also concern for CNS infection. --\n - Will treat empirically with meningitis coverage including\n HSV. LFTs mildly elevated without evidence of GB process.\n - Repeat CXR.\n - Pan cx's sent.\n - Will attempt for LP pending family consent.\n - Send c-diff--no diarrhea or recent antibx per report\n # Hyperglycemia---Most c/w HHS, with significant volume depletion on\n admission. No gap acidosis. Glucose improved.\n - Continue close electrolyte monitoring, repleting K.\n - Continue aggressive fluids as very volume down\nD51/2 NS\n monitorng resp status.\n - Would loosen glucose control (goal 130-200) with insulin\n gtt.\n - Reassess insulin requirements and transition to sq insulin.\n # Hypernatremia--significant free water deficit remains. Likely a\n subacute process insetting of HHS.\n - Give free water via peg in addition to IVF.\n - Monitor sodium Q 6 hrs.\n # ARF--pre-renal etiology, possibly with ATN component. Cr improving\n with hydration but still with poor urine outpt.\n - Continue to monitor\n - if no additional improvement with hydration will check renal\n ultrasound.\n # sz d/o--witnessed sz by ems.\n - Reloaded with dilantin.\n - follow level.\n # elevated CPK--likely elevated in setting of witnessed sz. Trop\n mildly elevated in setting of renal failure.\n - Repeat and monitor.\n ICU Care\n Nutrition:\n Comments: consult for TFs--via peg\n Glycemic Control: Insulin infusion but will change parameters for more\n lenient control of BS (130-200)\n Comments: calculate insulin requirements over 24 hrs and convert to SQ\n insulin\n Lines / Intubation:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 652507,
"text": "Briefly this is 73 y/o M w/ a PMH significant for dementia, CVA,\n (receptive & expressive aphasia @ ), dysphagia, L hemiplegia,\n seizure disorder, who presented from a Long term care facility febrile\n to 101 w/ multiple electrolyte abnormalities in setting of severe\n dehydration (hypernatrimic to 160\ns/ serum glucose 774). Since\n admission hyperglycemia was corrected w/ an insulin gtt, and he has\n since been converted to sliding scale, hypernatremia corrected w/ D51/2\n NS and free water boluses. He was placed on broad spectrum abx, which\n have since been d/c\nd as no source of infection has been found he is no\n longer febrile and his white count has trended down.\n Events:\n EEG performed @ bedside\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt off insulin gtt, FS range 250- tube feeds FS Nutren Pulmonary\n increased to goal ~ 50 cc/hr\n Action:\n Response:\n Need to increase sliding scale\n Plan:\n Continue to monitor FS qid, increase sliding scale as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile WBC 12.7 VSS bp 145/90\n Action:\n Pt just on Ceftriaxone for meningitis coverage for 2 wks.\n Response:\n Decreasing WBC\n Plan:\n Continue IV antibx for 2 wks, check regarding droplet precautions in\n am.\n SKIN: pt with long fingernails, scratched his scrotom\n skin\n bleeding. Also pt pulling at foley, and pulling at his\n Peg. Wrists retrained for safety. Restraints ordered\n. Pt\n turned freq.\n GI: passed small stool ob neg. on colace, lactulose\n NEURO: pt probably at . Pt pulls away at you with pm care.\n Need 2 people to turn. Pt more alert tonight, words\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 652508,
"text": "Demographics\n Attending MD:\n S.\n Admit diagnosis:\n EDEMA\n Code status:\n DNR / DNI\n Height:\n 68 Inch\n Admission weight:\n 73 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Hepatitis\n CV-PMH: CVA\n Additional history: CVA with aphasia & left weakness, seizure disorder\n strokes from ruptured intracerebral aneurysms in and or \n with residual left sided deficits (has not been able to walk since\n stroke in ') and aphasia, PEG for dysphagia\n h/o seizure do\n dementia\n HTN\n h/o HepC hepatitis, apparently not activh/o neurosyphilis, treated in\n \n hypothyroidism\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:154\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,924 mL\n 24h total out:\n 975 mL\n Pertinent Lab Results:\n Sodium:\n 148 mEq/L\n 05:08 AM\n Potassium:\n 4.3 mEq/L\n 05:08 AM\n Chloride:\n 116 mEq/L\n 05:08 AM\n CO2:\n 28 mEq/L\n 05:08 AM\n BUN:\n 12 mg/dL\n 05:08 AM\n Creatinine:\n 0.7 mg/dL\n 05:08 AM\n Glucose:\n 203 mg/dL\n 05:08 AM\n Hematocrit:\n 33.0 %\n 05:08 AM\n Finger Stick Glucose:\n 254\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: M/\n Transferred to: 11 R\n Date & time of Transfer: 12:00 AM\n Briefly this is 73 y/o M w/ a PMH significant for dementia, CVA,\n (receptive & expressive aphasia @ ), dysphagia, L hemiplegia,\n seizure disorder, who presented from a Long term care facility febrile\n to 101 w/ multiple electrolyte abnormalities in setting of severe\n dehydration (hypernatrimic to 160\ns/ serum glucose 774). Since\n admission hyperglycemia was corrected w/ an insulin gtt, and he has\n since been converted to sliding scale, hypernatremia corrected w/ D51/2\n NS and free water boluses. He was placed on broad spectrum abx, which\n have since been d/c\nd as no source of infection has been found he is no\n longer febrile and his white count has trended down.\n Events:\n EEG performed @ bedside (results pending\n Weaned from 4 L nasal to RA\n Soft wrist restraints ordered as pt attempted to pull @ PEG\n and PICC\n No other significant events\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Pt off insulin gtt, FS range 200-250 tube feeds @goal 50cc/hr\n Action:\n consulted\n Response:\n More aggressive sliding scale now in place\n Plan:\n Cont to monitor QID finger sticks and cover appropriately\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile WBC 12.7 VSS bp 145/90\n Action:\n With no obvious source of infection and WBC now normalized all abx\n have been d/c\n Response:\n Clinical presentation remains unchanged\n Plan:\n Transfer to floor prior to returning to long term care facility\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652180,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Remains on Insulin gtt at 10 units hour, IVF changed,\n NS with 40\n meq KCL @ 200 cc/hr, insulin gtt decreased to 4 units hour, FS 120-150\n range. FS dropped to 42\n one amp d50 given x 1, fluid changed to\n D5\n NS with 40 meq KCL @ 200 cc/hr, FS range 150\n remains on Insulin\n gtt at 3 units/hr K 3.1 Na 162 urine output 30-50 cc/hr\n Action:\n Current IVF d51/2 NS with 40 meq KCL @ 200 cc/hr x 2 liters. 40\n meq kcl per peg tube given x 1.\n Response:\n Urine output okay, NA coming down slowly\n Plan:\n Check electrolytes in am, replete K as needed. Adjust IVF\n accordingly.\n Seizure, without status epilepticus\n Assessment:\n Pt is nonverbal, but when name called opens his eyes, with pm care,\n pt moves head away, stiffens up, no sz acitivity noted. Dilantin\n level 7.9\n Action:\n 500 mg IV Dilantin given x 1\n Response:\n No seizure activity noted,\n Plan:\n Continue to monitor Dilantin 50 mg po bid check repeat Dilantin\n level as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile, WBC 16.0\n Action:\n Pt remains on Ampicillin, Vanco, Ceftriaxone\n Response:\n Afebrile\n Plan:\n Check cultures, follow WBC, temp, continue antibx.\n Alteration in Nutrition\n Assessment:\n Tube feeds FS Nutren Pulmonary FS @ 30 cc/hr, (goal 50 cc/hr) flush\n with 250 cc\ns water q 4 hrs. belly soft, no stool\n Action:\n Tubed feeds continue via peg\n Response:\n Tolerating tube feeds, no stool\n Plan:\n Goal is 50 cc/hr, check for stool\n SKIN: pt turned q 2 hrs, dsg intact on\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 652181,
"text": "73 yo M chronic NH resident, with h/o CVA's, baseline\n dysphagia/aphasic/L hemiplegia, sz d/o presents with multiple\n electrolyte abnormalities in setting of severe dehydration/HHS with\n fevers and leukocytosis.\n Noted to be lethargic at NH. Chem stick elevated. Chemistry\n panel then revealed glucose at 800, na 170's. Also febrile to 101-->\n sent to ED.\n Per EMS --> had 1-2 min witnessed tonic clonic sz which broke\n spontaneously without medication.\n In ED\nwas febrile but hd stable. Hyperglycemic to 774-->insulin\n gtt and fluids given. Labs also notable for sodium 158 (169 corrected\n for hyperglycemia), lactate 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had\n no obvious focal signs of infection-->cxr clear, u/a neg, benign abd-->\n pan cx's sent and given 1 gm vanco and ctx.\n Admitted to for further management.\n Overnight antibx broadened to cover for possible CNS infection.\n Hydration changed to D51/2 NS. Hyperglycemia improving with insulin\n gtt.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Remains on Insulin gtt at 10 units hour, IVF changed,\n NS with 40\n meq KCL @ 200 cc/hr, insulin gtt decreased to 4 units hour, FS 120-150\n range. FS dropped to 42\n one amp d50 given x 1, fluid changed to\n D5\n NS with 40 meq KCL @ 200 cc/hr, FS range 150\n remains on Insulin\n gtt at 3 units/hr K 3.1 Na 162 urine output 30-50 cc/hr\n Action:\n Current IVF d51/2 NS with 40 meq KCL @ 200 cc/hr x 2 liters. 40\n meq kcl per peg tube given x 1.\n Response:\n Urine output okay, NA coming down slowly\n Plan:\n Check electrolytes in am, replete K as needed. Adjust IVF\n accordingly.\n Seizure, without status epilepticus\n Assessment:\n Pt is nonverbal, but when name called opens his eyes, with pm care,\n pt moves head away, stiffens up, no sz acitivity noted. Dilantin\n level 7.9\n Action:\n 500 mg IV Dilantin given x 1\n Response:\n No seizure activity noted,\n Plan:\n Continue to monitor Dilantin 50 mg po bid check repeat Dilantin\n level as needed\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile, WBC 16.0\n Action:\n Pt remains on Ampicillin, Vanco, Ceftriaxone\n Response:\n Afebrile\n Plan:\n Check cultures, follow WBC, temp, continue antibx.\n Alteration in Nutrition\n Assessment:\n Tube feeds FS Nutren Pulmonary FS @ 30 cc/hr, (goal 50 cc/hr) flush\n with 250 cc\ns water q 4 hrs. belly soft, no stool\n Action:\n Tubed feeds continue via peg\n Response:\n Tolerating tube feeds, no stool\n Plan:\n Goal is 50 cc/hr, check for stool\n SKIN: pt turned q 2 hrs, dsg intact on R heel.\n"
},
{
"category": "Nutrition",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 652481,
"text": "Pertinent medications: HISS, Glargine, NS @ 10cc/hr, Colace, Lactulose,\n others noted\n Labs:\n Value\n Date\n Glucose\n 203 mg/dL\n 05:08 AM\n Glucose Finger Stick\n 252\n 05:00 AM\n BUN\n 12 mg/dL\n 05:08 AM\n Creatinine\n 0.7 mg/dL\n 05:08 AM\n Sodium\n 148 mEq/L\n 05:08 AM\n Potassium\n 4.3 mEq/L\n 05:08 AM\n Chloride\n 116 mEq/L\n 05:08 AM\n TCO2\n 28 mEq/L\n 05:08 AM\n Albumin\n 3.3 g/dL\n 05:00 AM\n Calcium non-ionized\n 8.5 mg/dL\n 05:08 AM\n Phosphorus\n 2.6 mg/dL\n 05:08 AM\n Magnesium\n 2.1 mg/dL\n 05:08 AM\n ALT\n 57 IU/L\n 04:00 AM\n Alkaline Phosphate\n 104 IU/L\n 05:00 AM\n AST\n 123 IU/L\n 04:00 AM\n Total Bilirubin\n 0.7 mg/dL\n 05:00 AM\n Phenytoin (Dilantin)\n 13.8 ug/mL\n 05:08 AM\n WBC\n 7.4 K/uL\n 05:08 AM\n Hgb\n 10.9 g/dL\n 05:08 AM\n Hematocrit\n 33.0 %\n 05:08 AM\n Current diet order / nutrition support: TF: Nutren Pulmonary @ 50cc/hr\n (1800kcal, 82g protein)\n GI: soft, +BS, + small BM o/n\n Assessment of Nutritional Status\n 73 y.o. M with h/o CVA and PEG for dysphagia, adm with new onset\n diabetes,severe dehydration/HHS with fevers and Leukocytosis.\n Electrolyte abnormalities and pre-renal condition improving with H20\n boluses (250cc q4hrs), and IVF have been decreased. BG remains\n elevated despite HISS, Glargine and low-carbohydrate TF formula. TF is\n at goal via PEG, pt tolerating thus far.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec cont with TF at goal. Also cont with H20 boluses,\n decreasing amount and/or frequency of H20 boluses as ideal Na is\n reached.\n 2) Monitor lytes, replete as needed.\n 3) Monitor TF tolerance with residual checks q4hrs and abd exam.\n 4) Cont with bowel meds for BM.\n 5) Tighten insulin regimen to aim for BG <150.\n Please page with ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Generic Note",
"row_id": 652030,
"text": "TITLE:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n given in ed. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n Critically high Blood sugars with negative urine Ketones.\n Assessment:\n FS 429 when admitted to MIcu, . Lactate reduced to 5 from 9.0\n Action:\n Continued on IV Regular Insulin 15 units/hr & 0.4 NS @ 150 mls/hr.\n Response:\n FS reduced to 239, started on D51/2 NS @ 150 mls/hr then increased to\n 250 mls/hr as urine output remained low. AT 4am FS 181 , insulin drip\n @ 11 units/hr\n Plan:\n Continue FS monitoring.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia) ? Meningitis.\n Assessment:\n Pt afebrile on admission to MICU.\n Action:\n Continued monitoring , had received motrin & Tylenol in ED. Cultures\n were sent in ED. Started on IV Anbx- ceftriaxone 1 dose given, IV Vanco\n 1 gram q 24 hrs, iv ampicillin q 6hrs,.\n Response:\n Cultures pending.\n Plan:\n ? LP. Monitor temp curve, Follow up on cultures.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n H?O stoke with left sided deficits. Unresponsive at baseline as per\n Nursing home. Patient opens eye spontaneously, does not follow command,\n does not track. Non purposeful movements noted to his right hand\n Action:\n Received iv dilantin 500 mgs one time dose & has orders for po\n phenytoin BD.\n Response:\n No seizures noted in MICU..\n Plan:\n Continue phenytoin, monitor for seizures.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Unknown baseline. Creatinine elevated at 2.1? prerenal. Urine output\n has been inadequate.\n Action:\n Meds are renally dosed. IV Fluids increased to 250 mls/hr.\n Response:\n Urine output remains low..\n Plan:\n Continue monitoring u/o, continue fluids, Monitor lytes.\n Electrolyte & fluid disorder, other\n Assessment:\n K+ 2.4 in MICU, Na 168\n Action:\n K-Dur 40 meq given via Peg tube.\n Response:\n AM labs k+ 2.9. Orders to replete 80 meq in divided doses, urine output\n is low. To confirm orders again. Will give 40 meq at present\n Plan:\n Continue monitoring labs.\n Skin Impairment\n Assessment:\n Patient came in from Nursing Home via ED with pressure ulcer with had\n a dressing on it.\n Action:\n Site examined, cleaned with NS, alevyn dressing applied. Has foam\n multipodus boots on bilaterally.\n Response:\n Unchanged.\n Plan:\n Continue skin care & frequent positioning.\n Daughter is the HCP.\n is a DNR/DNI\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652037,
"text": "Chief Complaint: 73 yo M with CVA, HTN, PEG who presents with\n hypernatremia, hyperglycemia/HHS, fevers with seizures, and acute renal\n failure.\n 24 Hour Events:\n -K remained low at 2.9, repleted with K through PEG, will likely need K\n added to IVFs\n -Na, Cre improved with IVFs\n - Insulin gtt decreased to 10 U/hr\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n Tylenol\n Insulin gtt\n Colace\n Heparin\n Phenytoin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 103 (101 - 116) bpm\n BP: 121/65(80) {100/61(71) - 138/76(90)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,545 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,645 mL\n Blood products:\n Total out:\n 0 mL\n 525 mL\n Urine:\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,020 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 2.9 mEq/L\n 44 mg/dL\n 136 mEq/L\n 167 mEq/L\n 46.4 %\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n .\n # hyperglycemia: markedly elevated glucose in a patient with no known\n history of diabetes and active infection as evidenced by fever, WBC.\n Anion gap 18 (not correcting for glc) with bicarb 20, but no ketones in\n urine, so more c/w HHS than with DKA.\n - check plasma acetone\n - insulin gtt\n - Q1h fingersticks\n - add D5 to fluids once blood sugar less than 250\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Has received 3L NS (hypotonic relative to pt), will recheck\n labs and likely change to 1/2NS for IVF for both free water repletion\n and volume expansion.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reload with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n .\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments: Not indicated\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: in ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 652044,
"text": "Chief Complaint: hyperglycemia, hypernatremia, , fevers\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 73 yo M with h/o CVA's, dysphagia, aphaisc at baseline, L hemipegia, sx\n d/o, NH resident. Lethargic at NH. Chem stick checked and high.\n Chemistry checked with glu 800, na 170's. febrile to 101--> sent to ED\n at . Per EMS--> had 1-2 min witnessed tonic clonic sz which broke\n upon IV placement.\n In ED--febrile, hd stable. Hyperglycemic to 774-->insulin gtt and\n fluids given. Sodium 158 (169 corrected for hyperglycemia), lactate\n 9.5-->5.3 with IVF, cr 2.1, wbc 16.3. Had no obvious focal signs of\n infection-->cxr clear, u/a neg, bengin abd--> pan cx'd and given 1 gm\n vanco and ctx.\n Patient admitted from: ER\n History obtained from Family / Medical records, Nh, HO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n per (reviewed)\n Past medical history:\n Family history:\n Social History:\n multiple cva's--ruptured cerebral aneurysms\n Nh resident since \n seizure d/o\n hep c\n h/o neurosyphiliis--treated in 's\n hypothyroidism, not on treatment\n htn\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives in \n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Flowsheet Data as of 09:10 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 108 (101 - 116) bpm\n BP: 145/76(88) {100/61(71) - 145/76(98)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,797 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,897 mL\n Blood products:\n Total out:\n 0 mL\n 575 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,222 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: r-sided gaze, fixed\n Head, Ears, Nose, Throat: Normocephalic, dry MM\n Lymphatic: Cervical WNL, supple neck\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, peg site c/d/i\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Not assessed, No(t) Oriented (to): (at\n baseline), Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 151 K/uL\n 46.4 %\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 44 mg/dL\n 21 mEq/L\n 136 mEq/L\n 2.9 mEq/L\n 167 mEq/L\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Imaging: head ct--old cva's, lacunar infarcts, no acute changes\n cxr--tort aorta\n ECG: sinus tach 130's, 1-2 mm std--no old for comparison\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73 yo M with CVA, htn, sz d/oi presents with fevers, leukocytosis\n hyperglycemia and hypernatremai\n # Fevers/leukocytosis--no obvious source, given sz concern for CNS\n infection. Treating empiricially with meningitis coverage including\n HSV. Pan ccx'd. Will attempt for LP. repeat CXR to asssess for\n blossoming infiltrate. LFts mildly elevated without evidence of GB\n process. Send s-diff--no diarrhe or recent antibx per report\n # Hyperglycemia---most c/w HHS, with signifciant volume depletion on\n admission. Glucose improved, no gap acidosis. Continue close\n electrolyte monitoring repleting K. Continue aggressive fluid\n repletion with D51/2 NS montiroing resp status.\n # hypernatremia--signifiacnt free water deficit remains. Free water via\n peg in additon to IVF. Monitor sodium Q 6 hrs.\n #ARF--pre-renal etiology, possibly with ATN component. Improving with\n hydration. Minimal urine outpt. Continue to montior and if no\n additonal improvement with hyration will check renal ultrasound.\n #sz d/o--witnessed sz by ems. Reloaded with dilantin. follow level.\n #elevated CPK--likely elevated in setting of witnessed sz. Trop mildly\n elevated in setting of renal failure. Repeat and monitor.\n ICU Care\n Nutrition:\n Comments: consult for TFs, via peg\n Glycemic Control: Insulin infusion but will change parameters for more\n lenient control\n Comments: calculate requirements over 24 hrs and convert to SQ insulin,\n goal sugars\n Lines / Intubation:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 652051,
"text": "Subjective\n Patient aphasic\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 73 kg\n 24.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70 kg\n 104\n Diagnosis: edema\n PMH : prior CVAs, PEG for dysphagia, aphasia, seizure disorder,\n dementia, hypertension, hepatitis C, neurosyphilis, hypothyroid\n Food allergies and intolerances: none noted\n Pertinent medications: KCl repletion (80meq), insulin gtt at 5u/hr\n Labs:\n Value\n Date\n Glucose\n 144 mg/dL\n 05:00 AM\n Glucose Finger Stick\n 124\n 09:00 AM\n BUN\n 44 mg/dL\n 05:00 AM\n Creatinine\n 1.5 mg/dL\n 05:00 AM\n Sodium\n 167 mEq/L\n 05:00 AM\n Potassium\n 2.9 mEq/L\n 05:00 AM\n Chloride\n 136 mEq/L\n 05:00 AM\n TCO2\n 21 mEq/L\n 05:00 AM\n Albumin\n 3.3 g/dL\n 05:00 AM\n Calcium non-ionized\n 9.0 mg/dL\n 05:00 AM\n Phosphorus\n 2.1 mg/dL\n 05:00 AM\n Magnesium\n 2.3 mg/dL\n 05:00 AM\n Current diet order / nutrition support: NPO\n GI: abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1800-2200 (BEE x or / 25-30 cal/kg)\n Protein: 73-95 (1-1.3 g/kg)\n Fluid: per team\n Specifics:\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia. Patient has PEG for dysphagia and\n consult received for tube feeding recommendations. Would consider\n holding until patient\ns lytes are more stable. Would then recommend\n starting Nutren Pulmonary to goal rate of 50ml/hr x 24 hours to provide\n 1800kcal and 82g protein. Will adjust tube feeding based on patient\n progress, lytes and blood glucose levels.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Once medically stable, would start Nutren Puilmonary at\n 20ml/hr, advance by 20ml q6H to goal rate of 50ml/hr x 24 hours\n 2. Monitor residuals q4H and hold tube feedings if >150ml\n 3. Will follow closely and make adjustments PRN\n 10:09 AM\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 652075,
"text": "Chief Complaint: 73 yo M with CVA, HTN, PEG who presents with\n hypernatremia, hyperglycemia/HHS, fevers with seizures, and acute renal\n failure.\n 24 Hour Events:\n -K remained low at 2.9, repleted with K through PEG, will likely need K\n added to IVFs\n -Na, Cre improved with IVFs\n - Insulin gtt decreased to 10 U/hr\n - started ppx abx and antiviral for presumed meningitis\n - fluids changed to D5\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 02:30 AM\n Ampicillin - 06:00 AM\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:49 AM\n Dilantin - 03:00 AM\n Other medications:\n Tylenol\n Insulin gtt\n Colace\n Heparin\n Phenytoin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 103 (101 - 116) bpm\n BP: 121/65(80) {100/61(71) - 138/76(90)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 16 mL\n 4,545 mL\n PO:\n TF:\n IVF:\n 16 mL\n 1,645 mL\n Blood products:\n Total out:\n 0 mL\n 525 mL\n Urine:\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n 4,020 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 14.6 g/dL\n 144 mg/dL\n 1.5 mg/dL\n 21 mEq/L\n 2.9 mEq/L\n 44 mg/dL\n 136 mEq/L\n 167 mEq/L\n 46.4 %\n 16.0 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n WBC\n 16.0\n Hct\n 46.4\n Plt\n 151\n Cr\n 1.8\n 1.5\n TropT\n 0.04\n Glucose\n 290\n 144\n Other labs: CK / CKMB / Troponin-T:2635/7/0.04, ALT / AST:47/60, Alk\n Phos / T Bili:104/0.7, Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 73M with h/o R sided strokes, seizure disorder, dementia, now with new\n onset diabetes and hyperglycemia/HHS, fevers, elevated WBC, and\n witnessed seizure, and hypernatremia\n .\n Plan:\n # fevers/elevated WBC: CXR clear. Urine clear except for high glucose.\n Abd soft, nontender. Seizures raise suspicion for CNS infection,\n although no signs of meningismus on exam. No signs of RUQ\n pathology/cholecystitis on LFTs.\n - f/u bld, urine cultures\n - will need LP; empirically treat for meningitis with CTX 2gm daily,\n vanc 1gm q24 (renally adjusted dose), ampicillin 2gm Q6h to cover\n Listeria, and acyclovir 10mg/kg q12h empirically\n - check C. diff\n - repeat CXR.\n .\n # hyperglycemia: Likely HHS (no ketones in urine, so unlikely DKA).\n Stimulant likely infectious process. Total Free water deficit 8.7 L.\n Would like to decrease Na by 12 mEq over 24 hours (0.5 mEq/hr), so\n amount of free water needed to correct this is 3.2 L.\n - continue insulin gtt ( to 5 U/hr)\n - Q1h fingersticks\n - change fluids to 40 meq K D5\n NS @ 250 ccs/hr\n - free H2O boluses at 150 q4H through PEG\n .\n # hypernatremia: Na 158 on chem7, but after correcting for Glc 774, Na\n is 169. Changed IVFs from NS in ED to 1/2NS for IVF for both free water\n repletion and volume expansion. Likely chronic process.\n .\n # acute renal failure: unknown baseline, but elevated at 2.1. Likely\n prerenal. Check urine lytes. Renally dose meds, avoid nephrotoxins.\n Check renal U/S if does not resolve.\n .\n # HTN: currently normotensive, dry, and infected, so will hold\n antihypertensives\n .\n # EKG changes: pt does have multiple cardiac risk factors, although\n nonspecific distribution of ST depressions more consistent with demand\n than plaque rupture physiology. Check cardiac enzymes.\n .\n # seizure do: has history of seizures and today had seizure in setting\n of fever and dilantin level of 3.8; not clear when last seizure was.\n With fevers and leukocytosis, will pursue LP as above. Reloaded with\n 500mg dilantin IV and increase maintenance dose to 50mg from 25mg\n . Re-Check dilantin level in PM prior to PM dose.\n .\n # FEN: has PEG, nutrition c/s for TF recommendations\n - replete K aggressively\n .\n # Access: PIV; for insulin, abx, will need at least a second PIV; may\n need PICC in am\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Insulin gtt\n Lines:\n 20 Gauge - 10:54 PM\n 18 Gauge - 01:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments: Not indicated\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: in ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 652465,
"text": "Chief Complaint: ARF, HHS, hypernatremia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n STOOL CULTURE - At 06:38 AM\n amp/vanco d/c'd. family declined LP, continued on meningitis dose\n ctx.\n Insulin gtt stopped yesterday--> glarine and SSI started\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:13 AM\n Ampicillin - 10:00 AM\n Ceftriaxone - 02:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 98 (81 - 98) bpm\n BP: 156/70(90) {123/56(76) - 164/103(143)} mmHg\n RR: 16 (16 - 26) insp/min\n SpO2: 98% FM\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,677 mL\n 1,092 mL\n PO:\n TF:\n 813 mL\n 452 mL\n IVF:\n 3,254 mL\n 140 mL\n Blood products:\n Total out:\n 1,905 mL\n 360 mL\n Urine:\n 1,905 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,772 mL\n 733 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, Thin, MS \n Eyes / Conjunctiva: No(t) PERRL, MMM\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:good AM,\n CTA without wheeze: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, no rash\n Neurologic: Responds to: Verbal stimuli, Oriented (to): at ,\n nonconversent, Movement: Not assessed, No(t) Sedated, No(t) Paralyzed,\n Tone: Increased\n Labs / Radiology\n 10.9 g/dL\n 71 K/uL\n 203 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 116 mEq/L\n 148 mEq/L\n 33.0 %\n 7.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:00 AM\n 11:23 AM\n 06:07 PM\n 04:00 AM\n 05:27 PM\n 10:00 PM\n 11:29 PM\n 05:08 AM\n WBC\n 16.0\n 12.7\n 7.4\n Hct\n 46.4\n 35.1\n 33.0\n Plt\n 151\n 94\n 71\n Cr\n 1.8\n 1.5\n 1.1\n 1.0\n 0.7\n 0.7\n 0.7\n 0.7\n TropT\n 0.04\n 0.04\n 0.02\n 0.02\n Glucose\n 290\n 144\n 155\n \n 257\n 218\n 203\n Other labs: PT / PTT / INR:15.4/55.0/1.4, CK / CKMB / Troponin-T:5812\n (decreasing) /10/0.02, ALT / AST:57/123, Alk Phos / T Bili:104/0.7,\n Lactic Acid:3.6 mmol/L, Albumin:3.3 g/dL, Ca++:8.5 mg/dL, Mg++:2.1\n mg/dL, PO4:2.6 mg/dL\n Imaging: CXR--no new imaging\n Microbiology: mciro--c diff neg, urine cx neg, bl ngtd\n Assessment and Plan\n WHEEZING\n ALTERATION IN NUTRITION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETIC KETOACIDOSIS (DKA)\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n TACHYCARDIA, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 73 yo M NH resident with h/o multiple prior CVAs, htn, sz d/o presents\n with fevers, leukocytosis, severe hypernatremia and hyperglycemia\n (HHS).\n # Fevers/leukocytosis--no obvious source on initial presentation and\n cx\nd have returned neg. Has no indwelling lines or catheters. O2 sats\n stable and in no resp distress though possibility of pna which might\n blossom with hydration remains. Given sz also concern for CNS\n infection\nbut have had low clinical suspicion for menegitis but family\n declined LP.\n - Majority of antibx d/c\nd yesterday. As all cxs neg and\n given low suspicion for CNS infection will d/c ctx. Has been AF here\n and WBC normalized.\n - F/u final cx results.\n # Hyperglycemia---Most c/w HHS on presentation, adeuqtely volume resus.\n - Continue close electrolyte monitoring, repleting K.\n - Converted from gtt insulin to glargine and ssi. Conginue to\n montior., c/s.\n # Hypernatremia--significant free water deficit on admit. Likely a\n subacute process insetting of HHS.\n - Give free water via peg\ncontinues to improve.\n - Monitor sodium Q 12 hrs.\n # ARF--pre-renal etiology, possibly with ATN component. Cr now\n normalized. U/o adequte\n # sz d/o--witnessed sz by ems.\n - Dilantin dose adjusted\nfollow levels. Eeg ordered. Known sz\n d/o.\n # elevated CPK--likely elevated in setting of witnessed sz. Trop\n mildly elevated in setting of renal failure.\n - have peaked and now trending down.\n -\n # thrombocytopenia\ndeveloped during hospitalization. Likely dilutional\n component. ? med related. Low suspicion for HIT. Will montior.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 01:19 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 10:54 PM\n PICC Line - 11:24 AM\n Prophylaxis:\n DVT: sq hep\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition : stable for floor transfer\n Total time spent: 40\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-20 00:00:00.000",
"description": "Generic Note",
"row_id": 651978,
"text": "TITLE:\n 73M, h/o seizures, CVA with L sided deficits, HTN, PEG for dysphagia,\n EMS reported that mental status is near baseline according to \n (localizes to pain), DNR/DNI, sent to ED because at , noted to be\n lethargic and had fsbg of 800. Not a known diabetic and no treatment\n for this was given at . Chem7 showed elevated Cr, Na, Glc, and WBC,\n so he was sent to . EMS witnessed a tonic clonic seizure, \n minutes, seizure activity broke by the time IV access was obtained, and\n then brought him to ED.\n On arrival to ED, did not open eyes, now moves arms somewhat and opens\n eyes. Blood sugar 774, given insulin 10 IV x2, then on drip at 10 for\n first hour, now on 15, b/c sugar is still critically high. 3rd L of NS\n given in ed. Also febrile to 102.6 on arrival. CXR clean, Urine clear.\n Abd soft, nontender. Blood and urine cultures sent. Given vanc and CTX\n empirically. At time of transfer, T102, HR 120s (sinus), BP 110s, O2\n sats 95-97% on 2L RR 18.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
}
] |
23,014 | 158,331 | The patient was medically managed initially and then underwent on , coronary artery bypass grafting x2 and a mitral valve annuloplasty with placement of intra-aortic balloon pump. He was transferred to the Intensive Care Unit in relatively stable condition. On postoperative day #1, his balloon pump was weaned and the patient was transferred at 2 units of packed red blood cells. He also began to wean off the ventilator. On postoperative day #1 in the evening, the patient was noted to go into atrial fibrillation, for which he was controlled and started on amiodarone, after which he converted again to normal sinus rhythm. He was extubated during postoperative day #1. On postoperative day #2, the patient was noted to be relatively stable. His balloon pump had already been removed and on postoperative day #3, he was transferred to the floor on Lopressor and amiodarone in normal sinus rhythm. On the floor, the patient was noted to do extremely well. Physical therapy was consulted and the patient was ambulating extremely well with minimal assistance. On postoperative day #4, he remained afebrile with stable vital signs on Lopressor at 25 mg po bid and an amiodarone dose. His left chest tube was discontinued at this time and his right chest tube was removed the following day on postoperative day #5. Currently, the patient is postoperative day #6. He remains afebrile with stable vital signs and the patient is ambulating to a level 5 with physical therapy and wishes to be discharged home today. | Normal sinus rhythm, rate 72Leftward axisConsider inferposterior MIPossible ischemiaBorderline intraventricular conduction delayClinical correlation suggestedAbnormal ECG PT ALERT AND ORIENTATED X3~FLAT AFFECT. CT CONT TO DRAIN.GI~+BS. TURNED AND REPOSITIONED Q2/HR'S. + BS THRU-OUT, TOLERATING SM. IABP right fem, site good.Plan: Pt currently receiving PRBC, one more unit ordered. VARIABLE ASSIST & AUGMENTATION NOTED,PLAN TO DC IABP IN A.M.IF REMAINS STABLE. CT'S CONT. CT'S CONT. POST EXTUBATION ABG GOOD. PT IN AFIB AT ~0200~CI REMAINED >2.0. redo CABG x 2 and MVR. VSS STABLE, HCT AND COAGS SENT AND WNL. Med CT D/ by NP. TO BE GOOD OFF MILRINONE AND & IABP. SELF LIMITING RUN OF SVT VS VT. MG++ REPLETED,OTHER LABS WNL. EXCELLENT HEMODYNAMICS,SVO2 ON MILRINONE & IABP @ 1:1. MSO4/TORDOL/SERAX @HS. AFTER PROPOFOL GTT D/ PT. Normal sinus rhythm, rate 65Left axis deviationOld inferior myocardial infarctAnterolateral ST-T abnormalitiesPartial Intraventricular conduction delayAbnormal ECG DSG REAPPLIED TO STERNUM~INTACT WITH CLIPS. ABLE TO QUICKLY WEAN TO EXTUBATE ONCE PROPOFOL GTT TURNED OFF. CI >2.0. CI >2.0. Converted to NSR. EXTREMITIES COOL BUT W RAPID REFILL & DOPPLERABLE PULSES.LT. DIURESIS VS VOLUME FOR LOW U/O. Into A-fib during days. MEDICATED WITH 2MG IV MSO4. TINGED SECREATIONS. Treated with protamine, PRBC, FFP. SBP controlled with neo. B/P STABLE WITH SYS >120 AND MAP'S >60 VIA NB/P. SHIFT UPDATE.PT. SHIFT UPDATE.PT. Amiodarone gtt started, IV lopressor given. Normal sinus rhythm, rate 72Leftward axisConsider inferoposterior MISince last ECG, no significant changeAbnormal ECG CO/CI CONT. Compared to the previous tracing nosignificant change.TRACING #2 P-R interval 0.20. P-R interval 0.20. PERIPH IV INTACT.RESP: BS CLEAR THRU-OUT, O2 DOWN TO 2L NP WITH SAT'S >97%. UPDATED: PT S/P REDO CABG WITH MV RING-NEURO: PT AWAKE, ALERT ORIENTED X 3, MAE, PUPILS 3CM EQUAL RX TO LIGHT.RESP: PT WEANED TO 2L NP WITH SAT >95%, BS CLEAR THRU OUT DIM IN BASES. DR TO BEDSIDE~PT CONVERTED TO SLOW SR~APACED AT 80 WITH IMPROVEMENT IN HEMODYNAMICS. GU~U/O AMBER AND <20CCX2 HRS, DR AWARE.SKIN~R LEG WITH STERIS AND WRAPPED WITH ACE. Sinus rhythm. Sinus rhythm. 61 y.o. T wave inversions with ST segmentdepressions in leads I, II, aVL and V4-V6 consistent with acute lateral wallischemia. PT. TO PUT OUT SEREOUS DRAINAGE ESPECIALLY WITH TURNING.GI/GU: HOURLY URINES CONT. OOB TO CHAIR X 2/HR'S.CARDIAC: CONT. Left atrial abnormality. Left atrial abnormality. CONT. Hct still low and CT still draining large amts. CT OUTPUT CONTINUES~CXR TO BE OBTAINED. FLAT AFFECT~MINIMAL CONVERSATION.CV~SR WITH MVO2 OF 58-60%. CT OUTPUT MODERATE IN PAST HOURS~DR AWARE~HE FELT THE OUTPUT LOOKED SEROUS IN NATURE. ASSESSMENT:NEURO: A&OX3, MAE TO COMMANDS, C/O SLIGHT STERNAL DISCOMFORT, MEDICATED WITH 2 PERCOCET WITH GOOD EFFECT. PACER REMAINS ATTACHED BUT OFF.RESP: BS DIMINISHED IN BASES, WHILE INTUBATED PT. Lateral ST segment depressions consistentwith acute lateral wall ischemia. Now in NSR.NSR, no ectopy. IABP 1:1 with good waveforms. UPPER ARM RAISED RASH NOTED ON ARRIVAL.? Sinus rhythm, rate 66Ventricular premature complexBorderline intraventricular conduction delayProbable inferior myocardial infarctLateral ST-T abnormalitiesSince last ECG, lateral ST depression lessAbnormal ECG TO BE >5.0/2.0. BENADRYL GIVEN PER PA,RESOLVED AFTER ~ 1 HR.PLAN TO CONTINUE PROPOFOL UNTIL A.M. & PLAN FOR EARLY EXTUBATION. DR. Placement checked.Adequate urine output.Pedal pulses by doppler. Pt remainds on vent with 100%sats.Skin intact, incisions CDI, no drainage.OG tube in place, to LCS. PT WITH 150MG AMIODARONE. Treated with more PRBC, possibly PLTS. IABP D/C'D BY CT TEAM AT ~0945AM, PRESSURE HELD X 30" AND C-CLAMP APPLIED X 1/HR, NO HEMATOMA NOTED AND SITE C&D, PRESSURE DSG APPLIED. SLIGHTLY OOZY W MILD COAGULOPATHY TREATED W FFP & PROTAMINE W EFFECT.APROPLAN TO KEEP SEDtedTININ COMPLETED AFTER 4 HRS. NEURO~INTACT. TRANSCUTANEOUS DEFIB PADS PLACED PROPHYLACTICALLY.HEMODYNAMICS REMAIN EXCELLENT ON PRESENT THERAPY. Normal sinus rhythm, rate 97Left axis deviation, consider left anterior fascicular blockEarly transitionLow voltage throughoutConsider inferior myocardial infarctNonspecific lateral T waves abnormalitiesSince last ECG, heart rate increased, without ventricular premature complexAbnormal ECG R GROIN SITE (IABP) D+I -BLEED/HEMATOMA~+DOPPLERABLE PULSES X4.PLAN~CLOSELY MONITOR CI/MVO2. SVO2 DECREASING DOWN HIGH 50'S AFTER EXTUBATION BUT CO/CI CONT. TO BE A-PACED WITH UNDERLYING IN THE 70'S. A&OX3, C/O STERNAL DISCOMFORT MEDICATED WITH MSO4 2MG IVP WITH GOOD EFFECT.CARDIAC: IABP WEANED TO 1:3 WITH GOOD CO/CI AND SVO2 HOLDING IN THE 60'S. PT OOB TO CHAIR WITH 2 PERSON ASSIST- WELL.PAIN: INC - AS STATED PT STARTED ON TORADOL AND REQUIRED PERCOCET B/W. Non-specificintraventricular conduction delay. AFIB BRADY INTO 40'S, PT WITH MVO2 OF LOW 50'S AND CI OF 1.9-1.8. PT ENCOURAGED TO TAKE DB&C, PT COUGHING WITHOUT RAISING- TOWARD END OF SHIFT PT RAISING THIN CLEAR SECRETIONS.CARDIAC: PT A PACED AT 90, MA SET AT 15- THRESHOLD 14, UNDERLYING RHYTHM 60 SR. PT OFF AMINODARONE IV CHANGED TO PO- 1ST DOSE GIVEN AT 1800. LABS WNL.RESP~O2 AT 4-5L NP WITH ADEQUATE SATS. ct ouput update called to dr ~will con't to montior at this time. Draining thin, serous, blood tinged fluid.Incisons CDI, no drainage.Urine output low, po lasix given this a.m.16 ga PIV from .Plan: Transfer to 6 today. Non-diagnosticintraventricular conduction delay. Extubated next day without difficulty. SERAX FOR HS, O2 CHANGED TO 5L NP WITH ADEQUATE SATS. 2L/NC with good sats. See flowsheet for specific amounts. CONVERTING IN NSR WITH RATES IN THE 80'S. ASSESSMENT:NEURO: INITIALLY SEDATED ON PROPOFOL GTT WITH GOOD SEDATION, SOFT WRIST RESTRAINTS ON FOR SAFTEY, PEERL. AWAKENING CALM AND ABLE TO FOLLOW COMMANDS, AFTER EXTUBATION PT. PT WITH BURSTS OF AFIB~STARTED ON LOPRESSOR AND AMIODARONE DRIP DECREASED TO .5MG/MIN AT 2200. Vitals stable throughout. TO BE >25CC, CONCENTRATED IN APPEARANCE. LAVAGED AND SUCTIONED FOR THICK BLD. TO MONITOR SVO2, HEMODYNAMICS AND RESP STATUS CLOSELY. Sinus rhythm, no ectopy. STRONG, NONPRODUCTIVE COUGH AT PRESENT. Resident notified of large output hours. AT ~1800 PT. Will recheck Hct, monitor CT drainage. TO DUMP VERY THIN SEREOUS DRAINAGE, UPTO 50-150CC. TO HAVE WEAK NON-PRODUCTIVE COUGH.GI/GU: HOURLY URINES DROPPING TO <20CC X2/HR EARLIER, GIVEN ADDITIONAL 40MG IVP LASIX X1 WITH GOOD EFFECT. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2162-09-12 00:00:00.000",
"description": "Report",
"row_id": 1563048,
"text": "UPDATE\nD: PT S/P REDO CABG WITH MV RING-\nNEURO: PT AWAKE, ALERT ORIENTED X 3, MAE, PUPILS 3CM EQUAL RX TO LIGHT.\n\nRESP: PT WEANED TO 2L NP WITH SAT >95%, BS CLEAR THRU OUT DIM IN BASES. PT ENCOURAGED TO TAKE DB&C, PT COUGHING WITHOUT RAISING- TOWARD END OF SHIFT PT RAISING THIN CLEAR SECRETIONS.\n\nCARDIAC: PT A PACED AT 90, MA SET AT 15- THRESHOLD 14, UNDERLYING RHYTHM 60 SR. PT OFF AMINODARONE IV CHANGED TO PO- 1ST DOSE GIVEN AT 1800. SBP >110/ CONSISTENTLY, PT NOT ON LOPRESSOR AT THIS TIME.\n\nGI: PT BS ACTIVE, PT SIPS OF CLEAR AND ICE CHIP[ WELL, NO APPETITE AT THIS TIME. NO BM POST-OP AS OF YET. PT STARTED ON ZANTAC TODAY- IST DOSE AT TONIGHT.\n\nGU: PT U/O APPROX 15-20CC THIS AM, PT WT UP 10 PT STARTED ON LASIX 20MG IVP X2 TODAY- AFTER IST DOSE U/O UP TO >200CC X 2 HRS AS DAY PROGRESSED U/O DOWN TO 15CC X 3HRS- SECOND LASIX GIVEN EARLY AT 1800-PENDING RESULTS. CREAT .8\n\nACTIVITY: PT TURNING IN BED WITH SOME DISCOMFORT- TORADOL STARTED TODAY. PT OOB TO CHAIR WITH 2 PERSON ASSIST- WELL.\nPAIN: INC - AS STATED PT STARTED ON TORADOL AND REQUIRED PERCOCET B/W. WITH GOOD RELIEF OF PAIN.\n\nCT: DRAINAGE 50CC/HR- DUMP UPON GETTING OOB TO A TOTAL OF 400CC- PT HCT CHECKED THEREAFTER-STABLE AT 32.\n\nPLAN: MONITOR CT DRAINAGE- PLAN FOR D/C TO IN AM- PROVATE BED HELD FOR PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-13 00:00:00.000",
"description": "Report",
"row_id": 1563049,
"text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, C/O SLIGHT STERNAL DISCOMFORT, MEDICATED WITH 2 PERCOCET WITH GOOD EFFECT. OOB TO CHAIR X 2/HR'S.\nCARDIAC: CONT. TO BE A-PACED WITH UNDERLYING IN THE 70'S. B/P STABLE WITH SYS >120 AND MAP'S >60 VIA NB/P. PERIPH IV INTACT.\nRESP: BS CLEAR THRU-OUT, O2 DOWN TO 2L NP WITH SAT'S >97%. CT'S CONT. TO DUMP VERY THIN SEREOUS DRAINAGE, UPTO 50-150CC. DR. AWARE. PT. CONT. TO HAVE WEAK NON-PRODUCTIVE COUGH.\nGI/GU: HOURLY URINES DROPPING TO <20CC X2/HR EARLIER, GIVEN ADDITIONAL 40MG IVP LASIX X1 WITH GOOD EFFECT. + BS THRU-OUT, TOLERATING SM. AMT'S OF H2O.\nSOCIAL: SPOKE WITH WIFE, UPDATE GIVEN.\nPLAN: CONT. TO MONITOR CT OUTPUT CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-13 00:00:00.000",
"description": "Report",
"row_id": 1563050,
"text": "61 y.o. redo CABG x 2 and MVR. Post-op: Large amts CT drainage, multiple units blood, FFP and plts given. Vitals stable throughout. Extubated next day without difficulty. Into A-fib during days. Amiodarone gtt started, IV lopressor given. Converted to NSR. Back into A-fib during nights. Now in NSR.\nNSR, no ectopy. 2 A and 2 V wires attached to pacer.\nLungs clear, strong cough, no sputum. 2L/NC with good sats. Med CT D/ by NP. Right and left pleural CT left in place, to separate pleuravacs to monitor drainage more closely. Draining thin, serous, blood tinged fluid.\nIncisons CDI, no drainage.\nUrine output low, po lasix given this a.m.\n16 ga PIV from .\nPlan: Transfer to 6 today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-11 00:00:00.000",
"description": "Report",
"row_id": 1563044,
"text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: INITIALLY SEDATED ON PROPOFOL GTT WITH GOOD SEDATION, SOFT WRIST RESTRAINTS ON FOR SAFTEY, PEERL. TURNED AND REPOSITIONED Q2/HR'S. AFTER PROPOFOL GTT D/ PT. AWAKENING CALM AND ABLE TO FOLLOW COMMANDS, AFTER EXTUBATION PT. A&OX3, C/O STERNAL DISCOMFORT MEDICATED WITH MSO4 2MG IVP WITH GOOD EFFECT.\nCARDIAC: IABP WEANED TO 1:3 WITH GOOD CO/CI AND SVO2 HOLDING IN THE 60'S. IABP D/C'D BY CT TEAM AT ~0945AM, PRESSURE HELD X 30\" AND C-CLAMP APPLIED X 1/HR, NO HEMATOMA NOTED AND SITE C&D, PRESSURE DSG APPLIED. CO/CI CONT. TO BE GOOD OFF MILRINONE AND & IABP. AT ~1400PM PT. HR GOING INTO RAF WITH RATES AS HIGH AS 140'S, TREATED WITH TOTAL OF 10MG IVP LOPRESSOR AND STARTED ON AMIODARONE GTT AT 1MG/MIN, DID RECEIVE LOADING DOSE OF 150MG OVER 10\". AT ~1800 PT. CONVERTING IN NSR WITH RATES IN THE 80'S. SVO2 DECREASING DOWN HIGH 50'S AFTER EXTUBATION BUT CO/CI CONT. TO BE >5.0/2.0. PACER REMAINS ATTACHED BUT OFF.\nRESP: BS DIMINISHED IN BASES, WHILE INTUBATED PT. LAVAGED AND SUCTIONED FOR THICK BLD. TINGED SECREATIONS. ABLE TO QUICKLY WEAN TO EXTUBATE ONCE PROPOFOL GTT TURNED OFF. POST EXTUBATION ABG GOOD. CT'S CONT. TO PUT OUT SEREOUS DRAINAGE ESPECIALLY WITH TURNING.\nGI/GU: HOURLY URINES CONT. TO BE >25CC, CONCENTRATED IN APPEARANCE. - BS THRU-OUT, TOLERATING SIPS OF H2O.\nSOCIAL: WIFE AND 2 SONS INTO VISIT UPDATE GIVEN, FAMILY VERY COOPERATIVE.\nPLAN: CONT. TO MONITOR SVO2, HEMODYNAMICS AND RESP STATUS CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-11 00:00:00.000",
"description": "Report",
"row_id": 1563045,
"text": "PT ALERT AND ORIENTATED X3~FLAT AFFECT. MEDICATED WITH 2MG IV MSO4. MVO2 57-6)%~, FALL TO HIGH 40'S WITH ACTIVITY. CI >2.0. PT WITH BURSTS OF AFIB~STARTED ON LOPRESSOR AND AMIODARONE DRIP DECREASED TO .5MG/MIN AT 2200. CT OUTPUT MODERATE IN PAST HOURS~DR AWARE~HE FELT THE OUTPUT LOOKED SEROUS IN NATURE. VSS STABLE, HCT AND COAGS SENT AND WNL. SERAX FOR HS, O2 CHANGED TO 5L NP WITH ADEQUATE SATS. STRONG, NONPRODUCTIVE COUGH AT PRESENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-12 00:00:00.000",
"description": "Report",
"row_id": 1563046,
"text": "ct ouput update called to dr ~will con't to montior at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-12 00:00:00.000",
"description": "Report",
"row_id": 1563047,
"text": "NEURO~INTACT. MSO4/TORDOL/SERAX @HS. FLAT AFFECT~MINIMAL CONVERSATION.\n\nCV~SR WITH MVO2 OF 58-60%. CI >2.0. PT IN AFIB AT ~0200~CI REMAINED >2.0. PT WITH 150MG AMIODARONE. DRIP AT .5MG/MIN. AFIB BRADY INTO 40'S, PT WITH MVO2 OF LOW 50'S AND CI OF 1.9-1.8. DR TO BEDSIDE~PT CONVERTED TO SLOW SR~APACED AT 80 WITH IMPROVEMENT IN HEMODYNAMICS. CT OUTPUT CONTINUES~CXR TO BE OBTAINED. LABS WNL.\n\nRESP~O2 AT 4-5L NP WITH ADEQUATE SATS. CT CONT TO DRAIN.\n\nGI~+BS. GU~U/O AMBER AND <20CCX2 HRS, DR AWARE.\n\nSKIN~R LEG WITH STERIS AND WRAPPED WITH ACE. DSG REAPPLIED TO STERNUM~INTACT WITH CLIPS. R GROIN SITE (IABP) D+I -BLEED/HEMATOMA~+DOPPLERABLE PULSES X4.\n\nPLAN~CLOSELY MONITOR CI/MVO2. DIURESIS VS VOLUME FOR LOW U/O.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-10 00:00:00.000",
"description": "Report",
"row_id": 1563041,
"text": "SLIGHTLY OOZY W MILD COAGULOPATHY TREATED W FFP & PROTAMINE W EFFECT.APROPLAN TO KEEP SEDtedTININ COMPLETED AFTER 4 HRS. EXCELLENT HEMODYNAMICS,SVO2 ON MILRINONE & IABP @ 1:1. VARIABLE ASSIST & AUGMENTATION NOTED,PLAN TO DC IABP IN A.M.IF REMAINS STABLE. EXTREMITIES COOL BUT W RAPID REFILL & DOPPLERABLE PULSES.LT. UPPER ARM RAISED RASH NOTED ON ARRIVAL.? DUE TO DRAPES. BENADRYL GIVEN PER PA,RESOLVED AFTER ~ 1 HR.PLAN TO CONTINUE PROPOFOL UNTIL A.M. & PLAN FOR EARLY EXTUBATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-10 00:00:00.000",
"description": "Report",
"row_id": 1563042,
"text": "SELF LIMITING RUN OF SVT VS VT. MG++ REPLETED,OTHER LABS WNL. TRANSCUTANEOUS DEFIB PADS PLACED PROPHYLACTICALLY.HEMODYNAMICS REMAIN EXCELLENT ON PRESENT THERAPY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-09-11 00:00:00.000",
"description": "Report",
"row_id": 1563043,
"text": "Sinus rhythm, no ectopy. IABP 1:1 with good waveforms. 2 A and 2 V pacing wires attached to pacer for back up rate only. SBP controlled with neo. Milrinone for CO, decreased by half at 0200.\nCT drainage up to 150cc/hr and down to 25 cc/hr. Resident notified of large output hours. Treated with protamine, PRBC, FFP. Hct still low and CT still draining large amts. Treated with more PRBC, possibly PLTS. No airleak. See flowsheet for specific amounts. CXR done, nothing significant per resident. Pt remainds on vent with 100%sats.\nSkin intact, incisions CDI, no drainage.\nOG tube in place, to LCS. Placement checked.\nAdequate urine output.\nPedal pulses by doppler. IABP right fem, site good.\nPlan: Pt currently receiving PRBC, one more unit ordered. Will recheck Hct, monitor CT drainage.\n"
},
{
"category": "ECG",
"chartdate": "2162-09-10 00:00:00.000",
"description": "Report",
"row_id": 243895,
"text": "Normal sinus rhythm, rate 97\nLeft axis deviation, consider left anterior fascicular block\nEarly transition\nLow voltage throughout\nConsider inferior myocardial infarct\nNonspecific lateral T waves abnormalities\nSince last ECG, heart rate increased, without ventricular premature complex\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-07 00:00:00.000",
"description": "Report",
"row_id": 244111,
"text": "Normal sinus rhythm, rate 72\nLeftward axis\nConsider inferposterior MI\nPossible ischemia\nBorderline intraventricular conduction delay\nClinical correlation suggested\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-08 00:00:00.000",
"description": "Report",
"row_id": 244112,
"text": "Normal sinus rhythm, rate 72\nLeftward axis\nConsider inferoposterior MI\nSince last ECG, no significant change\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-09 00:00:00.000",
"description": "Report",
"row_id": 244113,
"text": "Sinus rhythm, rate 66\nVentricular premature complex\nBorderline intraventricular conduction delay\nProbable inferior myocardial infarct\nLateral ST-T abnormalities\nSince last ECG, lateral ST depression less\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-07 00:00:00.000",
"description": "Report",
"row_id": 244114,
"text": "Normal sinus rhythm, rate 65\nLeft axis deviation\nOld inferior myocardial infarct\nAnterolateral ST-T abnormalities\nPartial Intraventricular conduction delay\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-06 00:00:00.000",
"description": "Report",
"row_id": 244115,
"text": "Sinus rhythm. P-R interval 0.20. Left atrial abnormality. Non-diagnostic\nintraventricular conduction delay. Lateral ST segment depressions consistent\nwith acute lateral wall ischemia. Compared to the previous tracing no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-09-06 00:00:00.000",
"description": "Report",
"row_id": 244116,
"text": "Sinus rhythm. P-R interval 0.20. Left atrial abnormality. Non-specific\nintraventricular conduction delay. T wave inversions with ST segment\ndepressions in leads I, II, aVL and V4-V6 consistent with acute lateral wall\nischemia. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
17,427 | 194,099 | Respiratory CarePt cont on prong CPAP. Remains on AMP+ gent given as ordered, alert, activewith care.A;tachypenic P; cont antibitics as ordered.#2. Will hold NPO for now.Abdomen benign. EKG- wnl. A;loving p; cont update nad support. CXR taken. Will cont during infat's hopsitlaization and remain avail post d/c. Skin w/o leiosn. Right sided mediastinal pneumothorax on CXR done for Et-tube placement. CXR done- looks" wet". 4 ext BP - wnl. Respiratory Care NotePt. CXR as above, ? CXR reviewed Et-tube in good position. Right chest prepped with betadine and sterile drapes applied. NPO for now with IV hydration. NeonatologyWeaned on FIo2 obvernight on CPAP. Occas grunting noted with cares. Close monitoring of BS. Comfortable appearing w/o distress this am. P; continue respsupport as needed.#3.Tf=60cc/kg/day,D10w infusing at PIV, NPO, BS+, no loops,voided, stooled mecx1. CXR reviewd chest tube in good position with pneumothorax resolving. ?TTN/RDS. P: Cont to support and update .#5Dev: Temps stable, pt swaddled in OAC. Skeleton normal.A- Term infant with moderate resp distress. Lab eval reassuring regarding absence of critical cyanotic HD.P- Admit NICU. Course will dictate ultimate dx. Erythro ointment and Vit K injection given as ordered. Remains in Nasal Prong CPAP 6cm, Fio2 24-38%,to maintainsats >94%, currently at o2 38%, BBS clear, equal, gruntingaudiable occassionally, mild subcostal/intercostalretracrtions present, tachypenic Resp rate in 120 NNP aware.murmur +, pale pink well perfused,A;requiredCPAP support, increased o2 requirement. Most recent CXR showed rsolved R pneumo. Nodesats or A/B's thus far today. V+S heme neg. R CT in place. Settles well withfentanyl q6hrs, given before cares. CXR this am shows resolution of significant ptx. P:Cont course of iv abx.FEN: CW 3395g (down 10g). LS courseto clr with sxn'ing. Pedi appt scheduled for Fri . Repeat PKU sent. Pt extubated. Lytes = 140/3.9/106/26. Doign well. P: Cont to monitor & support resp status.Bili: Bili this shift was 9.3/0.3, up from 8.0/0.2. Oniron and MVI. Sxn for sm-mod amts cldy sec from ETT. Desitin to butt PRN. sounds clear with mild retractions.#3O: Wt. extubatetonight- possibly d/c CT next 1-2 days ( as tolerated).A/P: Cont to monitor closely.F&N: Remains NPO. Sxn'd q6hrs for mod-lg amtyellow/white secretions. Genttrough = 1.1 & gent peak = 7.5. Will beginLytes in good range. ETT sx'ed for mod amt clear secretions. TF at 80 cc/k/d. NPN cont Abd bengin. TF ad lib no min BM 20. Fentanylgiven w/ cares w/ good effect. B.S. B.S. Br. Pt weaned to 17/4 RR 12 FIO2 21%, tol well. BS coarse-> clear. ess. Cap gas at 1430=7.34/47/70/26/0- PIPweaned to 22. Feeding ad lib demand on BM20 + BF. I/D=O/Continuing on Ampi and Gent r/t resp status.P/Cont with current Rx.2. Occass mild int sc rtxns. NPN#1 Sepsis- Remains on Amp+ Gent. CXR revealed R ptx. CXR this AM showed residual mediastinal ptx. RR 30's-60's withoccasional mild sc retractions. Dsg C/D/I. Nocrepitus noted. Updated by thisnurse. 13.6 cc Survanta as per protocol- tol well. PKU done. PO ad lib. LS c/=. Fentanyl given before cares q4hrs with goodeffect. A: Stablein RA. Cl and = BS. BS diminished R. fi02 weaning slowly. CBG: 7.31/48/75/25/-2. Fentanyl given x2 so far this shift with goodeffect. Moderate retractions. FEN=O/Remains NPO. NICU nursing note1. A/alt inFEN status. Bili - 14.9/0.3. A: Toleratingfeeds, taking adequate volumes. G&D=O/Temp stable nested on open warmer. )A/stable on present settings. Jaundice: Infant jaundiced/ruddy, sclera jaundiced.A/P: Check bili this am. Voiding qs, u/o=2.9cc/kg/hr. MD, and RTnote.#3 F/N- Abd soft,+bs, no loops. Abdbenign. Neonatology - progress NoteInfant is active with good tone. Sm mec stool x3. LS course to clr with sxn'ing.Sxn'd with cares for sm-mod amt cloudy secretions from ETT.CBG at 0200 was 7.36/49/115/29/1, rate decreased to 23 atthat time. Scant amt sero-sang dng noted in tubing. Cont to give FentanylPRN. BM20. P: Continue to monitor, put back in NC if infantstarts to spell or drift.#3: O: Current weight 3365g (-45g). Waking Q4hrs.Abd benign. TF at po ad lib. Feeds to be started this am as tolerated. A/stable in NCO2. A/stable in NCO2. CXR to be done. Murmur as before. A/^bili.P/Cont with current Rx and check check bili am. A/stablein NCO2. Wean NCO2 astol.3. FEN=O/Cont on adlib demand feeds of BM/Sim20. LS clearand =. Sm spitx1. A: ^Bili P: Check bili in am Transitional stool x2. PIV heplocked. FEN=O/Cont on adlib demand feeds of BM20. Lastdose of ampi held for loss of LArm IV. A/bottlefeedingvery well. NICU nursing note1. NICU nursing note1. V&S. NeonatologyDoign well. Wean O2 as tol.3. Sm spit x1. A&A with caresand settles well in between. Abdbenign. P/Cont to monitor for respdistress. Abd benign. Willcontinue to monitor and support. EKG to be refaxed to CH for interpretation.Wt 3375 down 25. P/Cont to monitor for respdistress.3. Willcontinue to monitor and support.FEN- Wt=3375g down 25g. A/altin FEN status. Chest tube dsg remains C/D/I. (Pleaserefer to flowsheet for assessments and po vols.) Remains on Fentynl prn - monitor blood gases - CXR taken ~1600 - wean as tolerated. Abdomen benign.Bili in 14.9 rang this am. ABdomen benign.Day of abx.Bili 9.3 yesterday. Lg spit x1. RR 30s-50s, HR 110s-140s; BS clear and =, no GFR.Murmer soft. LP done yest was benign & cx ispending. TF remain at 80cc/kg/day ofD10W with 2&1 infusing via right foot PIV without incidence.Abd exam benign. REASON FOR THIS EXAMINATION: following right sided pneumothorax FINAL REPORT CHEST, AP SUPINE Right apical chest tube is unchanged in position. The right apical chest tube is unchanged. The right apical chest tube is unchanged in position. Abg done 7.31/54/96/28/0. BSC and equal on NC with slight retractions. PIV replaced in right lg andisinfusing well. Abd benign, V/S,mec stooling. Bili yest was 9.3/0.3. Settles well inbetween cares. BS clear R. coarse L. Pt. Endotracheal tube is 1 cm above the carina. NPN 0700-1900SEPSIS: Day of Amp/ Gent. 30-60's, c/=, no WOB. The endotracheal tube remains above the carina. CTdressing is CDI. NeonatologyDoing well. Lp- done results are pending.Infant is comfortable w/ stable vital signs.RESP: Rec'd infant orally intuabted on settings of 20/5 x20. TF-80cc/kg/d- changed back toD10w w/ 2meq NACl+ 1meq KCL. The right chest tube has been removed. | 84 | [
{
"category": "Radiology",
"chartdate": "2184-01-03 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944909,
"text": " 3:38 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with PTX CT to water seal\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST: Persistent radiolucency is noted on the right. The mediastinum is\n shifted slightly to the left. Findings remain of concern for residual right\n pneumothorax. Left side down decubitus view is advised. Endotracheal tube is\n unchanged in position.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923864,
"text": "Respiratory Care Note\nPt. continues on 6cmh2O of nasal prong CPAP and FIO2 21-27%. BS clear. Continues to grunt at times and is tachypneic. FIO2 requirement has improved. To continue on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923865,
"text": "Neonatology\nWeaned on FIo2 obvernight on CPAP. Down to 21-27% . Comfortable appearing w/o distress this am. Murmur not present to my exam this am.\nRemains tachypneic. Will leave on CPAP for this am. Consider ability to wean off later this evening. WIll follow\n\nWt 3400. NPO TF at 60 cc/k/d. Will hold NPO for now.\nAbdomen benign. TF to be increased to 80 cc/k/d\n\nOn abx for 48 h r/o.\n\nJaundice not currently an issue.\n\nOn exam pink active sl small mandible. Skin w/o leiosn. Active alert. Lungs tachypneic, bilateral crackles. Abdomen benign. Genitalia normal. Neuro non-focal.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923866,
"text": "Student's notes\nExamination:\nBaby is lying supine, asleep, intermittently moving all 4 limbs.\n\nHead, Neck and Mouth:\nHead appears normal in shape, Both ant and post fontanelle patent, soft and flat\nRetrognathia noted, No other abnormal facies\nNo central cyanosis, No icterus\nNo palatal defects\nNo Neck swellings\n\nCardiovasculo-respiratory system:\nSkin colour pink-well perfused\nBaby has nasal prongs of CPAP in place. Intermittently grunting, mild subcostal retractions also present. Baby appears tachypneic but, no nasal flaring.\nLung sounds clear and equal on both sides.\nNo visible pulsations on the precordium\nS1 and S2 heard and are normal. Since baby is on CPAP, a comment on a murmer is not possible.\n\nPer Abdomen:\nAbdomen appears round, moving well with respiration\nOn Palpation, soft, no organomegaly\nBowel sounds adequate\n\nGenitalia and anal examination:\nNormal male genitalia\nA single central anal opening present, patent\n\nExtremities, spine and joints:\nNo limb anomalies\nSpine appears normal\nTest for congenital dysplasia of Hip- NEGATIVE bilaterally\n\nSkin:\nPink- well perfused\nNo other skin lesions\n\nNeurological and Behavioral examination:\nBaby is asleep, intermittently moving all 4 limbs\nNo facial asymmetry\nRooting and Suckling reflexes could not be elicited.\n\nImp: Baby still has some respirtory distress (tachypnea and intermittent grunting) and needs close monitoring. Condition: Guarded.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923870,
"text": "Neonatology Attending - Event/Procedure Note\nLarge right-sided pneumothorax with mediastinal shift noted on chest radiograph obtained for increased respiratory distress. Oxygen saturations drifting to 70% in 1.00 free-flow FiO2. Following proviodine prep, 23g butterfly introduced into 3rd intercostal space at mid-clavicular line, and 80ml air obtained. Oxygen saturations quickly returned to > 95%. Procedure tolerated well with no complications.\n\nDue to ongoing respiratory distress, infant was intubated uneventfully by , with radiographic recurrence of pneumothorax. Needle thoracentesis was repeated, followed by thoracostomy tube placement for ongoing clinical air leak (procedure notes to follow). Given radiographic and clinical evidence of poor lung compliance and possible surfactant deficiency, as well as maternal history of glucose intolerance, we will also proceed to surfactant administration and continue to titrate ventilatory support as indicated.\n\nI have updated parents regarding these events, including the risks and bebenfits of needle thoracenteses and thoracostomy tube placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923871,
"text": "Neonatal Nurse Practitioner procedure note\nIntubation procedure note:\n\nTime out observed. Infant positioned with continuous monitoring and given sedation. Under direct laryngoscopy #3.5 Et-tube through vocal cords to 10cm at the lips. Infant tolerated procedure well. CXR reviewed Et-tube in good position.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923872,
"text": "Neonatal Nurse Practitioner Procedure note\nNeonatal Nurse Practitioner procedure note: Right chest needling and chest insertion for right side mediastinal pneumothorax.\n\nTime out observed. Infant medicated with fentanyl prior to procedures. Right sided mediastinal pneumothorax on CXR done for Et-tube placement. Following a betadine prep, #23 gauge butterfly introduced at the 3rd intercostal mid-clavicular line ~100ml air aspirated.\n\nTime out observed. Infant positioned with right side up. Right chest prepped with betadine and sterile drapes applied. Lidocaine 1% given intradermly around insertion site prior to chest tube insertion. #12 Fr argle chest tube introduced into the 4th intercostal space. Chest tube placed on pleura vac to continuous wall suction. Chest tube sutured in placed at the 4cm. Infant tolerated procedure well. CXR reviewd chest tube in good position with pneumothorax resolving.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923873,
"text": "Neonatology note\nPE:\n\nNEURO: Infant nested on open warmer, quiet when left alone, active on exam, AFOS, sutures sl overlap, MAE x4.\n\nRESP: infant remains orally intubated, breath sounds = sl coarse with mild subcostal retractions.\n\nCARDIAC: Color pink/sl jaundice well perfused, soft audible murmur on exam, Gr I-II/VI, PMI ULSB, pulses palpable =x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: right chest tube dressing intact, no rashes, lesions or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal genitalia, testes descended bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923867,
"text": "SOCIAL WORK\nAsked by mother's OB to consult on this family with a hx of PPD in first preg and late PNC(34wks) with this pregnancy. Met with mother of who describes initial ambivalence re pregnancy and lack of health insurance so attempted to get PNC at free clinics. She and FOB( who is father of 2.5 yo , ) decided to continue pregnancy after extended family indicated their support. Pt describes great difficulty in obtaining Mass Health after moving here from NH and has only recently started with Mass Health. She also is getting WIC and food stamps now. The FOB works in retail and she hopes his new job will not require as much overtime as when she was pregnant, often working until 10pm.\nMother recall depression that started when she her first infant was about about 6months old. She refers to stress from situational circumstances that heightened this PPD, her parents took over care of infant and she began tx with affexor, gradually sxs resolving. Mother should be assessed for sxs of PPD while infant is hospitalized.\n\nGave motehr some resources on Headstart programs for daughter as info on Family Network support in . Will cont during infat's hopsitlaization and remain avail post d/c.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923868,
"text": "NPNOte\n\n\n#1. Remains on AMP+ gent given as ordered, alert, active\nwith care.A;tachypenic P; cont antibitics as ordered.\n\n#2. Remains in Nasal Prong CPAP 6cm, Fio2 24-38%,to maintain\nsats >94%, currently at o2 38%, BBS clear, equal, grunting\naudiable occassionally, mild subcostal/intercostal\nretracrtions present, tachypenic Resp rate in 120 NNP\n aware.murmur +, pale pink well perfused,A;required\nCPAP support, increased o2 requirement. P; continue resp\nsupport as needed.\n\n#3.Tf=60cc/kg/day,D10w infusing at PIV, NPO, BS+, no loops,\nvoided, stooled mecx1. D'stix 98.24hr lytes sent, A;\nmainatined d'stix P; cont current nutritional plan.\n\n#4. Parents visited, updated by NNP at bedside. A;\nloving p; cont update nad support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923869,
"text": "Respiratory Care\nPt cont on prong CPAP. Oxygen req has increased over course of shift. Currently in 36%. bs bilateral crackles. rr 80-100 with mild retractions. Occas grunting noted with cares. Plan to support as needed. Consider intubation and giving survanta if oxygen req escalates. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-12-31 00:00:00.000",
"description": "Report",
"row_id": 1923860,
"text": "Respiratory Care\nPt admitted to NICU for respiratory distress with gfring. Initially rec'd bbo2 then facial CPAP. CXR taken. ?TTN/RDS. Placed on +6cm H2O prong CPAP. FIO2 .30-.40. clear, rr 80's with mild retractions. Hyperoxia test done. TcO2 300mmHg with rec'ing 100% O2. Nurse . Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-12-31 00:00:00.000",
"description": "Report",
"row_id": 1923861,
"text": "Neonatology\nPatient is 3.4 kg product of G2P1->2 pregnancy to apparently healthy woman. Labor unremarkable. No sepsis risk factors. Received intrapartum abx in DR\n\nPrenatal screens complete and unremarkable. GBS?.\n\nAt delivery did well with Apgars 9,9. Over period of observation in L&D developed GFR prompting transfer to NICU.\n\nOn exam pink active infant well saturated in BBO2. Moderate GFR present. HEENT notable for recessed sl small mandible. Palate intact. Nares appear patent. Lungs coarse BS bilaterally. Cor NL s1s2 with Grade 2 SEM at MLSB. No DM. Precordium sl hyperactive. Pulses normal. Abdomen benign. Genitalia normal male. Anus patent. Hips normal. Spine intact. Neuro non-focal and age appropriate.\n\nBS 44. IV placed and repeat pending.\n\n\nHYperoxi test to > 250.\n4 ext Bps normal.\nEKG unremarkable to my review.\nCXR shows alveolar, intesrtitial pattern. Heart nl size. Sl upturned apex. Situs solitus. Skeleton normal.\n\nA- Term infant with moderate resp distress. Most likely dx indlude RFLF/AF aspiration or primary surfactanct deficiency. Course will dictate ultimate dx. Low but finite risk of sepsis. Murmur does not appear to be hemodynamically significamt. Lab eval reassuring regarding absence of critical cyanotic HD.\n\nP- Admit NICU.\n resp support with CPAP to begim\n Titration of support via clinical non-invasive and lab monitoring.\n require intubation and surf rx.\n CV monitoring.\n NPO for now with IV hydration.\n Close monitoring of BS.\n CBC diff BC.\n Abx for at least 48 h r/o.\n Usual attention to metabolic issues and bili.\n Parents aware of status and plam\n SPoke with fa at bedside.\n PMD will be at Peds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-12-31 00:00:00.000",
"description": "Report",
"row_id": 1923862,
"text": "NICU NURSING ADMIT NOTE\n\n Baby boy was admitted to the NICu at 1530 for resp distress.\nHe was born at 1419 via repeat C/s w/ Apgars of . Please see attending note for details of maternal history. Infant had + GFR- NICU team called and infant was transferred to NICU.\n\nRESP: On arrival, infant w/ loud grunting, moderate subcostal retractions. RR 50-70's. Became dusky w/ crying. Grunting improved slightly w/ facial CPAP. Breath sounds are clear and equal. CXR done- looks\" wet\". Infant placed on Prong CPAP-6cm, FIO2 30-60%. Grunting has subsided slightly and retractions are improved. Sats >94%.\nWill cont to follow closely.\n\nCV: Loud murmur audible. 4 ext BP - wnl. CXR as above, ? slightly large heart size. Infant passed hyperoxia- 300. EKG- wnl. Hr 130-140's. Color is pink and well perfused. Pulses are wnl.\n\nF&N: BW=3.400gms. NPo at present. Tf-60cc/kg/d of D10w via PIV in right hand. Initial D/s-44. Abd is round and soft w/ active bowel sounds. No void or stool yet.\n\nID: CBC w/ diff and blood cx sent- WBC-12.3, HCt-53.9, PLT-258, N-36, B-2, L-53. Due to persistnent grunting, FIO2 requirement, Amp and Gent started.\n\nDEV: Temp is stable on servo- warmer. Infant is irritable. Sucrose at bedside. Erythro ointment and Vit K injection given as ordered. ID tags checked w/ L&D nurse.\n\nPARENTS: Mom and DAd have been in to visit. Updated at bedside by Dr. and Dr. .\n\nA/P 38wk infant w/ reps distress- improved on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-01 00:00:00.000",
"description": "Report",
"row_id": 1923863,
"text": "NPN\n\n\nNPN#1 O= cont on IV Abx ampi & gent as ordered, blood cx\nresults pnd, active & alert with cares, good tone, A= r/o\nsepsis P= cont to monitor for S & S of sepsis, follow blood\ncx results, Abx as ordered\n\nNPN#2 O= remains on Prong CPAP of 6cm in mostly 21-25% FIO2,\ngrunting now intermittent, mild/mod SCR, LS clear & equal,\nhas become more tachypnic now that grunting decreasing with\nRR 70's-low 100's, CBG= 7.31/ 43/ 43/ 23/ -4....A=tachypnic,\ndecrease grunting, O2 requirement less P=cont to monitor\nresp status closely, wean O2 as tol,cont plan of care\n\nNPN#3 O= BW=3400 ( no new wt), NPO, TF at 60cc/kg/d of D10W\ninfusing well via PIV, DS= 102, abd exam softly rounded\n+active BS, trace mec stool, ou= 1.7cc/kg/hr over last 8hrs\nA=NPO/ receiving adequate hydration P= 24hr labs, I &\nO's,cont plan of care\n\nNPN#4 O= dad up to see x3 with brief bedside visits,\nupdated..asking app questions..pleased infant begining to\nsettle A= involved dad/ appropriately concerned P= cont to\nteach/ update & support\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-13 00:00:00.000",
"description": "Report",
"row_id": 1923932,
"text": "Neonatology NP Note\nDischarge Physical\nvigorous, nondysmorphic term male infant\nAFOF, sutures approximated\n+ bilateral red reflex, no eye drainage\noral mucosa without lesions\nneck supple and without masses\nclavicles intact\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused, quiet precordium, femoral pulses present\nabdomen soft, nontender and nondistended, active bowel sounds, cord dry, liver edge at RCM\ntestes descended bilaterally,\nhealing cirumcision\nno sacral anomalies\nhips stable\nnormal digits and creases\nthoracotomy tube insertion site healed on right chest with well approximated edges, no erythema\nface and trunk jaundiced\nactive with age appropriate and symmetric tone and reflexes\n\nspoke with pediatrician. Dr. by phone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-12 00:00:00.000",
"description": "Report",
"row_id": 1923928,
"text": "NPN 0700-1900\n\n\n#2Resp: Pt breathing comfortably in RA, sats 95-100%. RR\n30's-60's. Lung sounds clear and equal bilaterally. No\nretractions. No spells so far this shift. Curently day \nday spell countdown. P: Cont to monitor.\n\n#3FEN: Pt ad lib demand on BM20. Waking Q 4 hrs and bottling\napprox 65-75cc per feeding. Pt is eager and coordinated with\nPO's. Tolerating feedings well, no spits so far this shift.\nAbd soft and round, no loops, +BS. Voiding & stooling, heme\nneg. Desitin applied to bottom. Pt cont on iron & trivisol.\nP: Cont with current feeding plan.\n\n#4Par: No contact with so far this shift. Called\n and left a message notifying them that Dr. \nplans on doing infant's circumcision this afternoon (consent\nobtained previously). plan on coming in for CPR at\n1600. P: Cont to support and update .\n\n#5Dev: Temps stable, pt swaddled in OAC. Wakes for feedings.\nRemains alert and active during cares. Settles and sleeps\nwell in between care times. MAE. AFSF. Likes pacifier. Pt\nneeds carseat test and repeat PKU prior to discharge. P:\nCont to support dev needs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-12 00:00:00.000",
"description": "Report",
"row_id": 1923929,
"text": "NP NOTE\nPE: WELL APPEARING TERM INFANT PINK, JAUNDICED, BUNDLEDM IN OPEN CRIB. ALERT AND ACTIVE WITH EXAM.\nAFOF, sutures approximated, eyes clear, nares patent, MMMP\rchestb is clear, equal bs, CT dsg removed, appears to ahave stitch in place.\nCV: RRR, no murmur, pulses=2=\nAbd: soft,a ctivebs\nGU: testes in canals\nEXT: well developed, MAE\nneuro: active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-13 00:00:00.000",
"description": "Report",
"row_id": 1923930,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-100%.RR 30-60's.LS\nremain clear and equal with no work of breathing observed.No\nA's and B's or desats thus far.Day#.\n\nF/N:Infant cont's on ad lib demand shedule waking q 4 hrs.TF\nover 24 hrs.129cc's/kg/day.Infant rec'ing BM20 75-80cc's q 4\nhrs. with a yellow nipple.Appears coordinated.Weight=3.305\nup 20 grams.Abd. soft with pos bs,no loops or spits.Voiding\nand stooling heme negative.\n\nParenting: in tonight discharge teaching\ncompleted.Demonstrated a good understanding by asking\nappropriate questions.Mom demonstrated drawing up Trivisol\nand Fe with good technique.PKU drawn and sent.Car seat test\nin progress for 90 min.Appear very invested and loving.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-13 00:00:00.000",
"description": "Report",
"row_id": 1923931,
"text": "Doign well. REmains in RA. No spells.\nComfortable apeparing.\n\nWT 3305 up 20. Taking ad lib feeds well with good intake.\n\nDC summary to be dictated.\nPMD to be contact.\nPassed hearing.\nReceived HBV.\n\nPMD appointment to be arranged.\n\nReady for dc\n\nDC prep time 35 minutes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-13 00:00:00.000",
"description": "Report",
"row_id": 1923933,
"text": "Nursing Discharge Note\nBaby is breathing in RA, sats 95-100%. RR 40's-60's. Lung sounds clear and equal bilaterally. No retractions. No increased WOB. Completed 5 day spell countdown. Pt has no murmur, HR 120's-140's, BP 79/43 (56), pink & well perfused. Birth weight 3400 grams, current weight 3305 grams (up 20 gms). Feeding ad lib demand on BM20 + BF. Pt is eager and well coordinated with PO's, taking adequate volumes. Tolerating feedings well, no spits. Abd soft and round, no loops, +BS. Voiding and stooling, heme neg. Temps stable, pt wakes for feedings and remains alert and active during cares. Discharge teaching done. Pedi appt scheduled for Fri . declined VNA. plan to return to NICU for CPR, at a later date. Infant passed hearing test and carseat screen. Repeat PKU sent. Circ done, site appears to be healing well. Infant discharged home to , as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923889,
"text": "NPN 1900-0700\n\n\nRESP: Current vent settings 20/5 x20, FiO2 25-37%. PIP\nweaned from 22 to 20 at 2100 for art gas of 7.31/54/96/28/0.\nCT remains to H20 seal with scant amt serous to serosang dng\nin tubing. RR 20s-60s, tachypnic at times to 80s. Mild SC\nretractions noted x1, otherwise no retractions. LS course\nto clr with sxn'ing. Sxn'd q6hrs for mod-lg amt\nyellow/white secretions. Plan for repeat chest x-ray later\ntoday. P: Cont to monitor & support resp status.\n\nBili: Bili this shift was 9.3/0.3, up from 8.0/0.2. Infant\nis jaundice. P: Cont to monitor bili status prn.\n\nID: Infant is day 4 of 7 day course of ampi & gent. Gent\ntrough = 1.1 & gent peak = 7.5. No s/sx of infection. P:\nCont course of iv abx.\n\nFEN: CW 3395g (down 10g). NPO. TF remain at 80cc/kg/day\nof PND10 infusing via PIV without incidence. Abd exam\nbenign, +BS, no loops. Voiding, u/o= 2.2cc/kg/hr in 12 hrs.\nSm mec stool x1. Lytes = 140/3.9/106/26. DS 105. P: Cont\nto support nutritonal needs.\n\nG&D: Temps stable, nested on open warmer with boundaries in\nplace. Infant is drowsy with cares. Settles well with\nfentanyl q6hrs, given before cares. AFSF. P: Cont to\nsupport dev needs.\n\nSOCIAL: Mom & Dad in x1. Updated on infant's condition and\nplan of care. Loving, concerned parents. Mom will be\ndischarged from hospital tomorrow. Plan for family meeting\nlater today. P: Cont to update & support parents.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923890,
"text": "Neonatology\nRemains on vent. CXR this am shows resolution of significant ptx. CT to H20 seal since yesterday. Good gases on vent. Comfortable apepairng this am. Will decrease vent with hope for extubation later this am. Will attempt to extubate to NCO2. Soft murmur heard intermittently.\n\nWt 3395 down 10. Abdomen benign. TF at 80 cc/k/d. Will begin\nLytes in good range. Will begin feeds as tolerated following extubation.\n\nDay of abx for presumed pneumonia.\n\nBili 9.3 this am. WIll follow.\n\nPlan to meet with family today.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923891,
"text": "Respiratory Care Note\nPt strated shift intubated and on SIMV settings 20/5 RR 20 FIO2 21%. B.S. clear with good air entry. ETT sx'ed for mod amt clear secretions. Pt weaned to 17/4 RR 12 FIO2 21%, tol well. Pt extubated. On R/A SAO2 >97%, B.S. clear and equal with good air entry.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923892,
"text": "Neonatology note\nPE:\n\nNEURO: Infant nested on open warmer, active on exam, AFOS, sutures sl overlap.\n\nRESP: infant extubated to n/c, breath sounds = clear with mild subcostal retractions.\n\nCARDIAC: color pink/sl jaundice well perfused, no audible murmur on exam, pulses palpable = x4, cap refill <3secs, mucous membranes pink moist.\n\nSKIN: intact, right chest tube dsg intact, no rashes, lesions or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, pulses palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, teste descended bilaterally.\n\n procedure note:\n\nInfant premedicated with fentanyl. Right chest tube removed, xerform gauze, sterile 2x2 with tegaderm applied to site. Infant tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923883,
"text": "Neonatology note\nPE:\n\nNEURO: Infant nested in open warmer, active with exam, quiet when left alone on fentanyl, AFOS, sutures sl overlap, MAE x4.\n\nRESP: Infant remains orally intubated, breath sounds = sl coarse with mild subcostal retractions.\n\nCARDIAC: Color pink/sl jaundice well perfused, no audible murmur on exam, pulse palpable =x4, cap refill <3secs, mucous membranes pink and moist.\n\nSKIN: Right chest tube dsg intact, no rashes, bruises or lesions on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, testes descended bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923884,
"text": "Respiratory Care\nBaby rec'd on 26/5, R 25. 02 req this shift 31-40%. R CT in place. BS coarse-> clear. Sxn for sm-mod amts cldy sec from ETT. CBG: 7.36/49/115/29/-1; rate decreased to 23. RR 20's-40's. No spells noted. Will cont to follow closely, wean vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923885,
"text": "Neonatology Attending Note\nDOL# 3, CGA 38 wk\n\nSIMV 26/5 x 20, 30-40%\nCoarse BS with good tidal volumes\nCBG 7.36/49\nCT in place to suction\n\nP 110-120s\nMBP 52\n\nPink and jaundiced\nBili 8.0/0.2\n\nOn d3/7 Amp and Gent\n\nWt 3405 (up 50 gm)\nNPO, on TF 80 cc/kg D10 with 2NA/1K\nUO 2.9 cc/kg/hr\nStooling\nStable D-stick\n141/5.0/108/24\n\nA/P:\n infant wth pneumothorax, presumed pneumonia\nRESP: Wean vent as tolerated. Put CT to water seal and check gas and CXR later.\nCV: Stable.\nFEN: Remains NPO. Start PN and monitor lytes.\nID: COntinue on antibiotics and plan LP when more stable. Follow Gent levels.\nSOC: Plan family meeting today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923886,
"text": "NPN 0700-1900\n\n\nID: Day of Amp/Gent. Gent levels to be drawn this\nevening.\n\nRESP: Rec'd infant orally intubated on settings of 26/5 x\n25, FIO2 30%. Right chest tube set to water seal at\n1055(17cm h20) Rate and PIP weaned to settings of 24/5 x 20-\nFio2 range 30-40%. Cap gas at 1430=7.34/47/70/26/0- PIP\nweaned to 22. Current settings=22/5 x 20, FIO2-35%.\n Breath sounds are clear/slightly coarse. He is\noccasionally tachypneic( but comfortable) RR 40-80's.\n CXR at 1600= no pneumthorax. Plan is to ? extubate\ntonight- possibly d/c CT next 1-2 days ( as tolerated).\nA/P: Cont to monitor closely.\n\nF&N: Remains NPO. Tf-80cc/kg/d. To change to PN tonight.\nD/S-90. Lytes to be checked in am.\n Abd is round and soft w/ active bowel sounds and no loops.\nU/o=2.5cc/kg/hr X12hrs. No stool passed this shift.\n Mom is pumping - BM in refrigerator\n\nBILI: Infant is pink/jaundiced. Bili this am=8.0/0.2- Bili\nto be checked in am.\n\nPARENTS: Mom and Dad have been in throughout the day.\nUpdated at bedside. Pleased that has made some\nprogress and anxious to see him extubated. Mom will be\ndischarged tomorrow- needs family mtg.\n\nDEV: Pku to be sent. Temp stable on open warmer. Fentanyl\ngiven w/ cares w/ good effect.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923887,
"text": "Respiratory Care Note\nPt on SIMV settings of 22/5 RR 20 FIO2 30-40%. B.S. ess. clear with good air entry. ETT sx'ed for mod amt white secretions. CBG(7.34/47), PIP decreased to 22 from 24. Most recent CXR showed rsolved R pneumo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-11 00:00:00.000",
"description": "Report",
"row_id": 1923921,
"text": "Nursing\n\n\n#2O: in room air with O2 sats > 95% with no noted desats or\nspells. Br. sounds clear with mild retractions.\n#3O: Wt. down 40g on demand feeds, BM, waking q 4 - 5 hrs.\nBottles well, no spits. Took in 117cc/kg, . Belly\nsoft, voiding and stooling. Desitin applied to red bottom.\n#4O: in in between cares as they didin't know that\nson was on demand schedule. Both held son. Updated at the\nbedside and talked about d/c planning. Mom said that she\nhas signed consent for circ. filled out hearing screen\nform. Both hope for d/c soon.\n#5O: Problem resolved, color remains jaundiced.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-11 00:00:00.000",
"description": "Report",
"row_id": 1923922,
"text": "Neonatology Attending\n\nDOL 11 PMA 39 3/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 81/48 mean 50.\n\nFeeding ad lib on BM 20. Took 117 ml/kg yesterday. Voiding. Stooling. Wt 3295 grams (down 40).\n\nHep B vaccine given.\n\n in and up to date. desire circ.\n\nA: Stable. D3 of countdown. Feeding well.\n\nP: Monitor\n Car seat test\n Hearing screen\n Circ per ' request\n PKU # 2 before discharge\n Home when countdown complete\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-11 00:00:00.000",
"description": "Report",
"row_id": 1923923,
"text": "NPN \n\n\n\n #2. Infant conts in RA. RR 30-50 LS cl/=. Sating >91%. No\ndesats or A/B's thus far today. On day of brady\ncountdown. P: cont to monitor for AOP and document.\n\n #3. TF ad lib no min BM 20. Waking every 3.5-4hrs and\ntaking 60-75cc. \r\u0013\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-11 00:00:00.000",
"description": "Report",
"row_id": 1923924,
"text": "NPN cont\n\n\n\n Abd bengin. No spits. V+S heme neg. Desitin to butt PRN. On\niron and MVI. P: cont to support nutritional needs.\n\n #4. No contact as of this writing.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-11 00:00:00.000",
"description": "Report",
"row_id": 1923925,
"text": "NP NOTE\nPE: term ifnnat alert and active upon exam in open crib. Pink, jaundiced, well perfused in RA.\nAFOF sutures approxiamted, eyes clear, nares patent, MMMP\rChest is clear, equal bs, comfortable, CT site clean and dry.\nCV: RRR, no murmur, pulses+2=\nAbd: soft,active bs\nGU: testes in scrotum\nEXT: , \nNeuro: active wioth good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923880,
"text": "NICU nursing note\n\n\n1. I/D=O/Continuing on Ampi and Gent r/t resp status.\nP/Cont with current Rx.\n\n2. Resp=O/Remains intubated on SIMV settings of 26/5 R25,\nFIO2 30-43%. No spells or desats. Tachypneic at times but\nalso noted to \"ride\" the vent occas. Cxray done x2. Surfed\nx2 (last dose at 1700). CTube R upper chest to wall suction\nat 12cmH20. Dsg C/D/I. Scant serosang dng noted in tubing.\n(Please refer to flowsheet for assessments and CBGS.)\nA/stable on present settings. P/Cont to monitor for resp\ndistress closely.\n\n3. FEN=O/Remains NPO. TF increased to 80cc/k/d of D10W\nwith 2NaCl and 1KCl via patent/intact PIV Rhand. Abd\nbenign. (Please refer to flowsheet for assessments and\ndstick.) No spits. Voiding. Sm mec stool x3. A/alt in\nFEN status. P/Cont to monitor FEN status. Send bili \nam.\n\n4. Parents=O/Mom and dad in to visit. Updated by this\nnurse. A/loving, appropriate and actively involved family.\nP/Cont to support and educate parents.\n\n5. G&D=O/Temp stable nested on open warmer. Pain/stress\nmanaged well. Fentanyl given x2 so far this shift with good\neffect. Resting comfortably. Font S/F. A/alt in G&D.\nP/Cont to monitor and support G&D. Cont to give Fentanyl\nPRN.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-09 00:00:00.000",
"description": "Report",
"row_id": 1923916,
"text": "NPN 1500-2300\n\n\n#2 RESP O: Infant remains on RA, 02 sats >95%, no increased\nwob noted, BBS equal and clear, no gfr, no desats, no\nspells. Old Chest tube site with DSD and Tegaderm in place,\nold drainage noted inner side of DSD. A: Stable Resp P: cont\nto assess for increased wob, monitor and document all\nspells.\n#3 FEN O: Infant remains on ad lib demand feedings, infant\nawaking q 4 hours and bottles well initially but tires\neasily. Abd soft and nondistended, voiding and stooling, no\nspits this shift. A: Alt in FEN P: cont to assess for\nfeeding intolerence, wt q day, BF/PO ad lib.\n#4 PARENTING O: Mom and Dad in asking appropriate questions\nand updated on infant's progress. P: cont to inform and\nsupport family as needed.\n#5 Jaundice O: Infant remains pink and jaundiced, active and\nalert. Phototherapy off. P; Plan for bili in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-10 00:00:00.000",
"description": "Report",
"row_id": 1923917,
"text": "NPN\n\n\n2. Resp: Infant remains in RA, BBS clear/equal, comfortable\nWOB, RR 30-50's, no desats or bradys (last brady on ).CT\ndsd on R chest D&I, with old drainage.\nA: Stable resp exam, nl WOB.\nP: Cont to monitor resp exam and monitor for spells. CT dsd\nto be d/c'd this weekend.\n\n3. FEN: WT 3.335kg, down 35gr.Taking PO ad libs feeds of BM\n20, took in 93cc/kg/last 24hrs plus breastfeeding. Eagerly\nwaking for feeds, needing breaks, tiring during feed.\nAbd soft, no spits, stoolingx1 green heme neg.\nA: Tolerating PO feeds,building stamina.\nP: Monitor intake and wt gain. Started on mulivits and iron.\n\n4. Parenting: No contact from , prepare for d/c\nteaching.\n\n5. Jaundice: Infant jaundiced/ruddy, sclera jaundiced.\nA/P: Check bili this am.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-10 00:00:00.000",
"description": "Report",
"row_id": 1923918,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf, sutures approximated\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\njaundiced\nPRevious Chest tube site dressing occlusive\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-10 00:00:00.000",
"description": "Report",
"row_id": 1923919,
"text": "Neonatology Attending Progress Note:\nDOL #10\nPMA 39 2/7 weeks\nremains in RA x 36 hours, RR=30-50's, clear/equal, one brady day # spell countdown, murmur, 81/48 (mean=59)\nbili yesterday 14.9/0.3\nwt=3335g ( 30g), po ad lib\nvoiding, stooling\nImp/Plan: FT infant with apnea countdown, s/p pneumothorax\nspell countdown\nmonitor weight, encourage po feeding\nd/c planning\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-12 00:00:00.000",
"description": "Report",
"row_id": 1923926,
"text": "Nursing\n\n\n#2O: In room air with O2 sats > 92% with no noted desats or\nspells. br. sounds clear with no increase work of breathing\nnoted.\n#3O: Wt. down 40g, taking in 132cc/kg, BM eating about\nevery 4 hrs. Bottles well. Belly soft, voiding and\nstooling, no spits.\n#4O: brought in more breast milk. Will be in later\ntoday for CPR class. Hoping baby will go home .\nPassed hearing screen.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-12 00:00:00.000",
"description": "Report",
"row_id": 1923927,
"text": "Attending Note\nDay of life 12 PMA 39 \nin room air sat above 95% RR 50-60\nno spells day \nsoft murmur intermittent HR 110-130's BP 81/52 mean 61\nweight 3285 down 10 grams on ad lib demand took in 130 cc/kg/day all po\nvoiding and stooling\non iron\nstable temp in open air crib\npassed hearing screen\n\nIMP-infant making progress\nwill plan for circ prior to discharge\nwill anticipate discharge tomorrow\nwill have car seat test prior to discharge\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923881,
"text": "Neonatology - Progress Note\n\nInfant sleepy with exam. AFOF. He is pink, well perfused, no murmur auscultated. He remains vented on moderate settings. Right sided chest tube in place. Audible breath sounds bilaterally. CXR this AM showed residual mediastinal ptx. CXR late this afternoon showed smaller ptx. Abd soft, hypoactive bowel sounds. Stable temp on open warmer. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-03 00:00:00.000",
"description": "Report",
"row_id": 1923882,
"text": "NPN 1900-0700\n\n\nRESP: Received infant intubated on settings 26/5 x25. Now\nintubated with settings 26/5 x23, FiO2 33-40%. O2 sats\nmaintained 95-99%. RR 20s-40, infant rides the vent at\ntimes. No tachypnea noted. LS course to clr with sxn'ing.\nSxn'd with cares for sm-mod amt cloudy secretions from ETT.\nCBG at 0200 was 7.36/49/115/29/1, rate decreased to 23 at\nthat time. Chest tube to wall sxn at 12cmH20 as ordered.\nDsg CDI. Scant amt sero-sang dng noted in tubing. No\ncrepitus noted. P: Cont to support & monitor resp status.\n\nCV: Soft murmur heard. HR 110s-120s. Pink, sl jaundice.\nBP 69/36 m45. P: Cont to monitor cardiovascular status.\n\nID: Infant cont on 7 day course of ampi & gent. No s/sx of\ninfection. P: Cont to monitor for sepsis.\n\nFEN: CW 3405g (up 50g). NPO. TF remain at 80cc/kg/day of\nD10 with 2&1 infusing via PIV without incidence. Abd exam\nbenign. Voiding qs, u/o=2.9cc/kg/hr. No stool thus far.\nDS 97. Will check lytes & bili with next care, see lab\nflowsheet for results. P: Cont to support nutritonal needs.\n\nG/D: Temps stable, nested on servo warmer with boundaries\nin place. Fentanyl given before cares q4hrs with good\neffect. Infant remains calm & pain/stress well managed.\nAFSF. PKU done. P: Cont to support dev needs.\n\nSOCIAL: Parents in for 2 quick visits this shift. Updated\non infant's condition and plan of care by this RN. Parents\nverbalize their concern & stress re infant's stay in NICU.\nLoving, concerned family. P: Cont to update & support\nparents.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-08 00:00:00.000",
"description": "Report",
"row_id": 1923911,
"text": "NP NOTE\nPE: well developed term infant swaddled in open crib on biliblanket. Juandiced. PInk and well eprfused on low flow nasal canula. AFOF sutures approximated, eyes alert, icteric sclera.\nChest is symmetric with clear, equal bs, CT dsg D&I.\nCV: RRR, soft gr1/6 systolic murmur LUSB, pulses+2=\nAbd: soft,active bs\nGU: testes in scrotum\nEXT: well developed, MAE\nneuro: active with good tone, symmetric relfexes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-10 00:00:00.000",
"description": "Report",
"row_id": 1923920,
"text": "Neonatology - progress Note\n\nInfant is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air, breath sounds clear and equal. Chest tube dsg dry and intact. He is tolerating enteral feeds, abd soft, active bowel sounds, voiding/stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923874,
"text": "NPN\n\n\n#1 Sepsis- Remains on Amp+ Gent. BC PND.\n#2 Resp-Started out on Prong CPAP of 6cms in 35%.Increased\nretractions, RR, and int grunting. CBG of-7.21/60/37/25/-5\nlead to chest x-ray showing R sided pnemo.Needle asp of 80cc\nof air.Continued pneumo needing R chest tube now placed to\nsxn and resolving on x-ray. Draining small amt of bl in\ntubing.Dressing dry+ intact.Surf x1.Now on settings of\n26/5,r-25 in 35% down from 100%.Rpt\nCBG-7.31/48/75/25/-2.Plan for surf #2. MD, and RT\nnote.\n#3 F/N- Abd soft,+bs, no loops. Remains NPO. D/S=67.PIV\npatent infusing at 60cc/kg/day. Voiding.Sm mec x1.Wt down\n45gms.\n#4 Mom and Dad here to visit x2. Updated by MD \n.Will be back later to visit.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923875,
"text": "Respiratory Care\nBaby rec'd on prong CPAP 6 with 02 req 31-36%. RR 80's-90's with SCR. Occ grunting. BS clear, distant. CBG clotted x2 then 7.21/60/37/25/-5 @ 2400. CXR obtained after which infant crying, increased 02 req to 45%, then req further increase in 02. CXR revealed R ptx. Infant taken off CPAP and given 100% blow-by 02. Needle apiration of air by MD- 80 cc air obtained with improved Sa02. Orally by with 3.5 ETT taped @ 10 cm @ lip. CXR showed ETT in good placement, reaccumulation of air. Needle aspiration by for 100 cc and R CT placed. CXR improved. 13.6 cc Survanta as per protocol- tol well. CBG: 7.31/48/75/25/-2. No changes made @ that time as RR still 80's, fi02 requirement .50 when CBG drawn. Moderate retractions. BS diminished R. fi02 weaning slowly. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923876,
"text": "Neonatology\nReviewed films with CH radiology. No radiographic concern re potential for significant heart dfisease seen at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-09 00:00:00.000",
"description": "Report",
"row_id": 1923912,
"text": "NPN 1900-0700\n\n\n#2: O: Recieved infant in 100% NC O2, 13cc flow. Trialed in\nRA at 11pm and so far has kept sats >94%. RR 30's-60's with\noccasional mild sc retractions. LS c/=. No spells. A: Stable\nin RA. P: Continue to monitor, put back in NC if infant\nstarts to spell or drift.\n\n#3: O: Current weight 3365g (-45g). Infant is adlib feeding,\nbottling 65-70cc of bm20 each care. Abdomen benign, voiding\nand stooling, stools heme negative. No spits. A: Tolerating\nfeeds, taking adequate volumes. P: Continue to monitor.\n\n#4: O: in at start of shift. P: Continue to support\n in the care of their infant.\n\n#5: O: Infant continues on bili blanket. P: Shut off blanket\ntomorrow, check a rebound on Saturday.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-09 00:00:00.000",
"description": "Report",
"row_id": 1923913,
"text": "Neonatology Attending Note\nDay 9, PMA 39 2\n\nLast night transitioned to RA. Cl and = BS. Occass mild int sc rtxns. 1 spell past 24 hrs. +Soft murmur. HR 110-130s. BP 78/37, 56. Bili - 14.9/0.3. On phototherapy.\n\nWt 3365, down 45. PO ad lib. TFI: 130. BM20. Tol well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing term infant s/p pneumothorax progressing well now off O2 and feeding well. Is demonstrating immature cardioresp control with spontaneous bradycarycardia which will need a period of observation in the NICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-09 00:00:00.000",
"description": "Report",
"row_id": 1923914,
"text": "Nursing Progress Note\n\n\n#2 Respiratory-- O: RA with sats 97-100. No drifting/no\nspells. RR 30s-50s, HR 110s-140s; BS clear and =, no GFR.\nMurmer soft. Sl periorbital edema. Color jaundiced A: Stable\nin RA since 2300 yesterday. Occ spells P: Cont to monitor\nsats in Ra and for spells\n\n#3 Nutrition--O: Ad lib feeds. Woke for 0800 and po fed well\ntaking 66cc BM20 with sm-med spit with burp. Woken for 1200\nfeed- baby fed well at start, then tiring after 40cc. Abd\nexam benign, QVS, stooled x2 yellow, seedy. A: Tol feeds,\nall po P: Cont to enc po feeds, monitor tolerance and wt;\nstart vitamins and iron\n\n#4 Parenting-- O: No contact yet this shift. Discuss hep B\nvaccine with when they visit today\n\n#5 ^Bili-- O: Bili blanket d/c per order at 1100. Color\n jaundiced, VQS, stooling. A: ^Bili P: Check bili in am\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-09 00:00:00.000",
"description": "Report",
"row_id": 1923915,
"text": " Physical Exam\nPE: pink, mild jaundice, AFOF, breath sounds clear/equal with easy wOb, dressing on former chest tube site dry and intact, no murmur, abd soft, + bowel sounds, active with AGA tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923877,
"text": "Neonatology\nAs above required intubation and chest tube placement last night for development of right sided ptx. IMV 26/5 rate 35. CBG 7.30/52. FiO2 in mid 30s. Soft murmur heard this am. Reveiwed films with CH radiology\n\n\nCT to suction. Still bubbling.\n\nWt 3355 down 45. Tf at 60 cc/k/d. NPO will increase TF to 80 . Hold feeds for today. reconsider in am.\n\nOn abx for at least 7 day rx. BC remains negative\n\nBili 5.3. Will follow. Receheck in am\n\nFentanyl for pain control.\n\nStaff has spoken with familty throughout the am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923878,
"text": "Neonatology\nReviewed films with CH radiology. No radiographic concern re potential for significant heart dfisease seen at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-02 00:00:00.000",
"description": "Report",
"row_id": 1923879,
"text": "Respiratory Care Note\nInfant remains on SIMV 26/5, R25 - FIO2's mostly 30-30% - some increases with cares. Given 2nd dose of Survanta (13.6cc's) at 0930 today - riding vent rate when quiet, yet has some tachypnea when awake - BS sl. coarse, equal - R chest tube to suction - sx'ing mod cloudy secretions. Remains on Fentynl prn - monitor blood gases - CXR taken ~1600 - wean as tolerated. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923905,
"text": "NPNote\n\n\n#1.Antibiotics d/c'd.infant alert,active. P;problem\nresolved.\n\n#2.Remains in nasal cannula 100% 13cc, BBS clear, equal,\nmild subcostal/intercostal retractions present, resp rate\n40-70's, no spells thus far this shift. A; required\nsupplemental oxygen.P; cont to wean o2 as tolerated.\n\n#3.Tf=po adlib, MBM20 po fed tolerated, BS+, no loops,\nvoided, stooled, A; feeds tolerated. P; cont current feeding\nplan.\n\n#4.Mom called for a update, asking app questions.A; loving\np; cont update and support.\n\n#5.moderatly Jaundiced, on bili blanket,bili 16/0.3 today,\ninfant alert,active.A; moderatly jaundiced. P;bili in am,\ncont bili blanket.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923906,
"text": "1 Infant with Potential Sepsis\n5 Jaundice\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; d/c'd\n 5 Jaundice; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923907,
"text": "Lactation Consult\nMet w/ mother today to assess infant latch and mom's milk supply. Mom is pumping regularly and milk has come it. Infant is sleepy but does latch well when encouraged. Mom had a letdown and infant had audible swallows. Infant was held by cross cradle position; encouraged mom to use a breastfeeding support pillow instead of a a bed pillow. Reviewed signs of milk transfer, voids and stools and to feed the baby 8-12X per 24hrs. when at home. Gave mom written instructions and a breastfeeding diary. Also gave mom resources to call for breastfeeding help including her WIC office.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-08 00:00:00.000",
"description": "Report",
"row_id": 1923908,
"text": "NPN\n\n\nRESP- Infant continues on NC 13ccs, 100%FiO2. Trialed off\nbriefly but put back on cannula for drifting. LS clear and\n=. Mild subC to no retractions. No spells noted thus far.\nChest tube dsg intact, small amount of serous drainage\nnoted. Will continue to monitor and support as needed.\n\nFEN- Wt=3410g up35g. Infant continues on all PO ad lib\ndemand feeds of BM20. Infant took 132cc/kg/d yesterday.\nTolerating feeds well with no spits thus far. Abd is benign\nwith no visible loops and +BS. V&S. D sticks=51,102. Will\ncontinue to monitor and support. Will check another dstick\nbefore next feed.\n\nPAR- No contact thus far.\n\nBILI- Infant appears Jaundiced and continues on biliblanket.\n Bili this AM=14.9/0.3. Will continue to monitor and\nsupport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-08 00:00:00.000",
"description": "Report",
"row_id": 1923909,
"text": "Neonatology\nDoing well. Remains on low flow NCO2. Comfortable appearing. COntinuing to trial out of O2. Single brady to 61 yesterday.\n\nWt 3410 up 35 Tolerating feeds at ad lib. Abdomen benign.\n\nBili in 14.9 rang this am. Will continue photorx through am and recheck on Saturday\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-08 00:00:00.000",
"description": "Report",
"row_id": 1923910,
"text": "NICU nursing note\n\n\n2. Resp=O/Cont in NCO2 FIO2 100%, 13cc/min flow. NO spells\nor desats. (Please refer to flowsheet for resp\nassessments.) A/stable in NCO2. P/Cont to monitor for resp\ndistress.\n\n3. FEN=O/Cont on adlib demand feeds of BM20. Waking Q4hrs.\nAbd benign. (Please refer to flowsheet for assessments and\npo vols.) Lg spit x1. Voiding/stooling. A/bottlefeeding\nvery well. P/Cont to monitor FEN status.\n\n4. =O/No contact with so far this shift.\n\n5. Bili=O/Cont on bili blanket. Remains jaundiced. P/Cont\nwith current Rx and shut off blanket tomorrow per team\norders.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-06 00:00:00.000",
"description": "Report",
"row_id": 1923901,
"text": "NICU nursing note\n\n\n1. I/D=O/Cont on Ampi and Gent, now day 7:7 day course.\nP/Cont with current Rx until course completed.\n\n2. Resp=O/Cont in NCO2 FIO2 100%, 13cc/min flow. No spells\nor desats. (Please refer to flowsheet for resp\nassessments.) A/stable in NCO2. P/Cont to monitor for resp\ndistress. Wean O2 as tol.\n\n3. FEN=O/Cont on adlib demand feeds of BM/Sim20. Abd\nbenign. (Please refer to flowsheet for assessments and po\nvols.) Sm spit x1. Voiding. Transitional stool x2. A/alt\nin FEN status. P/Cont to monitor FEN status.\n\n4. Parents=O/Dad called x1. and mom will be in to visit\nlater today. Updated by this nurse. P/Cont to support and\neducate parents.\n\n5. Bili=O/Started on bili blanket at 1200. A/^bili.\nP/Cont with current Rx and check check bili am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923902,
"text": "NPN\n\n\nRESP- Infant remains stable on NC 13ccs 100% FiO2. LS clear\nand =. No increased WOB noted. No spells, no desats. Will\ncontinue to monitor and support.\n\nFEN- Wt=3375g down 25g. Ad lib demand feedings of BM20.\nTolerating feeds well with 1 spit thus far. Abd is benign\nwith no visible loops and +BS. V&S heme negative. Will\ncontinue to monitor and support.\n\nID- Infant on day 7 of 7 day course of Ampi and Gent. Last\ndose of ampi held for loss of LArm IV. No S/S of infection\nnoted. Will continue to monitor for signs of infection.\n\nPAR- No contact thus far.\n\nDEV- Temps remain stable swaddled in OAC. A&A with cares\nand settles well in between. Becomes sleepy with feeds.\nWakes for feeds. Brings hands to face and sucks on pacifier\nfor comfort. Will continue to support developmental growth.\n\nBili- Infant continues on BiliBlanket. Bili this\nAM=16.0/0.3. Will continue to monitor and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923903,
"text": "Neonatology\nDoign well. REmains in low flow NCO2. No spells. Comfortable apeparing. Murmur as before. 4 ext BPs have been normal. EKG to be refaxed to CH for interpretation.\n\nWt 3375 down 25. TF at po ad lib. Took in 80 cc/k/d yesterday. Abdomen benign. Will monitor intake.\n\nAbx completed after 7 day course.\n\nBili stable at 16.\nWill recheck bili in am. Continue photorx.\n\nContinue as at present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-07 00:00:00.000",
"description": "Report",
"row_id": 1923904,
"text": "Neonatology note\nPE:\n\nNEURO: Infant swaddled in open crib, active on exam, AFOS, sutures sl overlap, MAE x4\n\nRESP: infant in n/c, breath sounds = clear with mild subcostal retractions.\n\nCARDIAC: color pink/jaundice well perfused under bili blanket, soft audible murmur on exam, GrI/VI, PMI ULSB, pulses palp =x4, cap refill <3secs, mucous membranes pink and moist.\n\nSKIN: right chest tube dsg dry & intact, no rashes, lesions or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, testes descended bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-05 00:00:00.000",
"description": "Report",
"row_id": 1923895,
"text": "Neonatology\nDoing well. Remains in NCO2 at low flow. Comfortable. CXR to be done. CT out last night. Murmur continues soft. Will continue to follow.\n\nWt up 55. Feeds to be started this am as tolerated. ABdomen benign.\n\nDay of abx.\n\nBili 9.3 yesterday. Will repeat this am.\n\nFamily meeting held yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-05 00:00:00.000",
"description": "Report",
"row_id": 1923896,
"text": "NICU nursing note\n\n\n1. I/D=O/Cont on Ampi and Gent, now day 6:7 day course.\n\n2. Resp=O/Cont in NCO2 FIO2 100%, 13cc/min flow. No spells\nor desats so far this shift. Chest tube dsg remains C/D/I.\n(Please refer to flowsheet for resp assessments.) A/stable\nin NCO2. P/Cont to monitor for resp distress. Wean NCO2 as\ntol.\n\n3. FEN=O/Adlib feeds of BM/ 20 started at 1300 and IVF\nd/c'd per team orders. PIV heplocked. Abd benign. (Please\nrefer to flowsheet for assessments and po vols.) Sm spit\nx1. Voiding. No stool so far this shift. A/alt in FEN\nstatus. P/Cont to monitor FEN status. Will check dstick\nprior to next feed. Send bili am.\n\n4. Parents=O/Mom called x1. be in later to visit.\nUpdated by this nurse. P/Cont to support and educate\nparents.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-05 00:00:00.000",
"description": "Report",
"row_id": 1923897,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant on open warmer, heat off, nasal cannula O2\nSkin: warm and dry; color pink; rash\nHEENT: anterior fontanel open, level; saggital suture overriding;\nChest: breath sounds clear/=; minimal retractions\nCV: RRR, soft systolic murmur left sternal border; normal S1 S2; femoral pulses +2\nAbd: soft; no masses; + bowel sounds; cord on/drying\nGU: Normal male; testes descended\nExt: moving all\nNeuro: alert; + suck; + grasps; symmetric tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-06 00:00:00.000",
"description": "Report",
"row_id": 1923898,
"text": "NPN Noc\n\n\n#1 ID: Infant acting appropriately, temp is stable. Cont D\n7/7 Amp and Gent. P: Finish abx course, monitor for sx of\nsepsis.\n#2 Resp: Infant cont on NC 100% 13cc, sats consistently at\n100%, however infant drifts quickly to low 90's when cannula\nis removed. 30-60's, c/=, no WOB. No spells, CT site is\nC/D/I. P: Cont to monitor resp status, reeval need for NC in\ntime.\n#3 FEN: Infant is ad lib demand, waking about every 4 hours\nfor feeds. Taking 35-50cc per feed of BM20. Abd benign, V/S,\nmec stooling. D stick 71 and 79. PIV is heplocked. P: Cont\nto monitor FEN status.\n#4 Parents: No contact o/n. P: Cont to encourage parental\ncalls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-06 00:00:00.000",
"description": "Report",
"row_id": 1923899,
"text": "Neonatology\nDoing well. Remains in 13 cc NCO2 flow. Comfortable. CXR shows resolution of ptx after CT dced.\n\nWt 3400 down 50. Tolerating feeds at ad lib\n\nCompleting abx course.\n\nBili 16. Will start photorx and recheck in am.\n\nAwwiting weaning from O2 and demonstrated ability to take adequate po.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-06 00:00:00.000",
"description": "Report",
"row_id": 1923900,
"text": " Physical Exam\nAwake and alert in open crib. BSC and equal on NC with slight retractions. Right CT dressing secure with no new drainage. No audible murmur, well perfused with normal pulses. ABD soft and rounded with active BS, no HSM or masses, cord dry. Jaundiced. Normal GU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923893,
"text": "NPN 0700-1900\n\n\nSEPSIS: Day of Amp/ Gent. Lp- done results are pending.\nInfant is comfortable w/ stable vital signs.\n\nRESP: Rec'd infant orally intuabted on settings of 20/5 x\n20. CXR this am revealed no pneumothorax ( w/ chest tube to\nwater seal since 11am yesterday). Support weaned to 17/4 x\n12, FIO2 remained at 21%. Breath sounds are clear. RR\n30-60's and comfortable. LP was done w/o incident and\ninfant was extubated to room air shortly after that. Sats\ndrifted to low 90's- placed in NCO2, 50cc,100%. Sats has\nimproved and remain>95%. Medicated w/ 1mg/kg of Fentanyl at\n1500- and chest tube removed at 1515- site is covered w/\nDSD- no drainage noted. Infant is comfortable, rr have not\nincreased, no retractions. ? obtain CXR later tonight.\n\nF&N: Remains NPO at present. TF-80cc/kg/d- changed back to\nD10w w/ 2meq NACl+ 1meq KCL. PIV replaced in right lg and\nisinfusing well. Abd is benign. U/o=2.8cc/kg/hr x 12hrs.\nHad a large mec stool x 1 today.\n ? to begin enteral feeds later tonight or tomorrow. BM in\nrefrigerator.\n\nPARENTS: Mom was discharged today. Updated at bedside.\nSigned LP consent and met w/ Dr. to review \nNICU course, estimated discharge date. Parents are very\npleased that he has made progress in past couple of days.\nThey plan to return tonight.\n\nBILI- Infant is jaundiced but is stooling . No bili\ntomorrow. Bili this am=9.3/0.3.\n\nCV: SOft murmur audible. 4 ext BP's wnl. Color is\npink/jaundiced. Hr 100's to 130's.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-05 00:00:00.000",
"description": "Report",
"row_id": 1923894,
"text": "NPN 1900-0700\n\n\nRESP: Infant received on NC 100% FiO2, 25cc flow. Flow\nweaned to 13cc over night. RR 30s-60s. LS cl/=. Rare mild\nSC retractions noted, but mostly has no retractions. CT\ndressing is CDI. No bradys or desats. P: Cont to support &\nmonitor resp status.\n\nBili: Infant is jaundice. Bili yest was 9.3/0.3. P: Cont\nto follow.\n\nID: Infant is now day 6 of 7 day course of ampi & gent for\npresumed pneumonia. LP done yest was benign & cx is\npending. P: Cont to monitor for s/sx of infection.\n\nFEN: CW 3450g (up 55g). NPO. TF remain at 80cc/kg/day of\nD10W with 2&1 infusing via right foot PIV without incidence.\nAbd exam benign. Voiding, u/o = 2.1cc/kg/hr in 24 hours.\nNo stool this shift. P: Cont to support nutritonal needs.\n\nG&D: Temps stable, swaddled on off warmer. Infant is\ndrowsy with cares & does not open eyes. Settles well in\nbetween cares. AFSF. P: Cont to support dev needs.\n\nSOCIAL: No contact with family thus far. P: Update &\nsupport parents when possible.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-01-04 00:00:00.000",
"description": "Report",
"row_id": 1923888,
"text": "Respiratory Care Note\nPt. began shift on SIMV 22/5 R 20 FIo2 has been 25-37%. BS clear R. coarse L. Pt. was sx'd for lrge thick yellow plug. Abg done 7.31/54/96/28/0. Chest bounding--PIP decreased by 2 to 20. To follow.\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-04 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 944956,
"text": " 8:26 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: follow up previous findings\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with hx of pneumothorax\n REASON FOR THIS EXAMINATION:\n follow up previous findings\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE VIEW OF THE CHEST\n\n CLINICAL HISTORY: Three-day-old premature infant with history of\n pneumothorax.\n\n Comparison is made with the film dated at 3:47 p.m. The ET tube tip\n is at the thoracic inlet. The right apical chest tube is unchanged in\n position. There is no pneumothorax. A small amount of subcutaneous air is\n seen in the right lateral chest wall. The lungs are otherwise clear\n bilaterally.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-04 00:00:00.000",
"description": "PL BABYGRAM CHEST DECUB ONLY (71035) PORT LEFT",
"row_id": 944957,
"text": " 8:27 AM\n BABYGRAM CHEST DECUB ONLY () PORT LEFT Clip # \n Reason: follow up previous findings PLEASE DO LEFT SIDE DOWN\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with hx of pneumothorax\n REASON FOR THIS EXAMINATION:\n follow up previous findings PLEASE DO LEFT SIDE DOWN\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE VIEW OF THE CHEST IN THE LEFT LATERAL DECUBITUS POSITION\n\n CLINICAL HISTORY: Followup pneumothorax.\n\n No pneumothorax is identified. The right apical chest tube is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-12-31 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944478,
"text": " 4:02 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: Term infant with resp distress, small mandible.\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n Term infant with resp distress, small mandible.\n ______________________________________________________________________________\n FINAL REPORT\n Full-term baby with respiratory distress and heart murmur. The heart is\n enlarged and there is an uplifted cardiac apex and a somewhat narrow\n mediastinum. There is increase in the pulmonary vascular markings concerning\n for shunt vascularity. There are no pleural effusions. No osseous\n abnormalities are seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-05 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 945093,
"text": " 12:34 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: EVALUATE LUNGS, CHEST TUBE DISCONTINUED \n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RIGHT PNEUMOTHORAX\n REASON FOR THIS EXAMINATION:\n EVALUATE LUNGS\n CHEST TUBE DISCONTINUED \n ______________________________________________________________________________\n FINAL REPORT\n The cardiac silhouette is in the upper limits of normal. The right chest tube\n has been removed. There is no evidence of pneumothorax. The lungs are clear.\n No osseous abnormalities are seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-02 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944797,
"text": " 3:40 PM\n BABYGRAM (CHEST ONLY); -77 BY DIFFERENT PHYSICIAN # \n Reason: following right sided pneumothorax\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with right ptx and chest tube.\n REASON FOR THIS EXAMINATION:\n following right sided pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP SUPINE\n\n Right apical chest tube is unchanged in position. Endotracheal tube is 1 cm\n above the carina. Asymmetric lucency is noted, increased on the right side\n suggesting residual pneumothorax. Left lung is clear. Left lateral decubitus\n view is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-02 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944680,
"text": " 1:22 AM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: EVALUATE LUNGS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RIGHT PNEUMOTHORAX, RESPIRATORY DISTRESS\n REASON FOR THIS EXAMINATION:\n EVALUATE LUNGS\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM PERFORMED ON AT 1:20 A.M.\n\n Comparison is made with an examination performed earlier on the 19th. Since\n that time, the right pneumothorax has increased in size. There is shift of\n the mediastinum to the left.\n\n Since the last exam, the patient has been intubated. The endotracheal tube\n ends above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-02 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944722,
"text": " 8:42 AM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: s/p right chest tube placement.\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with right pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p right chest tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PERFORMED ON AT 8:35 A.M.\n\n Since our last exam earlier this morning, the right pneumothorax has slightly\n increased in size. It is now small, but much decreased since pre-thoracostomy\n tube insertion. The interstitial emphysema is less visible.\n\n The endotracheal tube remains above the carina. The chest tube is in the\n right apex.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-02 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944683,
"text": " 2:35 AM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: EVALUATE LUNGS, RIGHT PNEUMOTHORAX, CONFIRM CHEST TUBE POSIT\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, RIGHT PNEUMOTHORAX\n REASON FOR THIS EXAMINATION:\n EVALUATE LUNGS, RIGHT PNEUMOTHORAX\n CONFIRM CHEST TUBE POSITION\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION OF THE CHEST PERFORMED ON AT 2:33 A.M.\n\n Since our last exam earlier this morning, a right pleural tube has been\n introduced. The pneumothorax is much decreased in size. There is continued\n irregular aeration of the right lung, which is probably due to loculated\n interstitial air.\n\n The patient remains intubated with the endotracheal tube just above the\n carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-01-02 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 944677,
"text": " 12:23 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: respiratory distress\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with increase work of breathing\n REASON FOR THIS EXAMINATION:\n respiratory distress\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n This is our initial radiograph on this newborn with respiratory distress.\n\n The lung volumes are slightly low, and the lungs mildly granular. The\n findings would be consistent with mild hyaline membrane disease.\n\n\n"
}
] |
|
7,820 | 190,399 | 83 y/o M w/ CAD, CHF, DM, recurrent PNA admitted to ICU with hypoxic respiratory failure. Brief hospital course outlined below. . The patient was admitted to the ICU and intubated for hypoxic respiratory failure. The cause of his hypoxia was felt to be largely secondary to CHF exacerbation with volume overload. There was also a suspected component of aspiration pneumonia with thick purulent secretions noted by endotracheal suctioning. For his volume overload, he was diuresed aggressively with IV lasix, which he tolerated well. For his pneumonia, he was treated broadly with vancomycin, ceftaz, flagyl with gradual improvement of his oxygen requirement and reduction of secretions. He will complete his antibiotic course on . He was weaned of ventilatory support by and was quickly weaned down to nasal cannula with maintenance of oxygen saturation >97%. . Given his history of PE, he was continued on heparin IV anti-coagulation and transitioned to coumadin on . . In order to evaluate his cardiac function, an ECHO was performed which confirmed systolic heart failure with an EF of 20-25% in the setting of 2+ MR. was maintained on a medical regimen of b-blocker, ace-I, digoxin and daily lasix (see medication list for discharge doses) . Of note, initial imaging studies revealed evidence of gas in gall bladder wall. However repeat imaging did not confirm this finding and liver function tests remained stable throughout. No further evaluation was performed on this hospitalization. | GENERALIZED 2+ NON PITTING EDEMA NOTED.RESP: RECEIVED PT INTUBATED WITH VENT SETTINGS AC 12/600/ 60/ 10. amt of edema noted.GI/GU: + BS noted. Increased LVEDP.Mild-moderate mitral regurgitation. On Vanco, flagyl and ceftazidime. Sxd mod amts clear sputum. "Pt optimally PEEP'd" per results. Currently vented on a/c with occasional breaths noted above set rate. AWARE OF PLAN FOR BRONCH AND THORACENTESIS TODAY.PLAN:1. PT REMAINS AFEBRILE.PLAN: MONITOR ABGS FOR POSS EXTUBATION THIS AM. Continue vanco and flagyl, ceftazadime. BP labile 66/30 (post intubation). Mild (1+)aortic regurgitation is seen. PT IS IN DIRE NEED OF ALINE- TEAM IS AWARE- PLANS FOR LINE PLCMT.GI: ABD IS SOFT, NON-DISTENDED. ABGs cont to improve; able to lower PEEP and switch to PSV[ABG ]. CV: Sinus rhythm with rare to occn. CVP 6-10. cortisol level sent, cosyntropin given. Tf respalor fs at 60cc/hr via ogt, minimal residuals. Mild mitral annularcalcification. ON PT PRESENTED TO OSH- CXR SIGNIFICANT FOR BILATERAL EFFUSIONS. REPOSITIONED AND RETAPED BY THIS RN. Plan is to extubate this am. Stat electrolytes sent, K 4.1, Mg 1.9, Ca 8.0. ABG reveals Compensated metabolic alkalosis w/ hyperoxia. ABD soft, BS+, no BM this shift, please send stool C.diff x3. ABGS SENT,(SEE CAREVIEUW FOR RESULTS). Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. GI/GU: Abdomen softly distended with + bs. VERSED AND FENTANYL BOLUSES GIVEN FOR AGITATION.CV: HEART RYTHM SR WITH OCC PVCS, HR 80-100S. RR regular and unlabored. Repleat lytes as required. Spec sent MD. Will cont with vent support. The remaining segmentsare hypokinetic. Abp 100's to 130's systolic, site wnl, waveform sharp but can be positional. PIV's x 3 #18g. Resp Care Note:Pt cont intub with OETT sedated and on mech vent as per Carevue. Foley in place w/ adequate UO.ENDO: Elevated BG w/ SSI coverage given.ID: On triple antibiotics at this time. MAINTAIN SBP 90S-120S. bld cx pnding. bld cx pnding. agressively diuresed for extubation. Continues on flagyl, Vanco and ceftazidime. Pan cx'd. continues on Vanco, Ceftazidime, and flagyl. Prednisone taper. ps weaned to with goodabg/tidal vols. MAG 1.9, REPLETED, PTT 80.5, CONT HEPARIN 1400U/HR. sputum cx. mdi's given. resp. resp. vent per carevue. Plan: extubate this AM. coags pnding. Sxned Q4/hrs for small, bld tinged, thick.CV: 80-95 NSR. LS clear ~2hrs after Lasix and aformentioned interventions.Neuro: Remains on Fent. Follow digoxin level and QTc. Icreased temp and secretions ? F/U with swallow study once extubated and appropriate. lactate 1.1-1.2. HR=79-91 NSR with Lt BBB and rare PVC's noted. ID: Remains on Ceftaz., flagyl and vancomycin. mdi's started. TF's on hold d/t possible extubation. HEP DRIP 1400U/HR. MDI's ordered and given. to freq. BBS coarse-clears to snx. 99.7 oral. extubation. extubation. with freq. CURRENTLY PT OFF SEDATION. SENNA GIVEN. LAST ABGS: 7.46, 53, 107, 39. ABG on this 7.44/40/96. added to med regimne. occ. sbp 95-144. cvp 7-9. Vent changes made,MDI's given, abg sent. carept. carept. with pul. Foley cath draining adequate amounts UO; -3L LOS, slightly - since MN. Sbp 75-138. to follow CXR's, and abgs. +pp. Warfarin added back to regimen, once INR ~2, can D/C Heparin gtt. SBP 110S, CVP:. gtt's, titrated for light sedation. prelim. turning.ID: 99.9 tmax. urine cx (-). Left antecub with probable phlebitis, seems to be improving.ID: tmax 101 rectally. LS clear upper, diminished lower. Abp 100's to 170's systolic. F/U with cx data. BNP was7937. Need to replete K+. Lasix this am for fluid removal. lasix given. 7.47/54/112. pvc's noted. white sputum andrequires frequent sx'ing. Check coags including INR and DC Heparin gtt as appropriate pnding INR. LS currenlty clear. perrl 3mm/bsk. perrl 3mm/bsk. Perrl 3mm/bsk. Sputum spec. FIRST PTT:82.4. Cont. cont. Cont. Cont. Cont. COnt. new sputum spec. LAST 24 HR -933. Midaz. aware.with agitation SBP 120-140's. Sinus rhythm. A/O x3. Respiratory TherapyPt presents on PSV 10/8 .4. CHF vs. infective process. Left bundle-branch block.Compared to the previous tracing of occasional ventricular ectopy hasappeared. Within the right common femoral vein, a small nonocclusive clot is visualized. 10:52 AM BILAT LOWER EXT VEINS PORT Clip # Reason: EDEMA ? FINDINGS: ET tube, right internal jugular central venous line, and NG tube appear unchanged. PE No contraindications for IV contrast FINAL REPORT INDICATION: Dyspnea, history of prior pulmonary embolism, rule out pulmonary embolism. Again seen is endotracheal tube, nasogastric tube and right-sided central line in unchanged position. LIMITED RIGHT UPPER QUADRANT ULTRASOUND. Right common femoral vein nonocclusive thrombus. Allowing for this factor, multifocal predominantly alveolar pulmonary opacities are grossly unchanged as well as bilateral pleural effusions. Left superficial femoral vein nonocclusive thrombus. Comparison of the lung fields demonstrates rather unchanged appearance of the previously described bilateral (more on the right than left) parenchymal infiltrates consistent with multifocal pneumonia. Unchanged pulmonary abnormalities consistent with multifocal pneumonia and the presence of CHF. Right internal jugular central venous line tip overlies the SVC. FINAL REPORT INDICATION: Patient intubated, pneumothorax versus skinfold. Bilateral pleural effusions are again noted. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. A right internal jugular approach central venous line is seen and terminates overlying the SVC at a level 3 cm above the carina. -scale and Doppler son were performed of the right and left common femoral, superficial femoral, and popliteal veins. PE Admitting Diagnosis: HYPOXIA Field of view: 36 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) | 59 | [
{
"category": "Nursing/other",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 1367105,
"text": "Resp care: Pt remains intubated via #8 ETT rotated and advanced to 27cm MD. . BS decreased bilat. Sx'd for copious amt thick BRB sputum. Spec sent MD. PEEP ^'d to 20cm overnoc. ABG reveals Compensated metabolic alkalosis w/ hyperoxia. Esophageal balloon study done. \"Pt optimally PEEP'd\" per results. PEEP weaned to 17cm. ABG . No other vent changes made this shift. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 1367106,
"text": "MICU NPN 0700-1900\n\nREVIEW OF SYSTEMS:\nNEURO: sedated with fent 50mcg/hr and versed 4mg/hr, weaned to 2mg/hr, no daily wake up this am due to hypoxia and increase peep oxygen requirements, unresponsive, withdraw to painful stim,\nCV: echo done Ef 20-25%, LV enlargement with severe regional dysfunction, + MR, 1+aortic regurg, pulm hypertension, HR 70-80 NSR freq PVC's, K 3.4 repleted, BP 90-118/, po captopril 6.25mg x1 per BP paramaeters, SBP 94-96/ after dose, CVP 8-18, cont lasix gtt at 6mg/hr\nRESP: remains intubated with A/C 12/600/60%/20 peep, pao2 138, peep wean to 17, sat remains 99%, bilat breath sounds decreased t/o. CXR worsening bilat pulm edema, bilat pleural effusions\nGI: abd soft +bs, no stool, tube feeds respalor started at 10cc/hr, goal is 60cc/hr\nGU: foley intact with clear yellow urine 80-100cc/hr\nSKIN: cont kinair bed, skin intact, buttock with rash barrier cream applied\nACCESS: left rad aline placed, LIJ triple lumen intact\nSOCIAL: son and wife at bedside all day, updated on plan of care by this rn several times, met briefly with intern for update at bedside\n\nPLAN: cont supportive care, cont sedation for comfort, diurese with lasix gtt, follow lytes closely, prn sliding scale potassium and magnesium, tube feeds advance to goal of 60cc/hr\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-29 00:00:00.000",
"description": "Report",
"row_id": 1367108,
"text": "Shift Note 1900-0700\nCV: HR 70-80's, NSR with 2 episodes of 6beat run Vtach and 1 brief episode of SVT 150's (symptomatic with drop in SBP to 80's, however patient broke out of rhythm without intervention). Stat electrolytes sent, K 4.1, Mg 1.9, Ca 8.0. Repleted with 20meq KCL, 1gm Mg. Last night K 3.5 and repleted with total 60meq KCL.\n\nResp: Pt received on vent settings AC 12/600/60%/14. ABG showing PaO2 166 and FiO2 weaned to 40% with correlating ABG 7.44/41/116. AM ABG 7.44/53/126/37...RT aware, however no vent changes made since patient on lasix gtt and compensating with no change in pH. BBS clear-coarse, diminished bases. Snx thick blood-tinged secretions. Pt to have bronch performed, but plans are to diurese patient first and then reassess. CTA (-) PE, showing pleural effusions and pulmonary edema.\n\nNeuro: Pt sedated on fentanyl 50mcg and versed 2mg. Opens eyes to verbal stimulus and following simple commands. Denies pain or discomfort.\n\nGI/GU: Abdomen soft, BS present. Respalor TF's infusing at 30cc/hr with no residual. Goal 60cc/hr; advance 10cc/hr Q6hrs. Foley draining adequate UO, 100-200cc/hr on lasix gtt which has been weaned to 4mg/hr since patient already -1L today and goal -1-2L/day. -2.5L LOS and -1.6L at MN. No BM this shift.\n\nID: Afebrile. On Vanco, flagyl and ceftazidime. Vanco trough drawn last night 14.2. Resident aware and no changes made in dosage. Per pharmacy, patient needed to be switched to standard vanco dosing times. Trough drawn at 0000 and dose given. Next dose then due again at 8am. Resident aware.\n\nSocial: Family present at bedside last night. Staying at Inn and stated that they would be back this am.\n\nPlan: Follow lytes\n Titrate lasix gtt to goal -1-2L.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-29 00:00:00.000",
"description": "Report",
"row_id": 1367107,
"text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds bronchial @ dim @ bases suct sm th bldy sput. ABGs improving gas exchange able to wean FIO2 can begin to slowly wean PEEP. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-29 00:00:00.000",
"description": "Report",
"row_id": 1367109,
"text": "MICU NPN 0700-1900\n\nREVIEW OF SYSTEMS:\nNEURO: lightly sedated with fent 50mcg/hr and versed 2mg/hr, arouse to voice, moving all extrem purposefully, follow commands, nod yes/no appropriately, anxious with family hovering over bed touching him and asking him many questions, bolused with versed 2mgx2 and fent 25mcg x1. denies pain\n\nCV: HR 70-80 SR, freq pvc's, no runs VT or SVT, lytes repleted per sliding scale, BP 103-120's/48-50, MAP 65-75, cont lasix gtt at 4mg/hr, receiving all po cardiac meds captopril increased to 12.5mg, digoxin added x1 0.25mg, and 0.125mg x2 doses ordered. remains grossly edematous, + edema in extremities. extrem warm easily palpable pulses\n\nRESP: remains intubated, peep weaned to 10 with acceptable ABG, current vent settings a/c 40%/12/600/10peep, last abg 7.45/52/83/37/9. O2 sat >96%. Bilat breath sounds clear upper decreased bases, suctioning for blood tinged secretions\n\nGI: abd soft +bs no stool, po colace and po senna given, tube feeds respalor at goal of 60cc/hr\n\nGU: foley intact with clear yellow urine, ouptu 100-200cc/hr, current fluid balance -1L negative\n\nACCESS: RIJ tl, R rad aline\n\nSKIN: grossly intact\n\nSOCIAL: family at bedside since 8am, many questions, updated during am rounds by physicians, encouraged to over-stimulate him, as he is lightly sedated\n\nPLAN: cont lasix gtt goal 2L negative, follow lytes closely, wean peep as tol, follow tolerance to increased captopril\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-29 00:00:00.000",
"description": "Report",
"row_id": 1367110,
"text": "Respiratory Therapist\nBreath sounds exhibit few crackles, suctioned for copious thick yellowish and blood-tinged sputum, PEEP weaned down from 14 to 10, last ABGs on 600 x 12 40% +10 revealed fully compensated metabolic alkalosis with normoxemia.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-30 00:00:00.000",
"description": "Report",
"row_id": 1367111,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse and bronchial @ bases. ABGs cont to improve; able to lower PEEP and switch to PSV[ABG ]. Cont wean and perhaps extub later today or tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-30 00:00:00.000",
"description": "Report",
"row_id": 1367112,
"text": "NSG 7AM-7PM.\nSEE CAREVIEW FOR DETAILED V/S, IO, LABS.\n\nNEURO: PT ALERT, AWAKE AT TIME, ATTEMPT TO REPOS SELF IN BED. OBEYS COMMANDS CONTINUOUSLY. VERSED AND FENTANYL BOLUSES GIVEN FOR AGITATION.\n\nCV: HEART RYTHM SR WITH OCC PVCS, HR 80-100S. NO EPISODE OF V TACH. MAINTAIN SBP 90S-120S. TOLERATING CARDIAC MED REGIME. CONTINUE ON LASIX 4MG/HR, LARGE AMOUNT OF URINE OUTPUT. GOAL 2 LITER NEG. ACTUAL FLUID BALANCE FOR 24HR: -1682 AT MIDNIGHT. GENERALIZED 2+ NON PITTING EDEMA NOTED.\n\nRESP: RECEIVED PT INTUBATED WITH VENT SETTINGS AC 12/600/ 60/ 10. WEANED TO CPAP 40/600/5. PT MAINTAINS SPONT BREATH 13-16. GOAL TO WEAN OFF FROM VENT AND POSS EXTUBATION TODAY. ABGS SENT,(SEE CAREVIEUW FOR RESULTS). LUNG SOUNDS CLEAR AND COARSE AT BASES. RESP EFFORT UNLABORED AND EVEN. NO RESP DISTRESS.\n\nGI: ABD SOFT POS BS, NO BM. GT TUBE DELIVERING RESPAROL AT 60CC/HR. NO RESIDUAL. GT CLAMPED THIS AM, TO MAINTAIN PT NPO FOR POSS EXTUBATION.\n\nGU: FOLEY PATENT DRAINING LARGE AMOUNT OF CLEAR YELLOW URINE. BLOOD TINGED AT TIME. MAINTAIN ON LASIX DRIP 4MG/HR.\n\nSKIN: SKIN W/D. REDNESS ON COCCYX. NO BREAKDOWN. SKIN CARE DONE.\n\nID : VANCO LEVEL 17.5. VANCO DOSE DECREASES TO 24 HR. PT REMAINS AFEBRILE.\n\nPLAN: MONITOR ABGS FOR POSS EXTUBATION THIS AM.\n MAINTAIN FLUID BALANCE 2 LITER NEG WITH LASIX DRIP.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-27 00:00:00.000",
"description": "Report",
"row_id": 1367100,
"text": "MICU WEST Nursing Progress Note for 7a-7P: FULL CODE\n\nEvents: Failed BIPAP trial and further respiratory decompensated to the point of requiring intubation. Given a total of lasix 80mg IV PUSH for possible CHF w/ no response. Briefly on Nitro gtt. OFF prior to intubation. BP labile since intubation requiring brief period of Dopamine gtt and a total of 3L NS boluses w/ good response.\n\nNeuro: Adequately sedated w/ versed and fentanyl gtts. PERLA. MAE. Responds to voice/speech. Does not follow any commands at present.\n\nResp: Orally intubated w/ # 8.0 ETT on CMV 12, TV 600, FiO2 .60%, PEEP 10. Stable O2 sats 92-96%. Lung sounds coarse throughout at this time. RR regular and unlabored. Suctioned for thick bloody tan secretions.\n\nCV: NSR-ST w/ HR 75-119. Afebrile. BP labile 66/30 (post intubation). Goal is to keep MAP > 60 w/ fluid boluses prefer over pressors at this time. PIV's x 3 #18g. Palp. peripherial pulses x 4. Min. amt of edema noted.\n\nGI/GU: + BS noted. Abd is soft, NT, ND. OGT in place w/ placement confirmed via air instillation and chest x-ray. NO BM. Foley in place w/ adequate UO.\n\nENDO: Elevated BG w/ SSI coverage given.\n\nID: On triple antibiotics at this time. Afebrile\n\nPlan:\n--Give a total of 4 unit of FFP w/ coags to be check after third unit is in.\n--Central line placement, if needed after INR drops.\n--CT/A chest to r/o PE once BP more stable.\n--Social workers called and will speak to family concerning housing arrangements.\n--Bronchoscopy in AM.\n--Cont. w/ current plan of care. Monitor per protocol. Repleting electrolytes as needed. Update family frequently.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-27 00:00:00.000",
"description": "Report",
"row_id": 1367101,
"text": "Resp Care\n\nPt orally intubated this afternoon for worsening hypoxemia and increased resp distress. Currently vented on a/c with occasional breaths noted above set rate. BS course with few crackles at the bases sxing for small amts of blood tinged secretions. ETT secured/patent and advanced to 24cm at the lip per CXR. Will cont with vent support. Awaiting CTA for ? PE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 1367102,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds bronchial @ bases rales throughout entire lung fields; suct sm=>mod th bldy sput. ABGs ventilation stable but oxygenation marginal=>adjusted PEEP with good effect. Pt also being vigorously diuresed. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 1367103,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS AN 83 Y/O MALE WHO HAS A HISTORY OF REQUIRING HOSPITAL ADMISSION FOR PNEUMONIA OVER THE LAST FEW MONTHS. ON , PT HAD A SYNCOPAL EPISODE AT HOME AND INCREASED DYSPNEA ON EXERTION AND ORTHOPNEA. ON PT PRESENTED TO OSH- CXR SIGNIFICANT FOR BILATERAL EFFUSIONS. PT WAS DIURESED 2L BUT DID NOT IMPROVE GREATLY- TX TO FOR FURTHER MANAGEMENT. INITIATED BIPAP AND TX TO MICU. ON - PT HAD INCREASED DIFFICULTY BREATHING- ELECTIVE INTUBATION DUE TO RESPIRATORY DISTRESS. REPEAT CHEST CT SIGNIFICANT FOR NEGATIVE PE- WORSENING BILATERAL EFFUSIONS AND INCREASING FAILURE.\n\nNEURO: PT IS CURRENTLY SEDATED ON 4MG/HR VERSED AND 50MCG/HR FENTANYL GTT. APPEARS TO BE ADEQUATELY SEDATED. LOCALIZES PAIN- WILL OPEN EYES SPONTANEOUSLY AND WAS ABLE TO COMMUNICATE WITH FAMILY DURING EVENING VISIT. SEDATION INCREASED D/T PT'S DISCOMFORT WITH ETT- AS EVIDENCED BY CONTINUED ATTEMPTS TO TONGUE OUT. AFEBRILE. DOES NOT FOLLOW COMMANDS. PT RIGID BUT MAE X 4. ABLE TO SIT UP IN BED WELL. PERRLA, 3/BRISK. NO SEIZURE ACTIVITY NOTED. BILATERAL WRIST RESTRAINTS FOR SAFETY.\n\nRR: INTUBATED. ETT IS SECURE AND PATENT. REPOSITIONED AND RETAPED BY THIS RN. WORSENING BILATERAL BREATH SOUNDS AS SHIFT HAS PROGRESSED- CURRENTLY HAS RALES TO ALL LUNG FIELDS. BLOOD TINGED, FROTHY SECRETIONS- HAVE BEEN SUCTIONING Q 2HOURS. INCREASED OXYGENATION NEEDS- CURRENT VENTS SETTINGS ARE AC/12/600/60%- INCREASED PEEP FROM 10 TO CURRENT SETTING OF 20. SP02 > OR = TO 90- ALTHOUGH DID HAVE TRANSITORY EPISODES OF SPO2 IN THE HIGH 80'S- MOST LIKELY DUE TO FLUID OVERLOAD. BILATERAL CHEST EXPANSION NOTED. PLAN IS TO BRONCH PT THIS MORNING AS WELL AS TAP EFFUSIONS.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 80-90'S WITH NO SIGNS OF ECTOPY NOTED. PT HAS BEEN R/O FOR MI. SBP > OR = TO 90- HOWEVER HAVE HELD PT'S BETABLOCKERS FOR THE SHIFT AS HIS SBP HAS BEEN LESS THAN 100. PT RECEIVED TOTAL OF 6U FFP THIS PAST 24 HRS IN ATTEMPT TO REVERSE INR FOR LINE PLACEMENT. RT IJ CVL IS SECURE AND PATENT. REZEROED AND RECALIBRATED DURING THE SHIFT. CVP 15-18. LASIX GTT INITIATED- CURRENTLY AT 5MG/HR- TITRATING AS PT'S BLOOD PRESSURE WILL TOLERATE. OBTAINED POTASSIUM AND MAG REPLETION SLIDING SCALES. PT RECEIVED TOTAL OF 2AMPS CAGLUC, 40MEQ K AND 1GM OF MAG FOR AM VALUES. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT IS IN DIRE NEED OF ALINE- TEAM IS AWARE- PLANS FOR LINE PLCMT.\n\nGI: ABD IS SOFT, NON-DISTENDED. BS X 4 QUADRANTS. OGT IS SECURE AND PATENT. PROPER POSITIONING VERIFIED WITH AUSCULTATION OF 30CC/AIR. PASSING FLATUS. NO BM THIS SHIFT. NUTRITIONAL STATUS WILL NEED TO BE ADDRESSED.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS. AVG 100-300CC/HR- GENTLE DIURESES IN ATTEMPT TO RECTIFY WORSENING RESPIRATORY STATUS.\n\nINTEG: NO SIGNS OF BREAKDOWN\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 1367104,
"text": "NURSING PROGRESS NOTE 1900-0700\n(Continued)\n NOTED TO BACK OR BUTTOCKS. SOME REDNESS NOTED TO COCCYX- BARRIER CREAM APPLIED. PT CURRENTLY ON AIR MATTRESS. FREQUENT REPOSITIONING. BILATERAL VENODYNES APPLIED.\n\nSOCIAL: VERY DOTING FAMILY. DISCUSSED AT LENGTH PT'S PLAN OF CARE. ALL QUESTIONS ANSWERED. NO ISSUES. AWARE OF PLAN FOR BRONCH AND THORACENTESIS TODAY.\n\nPLAN:\n1. BRONCH\n2. THORACENTESIS.\n3. A-LINE INSERTION.\n4. FREQUENT ELECTROLYTE MONITORING IN LIGHT OF LASIX GTT.\n5. TITRATE LASIX GTT AS PT'S BP WILL TOLERATE- MAX OF 10MG/HR.\n6. INITIATE NUTRITION.\n7. ADEQUATE SEDATION.\n8. FAMILIAL SUPPORT.\n9. PLEASE DRAW LYTES AT 10AM.\n\nPLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n\n"
},
{
"category": "Echo",
"chartdate": "2101-03-28 00:00:00.000",
"description": "Report",
"row_id": 81653,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 75\nWeight (lb): 203\nBSA (m2): 2.21 m2\nBP (mm Hg): 99/43\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 11:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severe\nregional LV systolic dysfunction. TVI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal anteroseptal - akinetic; mid\nanteroseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic;\ninferior apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Focal calcifications in aortic root.\nMildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is moderately dilated with severe\nregional systolic dysfunction including akinesis of the inferior wall and\nbasal half of the anterior septum and anterior walls. The remaining segments\nare hypokinetic. The basal inferolateral wall contracts best. No masses or\nthrombi are seen in the left ventricle. E/e' is >15 c/w elevated LVEDP. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated. The ascending aorta is mildly dilated. The aortic valve\nleaflets are moderately thickened but no aortic stenosis is present. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: left ventricular cavity enlargement with severe regional\ndysfunction c/w multivessel CAD (or other diffuse process). Increased LVEDP.\nMild-moderate mitral regurgitation. Pulmonary artery systolic hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-02 00:00:00.000",
"description": "Report",
"row_id": 1367123,
"text": "1900-0700 rn notes micu\n\n83 yo male adnitted from OSH d/t respiratori failure, CHF,PNA, intubated.\n\nneuro:received lightly sedated on propofol 10mcg/kg/min easily arousable,follows simple commands inconsistntly, opens eyes to voice.,MAE. PERL 3mm/brisk.\n\nresp: received on CPAP 40%/peep 5/PS5, pt desat to 93-94,vent changed peep 8/ps10, sat 98-99%, sx for moderate bloody tinged secretion, LS coarse bilat. in the morning put back PS5/peep 5. pt required sx Q1-3hr, cough/gag reflex intact.\n\ncv: HR 60-70's,rare PVC's, when pt awake HR up 90's. received on Levofed 0.03mcg/kg/min, overnight stopped LEvofed, SBP 104-111/40's, MAP 55-58, Dr notified, please follow systolis BP, goal 90-100's. CVP 6-10. cortisol level sent, cosyntropin given. restart Heparin 1300u,no sings of bleeding. K+ at 1900 3.8,repleted. morning labs .\n\ngi/gu: foley in place, u/o 30-60cc/hr. ABD soft, BS+, no BM this shift, please send stool C.diff x3. cont TF at goal 60cc/hr.\n\nskin: redness on coccyx area, double guard apllied. left antecub pink d/t flebitis, but improved ,warm pack apllied.\n\naccess: Rt IJ,A-line, plan: new line placement d/t ?source of infection of IJ.\n\nId: Tmax 100.5, pan cx sent, cont VANCO/flagyl, ceftazidime for ?VAP.\n\nendo: cover by RISS.\n\nsocial: full code, family viseted updated by Dr .\n\nplan: cont monitoring neuro/resp/cardio statu\n cont pulm toilet.\n new line placesment attempt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-02 00:00:00.000",
"description": "Report",
"row_id": 1367124,
"text": "MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: No major changes this shift. Sbt this am lasted 1.5 hrs. Zyprexa added to med list.\n\n Neuro: Lightly sedated on propofol at 10 mcg/kg/min. Easily arousable to verbal stimulus, opens eyes and attempts to communicate by mouthing words, gestures and by using writing board. Using writing board freq. with family. Is able to make simple needs known by all three methods. Is following commands consistently and is moving all extrem., upper extrem. with purpose. Pupils 3mm and brisk. + cough and gag. Temperature max. 99.8 oral.\n\n Respiratory: Lung sounds are clear throughout. Ventilator settings are unchanged ps/.40/5/5, tv 580-600, rr 16-25. O2 saturation on present vent settings 94-100%. Suctioned every 1-2 hrs for sm to moderate amts of thick blood tinged sputum. Sputum spec. obtained and sent. Sbt this am tolerated for 1.5 hrs, then became tachypneic with decreased o2 sat, elev. bp. Placed back on and has remained comfortable.\n\n CV: Sinus rhythm with rare to occn. pvc's, rate 70's 80's. Ekg this am with no acute changes. Abp 100's to 130's systolic, site wnl, waveform sharp but can be positional. Rt ij site wnl. Heparin gtt remains unchanged at 1300 units/hr, last ptt 76. Hct stable at 29. Repleated with 40meq's potassium chloride this am.\n\n GI/GU: Abdomen softly distended with + bs. Tf respalor fs at 60cc/hr via ogt, minimal residuals. No bm this shift. Foley catheter patent and draining clear yellow urine 30-60cc/hr. Small amts of blood at meatus, appears to be from trauma.\n\n Endo: Riss in use, no coverage required this am. Glyburide 2.5 mg qd.\n\n ID: Vanomycin level 14. Continue vanco and flagyl, ceftazadime. Cx data .\n\n Social: Wife, son and daughters in to visit with pt throughout shift.\n\n Plan: Sbt in am. Stop tf in am for possible extubation. Frequent suctioning. Repleat lytes as required. Full code in micu.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-03 00:00:00.000",
"description": "Report",
"row_id": 1367125,
"text": "Neuro: Pt. continues on Propfol 10-20mcg/kg/min. Alert, following commands, makes needs know by gesturing, mouthing words, attemtpting to write. Denies pain. +MAE, +PERRLA, intact gag/cough.\nResp: On CPAP 5/5 rr 20s-30s, sats high 90s. Coughing frequently, suctioned for blood tinged thick secretions.\nCV: HR 80s-90s, SR with occasional PVCs. SBP 90s-170s. A-line is positional. Good UO (see careview for I&O). Labs . No pedal edema noted.\nGI/GU: Abd. soft, nontender, +BS, no BM. TF off since 0600. Foley patent, pink tinged urine cleared this AM, ? pt. pulling on catheter per family, team aware.\nSkin intact, slightly red at coccyx area, aloe vesta cream applied, pt. repositioned frequently.\nHep gtt cont at 1300u/hr, am PTT .\nSocial: Family visited last night, they are staying at the hotel across the street.\nPlan: Evaluate for extubation this AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-03 00:00:00.000",
"description": "Report",
"row_id": 1367126,
"text": "RESP CARE: Pt remains intubated/on mech vent per carevue. Lungs coarse bilat. Sxd mod amts clear sputum. RSBI-19. Plan is to extubate this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-03 00:00:00.000",
"description": "Report",
"row_id": 1367127,
"text": "RESP CARE: SBT begun at 0645 on 0 PEEP/5PS\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-03 00:00:00.000",
"description": "Report",
"row_id": 1367128,
"text": "Resp Care\n\nPt remains intubated and on CPAP/PSV 5/5. MV is in the 8-10L range with TV's in the low 500's. Secretions remain and issue but have been less than in prior days. Look for possible extubation in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-03 00:00:00.000",
"description": "Report",
"row_id": 1367129,
"text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: No significant changes in treatment or condition this shift. Secretions continue to be main inhibitor to extubation. Lasix this am for fluid removal.\n\n Neuro: Lightly sedated on propofol at 10 mcg/kg/min. Easily arousable to verbal stimulus, opens eyes and tracks, attempts to communicate through mouthing words, gestures or writing on clipboard. Is able to make basic needs known through these methods. Is able to move upper extrem. freely, lower extrem. on bed. Denies discomfort at this time. Temperature max. 99.7 oral.\n\n Respiratory: Lung sounds are clear in upper fields, coarse in lower fields bilat. Ventilator settings remain ps/.40/5/5. Tv 473-417,rr 17-30. O2 saturation 92-98% on present ventilator settings. Suctioned every 1-3 hrs for thin clear secretions which are now thickening up since lasix given. If pt can go 2-3hrs w/o suctioning will most likely be able to tolerate extubation.\n\n CV: Sinus rhythm with rare pvc's, rate 70's to 80's. Abp 100's to 170's systolic. A line site wnl, waveform sharp but is positional. Hct stable at 29.7. Repleated with 20 meq's potassium chloride this am for potassium 3.8 and again this pm for potassium of 3.8. Lasix 20 mg iv this am with very good response, at present is 2 liters negative for past 24 hrs.\n\n GI/GI: Abdomen soft with + bs. Ogt remains clamped at present ? extubation. No bm this shift. catheter patent and draining clear yellow urine 50-350cc/hr.\n\n Integ: Skin remains grossly intact. Coccyx remains reddened, doubleguard applied. Dried blood at meatus, apparently from trauma. Lt ue phlebitis site improving.\n\n Endo: Humalog ss in use, fs 159, covered 2 units humalog this am. Standing dose 2.5 glyburide in am's.\n\n ID: Remains on Ceftaz., flagyl and vancomycin.\n\n Social: Wife and daughters in to visit most of shift, pleasant, cooperative and inquisative.\n\n Plan: Extubate when secretions require suction every 2 hrs or more. REpleate lytes as required. REmain NPO for poss. extubation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-04 00:00:00.000",
"description": "Report",
"row_id": 1367130,
"text": "RESP CARE: Pt remains intubated/on mech. vent per carevue. Lungs coarse. Vts on 5 PS 400-500/RR 20s. Sxd mod amt thick clear. RSBI-35.6\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-01 00:00:00.000",
"description": "Report",
"row_id": 1367119,
"text": "1900-0700 rn notes micu\n\nneuro: received sedated on Versed 3mg/hr, Fentanyl50mcg/hr, easily arousable, follows simple commands, opens eyes to speech. after given bolus of Versed/Fentanyl for restlesness SBP down to 75-85 MD notified, decreased and stopped sedation, given Halidol 1mg x2 for restlesness with minimal effect ( PRN Halidol 2-10mg Q4hr) QTc .45.PERL 3mm/brisk.\n\nresp: received on CPAP 60%/PS10/peep5, decreased Fi02 to 40%, last ABG 7.45/48/117, sat 96-98%, LS coarse bilat, sx for bloody/bloody tinged thick secretion.\n\ncv: HR 90's,NSR, ocass PVC's, with restlesness HR up to 106, ST. SBP dropped to 75-85 w/o effect on u/o after bolus of Fentanyl/Versed, given fluid bolus 250ccx2 with minimal response,Dr. aware.with agitation SBP 120-140's. lactate 1.1-1.2. K+ 3.8, repleted. at 1900 PTT 119.5, Heparin stopped per Dr , last PTT 38.5, restart Heparin 1400, morning PTT of 0400 . pt neg 260cc, goal 500cc\n\ngu/gi: in the begining of shift foley drained pink/bloody urine, becomes clear overningt, u/o 80-200cc/hr. ABD soft, BS +, no BM, cont bowel meds. restart TF , currently at goal 60cc/hr, tolerated well, residual 5cc.\n\nid: Tmax 100.3, please reculture if Temp 101, cont ABX.\n\nendo: RISS, at 0000 BS 159, given 2u humolog.\n\nskin: redness on coccyx area, apllied double guard. left antecub red/warm, cont warm packs.\n\nsocial: full code, family visted/updated by team.\n\nplan: cont monitoring neuro/resp/cardio status,u/o\n Halidol PRN for agitation/restlesness\n wean sedation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-01 00:00:00.000",
"description": "Report",
"row_id": 1367120,
"text": "ADDENDUM TO NOTES ABOVE\n\nPT OFF SEDATION BECAME RESTLESS/AGITATED, TACHY 106-108, TACHYPNIC 25-33BPM, RESTART VERSED/FENTANYL SBP DOW TO 80',STOPPED SEDATION. CURRENTLY PT OFF SEDATION. MAG 1.9, REPLETED, PTT 80.5, CONT HEPARIN 1400U/HR. RSBI 43.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-01 00:00:00.000",
"description": "Report",
"row_id": 1367121,
"text": "npn 7a-7p\nFull Code\nNKDA\nPlease see carevue for additional data.\n\nShift events: Pt received restless with increased HR, RR, and marginal bp. IVP Haldol given 5mg iv, short lived effect. Also at this time Pt noted to have many secretions requiring suctioning every half hour. BP continued to trend down. Team notified(Dr. , decision made to implement 500cc NS bolus,Propofol and then eventually,Levophed gtts. Pan cultured. abx dosages increased on Vanco and Ceftazidime. Line to be resited.\n\nNeuro: Pt appears comfortable on 10mcg/kg/min of Propofol. Follows commands, opens eyes to speech. perrl 3mm/bsk. MAE, purposefully. Intact cough/gag.\nCV: 69-104 NSR-ST. Occasional PVC's. sbp 80-130, (130 with suctioning). Levophed gtt titrated to systolic of 95-100, MAP 60. Heparin gtt turned down from 1400units to 1200 after PTT of 111, then shut off at 13:00 for future line resiting. Received 500cc/NS bolus this AM as above, for hypotension, no effect noted. CVP 6-21, higher after fluid bolus. Received 2 units of FFP for line resiting. Enzymes cycled low bp. PM labs pnding.\nResp: Vent weaned to 5 of PS from 10, remains on 5peep/40%. ABG on this 7.44/40/96. Suctioned every half and hour to hour for moderated amounts of tan, yellowish, thick secretions. LS rhochi, to coarse, with crackles. Sats 95-98%.\nGI/GU: TF off for line resiting at 16:30. abd soft, non-tender, +BS. Still no stool, senna given. Foley patent draining adequate yellow, cloudy urine.\nENdo: continue on Glyburide, and Humalog SS.\nSkin: w/d/i. Pink coccyx, double guard applied. Left antecub with probable phlebitis, seems to be improving.\nID: tmax 101 rectally. Pan cx'd. bld and urine cx from with no growth. Vanco and Ceftazidime doses increased. Line to be resited.\nA/P hypotension, did not respond to ivf, cont to titrate Levophed gtt for map 60, sbp 95-100. Icreased temp and secretions ? VAP despite triple abx, doses of abx increased, line to be resited, pan cx'd. Cont following abg's and cont with aggressive pul. toilet. cont. to follow PTT Q6/hrs, next one pnding from 16:00 but Heparin gtt off for line resiting. Cont. with propofol for light sedation. F/U with cx data. Consider ID consult. Continue providing supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-01 00:00:00.000",
"description": "Report",
"row_id": 1367122,
"text": "resp. care\npt. remains intubated/vented. ps weaned to with good\nabg/tidal vols. continues to have cop. white sputum and\nrequires frequent sx'ing. mdi's given. continue intubation\nuntil secretions under control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 1367115,
"text": "NSG 7PM-7AM\n\nPLEASE REFER TO CAREVIEW FOR DETAILED VS, IO, LAB RESULTS.\n\nNEURO: PT ALERT, AGITATED AT TIMES, ATTEMPT TO LIFT SELF OUT OF BED, REACHES FOR TUBES. PT REQUIRES SEVERAL BOLUSES OF VERSED AND FENTANYL TO REMAIN CALM. OBEYS COMMANDS.\n\nCV: PT REMAINS IN NSR WITH FREQUENT PVCS. HR 80S-90S. HAS SHORT RUN OF SVT,. MD AWARE. MONITOR HR, RYTHM, POSS METOPROLOL IV IF MORE EPISODES OF SVTS OCCUR. SBP 110S, CVP:. FLUID BALANCE ABOUT EVEN. GOAL NEG 500- 1LITER PER DAY. LAST 24 HR -933. UOP DECREASES GRADUALLY. AVERAGE UOP 30CC/HR. LASIX 20MG IV GIVEN. WILL MONITOR UOP. HEP DRIP 1400U/HR. FIRST PTT:82.4. NEXT PTT WILL BE DRAWN AT 0600 THIS AM.\n\nRESP: RECEIVED PT ON CPAP 10+5 ABG: 7.46, 53 68, 39. INCREASED PEEP-> 10, CURRENT VENT SETTINGS CPAP 10+8, 40%. LAST ABGS: 7.46, 53, 107, 39. LUNG SOUND DIMINISHED. SUCTIONED MODERATE AMOUNT OF THICK BLOOD TINGED SECRETIONS. NO RESP DISTRESS. RR TEENS, LOOKS COMFORTABLE ON CPAP.\n\nGI: ABD SOFT POS BS, NO BM. SENNA GIVEN. NGT PATENT IN PLACE, CLAMPED AT MIDNIGHT TO MAINTAIN PT NPO FOR POSSIBLE EXTUBATION THIS AM.\n\nGU: FOLEY PATENT DRAINING CONCENTRATED URINE. NO HEMATURIA.\n\nSKIN: SKIN W/D. REPOS FREQUENTLY. SKIN CARE DONE. L AC AND UPPER ARM PRESENT WITH REDNESS, EDEMA 2+. WARM TO TOUCH. NO DRAINAGE. ELEVATED ON PILLOW.\n\nID: PT REMAINS AFEBRILE. TMAX: 99.6.\n\nPLAN: MAINTAIN FLUID BALANCE GOAL NEG 500CC-1L.\n NPO FOR POSSIBLE EXTUBATION TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 1367116,
"text": "Respiratory Therapy\nPt presents on PSV 10/8 .4. BS coarse bilat. Sx lge amt thick blood tinged secretions. When sedation wears off pt able to perform abd crunches. Plan: extubate this AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 1367117,
"text": "npn 7a-7p\n**FUll Code**\nNKDA\nPlease see carevue and fhp for additional data.\n\n**Shift Events**\n This am Pt had SBT for ~2hrs, seemed to be well tolerated, VS and sats stable. Around 14:00 Pt noted to have increased HR, bp, and restlessness. Attempted to bolus with sedation, did not relieve restlessness. Shortly Pt noted to have increased RR, cvp at this time ~8, LS coarse. Pt nods yes to feeling sob at this time, and increased wob noted. Dr. and RT alerted, examined, decision made to give 20mg iv lasix, ~500cc output to this with cvp down to 6 after. Also received 1mg iv Haldol at this time per Dr. , no effect noted. Pt still sounding rhonchurus, sxned for copious, rusty, thick secretions/plug. Vent changes made,MDI's given, abg sent. BP became labile sbp 75-85 MD's aware, sedation slowly weaned back down as tolerated, marginal effect on sbp. Sputum spec. sent, cxr obtained- seemingly unchanged according to Dr. . LS clear ~2hrs after Lasix and aformentioned interventions.\n\nNeuro: Remains on Fent. Midaz. gtt's, titrated for light sedation. No c/o pain. Perrl 3mm/bsk. Follows commands. Intermittently restless and trying to get oob. PRN Haldol added to med regimen.\nCV:> 80-123 NSR-ST occ. to freq. PVC's. Repleted 1 gram Calcium. Need to replete K+. Sbp 75-138. CVP 6-11. Currently ~(-)530cc/24/hrs. Received 20mg iv Lasix as above. QTC .49 today. Already received Digoxin load, daily Dig. added to med regimne. Carvedilol dose increased. Warfarin added back to regimen, once INR ~2, can D/C Heparin gtt. +pp. Slight edema. Fluid goal ~ 500 cc negative.\nResp:> Vent 60%/PS10/peep 5. abg on this with metabolic alkalosis. 7.47/54/112. LS currenlty clear. WOB comfortable. Sat 96-98%. Secretions increasing over coarse of day and with aforementioned decompensation sxned several times for copious, rusty, thick plugs. MDI's ordered and given. impaired gag, weak cough. PM CXR essentially unchanged per Dr. .\nGI/GU: abd soft, +BS, still no stool, despite bowel meds. foley patent, lt. yellow to pink urine out. Lasix 20mg iv as above. Detrol dc'd.\nEndo: Humalog SS.\nSkin: left antecub red, warm to touch, and hard to palpation.team evaluated, prob. phlebitis, warm compresses applied. Coccyx pink, on air bed, cont. with freq. turning.\nID: 99.9 tmax. bld cx pnding. new sputum spec. sent today. urine cx with no growth. Remains on IV vanco, Ceftazidime, and Flagyl.\nSocial: Family (wife, daughter,and son bedside today. Updated by this RN and Dr. , questions answered.\nA/P: Cont to monitor secretions, sats, cxrs,and follow abgs, cont. with pul. toilet. Cont. to monitor sbp, goal systolic 90's. continue to follow fluid balance, goal ~500cc negative, prn Lasix. Diamox ordered , may want to check with team prior to dosing labile sbp. Cont. to follow lytes and repleted prn. Check coags including INR and DC Heparin gtt as appropriate pnding INR. Follow digoxin level and QTc. Continue providing supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 1367118,
"text": "resp. care\npt. remains intubated/vented/sedated. passed rsbi and did a sbt\nfor 2 hours. became very sob with increased wob/bp/rr and decreasing\nsats/po2. sx'd for large thick bloody sputum. lungs sounds still coarse. lasix given. mdi's started. increased sedation and now on\nps 10/5 with 60%. see flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-30 00:00:00.000",
"description": "Report",
"row_id": 1367113,
"text": "npn 7a-7p\n**Full Code**\nNKDA\nplease see carevue and fhp for additional data.\n\nNeuro: Fent and Versed gtt weaned, with some intermittent bolusing for restlessness/agitation. Pt arouses to voice, attempts mouthing words. Follows commands. perrl 3mm/bsk. No indications of pain.\n\nResp: No vent changes made. LS clear upper, diminished lower. Sats 92-98%, noted to decrease when Pt positioned on Rt. side. CXR today with increased opacities, possible worsening aspiration vs. PNA, however clinical picture improving. RR 13-19. To redraw abg at 18:00. Sxned Q4/hrs for small, bld tinged, thick.\n\nCV: 80-95 NSR. occ. pvc's noted. sbp 95-144. cvp 7-9. Lasix gtt off this am. fluid goal ~500cc-1L negative. currently ~1L negative. Repleted 40mEq of potassium, and 1gram of Magnesium. coags pnding. QTc today .512, team aware, Detrol causes inc. QTc, cont. to follow.\n\nGI/GU: TF Respalor at goal, please dc at midnight for probable extubation tomorrow. abd soft, +BS. No BM, received Senna. Foley patent, draining adequate amounts of lt. yellow urine.\nEndo: ISS\nSKin: w/d/i. slight pink noted to coccyx, double guard applied, frequently turned.\nID: afeb. bld cx pnding. continues on Vanco, Ceftazidime, and flagyl. urine cx (-). prelim. sputum cx. (-).\nSocial: Daughter and wife at bedside today, questions answered by this RN and Dr. . Met with SW, and to meet with case management about long term care solutions.\nA/P: Resp failure prob. CHF vs. infective process. Cont. to follow CXR's, and abgs. Lasix gtt dc'd, cont to follow I&O's.IVP Lasix prn. Fluid goal 500- 1L (-). COnt. to follow coags and lytes. TF off at midnight. F/U with swallow study once extubated and appropriate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-30 00:00:00.000",
"description": "Report",
"row_id": 1367114,
"text": "Addendum:\n\nPt started on Heparin gtt for INR <2.o, hx of PE's. Gtt initiated with no bolus at 1400 units/hr. Will need PTT at midnight.\nAlso Pt noted to have episode of agitation around ~18:30 trying to get legs oob, which caused Foley to pull at this time. Noted to have bloody urine after this team aware. please continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-03-27 00:00:00.000",
"description": "Report",
"row_id": 1367099,
"text": " Admission Note:\n\nPt admitted from ED with CHF,Pneumonia. Medflighted from where he was after feeling weak and SOB at home. He usually walks with walker. He has no known allergies.\n\nPMH: CHF,Pneumonia,BPH,NIDDM,MI with stent placement,Lt BBB,Lap chole,AAA repair,Lt leg aneurysm, filter,repair of spinal stenosis,Throat CA ,P.emboli ,HTN.\n\nPt received 120mg IV Lasix in ED and 80mg IV Lasix upon arrival in MICU. He has had 4700cc u/o. BNP was7937. He was on IV NTG in ED but was weaned off for low BP. He was also on BIPAP for a few hours and when ABG's improved requested to try nasal cannula. However sats were 88% so NRB mask was applied for next few hours. Finally this am he is on 5l NC O2 and sats=92-95%.\n\nCVS: Afebrile. HR=79-91 NSR with Lt BBB and rare PVC's noted. SBP=94-110. Given Vancomycin,Ceftriaxone, and Flagyl IV.\n\nResp: O2 currently NC 5l, sats=95%. Lung sounds clear but diminished in rt base. Slight cough noted, no sputum production.\n\nGI: +BS. Taking sips of liquids.\n\nGU: U/O=4700+, K=3.2 given 40meq KCL po. Also, will repeat dose in 2hrs. Pt is noted also to have UTI.\n\nSkin: Some edema of ankles, 2+, Left ankle larger that rt. Which pt states is normal. No open or red areas noted.\n\nNeuro: A&Ox3, MAE, Pupils=+. Speech clear and appropriate.\n\nPlan: Continue to diurese pt as needed per CXR and Antibx. Monitor EKG's and labs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-04 00:00:00.000",
"description": "Report",
"row_id": 1367131,
"text": "Shift Note 1900-0700\nCV: HR 70's, NSR with rare PVC's. ABP via right radial art line 100-140/60's...art line positional and very difficult to draw back blood; flushes sluggishly. Receiving lopressor, dig.\n\nAccess: RIJ quad lumen intact. CVP transduced but dampened waveform.\n\nResp: Pt received on CPAP/PSV 5/5, FiO2 40%; am RSBI 35.6. BBS coarse-clears to snx. Snx moderate amount white thick secretions Q2-3hrs.\n\nGI/GU: Abdomen soft, BS present. TF's on hold d/t possible extubation. Foley cath draining adequate amounts UO; -3L LOS, slightly - since MN. Goal I/O even to -500cc. Pt on standing dose lasix. No BM this shift. OGT in place.\n\nNeuro: Pt dozing intermittently throughout night, requested something to help him sleep. Given 5mg PO ambien (pt slept for few hours after being medicated with ambien). Following commands, pleasant/cooperative with care. Mouthing words for communication or writing on board to communicate needs. A/O x3. Denies pain, but uncomfortable at times; reposition.\n\nID: Low grade temp 99.4. Prednisone taper. Continues on flagyl, Vanco and ceftazidime. Vanco level to be drawn this am.\n\nSocial: Wife and daughter in to visit last evening. Very supportive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-04 00:00:00.000",
"description": "Report",
"row_id": 1367132,
"text": " RN Note 0700-1900\n\nPt is a 83 yo male with CAD,CHF, DM recurrent PNA admitted for resp distress to CHF/ asp PNA Intubated. EF30% s/pMI . CXR/Chest CT revealled Multifocal Pneumonia.\n\nEvents: Extubated today @ 1500, Lasix diuresis goal (-1L), started Ace Inhibitor. Evaluation for PICC. NPO swallowing eval.\n\nNeuro: Started shift on Propofol 10mcg/kg/min wean to off @ 0800, Awake alert oriented x2 follows commands MAE random/puposeful equal strength, denies pain.\n\nCV: HR 78-65 NSR freq MFPVC LBBB, R radial aline inplace sharp wave form, BP 111/53-157/73 MAPS>65 recieved Lopressor/Digoxin per routine, started Captopril TID. IV access RIJ line IV NS 10cc/hr. Heparin 1300units/hr PTT within therapeudic range 60-100. Recieved routine lasix 40mg OGT and an additional Lasix 20mg IVP with responding diuresis. Labs to be sent @ 1800 result Plan repletion per sliding scale.\n\nHeme: Hct 32.5, PTT 69.5 INR 1.5\n\nResp: started shift Intubated Vent CPAP&PS 5/5 40% TV>450 MV RR 18-28, Sats 95-98%. Suctioned via ETT q30min-2hrs for mod amt thin white secretions. agressively diuresed for extubation. Extubated @ 1500 Placed on FT 60% Sats 95-90%, Strong cough able to expectorated mod amt thin white sputum. HOB maintained >30 degrees.\n\nID: WBC 9.1 T-Max 99.4, Cult no growth to date, Cont abx Vanco/ceftazidime/flagyl.\n\nGU: foley u/o 60-600cc/hr Bun Creat 16/0.7Goal FB-500 to 1L\n\nGI: Abd soft notender +BS no BM recieved Bowel regime. NPO. Started shift with OGT recieved PO meds, now d/c tried pt with sips po with poor swallowing/coughs. Maintain NPO. Plan Swallowing eval . MD to change meds to IV.\n\nDerm; Skin impaired, dry reddened coccyx. On specialty bed .\n\nSocial: Full code status, Daughter and wife visited most of day, met with team updated on plan of care. Met with SS and CM for discharge planning.\n\nPlan: FB -500-1L\n Swallowing Evaluation\n PICC placement IR\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-04-05 00:00:00.000",
"description": "Report",
"row_id": 1367133,
"text": "pmicu nursing progress 7p-7a\nreview of systems\nCV-vs have been stable.lopressor was changed to 5 mgs ivp q 6 hrs as pt is npo-all other cardiac po meds on hold.bp did dip a bit to the 80's/ but has come back up to 118/ without intervention.a-line tracing dampened at times.having freq pvcs.\n\nRESP-wearing o2 70% via face tent.breathing comfortably, rr 15-22.\nlungs sound coarse throughout.has a weak cough productive of thick white sputum in small amts-he is able to sx away.abg this am with po2 61, pco2 38 and pH 7.47.\n\nGI-abd is soft with positive bowel sounds.no stool overnight.pt npo awaiting swallow study.\n\nHEME-heparin infusing at 1300u/hr for ?PE.PTT this am= 77.\n\nF/E-has minimal peripheral edema.ivf at kvo.has had a good urinary output.was repleted with 2 amps Magnesium and an additional 20 meqs of KCl. am labs pnd.\n\nNEURO-has been alert and awake most of the night.MAE purposefully, was in bed.speech is clear.was tx with .5 mgs ivp ativan for sleeplessness but pt did not really sleep well at all.very pleasant.\n\nID-afebrile.receiving vanco, ceftaz and flagyl as ordered.wbc=8.8 this am.\n\nSKIN_grossly intact\n\nIV ACCESS-has a triple lumen R neck, a-line in place.eval for a PICC done--needs to be in IR.\n\nSOCIAL-daughter and wife in during the evenign-seem very devoted and attentive.\n\na-stable night,didn't sleep though\n\nP_needs PICC and swallowing study to be done.watch i's and o's, labs.keep family updated on all plans,procedures.\n"
},
{
"category": "ECG",
"chartdate": "2101-04-06 00:00:00.000",
"description": "Report",
"row_id": 204428,
"text": "Sinus rhythm\nBorderline first degree A-V delay\nLeft atrial abnormality\nLeft bundle branch block\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2101-04-02 00:00:00.000",
"description": "Report",
"row_id": 204429,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof sinus tachycardia is absent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 204430,
"text": "Sinus tachycardia. Left bundle-branch block. Compared to the previous tracing\nof -0 ventricular premature beats are absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2101-03-31 00:00:00.000",
"description": "Report",
"row_id": 204431,
"text": "Sinus rhythm ventricular premature beats. Left bundle-branch block. Compared to\nthe previous tracing of sinus tachycardia is absent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2101-03-27 00:00:00.000",
"description": "Report",
"row_id": 204432,
"text": "Sinus tachycardia with frequent ventricular ectopy. Left bundle-branch block.\nCompared to the previous tracing of the rate has increased and there is\nfrequent ventricular ectopy. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2101-03-26 00:00:00.000",
"description": "Report",
"row_id": 204433,
"text": "Sinus rhythm and occasional ventricular ectopy. Left bundle-branch block.\nCompared to the previous tracing of occasional ventricular ectopy has\nappeared. Otherwise, no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2101-03-26 00:00:00.000",
"description": "Report",
"row_id": 204434,
"text": "Sinus rhythm. Left atrial abnormality. The P-R interval 0.20. Left\nbundle-branch block. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 905200,
"text": " 1:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New line plcmt\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia, just electively intubated\n\n REASON FOR THIS EXAMINATION:\n New line plcmt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube placement.\n\n COMPARISON: .\n\n FINDINGS: ET tube is approximately 9 cm above the carina and should be\n advanced. Right internal jugular central venous line tip overlies the SVC. NG\n tube tip is not imaged. The heart is enlarged, and there has been interval\n increase in extent of severe bilateral alveolar pulmonary edema, right greater\n than left. Bilateral pleural effusions are again noted. There is no\n pneumothorax.\n\n IMPRESSION: Worsening bilateral pulmonary edema. ET tube should be advanced\n for more optimal placement. Findings discussed with Dr. at\n 10:35 a.m., .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905081,
"text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval progression\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia now s/p diuresis w/ iv lasix\n\n REASON FOR THIS EXAMINATION:\n eval for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: SOB, CHF, and status post diuresis.\n\n CHEST: A single portable chest exam at 4:30 a.m. is compared to previous\n examination a day ago. Again seen are bilateral alveolar pulmonary edema, if\n any, slightly improved since the previous exam. The more confluent\n parenchymal opacities may represent superimposed pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-27 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 905116,
"text": " 10:52 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: EDEMA ? DVT\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with h/o PE, BPH, now w/ dyspnea and unilateral RLE edema\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with history of PE, BPH, and now with dyspnea and\n unilateral right lower extremity edema. Question of DVT.\n\n -scale and Doppler son were performed of the right and left common\n femoral, superficial femoral, and popliteal veins. Within the right common\n femoral vein, a small nonocclusive clot is visualized. Within the left\n superficial femoral vein, lack of flow is present throughout the entire vessel\n consistent with nonocclusive thrombus.\n\n The remaining venous vasculature bilaterally demonstrates appropriate\n augmentation, flow, and compressibility.\n\n IMPRESSION:\n 1. Right common femoral vein nonocclusive thrombus. Left superficial femoral\n vein nonocclusive thrombus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905332,
"text": " 4:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: re-assess postion of ETT\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia, just electively intubated\n\n REASON FOR THIS EXAMINATION:\n re-assess postion of ETT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 16:51 HOURS.\n\n INDICATION: Shortness of breath. CHF and pneumonia. Reassess position of\n ETT.\n\n FINDINGS: Compared with the film earlier the same day at 1:43 a.m., the tip\n of the ETT now is slightly lower than previously and currently projects at the\n level of the manubrium approximately 8 cm above the carina.\n\n There has been considerable interval partial clearing of the bilateral\n pulmonary edema and/or underlying infiltrates, with more improvement on the\n left than on the right. Right pleural effusion is about the same size\n (small).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-04-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 906047,
"text": " 6:36 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: rule out pneuomothorax s/p unsuccessful right subclavian tlc\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83M w/ RIJ TLC and now s/p failed thread of wire into right subclavian vein\n despite cannulation on 4 attempts - please r/o PTX\n REASON FOR THIS EXAMINATION:\n rule out pneuomothorax s/p unsuccessful right subclavian tlc attetmpt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple failed right subclavian line placement attempts.\n Evaluate for pneumothorax.\n\n COMPARISON: Comparison is made to the study performed five hours earlier,\n same day.\n\n AP CHEST RADIOGRAPH: There is no evidence of pneumothorax. Again seen is\n endotracheal tube, nasogastric tube and right-sided central line in unchanged\n position. Also again seen are multifocal consolidations within both lungs\n consistent with pneumonia, unchanged from prior study.\n\n IMPRESSION: No evidence of pneumothorax. Otherwise no significant change\n from prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905985,
"text": " 12:20 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx vs. skin fold.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man intubated patient with ? ptx versus skin fold.\n REASON FOR THIS EXAMINATION:\n ptx vs. skin fold.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient intubated, pneumothorax versus skinfold.\n\n PORTABLE AP CHEST.\n\n Compared to the prior radiograph obtained earlier today, a skinfold again\n persists on the right side. There is no pneumothorax. ET tube and the right\n IJ catheter are in good position. Multifocal consolidations still persist in\n the right lower lobe and left upper lobe. Left lower lobe atelectasis\n persists.\n\n IMPRESSION: Multifocal pneumonia. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905013,
"text": " 1:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: h/o pe's too\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia\n REASON FOR THIS EXAMINATION:\n h/o pe's too\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 83-year-old man with shortness of breath, congestive heart\n failure, and pneumonia. History of pulmonary embolism.\n\n COMPARISONS: None.\n\n CHEST, UPRIGHT AP PORTABLE: The heart size is difficult to assess. The\n mediastinal and hilar contours are unremarkable. There are bilateral small\n effusions, but no pneumothorax. Bilateral mid lung alveolar opacities are\n consistent with acute pulmonary edema. In addition, there is patchy dense\n opacity in the right lower lobe, which is more focal, and although there is\n also edema, pneumonia cannot be excluded especially in this area.\n\n IMPRESSION:\n 1. Alveolar pulmonary edema.\n 2. Superimposed pneumonia is also possible and cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 905037,
"text": " 4:47 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for gas, abscess\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF, PNA, ccy in p/w SOB and RUQ discomfort, found at\n OSH CT abd to have gas w/ ?abscess, but film unavailable.\n REASON FOR THIS EXAMINATION:\n eval for gas, abscess\n ______________________________________________________________________________\n WET READ: BTCa SAT 8:08 PM\n Right pleural effusion. No evidence of fluid within the gallbladder fossa.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with CHF, pneumonia status post cholecystectomy\n presenting with shortness of breath and right upper quadrant discomfort.\n Evaluate for gas/abscess.\n\n COMPARISONS: None.\n\n LIMITED RIGHT UPPER QUADRANT ULTRASOUND. The visualized portions of the liver\n demonstrate normal echogenicity without evidence of focal hepatic mass. There\n is no definite intra- or extrahepatic biliary ductal dilatation. There is no\n evidence of a fluid collection within the gallbladder fossa. No perihepatic\n ascites is identified. Note is made of a right pleural effusion. Limited\n views of the right kidney demonstrate no hydronephrosis or calculi. Note is\n made of shadowing artifact from gas along the superior aspect of the liver,\n which may be secondary to an overlying loop of bowel.\n\n IMPRESSION:\n 1. Right pleural effusion.\n 2. No abnormal fluid collection within the gallbladder fossa.\n 3. No evidence of focal hepatic mass or intra- or extrahepatic biliary ductal\n dilatation in the visualized portions of the liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905142,
"text": " 2:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ng inserted and et tube advancemnt\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia, just electively intubated\n\n REASON FOR THIS EXAMINATION:\n ng inserted and et tube advancemnt\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: SOB, CHF, and pneumonia.\n\n CHEST: A single portable supine view at 1430 hours is compared to previous\n examination at 1329 hours from the same day. Since the previous exam, there\n has been insertion of an NG tube with the tip below the diaphragm. The\n bilateral parenchymal opacities and cardiomegaly remain stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-27 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 905180,
"text": " 8:41 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? PE\n Admitting Diagnosis: HYPOXIA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with dyspnea, prior h/o PE\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea, history of prior pulmonary embolism, rule out pulmonary\n embolism.\n\n COMPARISON: No CT studies are available for comparison.\n\n TECHNIQUE: MDCT acquired images of the chest were obtained before and after\n the administration of IV contrast. Coronal and sagittal reformatted images as\n well as obliquely reformatted images were also obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There is no evidence of\n pulmonary embolism. There are extensive vascular calcifications including\n coronary artery calcifications. There are moderate bilateral layering pleural\n effusions with associated compressive atelectasis. There are multifocal areas\n of consolidation in the right upper lobe, left upper lobe, right middle lobe,\n and bilateral lower lobes. There are also patchy bilateral areas of ground-\n glass opacity and interlobular septal thickening noted in the remaining\n aerated portions of the lower lungs. There are multiple prominent mediastinal\n lymph nodes including a 11 mm AP window node and a 9 mm precarinal node as\n well as a 13 mm precarinal node. The airways appear patent with small amounts\n of debris seen in the trachea. The patient's NG tube terminates below the\n diaphragm with the distal margin extending below the lower margin of this\n study. The endotracheal tube terminates at the thoracic inlet.\n\n Limited images of the upper abdomen demonstrate evidence of previous\n cholecystectomy as well as extensive vascular calcifications.\n\n Bone windows reveal degenerative changes with no suspicious lytic or sclerotic\n lesions.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Moderate layering bilateral pleural effusions with associated atelectasis\n with bilateral patchy areas of ground-glass opacity as well as areas of\n interlobular septal thickening consistent with pulmonary edema/volume\n overload. In addition, there are multiple bilateral patchy areas of\n consolidation involving all lobes of the lungs worrisome for multifocal\n pneumonia\n 3. Extensive atherosclerosis including atherosclerosis of the coronary\n arteries.\n\n (Over)\n\n 8:41 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? PE\n Admitting Diagnosis: HYPOXIA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905795,
"text": " 9:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for RIJ position\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia w/ more frequent PVC's\n\n REASON FOR THIS EXAMINATION:\n assess for RIJ position\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Shortness of breath and CHF with pneumonia. Frequent PVC's.\n Assess for right internal jugular central venous line position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. The patient remains intubated, the ETT terminating in\n the trachea some 7 cm above the level of the carina. An NG tube has been\n passed reaching below the diaphragm. A right internal jugular approach\n central venous line is seen and terminates overlying the SVC at a level 3 cm\n above the carina. No pneumothorax is identified. Comparison of the lung\n fields demonstrates rather unchanged appearance of the previously described\n bilateral (more on the right than left) parenchymal infiltrates consistent\n with multifocal pneumonia. Cardiac enlargement as before and the presence of\n COPD changes may explain absence of typical pulmonary edema.\n\n IMPRESSION: Unchanged appropriate position of indwelling lines. Unchanged\n pulmonary abnormalities consistent with multifocal pneumonia and the presence\n of CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905634,
"text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF and pneumonia\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia\n REASON FOR THIS EXAMINATION:\n CHF and pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, CHF, and pneumonia.\n\n COMPARISON: .\n\n FINDINGS: ET tube, right internal jugular central venous line, and NG tube\n appear unchanged. Mild cardiomegaly and calcified aorta are unchanged. Since\n the prior study, the patchy bilateral areas of consolidation have increased,\n most notably in the left lower lobe. Perihilar opacities consistent with CHF\n are again noted. There are small bilateral pleural effusions. There is no\n pneumothorax. Emphysematous changes at the apices are again noted.\n\n IMPRESSION: Emphysema with pulmonary edema and multifocal\n pneumonia/aspiration, worse since the previous study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905135,
"text": " 1:14 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? ETT placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with sob and chf and pneumonia, just electively intubated\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: CHF and pneumonia, endotracheal tube placement.\n\n CHEST: A single supine portable view at 13:20 hours is compared to previous\n exam at 4:30 a.m. from the same day. Since the previous exam, there has\n been insertion of endotracheal tube with the tip at the level of T2. The\n cardiomegaly and diffuse parenchymal opacities show no significant change\n since the previous exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905951,
"text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening pneumonia?\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man intubated patient worsening secretions\n REASON FOR THIS EXAMINATION:\n worsening pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:40 A.M., \n\n HISTORY: Intubated patient with worsening secretions, question worsening\n pneumonia.\n\n IMPRESSION: AP chest compared to through 23:\n\n Severe consolidation in most of the right lung and in the perihilar left upper\n lobe and at the left lung base is all stable since , worse compared to\n . Small bilateral pleural effusions may be present, but the heart is\n not enlarged, and there is no mediastinal vascular engorgement. Findings are\n most consistent with widespread pneumonia and/or pulmonary hemorrhage, given\n the appropriate clinical circumstances. There is no pneumothorax; a\n right-sided skinfold should not be mistaken for a pleural edge. ET tube,\n right internal jugular line, and nasogastric tube are in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-04-05 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 906449,
"text": " 8:09 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: would like double lumen PICC placed for abx\n Admitting Diagnosis: HYPOXIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with cad, chf, recurrent pna now s/p xtubation w/ rij placement\n but unable to thread new right subclavian tlc and picc line nurse ir guided placement\n REASON FOR THIS EXAMINATION:\n would like double lumen PICC placed for abx\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 83-year-old with recurrent pneumonia requiring IV antibiotics.\n\n RADIOLOGISTS: Doctors and . Dr. , the attending\n radiologist, was present for the entire exam.\n\n TECHNIQUE: Using ultrasound guidance, the right brachial vein was identified\n and confirmed to be patent. The right arm was prepped and draped in the usual\n sterile fashion. Using ultrasound guidance, the right brachial vein was\n accessed with a 21-gauge introducer needle. An 0.018 guidewire was advanced\n through the introducer needle into the superior vena cava under flouroscopic\n guidance. The introducer needle was exchanged for a 4.5-French sheath. Based\n on the markers on the guidewire, a length of 38 cm was deemed to be\n appropriate. The PICC was trimmed to length and advanced over the guidewire\n into the SVC. A final fluoroscopic image demonstrating catheter tip in the\n distal SVC was obtained. Hard copy ultrasound images pre- and post-insertion\n into the right brachial vein were also obtained.\n\n MEDICATIONS: 1% lidocaine for local anesthesia.\n\n IMPRESSION:\n\n Successful placement of a double lumen 38 cm PICC via the right brachial vein\n with its tip terminating in the distal SVC. The line is ready for use.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905867,
"text": " 3:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: atelectasis, ptx?\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute SOB in intubated patient.\n REASON FOR THIS EXAMINATION:\n atelectasis, ptx?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Previous study of earlier the same day.\n\n INDICATION: Shortness of breath.\n\n Endotracheal tube, central venous catheter as well as the nasogastric tube\n remain in satisfactory position. Cardiac and mediastinal contours are stable.\n The lung volumes appear slightly increased compared to the previous study.\n Allowing for this factor, multifocal predominantly alveolar pulmonary\n opacities are grossly unchanged as well as bilateral pleural effusions. There\n is no evidence of pneumothorax.\n\n\n"
}
] |
96,825 | 154,154 | Patient was brought to the trauma bay in critical condition, hypotensive with minimal IV access. Emergent femoral central venous lines were placed on the right and left side. She recieved 7u PRBC and 2L FFP in the trauma bay. She was emergently intubated for unfavorable change in mental status. When stabilized, patient underwent CT torso, CT neck and CT head. She was found to have bilateral small SAH, L frontal/tentorium SDH, L post 11th/12th rib fractures, L2-L5 bilateral transverse process fractures and a right posterior lung contusion. She was admitted directly to the Trauma ICU. On arrival to the ICU she was on a Levophed gtt, fully responsive and following commands. She shortly thereafter became hypotensive so a Level 1 was started with a total of 4L NS given. L axillary Aline placed, R MAC line placed. Bedside US revealed empty left ventricle thus resuscitation continued with another 5L NS, 2L LR and maintaining the levophed gtt. | IMPRESSION: Unchanged bilateral convexity subarachnoid hemorrhage with nodular components. Unchanged subarachnoid hemorrhage in the bifrontal and parietal regions. Subtle small patchy right perihilar opacity is seen, which may be confluence of vascular structures, although a small consolidation probably from contusion is not excluded. FINDINGS: Unchanged subarachnoid hemorrhage is noted in both frontal and parietal lobes. Nasogastric tube in appropriate position, although distal tip not seen. Unchanged bibasilar opacities, left greater than right. FINDINGS: Compared to the prior study, the right IJ Cordis has been removed. Small subgaleal hematomas are noted along the biparietal vertex are unchanged. The visualized mediastinal and hilar contours are within normal limits. Small-to-moderate left pleural effusion and left basal consolidation are unchanged. FINDINGS: Single AP portable view of the pelvis was obtained. Stable relatively thin bifrontal subdural fluid collections. Stable bifrontal subdural fluid collections. Stable bifrontal subdural fluid collections. Possible patchy right perihilar opacity, underlying pulmonary contusion is not excluded. ET tube is in standard placement, nasogastric tube passes into the stomach and out of view, and right jugular line ends just above its junction with the right subclavian vein. IMPRESSION: No definite acute fracture or dislocation. Given their continuous low attenuation appearance since inception, these could represent acute subdural hygromas. New mild mucosal thickening is present in the maxillary and ethmoid sinuses. FINDINGS: A single supine AP portable view of the chest was obtained. Left basilar opacity, stable or slightly increased. Bilateral interstitial opacities appear stable, and suggest mild pulmonary edema. Stable mild pulmonary edema. Stable mild pulmonary edema. Left subclavian line is unchanged. COMPARISON: Head CT from . THORACIC: The alignment, vertebral body height, and cord signal are normal. The paraspinal musculature demonstrates edema secondary to recent trauma. The prevertebral and paravertebral soft tissues are normal. ET tube is unchanged. Underlying trauma board partially obscures the view. LUMBAR: The alignment, marrow signal, and conus medullaris are normal. FINDINGS: CERVICAL: The alignment, vertebral body height, and cord signal are normal. Also noted is prominence of the extra-axial spaces anteriorly along the frontal lobes which are low in attenuation. No significant pleural effusion noted. COMPARISON: Portable supine chest radiograph from and CT torso from . Status post placement of endotracheal tube, terminating just above the level of the carina. COMPARISON: CT available from . Additionally, underlying trauma board partially obscures the view. There is bilateral alveolar edema and hazy vasculature suggesting fluid overload. PORTABLE AP FRONTAL CHEST RADIOGRAPH: The endotracheal tube terminates 2.7 cm above the carina. Similar but much smaller finding in the infrahilar right lower lobe is stable. FINDINGS: There has been interval decrease in the amount of hyperdense subarachnoid blood with residual blood layering in the sulci near the vertex. Interval decrease in amount of hyperdense subarachnoid blood with residual blood at the vertex. Interval decrease in amount of hyperdense subarachnoid blood with residual blood at the vertex. Prevertebral fluid in the cervical spine without evidence of a ligamentous disruption. The colon appears grossly within normal limits. The spleen is otherwise unremarkable. A small right perihilar patchy opacity is seen, and underlying contusion may be present. The cardiomediastinal silhouette is unchanged although patient is slightly rotated. The gallbladder is otherwise unremarkable. IMPRESSION: Right costophrenic angle not fully included. Previously seen small right pleural effusion has resolved. Punctate, non-obstructing right upper pole renal calculus. TECHNIQUE: CT C-spine without IV contrast. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass orvegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. The previously seen right pleural effusion has resolved. There is a small amount of subdural hemorrhage along the falx and along the tentorium as noted above. Visualized portion of the paranasal sinuses and mastoid air cells appear within normal limits. There is focal hypodensity at the lower tip of the spleen (300b:34), with no adjacent stranding, could be small hypoperfusion or tiny laceration. Themitral valve appears structurally normal with trivial mitral regurgitation. Left retrocardiac opacity is unchanged. FINDINGS: Single supine AP portable view of the chest was obtained. Imaged portions of pancreas appear within normal limits though the pancreatic tail and portions of the head are obscured by overlying bowel gas. Previously seen bilateral perinephric and left periadrenal fat stranding has resolved. Unchanged bilateral rib fractures and transverse process fractures, as described above. No mass orvegetation on tricuspid valve.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Bilateral small renal hypodensities, too small to characterize. Bilateral subtle foci of subarachnoid hemorrhage. Stranding posterior to the kidneys, retrocaval and periaortic concerning for focal ill-defined hematoma; however, no evidence of acute extravasation. Non-diagnosticrepolarization abnormalities. Patchy right perihilar opacity, non-specific, but contusion not excluded. Right costophrenic angle is not fully included on the image. The uterus appears normal. Low inferolateral lead T wave amplitude is non-specific. ABDOMEN CT: Aside from bibasilar atelectasis, left greater than right, the visualized portions of the lungs are clear. There is likely a punctate non-obstructing stone in the upper pole of the right kidney. The stomach is otherwise unremarkable. The left renal artery appears streched. The small bowel, colon, and appendix are normal appearing. Foci of hyperdense material in the left frontal extra-axial space, concerning for small left subdural hematoma. It appears well-corticated, and not an acute fracture. There are moderate scalp contusions bilaterally along the convexities with hyperdense material and subcutaneous air in keeping with recent trauma. Nomass or vegetation is seen on the mitral valve. Bilateral small renal hypodensities are likely cysts. The cardiac and mediastinal silhouettes are stable. There is cholelithiasis. Cholelithiasis, as seen before. Multiple small bilateral renal hypodensities are not significantly changed compared to the prior study. TECHNIQUE: Right upper quadrant ultrasound. Trace left pleural effusion with associated atelectasis, decreased compared to the prior study. NOTE ADDED AT ATTENDING REVIEW: The multiple areas of extra axial hemorrhage described above are primarily subarachnoid. | 24 | [
{
"category": "Radiology",
"chartdate": "2134-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194898,
"text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old female pedestrian struck by car.\n\n COMPARISON: Portable supine chest radiograph from and CT torso\n from .\n\n PORTABLE SEMI-ERECT FRONTAL CHEST RADIOGRAPH: The tip of the endotracheal\n tube terminates 3.3 cm above the level of the carina. A nasogastric catheter\n courses below the diaphragm and is incompletely imaged, though it is at least\n within the stomach. The right internal jugular central venous catheter\n terminates at the junction of the right brachiocephalic vein and upper SVC.\n There is no pneumothorax. Bilateral interstitial opacities appear stable, and\n suggest mild pulmonary edema. Opacification of the left lung base appears\n similar or slightly increased compared to prior. Findings may represent\n atelectasis, aspirtion, pneumonia or hemorrhage given the clinical history;\n correlation with clinical signs and symptoms is recommended. There is also a\n probable small left pleural effusion. The visualized mediastinal and hilar\n contours are within normal limits. Evaluation of the cardiac silhouette is\n limited due to overlying fluid.\n\n IMPRESSION:\n 1. Left basilar opacity, stable or slightly increased. Likely a combination\n of atelectasis and a small amount of pleural fluid, though aspiration and\n pneumonia could be considered.\n 2. Standard position of support devices. No pneumothorax.\n 3. Stable mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-31 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1194832,
"text": " 3:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for evolution of intracranial bleed\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n FINAL ADDENDUM\n There is slight interval enlargement of bifrontal extraaxial spaces, with\n fluid density, suggesting the possibility of developing subdural hygromas.\n Follow-up is recommended.\n\n DFDkq\n\n\n 3:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for evolution of intracranial bleed\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48yoF s/p MVA ped struck with SAH/SDH reported on admission CT\n REASON FOR THIS EXAMINATION:\n please evaluate for evolution of intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc MON 8:57 PM\n Minimally changed subarachnoid blood within the bilateral frontal and parietal\n regions, slightly less conspicuous since the study. Subdural\n blood along the left tentorial leaflet is also less apparent. No definite new\n hemorrhage or large vascular territorial infarction is seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle collision with subarachnoid hematomas.\n\n COMPARISON: CT available from .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without\n the use of IV contrast.\n\n FINDINGS:\n Again seen are multiple foci of frontal and parietal sulcal subarachnoid blood\n bilaterally, overall similar to the prior exam. Some of this foci are\n nodular, as before. Previously seen blood layering along the left tentorial\n leaflet is less apparent. No definite new intracranial hemorrhage is seen.\n There is no evidence of parenchymal edema or large vascular territorial\n infarction.\n\n There are bilateral subgaleal hematomas and scalp lacerations with skin\n staples.\n\n New mild mucosal thickening is present in the maxillary and ethmoid sinuses.\n Right mastoid tip air cells are newly opacified. These findings are likely\n related to recent endotracheal intubation.\n\n IMPRESSION: Unchanged bilateral convexity subarachnoid hemorrhage with\n nodular components. Subdural blood along the left tentorial leaflet is less\n apparent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1195132,
"text": " 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for change\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with SAH/SDH\n REASON FOR THIS EXAMINATION:\n please assess for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb WED 5:50 PM\n 1. Interval decrease in amount of hyperdense subarachnoid blood with residual\n blood at the vertex.\n 2. Stable bifrontal subdural fluid collections.\n 3. Possible loss of -white differentiation in some areas which may\n suggest developing cerebral edema. If indicated, MR could be performed for\n further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old female with post-traumatic subarachnoid and subdural\n hemorrhage. Evaluate for interval change.\n\n COMPARISON: and .\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast.\n\n FINDINGS: There has been interval decrease in the amount of hyperdense\n subarachnoid blood with residual blood layering in the sulci near the vertex.\n There has been no interval development of hydrocephalus or new focus of\n hemorrhage. There is no evidence for intraventricular hemorrhage. Bifrontal\n low-attenuation subdural collections are stable compared to most recent exam\n and slightly more prominent compared to the exam dated . There is no\n shift of normally midline structures. There is no evidence for a large mass.\n\n\n In places, the -white matter differentiation appears slightly obscured.\n However this does not appear appreciably changed and there has been no further\n ventricular or sulcal effacement. Significant bilateral scalp soft tissue\n swelling is again seen with overlying suture material likely corresponding to\n lacerations. There is no evidence for skull fracture. Fluid in the paranasal\n sinuses and mastoid air cells is likely secondary to supine positioning and\n intubation. Circumferential mucosal thickening is seen in the maxillary\n sinuses, bilaterally.\n\n IMPRESSION:\n 1. Interval decrease in amount of subarachnoid hemorrhage, likely reflecting\n resorption, with residual blood at the vertex.\n 2. Stable relatively thin bifrontal subdural fluid collections.\n 3. Possible loss of -white matter differentiation in some regions,\n raising the possibility of developing cerebral edema. If indicated clinically\n (and feasible), MR could be performed for further evaluation.\n (Over)\n\n 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for change\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1195133,
"text": ", TSICU 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for change\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with SAH/SDH\n REASON FOR THIS EXAMINATION:\n please assess for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval decrease in amount of hyperdense subarachnoid blood with residual\n blood at the vertex.\n 2. Stable bifrontal subdural fluid collections.\n 3. Possible loss of -white differentiation in some areas which may\n suggest developing cerebral edema. If indicated, MR could be performed for\n further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194735,
"text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48yoF pedestrian struck with multiple traumatic injuries (L posterior rib\n fractures, R pulmonary contusion, ? aspiration). Intubated and s/p 7U PRBCs\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pedestrian struck with multiple traumatic injuries\n with right pulmonary contusion.\n\n Portable AP radiograph of the chest was compared to .\n\n The ET tube tip is 2.5 cm above the carina. Diffuse right lower lobe opacity\n and left lower lobe opacity may represent pulmonary contusion in combination\n with atelectasis. No significant pleural effusion noted. No pneumothorax is\n seen.\n\n NG tube tip is in the stomach. Right internal jugular line tip is at the\n level of the junction of brachiocephalic vein and SVC. Lower left rib\n fractures and lower right rib fractures are better appreciated on the CT torso\n than on the chest radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194728,
"text": " 10:39 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n eval tube\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CHEST, SINGLE SUPINE AP PORTABLE VIEW.\n\n CLINICAL INFORMATION: 22-year-old female with history of intubation.\n\n COMPARISON: at 22:06.\n\n FINDINGS: A single supine AP portable view of the chest was obtained. There\n has been interval placement of an endotracheal tube, terminating just above\n the level of the carina, and which should be withdrawn approximately 2.5 cm.\n There has also been interval placement of a nasogastric tube, inferior tip not\n visualized, but is seen to coil in the left upper quadrant, in the expected\n position of the stomach. There are low lung volumes. Underlying trauma board\n partially obscures the view. Subtle small patchy right perihilar opacity is\n seen, which may be confluence of vascular structures, although a small\n consolidation probably from contusion is not excluded. No pleural effusion or\n pneumothorax is seen.\n\n IMPRESSION:\n\n 1. Status post placement of endotracheal tube, terminating just above the\n level of the carina. Recommend repositioning with withdrawal by approximately\n 2.5 cm.\n\n 2. Nasogastric tube in appropriate position, although distal tip not seen.\n\n 3. Low lung volumes. Possible patchy right perihilar opacity, underlying\n pulmonary contusion is not excluded.\n\n Findings and recommendation under #1 was discussed with Dr. on\n at 11 PM in person.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-31 00:00:00.000",
"description": "MR CERVICAL SPINE W/O CONTRAST",
"row_id": 1194865,
"text": " 8:41 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: please look for cord or ligamentous injury. Please scan T12-\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with L2-L5 bilateral transverse process fractures\n REASON FOR THIS EXAMINATION:\n please look for cord or ligamentous injury. Please scan T12-sacrum.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf TUE 7:28 AM\n Cord signal within normal limits.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: L2 to L5 bilateral transverse process fractures. Assessment for\n cord or ligament injury.\n\n TECHNIQUE: MRI cervical, thoracic, and lumbar spine without contrast.\n Sagittal T1, T2, STIR, axial T2 images.\n\n COMPARISON: CT torso, .\n\n FINDINGS:\n\n CERVICAL:\n\n The alignment, vertebral body height, and cord signal are normal. There is\n prevertebral fluid. Small disc bulges are seen at C5-6 and C6-7 levels\n without significant canal narrowing. The patient is status post intubation.\n No evidence of ligamentous injury.\n\n THORACIC:\n\n The alignment, vertebral body height, and cord signal are normal. The\n prevertebral and paravertebral soft tissues are normal. There is no evidence\n of a soft tissue injury.\n\n LUMBAR:\n\n The alignment, marrow signal, and conus medullaris are normal. There is no\n vertebral collapse. No evidence of bone edema is demonstrated. The canal\n dimensions are adequate throughout the lumbar spine. The paraspinal\n musculature demonstrates edema secondary to recent trauma. There is no\n abnormal signal in the interspinous tissues to suggest ligamentous injury.\n\n Bilateral transverse process fractures are better visualized on the recent CT\n study.\n\n IMPRESSION:\n 1. No evidence of a cord injury, epidural hematoma, vertebral compression, or\n paravertebral hematomas.\n (Over)\n\n 8:41 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n MR L SPINE W/O CONTRAST\n Reason: please look for cord or ligamentous injury. Please scan T12-\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Prevertebral fluid in the cervical spine without evidence of a ligamentous\n disruption.\n 3. Transverse process fractures in the lumbar spine are better demonstrated\n on the recent CT study.\n\n Findings were discussed with Dr. 10:25 a.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195170,
"text": " 8:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for PNA\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with temp spike\n REASON FOR THIS EXAMINATION:\n please assess for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old female post-trauma, pedestrian struck by car. Patient\n with new fever.\n\n COMPARISON: Chest radiographs dating back to , most recent from\n .\n\n PORTABLE AP FRONTAL CHEST RADIOGRAPH: The endotracheal tube terminates 2.7 cm\n above the carina. A nasogastric tube courses below the diaphragm and is at\n least within the stomach, though incompletely imaged. A right internal\n jugular catheter projects over the expected location of the proximal right\n internal jugular vein at the thoracic inlet. All lines and tubes are in\n standard position. There is no pneumothorax. Mild pulmonary vascular\n congestion persists but is stable. Bibasilar opacities, left greater than\n right, persist and may represent atelectasis or pneumonia in the appropriate\n clinical setting.\n\n IMPRESSION:\n 1. Standard position of support devices. No pneumothorax.\n 2. Stable mild pulmonary edema.\n 3. Unchanged bibasilar opacities, left greater than right. Possibly\n atelectasis, though pneumonia cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1195312,
"text": " 1:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please evaluate new L sided line\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p MVC, intubated with new L subclavian line placement\n REASON FOR THIS EXAMINATION:\n please evaluate new L sided line\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:42 P.M. ON \n\n HISTORY: 45-year-old woman, intubated with new left subclavian line after\n motor vehicle collision.\n\n IMPRESSION: AP chest compared to through :\n\n Tip of the new left subclavian line projects over the low SVC. No\n pneumothorax or mediastinal widening. Small-to-moderate left pleural effusion\n and left basal consolidation are unchanged. Whether this is pneumonia or\n atelectasis is radiographically indeterminate. Similar but much smaller\n finding in the infrahilar right lower lobe is stable. Over the past 20 hours,\n pulmonary vascular congestion and borderline interstitial edema have resolved.\n Heart size is normal. ET tube is in standard placement, nasogastric tube\n passes into the stomach and out of view, and right jugular line ends just\n above its junction with the right subclavian vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 1194727,
"text": " 10:25 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman s/p ped struck\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: PELVIS, SINGLE AP PORTABLE VIEW.\n\n CLINICAL INFORMATION: 20-year-old female with history of pedestrian struck.\n\n COMPARISON: None.\n\n FINDINGS: Single AP portable view of the pelvis was obtained. The superior\n iliac wings are not fully included on the image. Additionally, underlying\n trauma board partially obscures the view. Given the above, no evidence of\n acute fracture or dislocation is seen. The pubic symphysis and sacroiliac\n joints are not widened. Bilateral femoral catheters are noted.\n\n IMPRESSION: No definite acute fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1195421,
"text": " 9:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with trauma, decreased mvt rue\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with trauma and decreased movement of the right\n upper extremity.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n\n FINDINGS:\n\n Unchanged subarachnoid hemorrhage is noted in both frontal and parietal lobes.\n Also noted is prominence of the extra-axial spaces anteriorly along the\n frontal lobes which are low in attenuation. Small subgaleal hematomas are\n noted along the biparietal vertex are unchanged. No intra-parenchymal\n hemorrhage, large vascular territory infarct, shift of midline structures, or\n mass effect is present. The ventricles and sulci are normal in size and\n configuration. The visible paranasal sinuses show ethmoidal and sphenoidal\n mucosal thickening. The mastoid air cells are well aerated.\n\n IMPRESSION:\n\n 1. Hypoattenuating fluid in the bifrontal subdural regions have appeared\n without any prior imaging history of acute subdural hematomas. Given their\n continuous low attenuation appearance since inception, these could represent\n acute subdural hygromas.\n\n 2. Unchanged subarachnoid hemorrhage in the bifrontal and parietal regions.\n\n These findings were communicated to MD via telephone at 3:37 pm\n on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195573,
"text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, \n\n HISTORY: Intubation evaluation.\n\n REFERENCE EXAM: .\n\n FINDINGS: Compared to the prior study, the right IJ Cordis has been removed.\n NG tube tip is at least in the stomach with tip off the film. Left subclavian\n line is unchanged. ET tube is unchanged. There continues to be dense\n retrocardiac opacity consistent with volume loss/infiltrate/effusion. There\n is bilateral alveolar edema and hazy vasculature suggesting fluid overload.\n This has increased slightly compared to the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1194722,
"text": " 9:58 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CHEST, SINGLE SUPINE AP PORTABLE VIEW.\n\n CLINICAL INFORMATION: Trauma.\n\n COMPARISON: None.\n\n FINDINGS: Single supine AP portable view of the chest was obtained.\n Underlying trauma board partially obscures the view. Right costophrenic angle\n is not fully included on the image. There are relatively low lung volumes. A\n small right perihilar patchy opacity is seen, and underlying contusion may be\n present. The cardiac and mediastinal silhouettes are stable. No pleural\n effusion or pneumothorax is seen. No displaced fracture is seen.\n\n IMPRESSION: Right costophrenic angle not fully included. Low lung volumes.\n Patchy right perihilar opacity, non-specific, but contusion not excluded. No\n displaced fracture seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1194723,
"text": " 10:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman s/p MVC\n REASON FOR THIS EXAMINATION:\n acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 11:35 PM\n bilateral foci of SAH\n foci of subdural-extaraxial left frontal and left tentorium\n no displaced fracture seen\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle collision.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: No prior.\n\n FINDINGS: There are bilateral subtle foci of subarachnoid hemorrhage (2:17,\n 2:18, 2:19, 2:21, 22, 23). There is round focus of hyperdense material in the\n left frontal extra-axial space (2:26), could be foci of subdural hemorrhage in\n combination with contusion. There is a round hyperdense opacity at the right\n frontotemporal region (400:29), likely contusion. There is a trace of blood\n layering along the left tentorium (2:11); concerning for left small subdural\n hemorrhage. There is no shift of midline structures. Ventricles and sulci\n are normal in size and configuration. There is no evidence of fracture.\n Visualized portion of the paranasal sinuses and mastoid air cells appear\n within normal limits. The globes are intact. There are moderate scalp\n contusions bilaterally along the convexities with hyperdense material and\n subcutaneous air in keeping with recent trauma.\n\n IMPRESSION:\n 1. Bilateral subtle foci of subarachnoid hemorrhage.\n 2. Focal hyperdensity in the right frontotemporal region concerning for\n contusion.\n 3. Foci of hyperdense material in the left frontal extra-axial space,\n concerning for small left subdural hematoma.\n 4. Blood layering along the left tentorium concerning for left subdural\n hemorrhage.\n 5. Extensive soft tissue contusion along bilateral convexities with\n hyperdense material in keeping with hematoma.\n 6. No shift of midline structures.\n 7. No fracture.\n\n NOTE ADDED AT ATTENDING REVIEW: The multiple areas of extra axial hemorrhage\n described above are primarily subarachnoid. There is a small amount of\n subdural hemorrhage along the falx and along the tentorium as noted above.\n There are no definite parenchymal contusions, but given the evidence of\n (Over)\n\n 10:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n trauma, these may be present but missed on CT. If this is a clinical concern,\n an MR examination may be helpful.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1194724,
"text": " 10:20 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: acute injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman s/p MVC\n REASON FOR THIS EXAMINATION:\n acute injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 11:21 PM\n no fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle collision.\n\n TECHNIQUE: CT C-spine without IV contrast.\n\n COMPARISON: No prior.\n\n FINDINGS: There is no evidence of fracture or subluxation.There is no\n evidence of prevertebral soft tissue edema. The vertebral body height is\n preserved. There is a small osseous fragment anterior to C5-C6 vertebral\n bodies, likely small fractured osteophyte. There are posterior osteophytes at\n level C5-C6, 401B:24 impinging on thecal sac.\n\n IMPRESSION:\n 1. No evidence of acute fracture.\n 2. Degenerative changes in the cervical spine with posterior osteophytes\n impinging on thecal sac anteriorly at level C5-C6.\n\n NOTE ADDED AT ATTENDING REVIEW: The small ossified fragment noted anterior to\n the C6-7 interspace appears to represent ossified annulus and/or anterior\n longitudinal ligament. It appears well-corticated, and not an acute fracture.\n There is increased density and stranding in the posterior skin and\n subcutaneous tissue of the neck, perhaps reflecting post traumatic hemorrhage.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-05-30 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1194725,
"text": " 10:21 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: acute injury\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman s/p MVC\n REASON FOR THIS EXAMINATION:\n acute injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 11:44 PM\n bilateral opacities at the lung bases, could be aspiration\n no PTX\n L2-L5 bilateral transverse process fractures\n left posterior lower ribs fractures\n right posterior contusion (2:67)\n stranding:\n 1. posterior to left kidney (2:75)\n 2. posterior to right kidney\n 3. inferior to pancreatic tail\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motor vehicle collision.\n\n TECHNIQUE: CT torso with IV contrast. No oral contrast was administered.\n\n COMPARISON: No prior.\n\n FINDINGS:\n\n CT CHEST: There are bibasilar opacities at the lung bases with small\n bilateral pleural effusions, could be due to aspiration. No evidence of\n pneumothorax. The patient is intubated. There is an NG tube terminating in\n the stomach. There is no evidence of hematoma in the mediastinum. There is\n no pericardial effusion. There are no pathologically enlarged lymph nodes in\n the mediastinum, hilum, or axilla.\n\n CT ABDOMEN: The liver enhances homogeneously. There is cholelithiasis. The\n right adrenal gland is normal. There is focal hypodensity at the lower tip\n of the spleen (300b:34), with no adjacent stranding, could be small\n hypoperfusion or tiny laceration. At the inferior pole of the left adrenal\n gland and posterior to the body and tail of pancreas, there is fat stranding\n (2:55) concerning for contusion or hematoma in this region; however no\n evidence of active extravasation. The pancreas enhances homogeneously.\n\n There are multiple hypodensities in the kidneys; however, too small to be\n characterized. There is no hydronephrosis in the kidneys. The left renal\n artery appears streched. There is stranding concerning for ill-defined\n hematoma, in retrocaval, and periaortic distribution. Stranding is seen\n posterior to the right kidney (2:72) and at the inferior pole of the left\n kidney (2:74); concerning for ill-defined hematoma in this area; however,\n there is no evidence of acute extravasation. There is no evidence of free\n (Over)\n\n 10:21 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: acute injury\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n air. There is no bowel obstruction. The colon appears grossly within normal\n limits. The appendix is normal.\n\n There is Foley catheter in the urinary bladder. The uterus appears normal.\n There are no pathologically enlarged lymph nodes in the pelvic or inguinal\n area.\n\n OSSEOUS STRUCTURES: There are bilateral L2-L5 transverse process fractures.\n There is comminuted fracture at the left posterior 12th rib. Minimally\n displaced fracture through the left posterior eleventh rib, 800B:46 and\n 800B:43.\n\n SOFT TISSUE: There is stranding concerning for hematoma/contusion posteriorly\n in the subcutaneous tissue-flank region (2:74).\n\n IMPRESSION:\n\n 1. Hypodensity in the lower spleen (tip); could be hypoperfusion, or small\n laceration.\n 2. Stranding posterior to the kidneys, retrocaval and periaortic concerning\n for focal ill-defined hematoma; however, no evidence of acute extravasation.\n 3. Stranding inferior to the left adrenal gland, concerning for focal\n ill-defined hematoma, could be left adrenal injury; however, no evidence of\n acute extravasation.\n 4. Bilateral opacities at the lung bases with small effusion could be due to\n aspiration.\n 5. L2-L5 bilateral transverse process fracture.\n 6. Left posterior eleventh and twelfth rib fractures.\n 7. Cholelithiasis.\n 8. Stranding in the subcutaneous tissue in the posterior flank area\n concerning for subcutaneous hematoma; however, no evidence of active\n extravasation.\n 9. Bilateral small renal hypodensities, too small to characterize.\n Per Dr. patient is on Lithium; cannot exclude Lithium toxicity.\n\n Final read D/w Dr. at 10 am on by phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-04 00:00:00.000",
"description": "R HAND (AP & LAT) SOFT TISSUE RIGHT",
"row_id": 1195420,
"text": " 9:22 AM\n HAND (AP & LAT) SOFT TISSUE RIGHT Clip # \n Reason: please evaluate for right hand and wrist injury\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman pedestrian struck with intracranial bleed, intubated with\n decreased movement of right hand\n REASON FOR THIS EXAMINATION:\n please evaluate for right hand and wrist injury\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right hand three views .\n\n CLINICAL HISTORY: 45-year-old woman with trauma and intracranial bleed, has\n decreased movement of the right hand.\n\n FINDINGS: There are no signs for acute fractures or dislocations. There is\n normal osseous mineralization. Soft tissues are grossly normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-10 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1196289,
"text": " 7:55 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: fluid collection? evidence of pancreatic injury?\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with continued leukocytosis\n REASON FOR THIS EXAMINATION:\n fluid collection? evidence of pancreatic injury?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Continued leukocytosis, evaluate for fluid collection or evidence\n of pancreatic injury.\n\n TECHNIQUE: MDCT axial images were acquired from the lung bases through the\n ischial tuberosities following the administration of 130 cc of intravenous\n Optiray contrast material. Multiplanar reformations were performed.\n\n COMPARISON: CT torso from .\n\n ABDOMEN CT: Aside from bibasilar atelectasis, left greater than right, the\n visualized portions of the lungs are clear. There may be a trace left pleural\n effusion, decreased compared to the prior study. The previously seen right\n pleural effusion has resolved.\n\n The liver is normal in appearance. There is no intrahepatic biliary duct\n dilatation. The portal vein is patent. Cholelithiasis is again noted. The\n gallbladder is otherwise unremarkable. Previously seen hypodensities in the\n superior aspect of the spleen (2:26) are again seen and could be related to\n the recent trauma or alternatively could be small cysts. The spleen is\n otherwise unremarkable. There has been interval resolution of the previously\n seen bilateral perinephric and paraaortic fat stranding. The adrenal glands\n are unremarkable. Multiple small bilateral renal hypodensities are not\n significantly changed compared to the prior study. There is likely a punctate\n non-obstructing stone in the upper pole of the right kidney. The pancreas is\n normal in appearance. A PEG tube is new compared to the prior study. The\n stomach is otherwise unremarkable. The small bowel, colon, and appendix are\n normal appearing. Extensive fecal loading of the colon is noted, however.\n There is no free fluid or free air in the abdomen. No pathologically enlarged\n lymph nodes are seen. The aorta and its main abdominal branches are widely\n patent. Multiple injection granuloma are seen within the anterior\n subcutaneous tissue.\n\n Previously seen fat stranding overlying the bilateral flanks has developed\n into a more contained fluid collection, measuring up to 21.3 x 3.8 cm in the\n axial dimension and 15.2 cm in the craniocaudal dimension. On the left, this\n collection extends along the paraspinal musculature from approximately the T10\n through L3 level, while on the right, the collection extends out into the\n flank (2:54) where note is made of a fat-fluid level (2:56). Significant soft\n tissue stranding is seen surrounding to this collection. A high-density\n punctate focus within the left paraspinal portion of this collection (2:42,\n (Over)\n\n 7:55 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: fluid collection? evidence of pancreatic injury?\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 602B:53) is likely an osseous fracture fragment.\n\n PELVIS CT: A Foley catheter is seen within an otherwise normal-appearing\n bladder. The uterus and adnexa are unremarkable. There is no free fluid in\n the pelvis. No pathologically enlarged lymph nodes are seen in the pelvis.\n\n BONE WINDOW: A fracture of the lateral tenth right rib is better seen on\n today's study compared to the previous exam. A comminuted fracture of the\n left posterior twelfth rib and minimally displaced fracture of the left\n posterior eleventh rib are again noted. Bilateral L1 through L4 transverse\n process fractures are again seen.\n\n IMPRESSION:\n\n 1. New extensive fluid collection overlying the paraspinal musculature and\n right flank is likely an evolving hematoma. Infection of this collection\n cannot be excluded since surrounding stranding was present initially.\n\n 2. Previously seen bilateral perinephric and left periadrenal fat stranding\n has resolved.\n\n 3. Unchanged bilateral rib fractures and transverse process fractures, as\n described above.\n\n 4. Bilateral small renal hypodensities are likely cysts.\n\n 5. Cholelithiasis, as seen before.\n\n 6. Trace left pleural effusion with associated atelectasis, decreased\n compared to the prior study. Previously seen small right pleural effusion has\n resolved.\n\n 7. Punctate, non-obstructing right upper pole renal calculus.\n\n Pertinent findings were dicussed with Dr. by Dr. at 12:01 p.m.\n via telephone on the day of ths study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195773,
"text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, free air - pls shoot low film to eval GT pl\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F bpd now s/p PEG\n REASON FOR THIS EXAMINATION:\n interval change, free air - pls shoot low film to eval GT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with PEG.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The left subclavian line tip is at the level of mid SVC. The\n cardiomediastinal silhouette is unchanged although patient is slightly\n rotated. Left retrocardiac opacity is unchanged. No appreciable free air is\n noted on the current semi-erect portable radiograph. Bilateral pleural\n effusions are most likely present. No pneumothorax is seen. PEG was not\n included in the field of view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-11 00:00:00.000",
"description": "US HEMATOMA SUBCUT DRAIN INCISION",
"row_id": 1196540,
"text": " 2:05 PM\n US HEMATOMA SUBCUT DRAIN INCISION; GUIDANCE FOR ABSCESS () Clip # \n Reason: Please drain fluid collection on lower bacl\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ********************************* CPT Codes ********************************\n * US HEMATOMA SUBCUT DRAIN INCISION GUIDANCE FOR ABSCESS () *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with elevated white count has a fluid collection seen on CT.\n REASON FOR THIS EXAMINATION:\n Please drain fluid collection on lower bacl\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe FRI 6:06 PM\n Technically successful pigtail catheter placement in the right paraspinal\n fluid collection with aspiration of 450 cc of liquified blood. was\n left to suction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman with elevated white blood count and fluid\n collection.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n EXAMINATION: Fluid aspiration and drain placement (pigtail catheter).\n\n PROCEDURE: After explanation of the risks, benefits and alternatives to the\n procedure, written informed consent was obtained. A preprocedure timeout was\n performed using three patient identifiers and confirming the procedure to be\n performed.\n\n Patient was positioned in a left lateral decubitus position.\n\n Limited ultrasound of the paraspinal soft tissues at the right posterior\n lumbar spine revealed an about 20 x 2 cm elongated anechoic fluid collection\n in the subcutaneous tissues with multipl free floating hyperechoic bodies.\n\n 1% buffered lidocaine was used to anesthetize the soft tissues. A 5 French\n pigtail catheter was deployed in the fluid collection and 450 cc of\n liquified blood was aspirated. Specimens were sent for analysis. The\n catheter was left to suction.\n\n There were no immediate post-procedure complications.\n\n The procedure was performed by the attending radiologist, Dr. .\n\n IMPRESSION:\n Technically successful pigtail catheter placement in the right paraspinal\n subcutaneous fluid collection with aspiration of 450 cc of liquified blood.\n Catheter was left to suction.\n (Over)\n\n 2:05 PM\n US HEMATOMA SUBCUT DRAIN INCISION; GUIDANCE FOR ABSCESS () Clip # \n Reason: Please drain fluid collection on lower bacl\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-06-10 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1196294,
"text": " 8:13 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: evaluate gall bladder and bile ducts\n Admitting Diagnosis: S/P MOTOR VEHICLE CRASH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with traumatic brain injury, now with rising bili.\n REASON FOR THIS EXAMINATION:\n evaluate gall bladder and bile ducts\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Brain injury with rising bilirubin. Evaluate gallbladder and\n bile ducts.\n\n COMPARISON: CT abdomen and pelvis of same date.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n FINDINGS: The liver is diffusely echogenic consistent with fatty\n infiltration. Bandage material and the presence of an indwelling feeding tube\n somewhat limits son accessibility for examination of the right upper\n quadrant. The gallbladder contains a large (4.3 cm) shadowing gallstone but\n appears nondistended and there is no evidence of wall edema. Triangular\n relative of the hepatic parenchyma in the region of the\n gallbladder fossa is consistent with focal sparing. Common hepatic duct\n measures 4 mm and there is no intrahepatic biliary ductal dilation. There is\n no pericholecystic fluid. Portal vein patent with flow in the appropriate\n direction. Imaged portions of pancreas appear within normal limits though the\n pancreatic tail and portions of the head are obscured by overlying bowel gas.\n\n IMPRESSION: Large gallstone without evidence of cholecystitis. No biliary\n obstruction. Echogenic liver consistent with fatty infiltration. Other forms\n of liver disease, including more significant hepatic fibrosis or cirrhosis,\n cannot be excluded on the basis of this examination.\n\n"
},
{
"category": "Echo",
"chartdate": "2134-06-04 00:00:00.000",
"description": "Report",
"row_id": 91614,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 200\nBSA (m2): 1.98 m2\nBP (mm Hg): 118/74\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 17:48\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. Echocardiographic results were\nreviewed by telephone with the houseofficer caring for the patient.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque to 35 cm from the incisors. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion. No masses or\nvegetations are seen on the aortic valve. No aortic regurgitation is seen. The\nmitral valve appears structurally normal with trivial mitral regurgitation. No\nmass or vegetation is seen on the mitral valve. There is no pericardial\neffusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis\nDr. was notified by telephone.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-06-17 00:00:00.000",
"description": "Report",
"row_id": 248514,
"text": "Sinus tachycardia with ventricular premature depolarizations. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of \nthe heart rate is increased. Otherwise, no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-06-08 00:00:00.000",
"description": "Report",
"row_id": 248515,
"text": "Sinus rhythm. Low inferolateral lead T wave amplitude is non-specific. Tracing\nis probably within normal limits. No previous tracing available for comparison.\n\n\n"
}
] |
9,135 | 132,502 | 53 yo woman with depression, borderline personality, h/o suicidal ideation and | Normotensive, SBP 100-130's systolic. DUPLEX DOPPLER OF ABDOMEN: The main, left, right anterior, and right posterior portal veins are patent with appropriate direction of flow and normal waveforms. The splenic vein is patent with appropriate direction of flow and a normal waveform. Sinus rhythmInferior ST-T changes are nonspecificNo previous tracing please premed w/ benadryl. abd obese, hypoactive BS's. Sinus rhythmInferior/lateral ST-T changes may be nonspecificSince previous tracing of , no significant change The left, mid, and right hepatic veins are patent with appropriate direction of flow and normal waveforms. The pancreatic head appears unremarkable. denies suicidal ideations. erythemic site to R AC from IV infiltration. ?place on CIWA scale as pt was on significant dose of Clonazepam. 1 ppd smoker.NEURO/PSYCH- MAE. 2) Normal Doppler evaluation of liver vessels. acetaminophen level negative. appears to have had localized reaction to medications at IV infiltration site. Sinus rhythmInferior/lateral ST-T changes are nonspecificSince previous tracing of , no significant change Sinus rhythmInferior/lateral ST-T changes are nonspecificSince previous tracing of , no significant change pt reported took meds -2days ago, went to OSH w/ N/V. 11:20 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED Reason: Please do a liver US with dopplers to assess flow. denies pain. Tmax 100.3. currently recieving 40meq IV K for K of 3.2.RESP- on RA. please administer slowly. HISTORY: Tylenol overdose. The main, left and right hepatic arteries are patent with appropriate direction of flow and waveforms. pt to recieve IV benadryl prior to additional doses. side effects of IV mucomyst include urticaria, both local and systemic. hemodynamically stable.ROS-CV- NSR, hr 80-100's. Abnormal liver function tests. LS clear. pt admits to taking OD in an attempt "to finally stop the voices". admitted to MICU A for observation and monitoring of liver failure. foley placed. may change to continuous infusion if systemic reaction occurs. WET READ: DFDkq SAT 12:49 AM normal liver Doppler; gallstones and gallbladder wall edema - probably due to drug-induced hepatitis but can't exclude acute cholecystitis based on images alone; correlate clinically FINAL REPORT (REVISED) *ABNORMAL! REASON FOR THIS EXAMINATION: Please do a liver US with dopplers to assess flow. hct stablet at 42. extremities warm, pulses palpable. COMPARISON: No prior studies. PMH significant for psychosis w/ auditory hallucinations. letharic & Ox3. q 8hrs labs -lytes, liver enzymes, coags. Thank yo MEDICAL CONDITION: 53 year old woman with tylenol OD now with elevated transaminases. paranoid ideations- hearing voices that tells her to be suspicious of people/ things.GI/ pt on IV mucomyst q4hrs. liver enzymes very elevated, ALT , ALT . good amount clear brown urine.SKIN- grossly intact. neurologically intact. RIGHT UPPER QUADRANT ULTRASOUND: There are stones in the gallbladder. No abnormalities are identified on limited evaluation of the liver parenchyma. Thank you. otherwise no family involved. The gallbladder wall is edematous, measuring 4 mm. heat pack applied.ACCESS- 2 new 20g IV's placed in L arm. There is no intrahepatic or extrahepatic biliary ductal dilatation. IMPRESSION: 1) Cholelithiasis and gallbladder wall edema, likely representing an inflammatory process such as cholecystitis or hepatitis. There is no ascites. no cough or SOB. sitter at bedside for safety as pt is on suicide precautions. sitter at bedside for safety. The common duct measures 6 mm, which is the upper limits of normal. There is no pericholecystic fluid. Spo2 >95%. no stool. tolerating ice chips. frequent support/ encouragement. Nursing Progress Note 1900-0700Pt admitted to MICU A from after recent ingestion of approx 100-200 tylenol tablets. Pt lives in a group home, very unhappy there, SW consult needed to investigate other living arrangements.PLAN- q4hr IV mucomyst. | 6 | [
{
"category": "Radiology",
"chartdate": "2104-10-10 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 836603,
"text": " 11:20 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please do a liver US with dopplers to assess flow. Thank yo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with tylenol OD now with elevated transaminases.\n REASON FOR THIS EXAMINATION:\n Please do a liver US with dopplers to assess flow. Thank you.\n ______________________________________________________________________________\n WET READ: DFDkq SAT 12:49 AM\n normal liver Doppler; gallstones and gallbladder wall edema - probably due to\n drug-induced hepatitis but can't exclude acute cholecystitis based on images\n alone; correlate clinically\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n HISTORY: Tylenol overdose. Abnormal liver function tests.\n\n COMPARISON: No prior studies.\n\n RIGHT UPPER QUADRANT ULTRASOUND: There are stones in the gallbladder. The\n gallbladder wall is edematous, measuring 4 mm. There is no pericholecystic\n fluid. There is no intrahepatic or extrahepatic biliary ductal dilatation.\n The common duct measures 6 mm, which is the upper limits of normal. The\n pancreatic head appears unremarkable. No abnormalities are identified on\n limited evaluation of the liver parenchyma. There is no ascites.\n\n DUPLEX DOPPLER OF ABDOMEN: The main, left, right anterior, and right\n posterior portal veins are patent with appropriate direction of flow and\n normal waveforms. The left, mid, and right hepatic veins are patent with\n appropriate direction of flow and normal waveforms. The main, left and right\n hepatic arteries are patent with appropriate direction of flow and waveforms.\n The splenic vein is patent with appropriate direction of flow and a normal\n waveform.\n\n IMPRESSION:\n\n 1) Cholelithiasis and gallbladder wall edema, likely representing an\n inflammatory process such as cholecystitis or hepatitis.\n\n 2) Normal Doppler evaluation of liver vessels.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-10-11 00:00:00.000",
"description": "Report",
"row_id": 1382987,
"text": "Nursing Progress Note 1900-0700\nPt admitted to MICU A from after recent ingestion of approx 100-200 tylenol tablets. pt reported took meds -2days ago, went to OSH w/ N/V. acetaminophen level negative. liver enzymes very elevated, ALT , ALT . admitted to MICU A for observation and monitoring of liver failure. PMH significant for psychosis w/ auditory hallucinations. pt admits to taking OD in an attempt \"to finally stop the voices\". hemodynamically stable.\n\nROS-\n\nCV- NSR, hr 80-100's. Normotensive, SBP 100-130's systolic. hct stablet at 42. extremities warm, pulses palpable. Tmax 100.3. currently recieving 40meq IV K for K of 3.2.\n\nRESP- on RA. LS clear. Spo2 >95%. no cough or SOB. 1 ppd smoker.\n\nNEURO/PSYCH- MAE. denies pain. letharic & Ox3. neurologically intact. sitter at bedside for safety as pt is on suicide precautions. denies suicidal ideations. paranoid ideations- hearing voices that tells her to be suspicious of people/ things.\n\nGI/ pt on IV mucomyst q4hrs. appears to have had localized reaction to medications at IV infiltration site. side effects of IV mucomyst include urticaria, both local and systemic. pt to recieve IV benadryl prior to additional doses. please administer slowly. tolerating ice chips. abd obese, hypoactive BS's. no stool. foley placed. good amount clear brown urine.\n\nSKIN- grossly intact. erythemic site to R AC from IV infiltration. heat pack applied.\n\nACCESS- 2 new 20g IV's placed in L arm.\n\n pt has a distant brother that she has named as her contact person. otherwise no family involved. Pt lives in a group home, very unhappy there, SW consult needed to investigate other living arrangements.\n\nPLAN- q4hr IV mucomyst. may change to continuous infusion if systemic reaction occurs. please premed w/ benadryl. q 8hrs labs -lytes, liver enzymes, coags. ?place on CIWA scale as pt was on significant dose of Clonazepam. sitter at bedside for safety. frequent support/ encouragement.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-11 00:00:00.000",
"description": "Report",
"row_id": 280286,
"text": "Sinus rhythm\nInferior/lateral ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-12 00:00:00.000",
"description": "Report",
"row_id": 280287,
"text": "Sinus rhythm\nInferior/lateral ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-11 00:00:00.000",
"description": "Report",
"row_id": 280288,
"text": "Sinus rhythm\nInferior/lateral ST-T changes may be nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2104-10-10 00:00:00.000",
"description": "Report",
"row_id": 280518,
"text": "Sinus rhythm\nInferior ST-T changes are nonspecific\nNo previous tracing\n\n"
}
] |
4,486 | 136,145 | A/P: This is an 83-year-old man, Russian-speaking, with a Left temporo-parietal glioblastoma multiforme, s/p resection in , chronic Left frontal SDH and bilateral DVT's recently on Fragmin, and living in Rehabilitation Center receiving daily brain XRT. He initially presented with right arm weakness and non-fluent aphasia after an XRT session, and was found to have extension of his SDH. | + bilateral pitting edema.Resp - Lungs clear throughout, diminished at bases. ABDOMEN, SUPINE: There is distention of the large bowel likely representing ileus. IMPRESSION: Distended large bowel likely representing ileus. Comparison to a head CT of . Known glioblastoma and subdural hematoma. FINAL REPORT INDICATION: Abdominal distention. Left axis deviation withleft anterior fascicular block. CT scan showed L SDH acute on chronic with small amount midline shift. Staples reveal prior resection from the right upper lobe. Again note is made of high- density material within the subcutaneous tissue of the posterior neck, as was seen previously. There continues to be mild left to right midline shift and subfalcine herniation. + bowel sounds throughout. 1:09 AM PORTABLE ABDOMEN Clip # Reason: ilues, obstruction ? Pt attempting to communicate verbally, but also using gestures.CV - HR 80-100 A-FIB, with rare PVC's. s/p resection in . There is prominence of the left ambient cistern suggesting slight medial displacement of the left temporal uncus. HISTORY: Severe dysphagia. need speech and swallow, transfer to floor. There is left subdural fluid collection measuring 1.7 cm in thickness, associated with new fluid-fluid level with dependent hyperdensity measuring up to 43 , as well as areas of patchy high density anteriorly, increased in size since , 06, most likely representing acute on chronic subdural hematoma. There is prior craniostomy in the left parietal area. IMPRESSION: AP chest compared to : Small region of heterogeneous opacification at the base of the left lung could represent an acute aspiration and should be followed. Subsequent chest radiograph, performed at 7:15 p.m., available at the time of this dictation showed clearing of the left lower lobe abnormality, probably transient changes of either aspiration or atelectasis. HEAD CT WITHOUT CONTRAST: Comparison was made with a prior head CT dated . Further evaluation by MRI is recommended. Various consistencies of barium were administered to the patient. FINDINGS: The left-sided extra-axial fluid collection is very slightly larger than on the previous examination. Bolus formation and control were moderate-to-severely impaired. FINDINGS: The overall size of the subdural hematoma appears unchanged. Mild mucosal thickening in the ethmoid sinuses noted. Opacity projecting over the right mid lung laterally is probably overlying soft tissue. Sats 99% on RA.GI - Abdomen softly distended. Severe dysphagia. There was moderate-to- severe residue in the valleculae and piriform sinuses, solids greater than liquids, and this was cleared with multiple swallows and alternating with thin and solid consistency liquids. There was premature spillover into the piriform sinuses, especially with liquid consistency. Check NG tube. Check NG tube placement. Check NG tube placement. (Over) 12:03 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # Reason: assess stroke, known glioblastoma, SDH Admitting Diagnosis: SUBDURAL HEMATOMA FINAL REPORT (Cont) FINDINGS: Oropharyngeal video fluoroscopic evaluation was performed in conjunction with speech and swallow pathology. Wet read was flagged to ED dashboard. Follow up CT scan. obstipation. BP by cuff 100-130 systolic. MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES On the MIP sequence, there is some question of reduced flow in the lower basilar artery. Atrial fibrillation with a rapid ventricular response. Increase in size of left subdural hematoma compared to the prior study, with new fluid-fluid level with areas of hyperdensities, worrisome for acute on chronic subdural hematoma. Increased low density area on the left worrisome for recurrence. It has changed density in that the fluid-fluid level detected on the previous study is no longer identified, instead, there appears to be a more uniform distribution of density throughout the collection. An IVC filter is visualized. Had MRI around 0100. FINDINGS: The evaluation is somewhat limited due to motion. No acute infarct MRA BRAIN: Grossly normal intracranial vessels MD FINAL REPORT CLINICAL INFORMATION: Assess stroke. 10:53 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: Can patient tolerate any oral feeding? For further details, please consult the speech and swallow pathology note. Right bundle-branch block. Trace aspiration was seen with thin liquids, from residue spillover. Today on way back to rehab from radiation pt had sudden right side facial droop, weakness and aphasia. TSICU Nursing Admission NotePt with hx of brain tumor. There is a cavity in the left parietal lobe measuring 5.3 cm, increased in size and mass effect since prior study, worrisome for recurrent glioma in this patient with status post resection of glioma. + weak peripheral pulses. IMPRESSION: Some increased mass effect in left hemisphere when compared to the prior study associated with some increased edema and/or recurrent neoplasm around the operative site together with slight increase in the left- sided subdural fluid collection. REASON FOR THIS EXAMINATION: Can patient tolerate any oral feeding? Evaluate for obstruction. RR WNL. (Over) 7:13 PM CT HEAD W/O CONTRAST Clip # Reason: acute subdural FINAL REPORT (Cont) | 10 | [
{
"category": "Nursing/other",
"chartdate": "2198-01-11 00:00:00.000",
"description": "Report",
"row_id": 1320321,
"text": "TSICU Nursing Admission Note\nPt with hx of brain tumor. s/p resection in . UNdergoing chemo and radiation therapy. Today on way back to rehab from radiation pt had sudden right side facial droop, weakness and aphasia. Taken to hospital. CT scan showed L SDH acute on chronic with small amount midline shift. To for further eval.\n\nNeuro - Pt alert, dozing a little through night. Pt is speaking only. UNderstands some English but unable to speak it at baseline. MAE's with great strength, Equal bilateral with uppers and lowers. Able to follow nurse . PERRLA 3mm brisk. Had MRI around 0100. Upon admission pt unable to form any sounds or words. Daugher here and speaking in to him. However throughout night pt has improved and had increased speech. UNsure if it is or garbled. However has increased. Pt attempting to communicate verbally, but also using gestures.\n\nCV - HR 80-100 A-FIB, with rare PVC's. BP by cuff 100-130 systolic. Goal 110-160. + weak peripheral pulses. + bilateral pitting edema.\n\nResp - Lungs clear throughout, diminished at bases. pt s/p lung resection 40yrs ago due to TB. RR WNL. Sats 99% on RA.\n\nGI - Abdomen softly distended. + bowel sounds throughout. no BM have sips except meds.\n\nGU - Foley draining clear yellow urine in adequate amounts.\n\nEndo - BS 144. No sliding scale written.\n\nId - tmax 98.1 axillary. NOt on antibiotics.\n\nSkin - all areas intact.\n\nPsych/social - Pt speaking only. Will need translator. Daughter in with pt upon arrival. PT also has a son who is still in who is a doctor there. wife is still here, and prior to all these recent hospitalizations pt lived at home with wife.\n\nA - s/p L SDH, altered mental status\n\nPlan - Continue to monitor per routine. Follow up CT scan. TRanslator for full neuro exam. ? need speech and swallow, transfer to floor. Continue to update pt and family of current plan of care.\n"
},
{
"category": "ECG",
"chartdate": "2198-01-10 00:00:00.000",
"description": "Report",
"row_id": 174970,
"text": "Atrial fibrillation with a rapid ventricular response. Left axis deviation with\nleft anterior fascicular block. Right bundle-branch block. Compared to the\nprevious tracing of no significant diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940158,
"text": " 7:02 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?NGT placement after adjustment x 2\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with GBM, severe dysphagia\n\n REASON FOR THIS EXAMINATION:\n ?NGT placement after adjustment x 2\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:19 P.M. \n\n HISTORY: Brain tumor, dysphagia. Check NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Inappropriate technical factors renders this chest film nearly unreadable\n except to say that the nasogastric tube loops in the stomach and returns to\n the esophagus and needs to be repositioned, and there is no pneumothorax or\n large scale pulmonary abnormality. Heart size is normal. Dr. was\n paged to report these findings, at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940154,
"text": " 6:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?NGT placement after adjustment\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with GBM, severe dysphagia\n\n REASON FOR THIS EXAMINATION:\n ?NGT placement after adjustment\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:34 P.M. \n\n HISTORY: Brain tumor. Severe dysphagia. Check NG tube.\n\n IMPRESSION: AP chest compared to 5:50 p.m.:\n\n Nasogastric tube still loops in the stomach and passes retrograde into the\n distal esophagus. Lungs grossly clear. Heart size normal.\n\n These findings were discussed with the clinical house officer caring for this\n patient at the time of dictation of the proceeding examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 939843,
"text": " 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute subdural\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with\n REASON FOR THIS EXAMINATION:\n acute subdural\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa WED 10:35 PM\n Increased acute on chronic SDH. Increased low density area on the left\n worrisome for recurrence.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with acute subdural hematoma.\n\n HEAD CT WITHOUT CONTRAST: Comparison was made with a prior head CT dated\n .\n\n FINDINGS: The evaluation is somewhat limited due to motion. There is left\n subdural fluid collection measuring 1.7 cm in thickness, associated with new\n fluid-fluid level with dependent hyperdensity measuring up to 43 , as well\n as areas of patchy high density anteriorly, increased in size since , 06, most likely representing acute on chronic subdural hematoma. Again\n note is made of mild shift of normally midline structures measuring 6 mm.\n There is a cavity in the left parietal lobe measuring 5.3 cm, increased in\n size and mass effect since prior study, worrisome for recurrent glioma in this\n patient with status post resection of glioma. Again note is made of high-\n density material within the subcutaneous tissue of the posterior neck, as was\n seen previously. There is prior craniostomy in the left parietal area. Mild\n mucosal thickening in the ethmoid sinuses noted.\n\n IMPRESSION:\n\n 1. Increase in size of left subdural hematoma compared to the prior study,\n with new fluid-fluid level with areas of hyperdensities, worrisome for acute\n on chronic subdural hematoma.\n\n 2. Slightly increased shift of midline structures.\n\n 3. Increase in size of the post-glioma resection cavity with increased mass\n effect, worrisome for recurrence of the glioma. Further evaluation by MRI is\n recommended.\n\n 4. High density in the subcutaneous tissue in the neck.\n\n Wet read was flagged to ED dashboard. Findings discussed with Dr. at\n 10:30 PM.\n (Over)\n\n 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute subdural\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 939922,
"text": " 9:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute on chronic SDH\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST \n\n HISTORY: Acute on chronic subdural hematoma.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: The overall size of the subdural hematoma appears unchanged. It\n has changed density in that the fluid-fluid level detected on the previous\n study is no longer identified, instead, there appears to be a more uniform\n distribution of density throughout the collection. There continues to be mild\n left to right midline shift and subfalcine herniation. There is no evidence\n of new hemorrhage.\n\n CONCLUSION: No evidence of enlargement of the subdural hematoma since\n . The density appears more uniform than on the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-16 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 940592,
"text": " 10:53 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Can patient tolerate any oral feeding?\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with GBM and chronic SDH failed multiple swallowing studies,\n though improved.\n REASON FOR THIS EXAMINATION:\n Can patient tolerate any oral feeding?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old with glioblastoma multiforme and chronic SDH with\n failed multiple swallowing studies. Can patient tolerate any oral feeding?\n\n FINDINGS: Oropharyngeal video fluoroscopic evaluation was performed in\n conjunction with speech and swallow pathology. Various consistencies of\n barium were administered to the patient. Bolus formation and control were\n moderate-to-severely impaired. There was premature spillover into the\n piriform sinuses, especially with liquid consistency. There was moderate-to-\n severe residue in the valleculae and piriform sinuses, solids greater than\n liquids, and this was cleared with multiple swallows and alternating with thin\n and solid consistency liquids. There is moderately weak bolus propulsion.\n Trace aspiration was seen with thin liquids, from residue spillover. The\n patient was able to initiate a spontaneous cough and clear most of the\n residue. There is significantly increased residue with thick liquids. For\n further details, please consult the speech and swallow pathology note.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940150,
"text": " 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?NGT placement\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with GBM, severe dysphagia\n REASON FOR THIS EXAMINATION:\n ?NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:55 P.M., .\n\n HISTORY: Severe dysphagia. Check NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Small region of heterogeneous opacification at the base of the left lung could\n represent an acute aspiration and should be followed. Opacity projecting over\n the right mid lung laterally is probably overlying soft tissue. There is no\n appreciable pleural effusion. Heart size normal. Upper lungs clear. Staples\n reveal prior resection from the right upper lobe.\n\n Subsequent chest radiograph, performed at 7:15 p.m., available at the time of\n this dictation showed clearing of the left lower lobe abnormality, probably\n transient changes of either aspiration or atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-11 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 939862,
"text": " 12:03 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: assess stroke, known glioblastoma, SDH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with transient dysarthria/ right sided weakness\n REASON FOR THIS EXAMINATION:\n assess stroke, known glioblastoma, SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:56 AM\n MRI BRAIN:\n 6 cm L parietal mass (known)\n L hemispheric subdural collection, up to 1.1cm thick. Causes 8mm transfalcine\n shift to R\n Small vessel changes. No acute infarct\n\n\n MRA BRAIN:\n Grossly normal intracranial vessels\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Assess stroke. Known glioblastoma and subdural\n hematoma.\n\n MRI OF THE BRAIN\n\n Examination is compared to the prior study of .\n\n FINDINGS: The left-sided extra-axial fluid collection is very slightly larger\n than on the previous examination. There is some increased signal surrounding\n the operative cavity with slightly increased mass effect in the left\n hemisphere when compared to the previous examination. There is prominence of\n the left ambient cistern suggesting slight medial displacement of the left\n temporal uncus. There is no evidence of abnormal diffusion to suggest the\n presence of acute infarction. There is no definite evidence of new recent\n hemorrhage.\n\n IMPRESSION: Some increased mass effect in left hemisphere when compared to the\n prior study associated with some increased edema and/or recurrent neoplasm\n around the operative site together with slight increase in the left- sided\n subdural fluid collection.\n\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES\n\n On the MIP sequence, there is some question of reduced flow in the lower\n basilar artery. There is no evidence of abnormal signal in this area on the\n axial T2-weighted MRI sequences and this is felt to represent artifact. There\n is no definite evidence of flow abnormality.\n (Over)\n\n 12:03 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: assess stroke, known glioblastoma, SDH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 940382,
"text": " 1:09 AM\n PORTABLE ABDOMEN Clip # \n Reason: ilues, obstruction ?\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with GBM, now with abd distention and ? obstipation.\n\n REASON FOR THIS EXAMINATION:\n ilues, obstruction ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention. Evaluate for obstruction.\n\n ABDOMEN, SUPINE: There is distention of the large bowel likely representing\n ileus. An IVC filter is visualized. The osseous structures appear\n unremarkable.\n\n IMPRESSION: Distended large bowel likely representing ileus.\n\n\n"
}
] |
323 | 106,158 | The patient is a 53 year old man with a history of coronary artery disease, myocardial infarction and renal transplant as well as insulin dependent diabetes mellitus and congestive heart failure. 1. Cardiovascular - From the cardiovascular standpoint the patient presented in acute decompensated heart failure in the setting of ischemic heart disease. From a coronary artery disease standpoint the patient has severe three vessel disease. Multiple interventions including recent percutaneous transluminal coronary angioplasty and brachiotherapy to the left anterior descending now presented with recurrent in-stent left anterior descending stenosis, status post percutaneous transluminal coronary angioplasty. The patient was ruled out for myocardial infarction. He was evaluated by Cardiac Surgery who felt that the patient was not a coronary artery bypass candidate. He was continued on Aspirin, Plavix and Beta blockers as well as Pravachol. From a myocardial standpoint the patient had an ejection fraction of 20% with severe hypokinesis, left ventricular hypertrophy, and diastolic dysfunction. He presented with decompensated heart failure. He ruled out for myocardial infarction, however, his congestive heart failure was felt to be secondary to ischemic heart disease. The patient was diuresed with Lasix and eventually a combination of Diuril and Lasix. The patient was started on Natrecor which initially caused some hypotension but then the patient reported improvement in his shortness of breath. He had augmented diuresis while on the Natrecor. The patient was considered for Aldactone although with his history of hyperkalemia this was deferred. Plan was to use BiPAP if the patient were to have further acute pulmonary edema. Post cardiac catheterization the patient had an episode of acute pulmonary edema which was responsive to Morphine and Lasix. The patient was continued on his outpatient heart failure regimen which included Enalapril, Isordil, and Toprol. From a conduction standpoint the patient remained in sinus rhythm and was continued on his Beta blocker. From an endocrine standpoint the patient presented with a history of insulin dependent diabetes mellitus and was maintained on a regimen of NPH and regular insulin sliding scale as per his outpatient regimen. From a renal standpoint the patient is status post renal transplant on an immunosuppressant regimen. He presented at his baseline creatinine. However, with fingerstick diuresis the patient's creatinine climbed from 1.4 to approximately 1.8. His Cyclosporin level of 113 was within normal limits. The renal transplant team followed the patient. His creatinine gradually began to trend down at the end of the hospital course. Infectious disease - The patient presented with a left knee ulcer near the site of the left below the knee amputation. Vascular surgery was consulted and felt the patient should be on Levofloxacin and Flagyl. They debrided the ulcer. The patient was continued on Levofloxacin and Flagyl for approximately a course of 14 days. The patient had a swab that grew Enterobacter as well as Stenotrophomonas. Infectious Disease was contact regarding the treatment of his Stenotrophomonas. Given the marked clinical improvement in the ulcer, the feeling was that the Stenotrophomonas was a colonizer and that there was no need to add additional coverage. Vascular Surgery recommended the patient follow up with his vascular surgeon at . | Agressively being for MD preference.ID: T-max 99.3. remains on levo and flagyl. ABD SOFT.GU: U/O RESPONDING TO LASIX > 100CC/HRSKIN: AKA/BKA NOTED. drainage- continues on levaquin & flagyl.A- decreased C.O. HR 80's NSR w/o ectopy. PVC- HR 69-79 SBP 108-128/38-57- R femoral PA line PAS 52-72/ PAD 33-46 CVP 5-11 mixed venous sat @ 4am 61- CO 4.0CI 2.41 SVR 1140- Diuril 500mg po & lasix 120mg IV given @ 11pm- diurising well- Con't on Natrecor gtt @ .02mcq/kg/min. Per team pt with episode of flash pulm edema. Pt remains on 0.02 mcg/kg/min of natricore. this AM.resp- O2 5L via NC- Lung sounds with bibasilar crackles- resp.even-non-labored- Sao2 95-98.gi- abd. soft non-tender + bowel sounds- po intake poor- glu 307 @ 12am. PRESENTLY ON 2.2 MCG/KG/MIN AND SBP NOW 94-110. CXR IN EW SHOWED MILD FAILURE,LG R PLEURAL EFFUSION. PA 59-75/26-33, CO/CI/SVR 3.2/1.93/1500, CVP 7-15. Creat 1.8 and BUN 45.ID: afebrile. W-D DSG APPLIED.ID: AFEBRILE. L groin dsg changed and there was no ooze.A: Natricor begun/u/o low/pad increasedP: Monitor I & O closely. pvc's -HR- 76-89- SBP 116-148/43-63-R groin PA line-PAS75-83 PAD 25-36 CVP 7-13 mixed venous sat @ 12am 60- C.O 3.9 C.I. Rec'd 110cc contrast. There has been interval decreased vascular engorgement and interval improvement in central alveolar pattern with residual hazy perihilar opacities remaining. IT HAS PURLENT DRAINAGE AND APPEARS TO NEED DEBRIDEMENT. C.O 5.5/3.31/960. ADM EKG SHOWING NSR,Q IN 2, ELEVATION V2-V3,PEAKED T'S IN V3 AND ST DEPRESSION V6,1. SBP 120-130/70'S. Pts BP 106-134/27-63. BP STABLE WITH MAP'S >60 IV NGT TITRATED UP TO 113MCG. BP stable in low 100's on current antihypertensive regimen. Denies feelings of SOB.CARDIAC: SBP 90-115. CV: Afebrile. numbers-id- afebrile - L knee dsg changed @ 10p- sm. Pt is -488cc at this time. PRESENTS WITH PROGRESSIVE SOB. RALES ON L/R. R arterial sheath removed.Pt rec'd po caridac meds. Pt in NSR with occas ventricular ectopy. Fi02 weaned down from 100% NRB to 3 L NC with spo299% and rr 8-16. Small inferior Q wavessuggesting possible old inferior myocardial infarction. Low limb lead voltage.Compared to the previous tracing of the lateral T wave inversion isless and ST segment changes in the inferior leads persist. 12pm 152 pt rec'd 2u reg per insulin ss. Q waves in leads VI-V4 suggesting oldanteroseptal and anterior myocardial infarction. PA pressures 70's/27-33. Ocassional tinge of blood.CR down this morning from 1.8 to 1.3! Pt conts on flagyl and levaquin for broad spectrum coverage.ENDO: FS 7:30 am 181 pt rec'd 2uR and 10u NPH. R groin swan in place. Pt w/o CP. Pt asymptomatic during episode. HR SR WITH OCCASIONAL PVC'S. CCU NSG PROGRESS NOTE 7P-7AO-see flowsheet for all objective data.cv- Tele: SR rare- occ. +BS. TOL DECREASE IN O2 REQUIREMENTS.P--OFFER SUPPORT. -488cc this eve.ACCESS: Right groin swan; 2 peripheral IVS left arm.STATUS: full code. SPONT RESP 22-32. CHEST AP: Comparison is made to the prior film dated . Administer IV lasix. D/C PA line today? Pt denies CP or SOB.GI: Abd soft NT +BS. with bolusK3.7 yest.- KCL 40 meq po given- diuril 500mg po given @ 0155- lasix 120mg IV given @ 0225- mixed venous sat repeated at 0400 57- C.O.3.6C.I. 02 SATS 97-99%.CV: REMAINS IN NSR WITH HR 90-91. IMPRESSION: Cardiomegaly with overt CHF. amber colored urine ( approx- 20cc/hr) HO aware- no c/o SOB.id- afebrile- started on levaquin and metronidazole- L knee dsg changed- sm. Goal u/o 100cc/hr. Goal u/o 100cc/hr. Left atrial abnormality. Abd soft, ND, NT. Moderate bilateral pleural effusions. FINAL REPORT INDICATION: SOB. PRESENT BS. Continue on ss reg coverage.SKIN: Dressing on L stump changed. Pt with crackles bibasilary. After multiple doses of lasix, am lytes with K+=3.7, Mg=2.2. CCU Nsg Progress Note 7P-7AS- " Am I doing alright? Pt receiving lasix prn. Possible ascites. Sinus rhythm. Sinus rhythmPossible left atrial abnormalityOld anteroseptal infarctInferior/lateral ST-T changes may be due to myocardial ischemiaLow QRS voltages in limb leadsSince last ECG, no significant change -N/V, +BS, -BM, abd soft NT.GU: Pt has f/c with good urine output. Sinus tachycardiaAnteroseptal infarct - age undeterminedInferior/lateral ST-T changes may be due to myocardial ischemiaLow QRS voltages in limb leadsSince last ECG, no significant change +SOB, anxious, diaphoretic with RR 30's Placed on 100% NRB and 10L NC with sats in 80's. 2.17 SVR 1733- HO called- Natrecor gtt increased to .02mcq/kg/min. CCU NSG NOTE: 3p-7p ALT IN CV/DIABETESS: "I feel much better than yesterday".O: For complete VS see CCU flow sheet.ID: T-max 99.1 po. SINGLE CHEST: There are moderate bilateral pleural effusions. CCU Nursing Porgress NoteNeuro: Pt is A&O x3. since IABP dc'd- IDDM with multiple complications.P- con't increasing natrecor gtt until optimal diuresis is achieved- ? Abd soft NT. DIURESE AS ORDERED. IMPRESSION: Mild CHF. "O- see flowsheet for all objective data.cv- no cardiac c/o this shift- con't on Ntg gtt @ 2.2mcg/kg/min- SBP 80-116/25-46 HR-77-87 RR-16-22 NPO for cardiac cath. TO GET 80 MG IV LASIX. Episode resolved with above treatment.Pt conts on NTG gtt at 2.2mcg and integrillin gtt 1mcg until 5am . BP initially dropped to 80s, but within 30 min was back to 120-130s/30-40s.RESP: After natricor was begun sat dropped to low 90s for ~ 1hour, but is now back to high 90s on 4L NP. RECEIVED OF NPH DOSE (10 U) AND COVERED WITH SS INSULIN PER SHEET AND HO.CARDIAC--DENIES CP. amt. amt. Pt rec'd lasix 80mg IV with fair response. H.O. CVP 12. GOING FOR CATH TODAY AS AN ADD-ON CASE. NTG continues at 2.2 mcg/kg/min with no c/o CP/SOB. IMPRESSION: Findings consistent with CHF. Distal circulaton appears intact (BKA warm, CR WNL). The heart is upper limits of normal in size. Pt with hypotension during procedure therefore low dose dopa started and d/c'd prior to transfer back to CCU. A Swan-Ganz catheter remains in place, terminating in the expected location of the main pulmonary artery. | 18 | [
{
"category": "ECG",
"chartdate": "2116-05-03 00:00:00.000",
"description": "Report",
"row_id": 129570,
"text": "Sinus rhythm\nInferior infarct - age undetermined\nAnterior infarct - age undetermined\n Lateral ST-T changes offer additional evidence of ischemia\nLow QRS voltages in limb leads\nST segment elevation anteriorly, consider repolarization +/or recent +/or\n aneurysm\n\n"
},
{
"category": "ECG",
"chartdate": "2116-05-08 00:00:00.000",
"description": "Report",
"row_id": 129567,
"text": "Sinus rhythm. Left atrial abnormality. Q waves in leads VI-V4 suggesting old\nanteroseptal and anterior myocardial infarction. Small inferior Q waves\nsuggesting possible old inferior myocardial infarction. Low limb lead voltage.\nCompared to the previous tracing of the lateral T wave inversion is\nless and ST segment changes in the inferior leads persist. Clinical correlation\nis suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-05-05 00:00:00.000",
"description": "Report",
"row_id": 129568,
"text": "Sinus tachycardia\nAnteroseptal infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2116-05-06 00:00:00.000",
"description": "Report",
"row_id": 129569,
"text": "Sinus rhythm\nPossible left atrial abnormality\nOld anteroseptal infarct\nInferior/lateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-07 00:00:00.000",
"description": "Report",
"row_id": 1264749,
"text": "CCU Nursing Porgress Note\nNeuro: Pt is A&O x3. Pt able to move self well, pt would like to sit up more, however has groin .\n\nCardiac: Pt in SR HR 71-88, no ectopy. Pts BP 106-134/27-63. Pt tolerating cardiac meds well. PA 59-75/26-33, CO/CI/SVR 3.2/1.93/1500, CVP 7-15. Pt remains on 0.02 mcg/kg/min of natricore. Pt also given lasix and diaurel in afternoon, diauresing moderately. Pt con't to have R groin , be pulled tomorrow.\n\nResp: Pt remains on NC at 2L. O2 sat 92-100%. BS clear bilaterally with rales in bases at times.\n\nGI: Pt tolerating a full cardiac and diabetic diet. -N/V, +BS, -BM, abd soft NT.\n\nGU: Pt has f/c with good urine output. Agressively being for MD preference.\n\nID: T-max 99.3. remains on levo and flagyl. Pts L knee dgs needs to be changed q12, WTD; surgery did not come by.\n\nMisc: Pt may be txr to floor tomorrow, con't to monitor cardiac status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-08 00:00:00.000",
"description": "Report",
"row_id": 1264750,
"text": "CCU NSG PROGRESS NOTE 7P-7A\n\nO-see flowsheet for all objective data.\n\ncv- Tele: SR rare- occ. PVC- HR 69-79 SBP 108-128/38-57- R femoral PA line PAS 52-72/ PAD 33-46 CVP 5-11 mixed venous sat @ 4am 61- CO 4.0\nCI 2.41 SVR 1140- Diuril 500mg po & lasix 120mg IV given @ 11pm- diurising well- Con't on Natrecor gtt @ .02mcq/kg/min. K 3.8 yesterday\nKcl 20 meq po given @11pm. AM labs drawn & pending.\n\nresp- O2 2L via NC- lung sounds diminished @ bases otherwise clear-SaO2' 95-99%.\n\ngu- foley draining large amts of clear yellow urine.\n\nid- L knee dsg changed- scant amt sero-sang drainage noted- afebrile on levaquin & flagyl.\n\nendo- glu 374 @ midnoc- 8u reg insulin given- glu checked again @ 4am\n206.\n\nneuro- alert & oriented X3- moves self well.\n\nA- resolving CHF\n\nP- Cont't natrecor gtt- monitor vs, I&O, & labs- ? D/C PA line today\n? transfer to floor.\n\nP\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-06 00:00:00.000",
"description": "Report",
"row_id": 1264747,
"text": "CCU NSG NOTE: 3p-7p ALT IN CV/DIABETES\nS: \"I feel much better than yesterday\".\nO: For complete VS see CCU flow sheet.\nID: T-max 99.1 po. Pt feeling very hot.\nCV: Natricor was begun after 2mic/kilo bolus at .01mic/kilo at 2:30pm. CO/CI at 4p was increased to 4.3/2.59 with svr 1098. His pad, however has not dropped, in fact has increased from 70/25 to 80s/30 with ra . BP initially dropped to 80s, but within 30 min was back to 120-130s/30-40s.\nRESP: After natricor was begun sat dropped to low 90s for ~ 1hour, but is now back to high 90s on 4L NP. Pt is not dyspnic. He does have rales up ~ bilaterally.\nRENAL: Pts urine output has dropped off and 160mg IV lasix given at 5pm with poor results at 6pm--only 80cc out.\nGI: Pt apetite remains poor and has not eaten anything for dinner. He may have snack later.\nENDO: Pt received 1/2 dose NPH 7u SQ at 6pm. Continue on ss reg coverage.\nSKIN: Dressing on L stump changed. Area looks clean, but more debreeding is needed. L groin dsg changed and there was no ooze.\nA: Natricor begun/u/o low/pad increased\nP: Monitor I & O closely. Monitor c/o ~10pm. Notify ho is u/o doesn't increase. Encourage pt to eat snack.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-07 00:00:00.000",
"description": "Report",
"row_id": 1264748,
"text": "CCU Nsg Progress Note 7P-7A\n\nS- \" Am I doing alright?\"\nO- see flowsheet for all objective data.\n\ncv- Tele: SR occ. pvc's -HR- 76-89- SBP 116-148/43-63-R groin PA line-\nPAS75-83 PAD 25-36 CVP 7-13 mixed venous sat @ 12am 60- C.O 3.9 C.I. 2.35 SVR 1415 Natrecor gtt increased .015 mcq/kg/min. with bolus\nK3.7 yest.- KCL 40 meq po given- diuril 500mg po given @ 0155- lasix 120mg IV given @ 0225- mixed venous sat repeated at 0400 57- C.O.3.6\nC.I. 2.17 SVR 1733- HO called- Natrecor gtt increased to .02mcq/kg/min. with bolus given- U/O increasing.\n\nresp- In o2 4l nc- lung sounds with bibasilar crackles- Sao2's 96-99%-\nslight nose bleed noted x2 during night- reported to HO Afrin nose spray ordered & given- no further nose bleeds.\n\ngi- appetite poor- c/o nausea at intervals- no vomiting- abd. soft + bowel sounds- glu @ 7p 290 4u reg insulin sc given- 12a glu 248 2u reg insulin sc given.\n\ngu- negative output noted- increased u/o despite lower c.o. numbers-\n\nid- afebrile - L knee dsg changed @ 10p- sm. amt. sero-sang. drainage- continues on levaquin & flagyl.\n\nA- decreased C.O. since IABP dc'd- IDDM with multiple complications.\n\nP- con't increasing natrecor gtt until optimal diuresis is achieved- ? starting an inotrope med- monitor vs, i&o, & labs- ? debriding L knee wound.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-04 00:00:00.000",
"description": "Report",
"row_id": 1264741,
"text": "NSG ADM NOTE\n\nPT INITIALLY ADM TO EW @ 2100. PRESENTS WITH PROGRESSIVE SOB. CXR IN EW SHOWED MILD FAILURE,LG R PLEURAL EFFUSION. ADM EKG SHOWING NSR,Q IN 2, ELEVATION V2-V3,PEAKED T'S IN V3 AND ST DEPRESSION V6,1. TO 3,BUT HAD WORSENING OF SOB. RECEIVED ADDITIONAL LASIX 80MG IV ON FLOOR, SATS DROPPING TO 80'S., NRB APPLIED,FOLEY INSERTED AND PT TO CCU.\n\nPT IS 53 YR OLD MALE WITH COMPLICATED PMH: IDDM X40YRS\n LEGALLY BLIND\n INOP. 3VD\n S/P RENAL TX 90\n ELEVATED CHOL\n S/P R AKA L BKA\n HX CHF CURRENTLY EF 20-30%\n\nRESP: ADM ON NRB. RR-38, COLOR FAIR. O2 SATS 97%. IV NTG INCREASED AND PT RECEIVED ADDITIONAL LASIX 80MG WITH FAIR U/O. CURRENT RR-18. APPEARS MORE COMFORTABLE. RALES ON L/R. CON'T ON NRB. 02 SATS 97-99%.\n\nCV: REMAINS IN NSR WITH HR 90-91. NO ECT. NOTED. BP STABLE WITH MAP'S >60 IV NGT TITRATED UP TO 113MCG. TOL WELL.\n\nNEURO: A&O,NAPPING INTERMITTENTLY. FOLLOWS COMMANDS. PLEASANT. MAE\n\nGI: + BS NO STOOL WILL REMAIN NPO. ABD SOFT.\n\nGU: U/O RESPONDING TO LASIX > 100CC/HR\n\nSKIN: AKA/BKA NOTED. L STUMP HAS OPEN AREA ANTERIORLY. QUARTER SIZE,OPEN WITH PINK EDGES. AREA CULTURED. HAS YELLOW DRAINAGE NOTED. NO ORDER DETECTED. W-D DSG APPLIED.\n\nID: AFEBRILE. PT ON THERAPY.\n\nIV: PHERP X2 IN L ARM FUNCTIONING. AV FISTULAR ON L INSERTED IN .\n\nLABS; AM LABS DRAWN AWAITING RESULTS.\n\nSOCIAL: PT LIVES IN . LIVES ALONE HAS 4 CHILDREN IN SURROUNDING TOWNS. PT STATES HIS WIFE DIED FROM RENAL DISEASE. VNA CURRENTLY SEES PT X2/DAY,OTHERWISE PT CARES FOR SELF ADL'S AND MEALS.\n\nDISPOSITION: FULL CODE\n\nA: GUARDED/STABLE\n\nP: CON'T PER NSG JUDGEMENT\n AWAIT AM LABS\n SUPPORT AS NEEDED\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-04 00:00:00.000",
"description": "Report",
"row_id": 1264742,
"text": "NURSING PROGRESS NOTE 0700-1500\nRESP--O2 WEANED DOWN TO 5L NC WITH SAO2 95-97%. SPONT RESP 22-32. R LUNG HAS CRACKLES IN BASE BUT CLEAR IN UPPER LOBES BILATERALLY. LL BASE IS DIMINISHED. DENIES SOB AND STATES THAT HE IS FEELING SO MUCH BETTER THAN YESTERDAY.\n\nGU--INITIALLY GOOD UO >80 CC HR BUT HAS NOW DIMINISHED TO 40 CC HR. TO GET 80 MG IV LASIX. URINE IS CLEAR.\n\nGI--NPO EXCEPT FOR MEDS. PRESENT BS. NO STOOL.\n\nENDO--BS 207 AT 1100. RECEIVED OF NPH DOSE (10 U) AND COVERED WITH SS INSULIN PER SHEET AND HO.\n\nCARDIAC--DENIES CP. HR SR WITH OCCASIONAL PVC'S. SBP 120-130/70'S. ON NTG GTT WHICH HAS BEEN INCREASED (PER DR ). PRESENTLY ON 2.2 MCG/KG/MIN AND SBP NOW 94-110. MAP 65-70. GOING FOR CATH TODAY AS AN ADD-ON CASE. 1330 K+ ,CPK DRAWN\n\nSKIN--L KNEE ULCER IS ~ THE SIZE OF A QUARTER AND IS ~ INCH DEEP. IT HAS PURLENT DRAINAGE AND APPEARS TO NEED DEBRIDEMENT. HO IN TO SEE WOUND. VASCULAR TEAM CONSULTED. TO OBTAIN WOUND CX WITH NEXT DRESSING CHANGE DUE AT 10PM.\n\n AND DAUGHTER HAVE PHONED.\n\nA--DENIES CP. ?WOUND INFECTION. TOL DECREASE IN O2 REQUIREMENTS.\n\nP--OFFER SUPPORT. DIURESE AS ORDERED. KEEP NPO FOR CATH LATER TODAY.CON'T TO MONITOR. CHECK LAB RESULTS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-05 00:00:00.000",
"description": "Report",
"row_id": 1264743,
"text": "CCU Nsg Progress Note 7p-7a\n\nS- \" My breathing is better today.\"\nO- see flowsheet for all objective data.\n\ncv- no cardiac c/o this shift- con't on Ntg gtt @ 2.2mcg/kg/min- SBP 80-116/25-46 HR-77-87 RR-16-22 NPO for cardiac cath. this AM.\n\nresp- O2 5L via NC- Lung sounds with bibasilar crackles- resp.even-non-labored- Sao2 95-98.\n\ngi- abd. soft non-tender + bowel sounds- po intake poor- glu 307 @ 12am. 8u reg. insulin given. repeat labs drawn @ 6am.\n\ngu- foley draining small amts conc. amber colored urine ( approx- 20cc/hr) HO aware- no c/o SOB.\n\nid- afebrile- started on levaquin and metronidazole- L knee dsg changed- sm. amt. sero-sang. drainage noted - wound culture obtained.\n\nA- CRF with recurrent CHF and inoperable 3 vessel cardiac disease.\n\nP- Cardiac cath. this am- con't to monitor vs, i & o, & labs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-05 00:00:00.000",
"description": "Report",
"row_id": 1264744,
"text": "Nursing Progress Note 7a-7p:\n\nNeuro: Pt alert and oriented x 3. Pt moving all extremities spontaneously. Pt very pleasant and cooperative with all nursing interventions.\n\nCV/PULM: Pt underwent cardiac cath this am. Cath revealed reoccluded LAD with a cutting balloon old stent reopened. Rec'd 110cc contrast. Pt with hypotension during procedure therefore low dose dopa started and d/c'd prior to transfer back to CCU. IABP placed due to high filling pressures and to maximize heart fxn. Pt to be evaluated for CABG.\nPt restarted on ntg gtt at 2.2mcg (as prior to cath) and renal dose Dopa per attending. MV and arterial sats 81% at 12pm.\nAppox 30min after pt arrived to CCU. Pt's sats dropped to 79% on 5L NC, PAD's 48, maps 144 and HR 120's with frequent PVC's. Pt w/o CP. +SOB, anxious, diaphoretic with RR 30's Placed on 100% NRB and 10L NC with sats in 80's. Pt with crackles bibasilary. Pt rec'd lasix 80mg IV with fair response. Pt bolused with NTG and rec'd a total of 16mg of morphine with effect. Per team pt with episode of flash pulm edema. Episode resolved with above treatment.\nPt conts on NTG gtt at 2.2mcg and integrillin gtt 1mcg until 5am . Oxygen weaned to 100% NRB with sats 94%. C.O 5.5/3.31/960. CVP 12. Pt to receive additional 120mg IV lasix tonight.\n\nIABP with good wave form, fair augmentation, maps in the 60's. IABP weaned from 1:1 to 1:3 over afternoon and then d/c'd at 6pm per Cardiac fellow. R arterial sheath removed.\n\nPt rec'd po caridac meds. SBP currently 90-110. HR 80's NSR w/o ectopy. Pt denies CP or SOB.\n\nGI: Abd soft NT +BS. No stool this shift. Pt taking only taking sips of fluids with pills.\n\nGU: renal transplant pt on immunosuppressant therapy and prednisone. Foley cath patent draining clear yellow urine. 50-70cc/hr. Goal u/o 100cc/hr. Pt receiving lasix prn. Creat 1.8 and BUN 45.\n\nID: afebrile. Cultures pending. Pt conts on flagyl and levaquin for broad spectrum coverage.\n\nENDO: FS 7:30 am 181 pt rec'd 2uR and 10u NPH. 12pm 152 pt rec'd 2u reg per insulin ss. Cont Fs QID.\n\nSKIN: Coccyx red, cream appiled. Pt turned side to side. LLE with 50 cent piece size ulcer 3cm deep. Ulcer draining small amt serous drainage. Vascular team following. Await wound culture results.\n\nLINES: R pa line and L PIV's.\n\nDISPO: Full Code\n\nSOCIAL: Pt with 2 daughters and 2 son's. H.O. updated pt's mother following cardiac cath. No visitors this shift.\n\nP: Follow HR and BP off IABP on NTG gtt. Follow PA numbers.\n Wean oxygen as tolerated. Administer IV lasix.\n ? advancing diet.\n Goal u/o 100cc/hr.\n Skin Care. Provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-06 00:00:00.000",
"description": "Report",
"row_id": 1264745,
"text": "CCU NPN 1900-0730:\n NEURO: Pt slept well overnight, arousable, oriented and cooperative with POC. Pt moves all extremities strongly and attempts to help with turns in the bed. No c/o anxiety or pain.\n CV: Afebrile. Pt in NSR with occas ventricular ectopy. At 0400, pt had one run of SVT lasting about 10 seconds that resolved without intervention. Pt asymptomatic during episode. BP stable in low 100's on current antihypertensive regimen. NTG continues at 2.2 mcg/kg/min with no c/o CP/SOB. Pt aggressively diuresed overnight but NFB remaines about + 150cc for last 30 hours. R groin swan in place. CVP ranging from , PA pressures have persistantly remained high 70's/30's. FICC/CI = 3.6/2.17 at midnight. Swan does not wedge secondary to groin placement. After multiple doses of lasix, am lytes with K+=3.7, Mg=2.2. IABP d/c'd from L groin at 1800--site has remained soft and benign overnight with minimal ammount blood on gauze over sight. Distal circulaton appears intact (BKA warm, CR WNL).\n Pulm: Pt with no s/sx CHF. Fi02 weaned down from 100% NRB to 3 L NC with spo299% and rr 8-16. Lungs CTA anteriorally. No DOE noted. No orthopnea(pt able to tollerate lying flat all night after IABP removal).\n GI: Pt taking liquids/pills without difficulty. Plan to resume diet today. Insulin ss/standing dose were revised yesterday in setting of NPO status--will discuss with team need for changing back to pts baseline regimen. Abd soft, ND, NT.\n GU: Pt with good ammounts yellow urine. Ocassional tinge of blood.\nCR down this morning from 1.8 to 1.3! Mucomyst to continue for 2 more doses.\n No inquiries/calls from family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-06 00:00:00.000",
"description": "Report",
"row_id": 1264746,
"text": "CCU NURSING PROGRESS NOTE 7A-3P\n\nNEURO: Pleasant, alert and oriented x3. Able to assist with turning; minimal assist req'd with feeding.\n\nRESP: LS essentially clear. Wearing 4L NC with sats >96%. Denies feelings of SOB.\n\nCARDIAC: SBP 90-115. PA pressures 70's/27-33. Rec'd standing dose of 80mg IV lasix this am. Pt is -488cc at this time. CO/CI unchanged. NTG dc'd ~12:30pm. Pt to start natrecor this afternoon.\nDenies CP, SOB, palps.\n\nGI: Tolerating cardiac/diabetic diet. Abd soft NT. +BS. No stool.\n\nGU: foley draining concentrated yellow urine. -488cc this eve.\n\nACCESS: Right groin swan; 2 peripheral IVS left arm.\n\nSTATUS: full code.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759614,
"text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ACUTE SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, CHF know with acute SOB.\n REASON FOR THIS EXAMINATION:\n PLease evaluate for CHF.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: SOB.\n\n CHEST AP: Comparison is made to the prior film dated . The heart is\n within normal limits. The hilar, mediastinal contours are unremarkable. There\n is slight upper zone redistribution. Pulmonary vasculature is somewhat\n prominent. Noted is evidence of bilateral pleural effusion, right slightly\n greater than left. No evidence of focal consolidation. There is no\n pneumothorax. The visualized osseous structures are unremarkable. There is a\n possible ascites.\n\n IMPRESSION: Mild CHF. Possible ascites. No evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759769,
"text": " 12:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, CHF know with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n eval for failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF acute shortness of breath evaluate for failure.\n\n Comparison study .\n\n CHEST SINGLE VIEW: The heart is enlarged. There is diffuse predominantly\n perihilar alveolar opacity compatible with pulmonary edema. Small bilateral\n pleural effusions are seen.\n\n IMPRESSION: Cardiomegaly with overt CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760000,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, CHF know with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n evaluate for chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, : Compared to 3 days earlier.\n\n CLINICAL INDICATION: Shortness of breath.\n\n A Swan-Ganz catheter remains in place, terminating in the expected location of\n the main pulmonary artery. A previously identified intra-aortic balloon pump\n is no longer visualized.\n\n The heart is upper limits of normal in size. There has been interval\n decreased vascular engorgement and interval improvement in central alveolar\n pattern with residual hazy perihilar opacities remaining. Bilateral pleural\n effusions also appear slightly improved.\n\n IMPRESSION: Improving congestive heart failure pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759607,
"text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt w/ new diagnosis of chf, feeling sob, breathing in tripod\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with DM, CHF\n REASON FOR THIS EXAMINATION:\n pt w/ new diagnosis of chf, feeling sob, breathing in tripod stance, low o2 sat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Diabetes, CHF, SOB with low oxygen saturations.\n\n COMPARISONS: .\n\n SINGLE CHEST: There are moderate bilateral pleural effusions. The heart size\n is difficult to assess on this AP technique. There appears to be vascular\n redistribution. These findings are compatible with CHF.\n\n IMPRESSION: Findings consistent with CHF. Moderate bilateral pleural\n effusions. A consolidation at either lung base would be difficult to exclude\n and repeat chest x-rays after diuresis may be considered in the appropriate\n clinical context.\n\n"
}
] |
59,829 | 147,595 | 50yo woman with breast cancer metastatic to liver, lungs, bone, and brain admitted with seizures and RLL pneumonia. | -Fluid balance goal of even today -could consider non-invasive positive pressure ventillation if clinically worsening -Continue PCP treatment with IV Bactrim (day 3). -Fluid balance goal of even today -could consider non-invasive positive pressure ventillation if clinically worsening -Continue PCP treatment with IV Bactrim (day 2). #s/p Fall: Neurological Exam stable, Head CT and C spine wnl. -Continue aggressive diuresis today, 80mg lasix x 1 -could consider non-invasive positive pressure ventillation if clinically worsening -Continue Prophylactic PCP treatment /u sputum cx -Continue Decadron taper 4mg today . Patient is currently NPO d/t tenuous respiratory status. CODE: DNR/DNI ICU Care Nutrition: Glycemic Control: Lines: Indwelling Port (PortaCath) - 12:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: - Continue to trend, but can likely change to every other day lab draws ICU Care Nutrition: Regular diet, soft Glycemic Control: None Lines: Indwelling Port (PortaCath) - 12:19 AM Prophylaxis: DVT: SC heparin Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: Likely to LTACH in next few days with hospice vs staying in ICU - Continue to trend daily - Guaiac all stools ICU Care Nutrition: Regular diet, soft Glycemic Control: None Lines: Indwelling Port (PortaCath) - 12:19 AM Prophylaxis: DVT: SC heparin Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: Likely to LTACH in next few days with hospice ? HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. Transferred from 7s for hypoxia. Transferred from 7s for hypoxia. # PROPHY: -SC heparin -bowel regimen . # PROPHY: -SC heparin -bowel regimen . # FEN/GI: -NPO until respiratory status improves . # FEN/GI: -NPO until respiratory status improves . # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. This shift pt stated that the pain was an . CXR was done which showed worsening bilateral infiltrates. CXR was done which showed worsening bilateral infiltrates. -Fluid balance goal of even today -could consider non-invasive positive pressure ventillation if clinically worsening -Continue PCP treatment with IV Bactrim (day 3). -Hypotensive (got Atenolol in AM, which was subsequently d/c'd), so we were unable to diurese further in AM> Gave 80mg IV Lasix in PM, with good response. (no Tylenol unless pt physiologically uncomfortable a sper team) On cefipime and vanco and started on tamiflu..1^st dose given. (no Tylenol unless pt physiologically uncomfortable a sper team) On cefipime and vanco and started on tamiflu..1^st dose given. Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: -management per oncology recs - ct seizure ppx w/ keppra . -management per oncology recs - ct seizure ppx w/ keppra . Respiratory failure, acute (not ARDS/) Assessment: Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has been 90-96%, she desaturares to the low 80s very quickly when the 02 Action: ABG on 60% was 7.48/40/84, had a sputm induction for PCP and Response: Resp status is still tenuous Plan: Cont to follow, would try noninvasive ventilation if needed, cont abx, f/u on clx results Respiratory failure, acute (not ARDS/) Assessment: Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has been 90-96%, she desaturares to the low 80s very quickly when the 02 Action: Response: Plan: -Continue aggressive diuresis today, 80mg lasix x 1 -could consider non-invasive positive pressure ventillation if clinically worsening -Continue Prophylactic PCP treatment /u sputum cx -Continue Decadron taper 4mg today . PATIENT/TEST INFORMATION:Indication: Evaluate LV & RV function, Evaluate valvesHeight: (in) 63Weight (lb): 150BSA (m2): 1.71 m2BP (mm Hg): 106/64HR (bpm): 66Status: InpatientDate/Time: at 12:32Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Respiratory failure, acute (not ARDS/) Assessment: Pt remains on NRB, SATs go from 91-94%, she desats to the 70s very quickly when she takes her mask off. Respiratory failure, acute (not ARDS/) Assessment: Pt remains on NRB, SATs go from 91-94%, she desats to the 70s very quickly when she takes her mask off. Education / Communication: c RN RE Pt status/ BP/ SaO2 Pt RE Pacing/DB Other: Pulm: Decreased R BS. Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: LUNGS: diffuse late inspiratory crackles ABDOMEN: +BS. | 115 | [
{
"category": "Nutrition",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 607251,
"text": "Subjective\n Patient NPO, coughed up eggs yesterday when RT tried to induce sputum,\n on NRB\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 68 kg\n 69.1 kg ( 02:00 PM)\n 25.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 57 kg\n 119%\n kg\n 68-71kg kg\n %\n Diagnosis: PNA seizure\n PMHx: breast cancer with mets to , , liver and lungs\n s/p mastectomy () and chemo\n s/p suboccipital craniotomy and resection of cerebellar mass ()\n Food allergies and intolerances: none noted\n Pertinent medications: lasix, omeprazole, others noted\n Labs:\n Value\n Date\n Glucose\n 129 mg/dL\n 03:31 AM\n Glucose Finger Stick\n 141\n 12:00 PM\n BUN\n 38 mg/dL\n 03:31 AM\n Creatinine\n 0.8 mg/dL\n 03:31 AM\n Sodium\n 144 mEq/L\n 03:31 AM\n Potassium\n 4.2 mEq/L\n 03:31 AM\n Chloride\n 101 mEq/L\n 03:31 AM\n TCO2\n 35 mEq/L\n 03:31 AM\n PO2 (arterial)\n 94. mm Hg\n 08:48 PM\n PCO2 (arterial)\n 45 mm Hg\n 08:48 PM\n pH (arterial)\n 7.43 units\n 08:48 PM\n pH (urine)\n 8.5 units\n 02:53 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 08:48 PM\n Calcium non-ionized\n 8.7 mg/dL\n 03:31 AM\n Phosphorus\n 3.1 mg/dL\n 03:31 AM\n Ionized Calcium\n 1.02 mmol/L\n 08:54 AM\n Magnesium\n 2.8 mg/dL\n 03:31 AM\n Current diet order / nutrition support: NPO (was on moist, soft solids\n with nectar thick liquids d/t silent aspiration)\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1700-2040 (BEE x or / 25-30 cal/kg)\n Protein: 80-100 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Specifics:\n 50 year old female with metastatic breast cancer to brain, , liver\n and lungs admitted with seizures and pneumonia now on NRB mask. Noted\n desats very quickly when taken off. Patient s/p video swallow on \n which demonstrated silent aspiration. Patient is currently NPO d/t\n tenuous respiratory status. Patient may require tube feedings via NJ\n tube since not able to meet nutritional requirements through PO intake.\n Recommend Nutren Pulmonary at 50ml/hr x 24 hours to provide 1800kcal\n and 82g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n If needed, start Nutren Pulmonary at 20ml/hr, advance by\n 20ml q6H to goal rate of 50ml/hr x 24 hours\n Advance diet when possible to moist, soft solids and nectar\n thick liquids. Add Ensure Pudding with meals.\n Will follow closely\n 12:59 PM\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607246,
"text": "TITLE: PROGRESS NOTE\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -change steroid dosage to 4mg \n -needs family mtg w/ Drs (primary onc) & (neuro-onc)\n -RT couldn't get induced sputum because she coughed up food when they\n tried\n -Have very low urine output so gave 80mg IV lasix at 4pm, after which\n she started peeing more, then tapered off\n -Was temporarily off nonrebreather but had to be placed back on\n non-rebreather\n Allergies: NKDA\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 02:41 PM\n Vancomycin - 07:15 PM\n Cefipime - 04:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 AM\n Furosemide (Lasix) - 04:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 63 (57 - 80) bpm\n BP: 139/76(92) {120/66(80) - 146/85(98)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Total In:\n 960 mL\n 177 mL\n PO:\n 120 mL\n TF:\n IVF:\n 840 mL\n 177 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,090 mL\n Urine:\n 2,300 mL\n 1,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,340 mL\n -913 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///35/\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 588 K/uL\n 9.4 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 101 mEq/L\n 144 mEq/L\n 29.7 %\n 18.1 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n Plt\n 88\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n Other labs: PT / PTT / INR:13.5/37.2/1.2, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:95.2 %, Lymph:2.5 %, Mono:2.2 %,\n Eos:0.1 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA. This is most likely due to lymphangitic spread of her\n BRCA, acc to outpatient oncologist.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 4)\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 80mg lasix x 1\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n /u sputum cx\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: NPO (since was aspirating, taking pills w/ applesauce)\n Glycemic Control: none\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n plan on family mtg later in\n PM to discuss goals of care\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607586,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished, scattered rales all fields\n Continues to have high O2 requirement, desaturates easily with any\n activity\n Action:\n Head and neck CT today\n Family meeting to discuss prognosis and plan of care\n Palliative Care consult ordered\n Response:\n Pt has maintained SpO2 > 94% with oxygen on\n Plan:\n Continue antibiotics\n Continue steroid taper\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607630,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Picked up this patient @ 2200.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n Family wants discharge to inpatient (hospice) facility near .\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n 19\ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607729,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was on 100% NRB today on rounds with O2 sat 99%. Continues to\n desaturate quickly with O2 off but team asked us to try high flow neb\n and wean as tolerated. She continues to have diffuse crackles\n throughout but CXR shows slight improvement in haziness which suggests\n good effect from diuresis.\n Action:\n Pt put on 100% high flow neb and weaned down as tolerated to keep sat\n >92%. Given lasix 80mg IV at 1200.\n Response:\n Fair diuretic effect from the lasix. Able to wean her high flow neb to\n 60% with O2 sat 95% or greater. BP has come down slightly with these\n last three days of diuresis/ Currently BP 104-110/60. HR stable in the\n 60 range sinus rhythm. K+ 3.7 this evening and 20meq Kcl given IV.\n Plan:\n Continue to follow resp status and wean oxygen as tolerated.\n Family met with team for update on pt condition. They would like to\n continue with aggressive care at this time and are aware of grim\n prognosis. They will consider hospice care in the future if condition\n deteriorated.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607782,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. She has been diuresed and felt to be as dry\n as she is going to get. Plan is to try to keep pt even at this point.\n BP is running low 100\ns with HR 70\n Paliative care consult was made and RN has planned to see\n this pt and her husband tomorrow at 1630 to discuss options for further\n care/hospice. Husband has expressed his wishes that pt be transferred\n to hospice care closer to home when she is ready. Team wants he to\n complete the course of Bactrim which was started over the weekend and\n then they feel that every chance has been given to this pt for\n improvement..\n She is tolerating small amts PO\ns and is on aspiration precautions due\n to dysphagia. No signs of aspiration at this point. Meds are well\n tolerated mixed in applesauce.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt tolerating 95% high flow neb with O2 sat 97% or greater. Team asked\n me to wean as tolerated.\n Action:\n Weaned pt to 80% with her O2 sats dropping at times to 90%-91%.\n Response:\n Some drop in her sat with weaning O2. Will follow closely.\n Plan:\n Family meeting tomorrow at 1630 to discuss plan of care options. I have\n notified social work and case management. Continue to titrate O2 as\n tolerated and Keep O2 sat 90% or greater. Team will stop all\n antibiotics except for bactrim after today\ns doses.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt assisted to chair by two PT with minimal problems. She has unsteady\n gait. She is forgetful but has not been seen trying to get up OOB on\n her own today.\n Action:\n Sat in chair for about one hour. Tolerated this well. Pt posied and on\n chair alarm seat while OOB to chair. Waist belt on while in bed.\n Response:\n Pt safe and assisted with all ADL\ns and hygeine\n Plan:\n Continue to assist with mobility and assess endurance.\n .H/O fall(s)\n Assessment:\n Pt had a fall OOB over the weekend sustaining a bruise above her left\n eye. All scan are negative for any injury and safety precautions have\n been increased since this accident.\n Action:\n Pt in waist belt while in bed and up in chair. Checked on pt Q1 hr and\n more frequently today. Bed locked in low position with exit alarm on.\n New bed with functioning exit alarm brought in today. Frequent pt\n reminders to stay in bed and leave her O2 on today.\n Response:\n She has been less confused today without any attempts to get OOB on her\n own. Reminded frequently to stay safe in bed.\n Plan:\n Continue with all safety measures mentioned above and obtain sitter if\n her mental status deteriorates and she is at further risk of falls.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607628,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Picked up this patient @ 2200.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n \ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607625,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Picked up this patient @ 2200.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n To discharge to inpatient hospice.\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n \ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607553,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Satting in mid-90s on 60% face mask, but does not tolerate any\n physical exertion.\n -Hypotensive (got Atenolol in AM, which was subsequently d/c'd), so we\n were unable to diurese further in AM. Gave 80mg IV Lasix in PM, with\n good response. However, positive as was getting extra IVF with Bactrim\n (most concentrated possible).\n -Started on empiric treatment for PCP with IV Bactrim (concentrated in\n order to minimize fluids).\n -The patient fell out of bed and was found on the floor. She was alert\n and oriented, but unable to state how she ended up there. She was\n returned back to bed. O2 sats returned to high 90s. Neurological exam\n was non-focal. She was placed in Posey restraints. J collar\n ordered. STAT CT head and C-spine were ordered (will be done at 7am)\n Event note was written. Attending was notified.\n -Was transiently on 100% mask after fall, but is now back on 60%\n face mask and satting >95%.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Vancomycin - 08:22 PM\n Bactrim (SMX/TMP) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:23 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (54 - 78) bpm\n BP: 120/64(78) {85/39(53) - 133/88(88)} mmHg\n RR: 20 (8 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,319 mL\n 577 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,199 mL\n 577 mL\n Blood products:\n Total out:\n 1,380 mL\n 280 mL\n Urine:\n 1,380 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -61 mL\n 297 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: ///34/\n Physical Examination\n GENERAL: Alert, responsive, NAD on 60% face mask\n CARDIAC: Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 605 K/uL\n 9.8 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 37 mg/dL\n 98 mEq/L\n 142 mEq/L\n 29.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 88\n 614\n 605\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n .\n s/p Fall: Neurological Exam stable\n -Serial Neurological Exams\n -CT head and C-spine\n -Continue Posey restraints and fall precautions\n -Continue C-collar until negative CT C-spine\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. This is most likely due to lymphangitic spread of\n her BRCA, acc to outpatient oncologist.\n There also could be contribution from pulmonary edema diastolic\n dysfunction and possible infectious process / PNA.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 6 of a 7 day course)\n -No lung biopsy given respiratory distress and patient wishes.\n -Fluid balance goal of even today\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue PCP treatment with IV Bactrim (day 2).\n -f/u all outstanding cultures\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: nectar thick liquids and soft, moist solids\n Glycemic Control: none\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed. Discussion with family regarding status\n and possibility of inpatient hospice.\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2143-11-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 607564,
"text": "Clinician: Attending\n Husband and daughter updated in full on current clinical course\n including fall of last evening.\n Awaiting head CT final but clinical exam ressuring\n Have clearly described that this likely represents a plateau in the\n patients respiratory function and will continue to treat with\n antibiotics, diruetics and hope for improvement but do need to plan for\n next steps around current level of function.\n Wishes are to move to inpatient facility closer to home in for\n ease of visits. Do not expect full recovery and view expected life\n duration in weeks.\n They were quite clear that patient should be DNR/DNI at this time given\n underlying malignancy and concern for absence of meaningful improvement\n should cardiac arrest or respiratory failure seen.\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607626,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Picked up this patient @ 2200.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n To discharge to inpatient hospice.\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n \ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Rehab Services",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 607699,
"text": "Attending Physician: \n Referral date:\n Medical Diagnosis / ICD 9: 482\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: Pt is 50 yoF with\n met breast cancer admitted w/? seizure activity and increased\n falls. Course complicated by pna, hypotension and transferred to \n .\n Past Medical / Surgical History: please see initial eval \n Medications:\n Radiology: CT head : No acute intracranial injury. Stable\n post-surgical change in the posterior fossa. Fluid in the mastoid air\n cells. CT c-spine : No acute cervical fracture or malalignment.\n Known C4 metastasis. Sclerotic lesion seen on the vertebral body, also\n suspicious for metastasis. CXR no significant changes\n Labs:\n 29.4\n 9.6\n 578\n 16.1\n [image002.jpg]\n Other labs:\n Activity Orders: OOB w/assist\n Social / Occupational History: please see initial eval \n Living Environment: please see initial eval\n Prior Functional Status / Activity Level: please see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt A&Ox2-3 knows in\n hospital, year, initially stated moth is but once asked which\n holiday celebrated and she stated she corrected month to\n , year\n, follows commands appropriately\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n Rest\n 70\n 101/60\n 13\n 100% on 95% FM\n Sit\n Activity\n 100\n 86/51\n 23\n 81% on 95% FM\n Stand\n Recovery\n 83\n 104/60\n 19\n 96% on 95% FM\n Total distance walked:\n Minutes:\n Pulmonary Status: BS R lung fields but CTA\n Integumentary / Vascular: Telemetry, foley, portacath R chest,\n Sensory Integrity: B UE/LE grossly intact to light touch\n Pain / Limiting Symptoms: pt denies pain at rest and with mobility\n Posture: rounded shoulders, leans to L sitting.\n Range of Motion\n Muscle Performance\n B UE/LE WNL\n B UE/LE > throughout\n Motor Function: B thumb to finger opposition intact, min dysmetria L UE\n FNG, R UE intact FNF, head neck and trunk tremors\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: min A x2 sit<>stand, pt step pivot eob<>chair w/B HHA\n min A x2\n Rolling:\n Supine /\n Sidelying to Sit:\n Transfer:\n x2\n Sit to Stand:\n x2\n Ambulation:\n Stairs:\n Balance: CG maintain sitting eob w/BUE support 2* tremors and leaning\n to L, mod A w/pad pull to scoot to eob. Min A x2 for step pivot\n transfer w/HHA as above.\n Education / Communication: ed pt re: role of PT, , d/c planning,\n goals of care, deep breathing, pacing\n Intervention: spoke w/RN re: pt status\n Other:\n Diagnosis:\n 1.\n Impaired gas exchange\n 2.\n Decreased Independence with transfer\n 3.\n Impaired Balance\n 4.\n Impaired gait\n Clinical impression / Prognosis: Pt is 50 yoF admitted with\n metastatic breast cancer to bones, liver, lungs and cerebellum course\n c/b hypoxia, B pulmonary infiltrates and hypotension. Pt demonstrates\n decreased activity tolerance since initial eval limited by desat\n with mobility despite 95% high flow mask and hypotension. Given pt\n progressive decrease in mobility limited by respiratory status pt is\n not safe for d/c home at this time without constant assist from family.\n From notes from family meeting family prefers hospice upon d/c\n when pt medically stable. Will continue to follow as appropriate.\n Goals\n Time frame: 1 week\n 1.\n Sats >90% w/mobility on high flow mask\n 2.\n CG sit<>stand w/RW\n 3.\n Maintain sitting EOB > 30 sec with supervision\n 4\n Amb 20ft w/RW CG\n Anticipated Discharge: rehab v. hospice\n Treatment Plan: transfer, therex, gait training, endurance, balance.\n Frequency / Duration: 2-3x/wk\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face Time: 10:10-10:45\n"
},
{
"category": "Nutrition",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 607706,
"text": "Subjective\n Patient on mask\n Objective\n Pertinent medications: omeprazole, lasix, others noted\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 141\n 12:00 PM\n BUN\n 26 mg/dL\n 04:00 AM\n Creatinine\n 0.9 mg/dL\n 04:00 AM\n Sodium\n 135 mEq/L\n 04:00 AM\n Potassium\n 4.4 mEq/L\n 04:00 AM\n Chloride\n 99 mEq/L\n 04:00 AM\n TCO2\n 22 mEq/L\n 04:00 AM\n PO2 (arterial)\n 94. mm Hg\n 08:48 PM\n PCO2 (arterial)\n 45 mm Hg\n 08:48 PM\n pH (arterial)\n 7.43 units\n 08:48 PM\n pH (urine)\n 8.5 units\n 02:53 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 08:48 PM\n Calcium non-ionized\n 6.9 mg/dL\n 04:00 AM\n Phosphorus\n 3.8 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.02 mmol/L\n 08:54 AM\n Magnesium\n 2.0 mg/dL\n 04:00 AM\n Current diet order / nutrition support: Soft with nectar thick liquids\n GI: Abdomen soft with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 50 year old female with metastatic breast cancer to brain, bone, liver\n and lungs admitted with seizures and pneumonia now on NRB mask. Noted\n desaturates very quickly when taken off. Patient\ns diet was advanced to\n soft solids and nectar thick liquids, but difficult to take POs d/t\n desaturations. Noted likely discharge to hospice so tube feeding would\n not be appropriate. If plan of care changes, patient may require tube\n feedings via NJ tube since not able to meet nutritional requirements\n through PO intake. Recommend Nutren Pulmonary at 50ml/hr x 24 hours to\n provide 1800kcal and 82g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n c/w diet as ordered, encourage PO intake\n If needed, start Nutren Pulmonary at 20ml/hr, advance by\n 20ml q6H to goal rate of 50ml/hr x 24 hours\n Will follow closely\n 12:38 PM\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 607709,
"text": "Chief Complaint: Hypoxemic Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Family meeting with extensive discussion--currently we expect a\n persistence of respiratory compromise and hypoxemia given absence of\n further trend to improvement. Will maintain patient as DNR/DNI in\n concert with their wishes. Will continue with full treatment course at\n this time and look to move to hospice based facility with inpatient\n capacity going forward.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:44 AM\n Bactrim (SMX/TMP) - 07:05 AM\n Vancomycin - 07:46 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 AM\n Omeprazole (Prilosec) - 07:47 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Tachypnea\n Flowsheet Data as of 12:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.2\nC (97.2\n HR: 77 (53 - 77) bpm\n BP: 101/60(70) {99/44(0) - 131/82(86)} mmHg\n RR: 22 (6 - 22) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,190 mL\n 850 mL\n PO:\n TF:\n IVF:\n 2,190 mL\n 850 mL\n Blood products:\n Total out:\n 670 mL\n 900 mL\n Urine:\n 670 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,520 mL\n -50 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 90%\n ABG: ///22/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 578 K/uL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.4 %\n 16.1 K/uL\n [image002.jpg]\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n Plt\n 426\n 557\n 588\n \n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n Other labs: PT / PTT / INR:16.5/32.0/1.5, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:94.3 %, Lymph:2.9 %, Mono:1.9 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR-Patient with improvement in pulmonary infiltrates in left\n side\n CT Head-no bleed\n C-Spine-no fracture\n Assessment and Plan\n 50 yo female with metastatic breast cancer and with significant\n involvment in brain, bone and lung. We have persistent respiratory\n compromise with ongoing treatment and this is likely attributable to\n non-cardiogenic edema, possible initial infectious insult but do not\n have pathogen identified and some contribution from lymphangitic\n carcinomatosis. In this setting we have worked with family to\n Respiratory Failure-Patient with small amount of improvement in\n pulmonary infiltrates but with persistent and significant hypoxemia\n -Dex 4mg q 12 hours to continue primarily for CNS invovlement\n -Cefepime/Vanco to be completed today\n -Bactrim IV\nwould expect improvement at 5 days\n -Will look to wean FIO2 as possible today\n -No further diuresis given creatinine rise and current orthostasis\n Breast Cancer-\n -Keppra\n -Will need to plan for disposition based on clinical course which has\n been static but with some improvement\n ICU Care\n Nutrition: po intake\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607710,
"text": "Chief Complaint:\n 24 Hour Events:\n - Held family meeting. Now DNR/DNI. Plan is to get palliative care\n team to speak with patient/family tomorrow and initiate movements\n towards discharge, likely to an LTAC. Plan to give PCP treatment few\n days to work and likely discharge to facility mid-week.\n - Fluid balance was positive 1.5L at midnight so gave 80mg IV Lasix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 03:44 AM\n Bactrim (SMX/TMP) - 07:05 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 PM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.1\n HR: 66 (53 - 77) bpm\n BP: 113/44(62) {99/44(62) - 138/82(88)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,190 mL\n 627 mL\n PO:\n TF:\n IVF:\n 2,190 mL\n 627 mL\n Blood products:\n Total out:\n 670 mL\n 820 mL\n Urine:\n 670 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,520 mL\n -193 mL\n Respiratory support\n O2 Delivery Device: High flow neb, 95% FiO2\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: (S1: Normal), (S2: Normal), No murmur appreciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Bronchial: ), coarse\n breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. no rebound or guarding, nondistended.\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 578 K/uL\n 9.6 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.4 %\n 16.1 K/uL\n [image002.jpg]\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 426\n 557\n 588\n 614\n 605\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n C Spine:\n IMPRESSION:\n 1. No acute cervical fracture or malalignment.\n 2. Known C4 metastasis. Sclerotic lesion seen on the vertebral body,\n also\n suspicious for metastasis.\n 3. Incompletely assessed posterior facets despite stable post-surgical\n appearance.\n Head CT:\n No acute intracranial injury. Stable post-surgical change in the\n posterior fossa. Fluid in the mastoid air cells.\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n .\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. This is most likely due to lymphangitic spread of\n her BRCA, acc to outpatient oncologist.\n There also could be contribution from pulmonary edema diastolic\n dysfunction and possible infectious process / PNA.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 6 of a 7 day course)\n -No lung biopsy given respiratory distress and patient wishes.\n -Fluid balance goal of even today\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue PCP treatment with IV Bactrim (day 3).\n -f/u all outstanding cultures\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n s/p Fall: Neurological Exam stable\n -Serial Neurological Exams\n -CT head and C-spine\n -Continue Posey restraints and fall precautions\n -Continue C-collar until negative CT C-spine\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n CODE: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607715,
"text": "Chief Complaint:\n 24 Hour Events:\n - Held family meeting. Now DNR/DNI. Plan is to get palliative care\n team to speak with patient/family tomorrow and initiate movements\n towards discharge, likely to an LTAC. Plan to give PCP treatment few\n days to work and likely discharge to facility mid-week.\n - Fluid balance was positive 1.5L at midnight so gave 80mg IV Lasix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 03:44 AM\n Bactrim (SMX/TMP) - 07:05 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 PM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.1\n HR: 66 (53 - 77) bpm\n BP: 113/44(62) {99/44(62) - 138/82(88)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,190 mL\n 627 mL\n PO:\n TF:\n IVF:\n 2,190 mL\n 627 mL\n Blood products:\n Total out:\n 670 mL\n 820 mL\n Urine:\n 670 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,520 mL\n -193 mL\n Respiratory support\n O2 Delivery Device: High flow neb, 95% FiO2\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: (S1: Normal), (S2: Normal), No murmur appreciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Bronchial: ), coarse\n breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. no rebound or guarding, nondistended.\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 578 K/uL\n 9.6 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.4 %\n 16.1 K/uL\n [image002.jpg]\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 426\n 557\n 588\n 614\n 605\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Aspergillus Ag and B Glucan pending\n C Spine:\n IMPRESSION:\n 1. No acute cervical fracture or malalignment.\n 2. Known C4 metastasis. Sclerotic lesion seen on the vertebral body,\n also\n suspicious for metastasis.\n 3. Incompletely assessed posterior facets despite stable post-surgical\n appearance.\n Head CT:\n No acute intracranial injury. Stable post-surgical change in the\n posterior fossa. Fluid in the mastoid air cells.\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n .\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. Respiratory distress felt to be likely\n lymphangitic spread of her , outpatient oncologist. Improvement\n over past several days could be due to diuresis versus PCP tx, although\n low suspicion for PCP .\n - empiric Abx treatment with vancomycin, cefepime to end today (7 day\n course completed)\n -No lung biopsy given respiratory distress and patient wishes.\n -Fluid balance goal of even today\n - attempt to wean oxygen as tolerated\n -Continue PCP treatment with IV Bactrim for total 5 day course to end\n .\n -f/u all outstanding cultures\n -Continue Decadron 4mg \n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction. Palliative care to see patient\n today and discuss goals of care.\n -cont seizure ppx w/ keppra\n .\n .\n #s/p Fall: Neurological Exam stable, Head CT and C spine wnl.\n -Continue Posey restraints and fall precautions\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n .\n #FEN: regular diet, soft\n .\n PPX: heparin SQ, PPO\n # Access Rt Subclavian port\n .\n CODE: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 608087,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Persistent hypoxia at rest\n Acute dyspnea at rest\n Action:\n Started morphine drip at 2mg /h\n Re-posititoned q2 hours\n Response:\n Pt reports less dyspnea\n Plan:\n Continue morphine drip and titrate as needed\n Position for comfort\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607622,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n Picked up this patient @ 2200 on .\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n To discharge to inpatient hospice.\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n \ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607621,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Response:\n Plan:\n To discharge to inpatient hospice.\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n \ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607768,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. She has been diuresed and felt to be as dry\n as she is going to get. Plan is to try to keep pt even at this point.\n BP is running low 100\ns with HR 70\n Paliative care consult was made and RN has planned to see\n this pt and her husband tomorrow at 1630 to discuss options for further\n care/hospice. Husband has expressed his wishes that pt be transferred\n to hospice care closer to home when she is ready. Team wants he to\n complete the course of Bactrim which was started over the weekend and\n then they feel that every chance has been given to this pt for\n improvement..\n She is tolerating small amts PO\ns and is on aspiration precautions due\n to dysphagia. No signs of aspiration at this point. Meds are well\n tolerated mixed in applesauce.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt tolerating 95% high flow neb with O2 sat 97% or greater. Team asked\n me to wean as tolerated.\n Action:\n Weaned pt to 80% with her O2 sats dropping at times to 90%-91%.\n Response:\n Some drop in her sat with weaning O2. Will follow closely.\n Plan:\n Family meeting tomorrow at 1630 to discuss plan of care options. I have\n notified social work and case management. Continue to titrate O2 as\n tolerated and Keep O2 sat 90% or greater.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt assisted to chair by two PT with minimal problems. She has unsteady\n gait. She is forgetful but has not been seen trying to get up OOB on\n her own today.\n Action:\n Sat in chair for about one hour. Tolerated this well. Pt posied and on\n chair alarm seat while OOB to chair. Waist belt on while in bed.\n Response:\n Pt safe and assisted with all ADL\ns and hygeine\n Plan:\n Continue to assist with mobility and assess endurance.\n .H/O fall(s)\n Assessment:\n Pt had a fall OOB over the weekend sustaining a bruise above her left\n eye. All scan are negative for any injury and safety precautions have\n been increased since this accident.\n Action:\n Pt in waist belt while in bed and up in chair. Checked on pt Q1 hr and\n more frequently today. Bed locked in low position with exit alarm on.\n New bed with functioning exit alarm brought in today. Frequent pt\n reminders to stay in bed and leave her O2 on today.\n Response:\n She has been less confused today without any attempts to get OOB on her\n own. Reminded frequently to stay safe in bed.\n Plan:\n Continue with all safety measures mentioned above and obtain sitter if\n her mental status deteriorates and she is at further risk of falls.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607960,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. Palliative care consult made and meeting set\n for today at 1630. with family and medical team as well as case\n management and social work.\n Her resp status has deteriorated further in the past 24hrs requiring 5L\n N/C in addition to 95% high flow neb. Boarderline sat in the 88%-91%\n range. She has poor activity tolerance and has been ordered for\n morphine PRN dyspnea, pain or anxiety due to air hunger.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Remains on 95% high flow with 5L NC with boarderline O2 sats.\n Desaturates with any activity and unable to stay on her side due to\n SOB/low sats.\n Action:\n Medicated with Morphine 1mg IV to see if she could get comfortable on\n her right side. Encouraged to cough and deep breath to try to get O2\n sats up after activity and assisted with all ADL\ns. Turned back on her\n back when her sats would not come up.\n Response:\n Boarderline O2 sats 85%-92% most of the day. Anxious with low O2 sats\n Plan:\n Family meeting this afternoon with palliative care, MICU team and\n family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o SOB/discomfort and being anxious with increased work of\n breathing and hypoxia.\n Action:\n Medicated with morphine 1-2mg PRN for anxiety/hypoxia.\n Response:\n Some improvement in comfort level but it did not seem to help her O2\n sats at all.\n Plan:\n Met with family this afternoon and plan of care switched to hospice\n like care. All non-essential meds stopped and pt started on Q6hr\n ativan 0.5mg PO as well as PRN morphine ordered. Diet changed to\n regular as tolerated. Plan is to continue to watch pt overnight with\n plan to transfer to the floor tomorrow with hospice care. \n involved. She will contact a hospice agency which is close to\n home to come to to evaluate her to see if they could provide\n hospice care for her at home. Her wish is to go home but she fears it\n will be too much for her husband and daughter. She may end up staying\n her at to see how her condition is coming along.\n"
},
{
"category": "Nutrition",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Generic Note",
"row_id": 608061,
"text": "Nutrition:\n Patient is now CMO, no plans for nutrition support will sign off please\n reconsult if there is change in plan of care. Page with questions\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 608065,
"text": "Chief Complaint: Hypoxemic Respiratory Failure\n Metastatic Breast Cancer\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Extensive discussions held with family and current plan of care based\n upon inability to develop a reasonable trend to improvement despite\n maximal medical therapy for acute change in the setting of significant\n metastatic breast cancer goals of care were moved to be ones of comfort\n measures and hospice placement.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Lorazepam (Ativan) - 04:44 AM\n Morphine Sulfate - 07:46 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:33 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 73) bpm\n BP: 109/60(72) {99/48(60) - 119/79(88)} mmHg\n RR: 18 (5 - 22) insp/min\n SpO2: 81%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 798 mL\n PO:\n 60 mL\n TF:\n IVF:\n 738 mL\n Blood products:\n Total out:\n 1,170 mL\n 80 mL\n Urine:\n 1,170 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -372 mL\n -80 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 81%\n ABG: ////\n Physical Examination\n General Appearance: No(t) No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 536 K/uL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 50 yo female with metastatic breast cancer and with significant and\n persistent impairment in regards to oxygenation despite maximal medical\n therapy. We have a continued tension with persistent hypoxemia and now\n with MSO4 used for symptom control in interaction with patient around\n dosing. Ativan to be used as well. We do have very clear discussions\n with patient and family with current goals of care clear and plan to\n manage symptoms in place.\n -MSO4 PRN\n -Ativan PRN\n -O2 as needed\n -Will continue to discuss with palliative care team disposition going\n forward.\n ICU Care\n Nutrition: PO as desired\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor with hospice plan clarified\n Total time spent: 40 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 608074,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - Still has continuous desats on NRB\n - Family meeting held and patient made CMO\n - Plan to stay in ICU for now with possible hospice at home versus\n hospice facility\n - Changed medications to increase morphine with standing ativan\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 07:41 AM\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Morphine Sulfate - 04:44 AM\n Lorazepam (Ativan) - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 73) bpm\n BP: 109/60(72) {94/48(60) - 119/79(88)} mmHg\n RR: 18 (5 - 22) insp/min\n SpO2: 81%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 798 mL\n PO:\n 60 mL\n TF:\n IVF:\n 738 mL\n Blood products:\n Total out:\n 1,170 mL\n 0 mL\n Urine:\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -372 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 81%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: RRR, No murmur appreciated\n Respiratory / Chest: Coarse breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. No rebound or guarding, nondistended.\n Extremities: No peripheral edema, skin warm\n Neurologic: Attentive, follows simple commands\n Labs / Radiology\n 536 K/uL\n 9.4 g/dL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n No labs drawn today\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n No Chest Xray today\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia: Patient is not able to be weaned from\n her oxygen requirement and she understands the poor prognosis of her\n condition. Family meeting was held yesterday and patient was made\n comfort measures only. She has finished a course of antibiotics and\n trial of Bactrim for PCP without effect.\n - Continue morphine for air hunger and comfort\n - Have added Ativan 0.5mg q6h scheduled to help anxiety and will allow\n patient to refuse if she wishes to be more awake with her family\n - Added prn Ativan\n - Continue current prn oxycodone for pain\n - Continue morphine 2-5mg IV or 5-10mg SL q2h prn for SOB\n - Will explore with care management hospice at home vs inpatient\n hospice here\n - F/u all outstanding cultures\n - Continue Decadron 4mg IV BID\n - Will d/c PPI/venlafaxine\n #. Metastatic Breast Cancer: She was getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n - Appreciate palliative care recs\n - Continue seizure ppx w/ keppra\n - Future care planning as above\n #. S/p Fall: Neurological exam continues to be stable, Head CT and C\n spine wnl.\n - Continue Posey restraints and fall precautions\n #. Mild oral and pharyngeal dysphagia: Has reduced coordination c/w\n cerebellar mets.\n - Diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n - Pills whole with apple sauce\n - Food given for comfort only\n - Aspiration precautions\n # Anemia: HCT currently 28.6 and stable.\n - Continue to trend, but can likely change to every other day lab draws\n ICU Care\n Nutrition: Regular diet, soft\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SC heparin\n will stop\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Likely to LTACH in next few days with hospice vs staying\n in ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607824,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt. in 80% hi flow mask at shift change, eventually desated to low 80\n unable to get sats above 86%\n Action:\n O2 was increased to 95%, still unable to raise sats, was given resp. rx\n which did not help , additional o2 5l was added via n/c. and 80mg of iv\n lasix was given\n Response:\n Pt. duiresed approx. 500cc from lasix, sats still in low 90\ns, desats\n with any activity ..turning , bed bath, changing hi-flow h20 bottle and\n it takes her quite a while compensate for it/\n Plan:\n Palliative care consult with husband and daughter this afternoon,\n continue to monitor resp. status, pt is a DNR, transition to comfort\n care.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607930,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. Palliative care consult made and meeting set\n for today at 1630. with family and medical team as well as case\n management and social work.\n Her resp status has deteriorated further in the past 24hrs requiring 5L\n N/C in addition to 95% high flow neb. Boarderline sat in the 88%-91%\n range. She has poor activity tolerance and has been ordered for\n morphine PRN dyspnea, pain or anxiety due to air hunger.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Remains on 95% high flow with 5L NC with boarderline O2 sats.\n Desaturates with any activity and unable to stay on her side due to\n SOB/low sats.\n Action:\n Medicated with Morphine 1mg IV to see if she could get comfortable on\n her right side. Encouraged to cough and deep breath to try to get O2\n sats up after activity and assisted with all ADL\ns. Turned back on her\n back when her sats would not come up.\n Response:\n Boarderline O2 sats 85%-92% most of the day. Anxious with low O2 sats\n Plan:\n Family meeting this afternoon with palliative care, MICU team and\n family.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o SOB/discomfort and being anxious with increased work of\n breathing and hypoxia.\n Action:\n Medicated with morphine 1-2mg PRN for anxiety/hypoxia.\n Response:\n Some improvement in comfort level but it did not seem to help her O2\n sats at all.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 608021,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - Still has continuous desats on NRB\n - Family meeting held and patient made CMO\n - Plan to stay in ICU for now with possible hospice at home versus\n hospice facility\n - Changed medications to increase morphine with standing ativan\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 07:41 AM\n Heparin Sodium (Prophylaxis) - 11:48 PM\n Morphine Sulfate - 04:44 AM\n Lorazepam (Ativan) - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 73) bpm\n BP: 109/60(72) {94/48(60) - 119/79(88)} mmHg\n RR: 18 (5 - 22) insp/min\n SpO2: 81%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 798 mL\n PO:\n 60 mL\n TF:\n IVF:\n 738 mL\n Blood products:\n Total out:\n 1,170 mL\n 0 mL\n Urine:\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -372 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 81%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: RRR, No murmur appreciated\n Respiratory / Chest: Coarse breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. No rebound or guarding, nondistended.\n Extremities: No peripheral edema, skin warm\n Neurologic: Attentive, follows simple commands\n Labs / Radiology\n 536 K/uL\n 9.4 g/dL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n No Chest Xray today\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia: Patient is not able to be weaned from\n her oxygen requirement and she understands the poor prognosis of her\n condition. Family meeting was held yesterday and patient was made\n comfort measures only. She has finished a course of antibiotics and\n trial of Bactrim for PCP without effect.\n - Continue morphine for air hunger and comfort\n - Have added Ativan 0.5mg q6h scheduled to help anxiety and will allow\n patient to refuse if she wishes to be more awake with her family\n - Added prn Ativan\n - Continue current prn oxycodone for pain\n - Continue morphine 2-5mg IV or 5-10mg SL q2h prn for SOB\n - Will explore with care management hospice at home vs inpatient\n hospice here\n - F/u all outstanding cultures\n - Continue Decadron 4mg IV BID\n #. Metastatic Breast Cancer: She was getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n - Appreciate palliative care recs\n - Continue seizure ppx w/ keppra\n - Future care planning as above\n #. S/p Fall: Neurological exam continues to be stable, Head CT and C\n spine wnl.\n - Continue Posey restraints and fall precautions\n #. Mild oral and pharyngeal dysphagia: Has reduced coordination c/w\n cerebellar mets.\n - Diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n - Pills whole with apple sauce\n - Food given for comfort only\n - Aspiration precautions\n # Anemia: HCT currently 28.6 and stable.\n - Continue to trend, but can likely change to every other day lab draws\n ICU Care\n Nutrition: Regular diet, soft\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Likely to LTACH in next few days with hospice vs staying\n in ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607449,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with crackles throughout all lobes. O2 at 80% high flow neb.\n Action:\n Pt did receive lasix 80 mg iv. Pt has also been started on Bactrim iv\n to treat PCP pna if pt is pos. received pt on 60% high flow neb but had\n to increase o2 as sao2 was decreasing after pt received the fluids in\n iv antibiotics.\n Response:\n Pt is diuresing well from the lasix. Becomes restless and somewhat\n confused at night.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607160,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 607375,
"text": "Chief Complaint: Hypoxemia\n Pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Decadron weaned down to 4mg dosing\n -Family meeting held with patient to be maintained as full code status\n -Continued hypoxemia prominent\n -Patient with continued negative fluid balance noted\n -FIO2 decreased to 0.6 but with rapid desaturation with any activity\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 02:41 PM\n Cefipime - 03:53 AM\n Vancomycin - 07:49 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 03:53 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Tachypnea\n Pain: Mild\n Flowsheet Data as of 09:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 60 (57 - 74) bpm\n BP: 103/60(71) {95/50(60) - 139/72(87)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 890 mL\n 352 mL\n PO:\n 60 mL\n TF:\n IVF:\n 890 mL\n 292 mL\n Blood products:\n Total out:\n 2,940 mL\n 135 mL\n Urine:\n 2,940 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,050 mL\n 217 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 95%\n ABG: ///35/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Diffuse, all lung fields., Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 614 K/uL\n 99 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.3 %\n 16.8 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n Plt\n 88\n 614\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n Other labs: PT / PTT / INR:14.3/33.6/1.2, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:9.0 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR-persistent bilateral patchy infiltrates\nall concerning for\n persistent impact of edema, pneumonitis and likely component of\n lymphangitic carcinomatosis.\n Microbiology: Flu-negative, no new bacterial cultures\n Assessment and Plan\n 50 yo female with history of metastatic breast cancer now admitted with\n hypoxemia and diffuse pulmonary infiltrates noted with concern for both\n influenza and bacterial insult driving presentation.\n 1)Respiratory Failure\nEdema may be playing a role and will continue to\n treat with diruesis. We do not have a final clear picture of the\n unifying diagnosis as regards infection as cultures have been negative\n to date. Will continue to provide treatment for likley infectious\n source and maintain steroids and diruesis across time now. Aspiration\n as possible is suggested but not obvious clear single trigger\n -No further Rx per oncology, we have trialed high dose steroids\n -Vanco/Cefepime/Bactrim DS qd with Vanco/Cefepime x 7 days and bactrim\n while steroids in place\n -Will maintain negative fluid balance as possible\n -Wean O2 as tolerated across time\n ICU Care\n Nutrition: Po diet limited by speed of desaturation\nwill work to\n maintain po intake as possible but is severely limited.\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: Hep Sq\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Will continue to discuss trend and treatment\n with family and patient.\n Code status: Full code\n Disposition :ICU\n Total time spent: 38 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607867,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - Unable wean O2 yesterday, is now requiring 95% face mask plus 5L NC\n - I/O: +600 at 2100, gave lasix 80 mg IV\n - Vanc and cefepime course completed yesterday\n - Plan for family meeting today at 1630\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 06:04 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 01:04 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 68 (62 - 84) bpm\n BP: 110/62(74) {90/44(56) - 121/70(80)} mmHg\n RR: 16 (6 - 22) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,230 mL\n 323 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,990 mL\n 323 mL\n Blood products:\n Total out:\n 1,560 mL\n 595 mL\n Urine:\n 1,560 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 670 mL\n -272 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: RRR, No murmur appreciated\n Respiratory / Chest: Coarse breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. No rebound or guarding, nondistended.\n Extremities: No peripheral edema, skin warm\n Neurologic: Attentive, follows simple commands\n Labs / Radiology\n 536 K/uL\n 9.4 g/dL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n 12:04 pm SPUTUM Site: INDUCED\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): BUDDING YEAST.\n RESPIRATORY CULTURE (Final ):\n Commensal Respiratory Flora Absent.\n YEAST. SPARSE GROWTH.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia: Some mild clinical improvement after\n aggressive diuresis but overall patient is not able to be weaned fro\n her oxygen requirement. Her distress is likely combination of\n lymphangitis spread of her breast cancer, fluid overload that is not\n being adequately mobilized from her lungs for diuresis, and possible\n infection.\n - Antibiotic 8-day course with vancomycin, cefepime ended \n - No lung biopsy given respiratory distress and patient wishes.\n - Fluid balance goal of even today, requiring 80mg IV Lasix to keep her\n even every day\n - Attempt to wean oxygen as tolerated\n - Continue PCP treatment with IV Bactrim for total 5 day course to end\n (currently on day 4)\n - F/u all outstanding cultures\n - Continue Decadron 4mg \n .\n #. Metastatic Breast Cancer: She was getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n - FU palliative care recs\n - Continue seizure ppx w/ keppra\n - Plan for family meeting today at 4:30pm\n .\n #. S/p Fall: Neurological exam continues to be stable, Head CT and C\n spine wnl.\n - Continue Posey restraints and fall precautions\n .\n #. Mild oral and pharyngeal dysphagia: Has reduced coordination c/w\n cerebellar mets.\n - Diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n - Pills whole with apple sauce\n - Aspiration precautions\n # Anemia: HCT currently 28.6 and stable.\n - Continue to trend daily\n - Guaiac all stools\n ICU Care\n Nutrition: Regular diet, soft\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Likely to LTACH in next few days with hospice ?\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 607878,
"text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Patient with persistent hypoxemic respiratory compromise\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 06:04 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:04 PM\n Furosemide (Lasix) - 10:19 PM\n Omeprazole (Prilosec) - 07:41 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Tachypnea\n Flowsheet Data as of 09:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (63 - 84) bpm\n BP: 113/68(80) {90/44(56) - 118/70(80)} mmHg\n RR: 21 (7 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,230 mL\n 347 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,990 mL\n 347 mL\n Blood products:\n Total out:\n 1,560 mL\n 635 mL\n Urine:\n 1,560 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 670 mL\n -289 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: ///32/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Stable eccymosis at left orbit\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : , Rhonchorous: ), Some decrease in crackles\n intesity but still present\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 536 K/uL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: AG-11\n Imaging: CXR-Worsening right lower lobe opacity--other areas unchanged\n Microbiology: No new culture data\n Assessment and Plan\n 50 yo female with metastatic breast cancer now admitted wtih hypoxemic\n respiratory compromise who has persistent and significant hypoxemia\n despite maximal medical therapy. We have continued to treat all\n categories of insult. This has resulted in a very clear plateau at\n this time with persistent hypoxemia and inability to maintain capacity\n to oxygenate with even the most minimal effort such as turning in bed.\n Respiratory Failure/Hypoxemia-\n -Bactrim in place at 3 days of trial and we simply have no change in\n status\nwill continue to 5 days to evaluate for any improvement and\n consider D/C if no change seen\n -Continue to maintain even fluid balance to negative if possible\n -O2 as needed\n Metastatic Breast Cancer-\n -Neurontin\n -Decadon\n -Keppra\n -No further Rx possible per Dr. \n ICU Care\n Nutrition: po intake as possible\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Discussed with Dr. and Family and do\n need to determine pathway of care in the setting of no expected change\n in clinical picture. Home is not reasonable, continued care in ICU is\n undesirable to patient, will look to inpatient facility closer to home\n in . This was discussed with patient in detail.\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 40 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607731,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. She has been diuresed and felt to be as dry\n as she is going to get. Plan is to try to keep pt even at this point.\n BP is running low 100\ns with HR 70\n Paliative care consult was made and RN has planned to see\n this pt this afternoon. Husband has expressed his wishes that pt be\n transferred to hospice care closer to home.\n She is tolerating small amts PO\ns and is on aspiration precautions due\n to dysphagia. No signs of aspiration at this point. Meds are well\n tolerated mixed in applesauce.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt tolerating 95% high flow neb with O2 sat 97% or greater. Team asked\n me to wean as tolerated.\n Action:\n Weaned pt to 80%\n Response:\n Plan:\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt assisted to chair by two PT with minimal problems. She has unsteady\n gait. She is forgetful but has not been seen trying to get up OOB on\n her own today.\n Action:\n Sat in chair for about one hour. Tolerated this well. Pt posied and on\n chair alarm seat while OOB to chair. Waist belt on while in bed.\n Response:\n Pt safe and assisted with all ADL\ns and hygeine\n Plan:\n Continue to assist with mobility and assess endurance.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607864,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - Unable wean O2 yesterday\n - I/O: +600 at 2100, gave lasix 80 mg IV\n - Vanc and cefepime stopped\n - Plan for family meeting today at 1630\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 06:04 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 01:04 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 68 (62 - 84) bpm\n BP: 110/62(74) {90/44(56) - 121/70(80)} mmHg\n RR: 16 (6 - 22) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,230 mL\n 323 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,990 mL\n 323 mL\n Blood products:\n Total out:\n 1,560 mL\n 595 mL\n Urine:\n 1,560 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 670 mL\n -272 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: RRR, No murmur appreciated\n Respiratory / Chest: Coarse breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. No rebound or guarding, nondistended.\n Extremities: No peripheral edema, skin warm\n Neurologic: Attentive, follows simple commands\n Labs / Radiology\n 536 K/uL\n 9.4 g/dL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n 12:04 pm SPUTUM Site: INDUCED\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): BUDDING YEAST.\n RESPIRATORY CULTURE (Final ):\n Commensal Respiratory Flora Absent.\n YEAST. SPARSE GROWTH.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia: Some mild clinical improvement after\n aggressive diuresis but overall patient is not able to be weaned fro\n her oxygen requirement. Her distress is likely combination of\n lymphangitis spread of her breast cancer, fluid overload that is not\n being adequately mobilized from her lungs for diuresis, and possible\n infection.\n - Antibiotic 8-day course with vancomycin, cefepime ended \n - No lung biopsy given respiratory distress and patient wishes.\n - Fluid balance goal of even today, requiring 80mg IV Lasix to keep her\n even every day\n - Attempt to wean oxygen as tolerated\n - Continue PCP treatment with IV Bactrim for total 5 day course to end\n (currently on day 4)\n - F/u all outstanding cultures\n - Continue Decadron 4mg \n .\n #. Metastatic Breast Cancer: She was getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n - FU palliative care recs\n - Continue seizure ppx w/ keppra\n .\n #. S/p Fall: Neurological exam continues to be stable, Head CT and C\n spine wnl.\n - Continue Posey restraints and fall precautions\n .\n #. Mild oral and pharyngeal dysphagia: Has reduced coordination c/w\n cerebellar mets.\n - Diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n - Pills whole with apple sauce\n - Aspiration precautions\n # Anemia: HCT currently 28.6 and stable.\n - Continue to trend daily\n - Guaiac all stools\n ICU Care\n Nutrition: Regular diet, soft\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Likely to LTACH in next few days with hospice ?\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 608114,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Persistent hypoxia at rest\n Acute dyspnea at rest\n Action:\n Started morphine drip at 2mg /h\n Re-posititoned q2 hours\n Response:\n Pt reports less dyspnea\n Plan:\n Continue morphine drip and titrate as needed\n Position for comfort\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 608210,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt required increased MSO4 drip to 12mg/hr for a turn at 11AM\n Action:\n Drip increased from 10mg to 12mg at 11AM for pt comfort.\n Response:\n Pt became ashen grey in color and HR slowly dropped over the next few\n minutes and pt stopped breathing and became asystolic at 11:15\n Plan:\n Pt remained comfortable with her family at her bedside for her death.\n Team to pronounce and address autopsy.\n"
},
{
"category": "General",
"chartdate": "2143-11-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 608222,
"text": "Clinician: Resident\n Asked by nursing to examine patient as likely deceased at 11:25 am\n Patient non-responsive and skin warm. No heart sounds or respiratory\n movement. Pupils non-reactive. Death pronounced at 11:26am.\n Husband was notified and declined autopsy.\n Report of death to be filed this afternoon.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 608197,
"text": "Chief Complaint: Respiratory Failure\n Breast Cancer-Metastatic\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Patient with ongoing MSO4 dosing to aid with patient comfort which has\n been successful in maintaining patient comfort.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Morphine Sulfate - 08:05 PM\n Lorazepam (Ativan) - 09:45 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: Tachycardia\n Respiratory: Tachypnea\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 101 (101 - 119) bpm\n BP: 80/50(71) {80/50(71) - 105/64(71)} mmHg\n RR: 19 (16 - 25) insp/min\n SpO2: 70%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 47 mL\n 100 mL\n PO:\n TF:\n IVF:\n 47 mL\n 100 mL\n Blood products:\n Total out:\n 240 mL\n 50 mL\n Urine:\n 240 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -193 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 70%\n ABG: ////\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Dullness : ), (Breath Sounds:\n Diminished: , Rhonchorous: )\n Abdominal: Soft\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 536 K/uL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 50 yo female with metastatic breast cancer now with progression of\n hypoxemic respiratory failure now with persistent hypoxia and inability\n to improve clinical course now with move to CMO patient has had\n persistent hypoxemia and poor mental status which is secondary to both\n hypoxia and medications required to support patient comfort. Patient's\n family has ongiong difficulty with acceptance of patient passing being\n prolonged and expressing exhaustion and frustration that process has\n been prolonged.\n 1)Hypoxia-\n -O2 support in place\n -As needed will be used\n 2) COMFORT CARE (CMO, COMFORT MEASURES)\n -MSO4 gtt in place\n -Social Work support in place as well as palliative care\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Discussed with family\nwill find out about\n access to bed for them to get some sleep during the day given ongoing\n vigil.\n Code status: Comfort measures only\n Disposition :ICU\n Total time spent: 25 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 608199,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - On morphine gtt\n - Family at bedside entire night, including husband\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:05 PM\n Lorazepam (Ativan) - 09:45 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 104 (104 - 119) bpm\n BP: 80/50(71) {80/50(71) - 105/64(71)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 70%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 47 mL\n 53 mL\n PO:\n TF:\n IVF:\n 47 mL\n 53 mL\n Blood products:\n Total out:\n 240 mL\n 50 mL\n Urine:\n 240 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -193 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 70%\n ABG: ////\n Physical Examination\n General: Patient with agonal breathing laying in bed, minimally\n responsive, family at bedside\n HEENT: Lips and skin blue\n Labs / Radiology\n No labs today\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia and Metastatic Breast Cancer: Currently\n comfort measures only. On morphine gtt and ativan prn.\n - Continue morphine for air hunger and comfort\n - Add scopolamine patch for secretions\n - FU palliative care recs\n - Have dc\ned all other meds as patient not likely to benefit and can\n take\n - Have added PR Tylenol\n #. Mild oral and pharyngeal dysphagia: Food given for comfort only\n ICU Care\n Nutrition: As above\n Glycemic Control:\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: None\n Stress ulcer: None\n VAP: None\n Comments:\n Communication: Comments: With family, at bedside\n Code status: Comfort measures only, DNR/DNI\n Disposition: Will stay in unit with palliation\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 608175,
"text": "TITLE: Resident Progress Note\n Chief Complaint: metastatic breast cancer\n 24 Hour Events:\n - On morphine gtt\n - Family at bedside entire night, including husband\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 12:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:05 PM\n Lorazepam (Ativan) - 09:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 104 (104 - 119) bpm\n BP: 80/50(71) {80/50(71) - 105/64(71)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 70%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 47 mL\n 53 mL\n PO:\n TF:\n IVF:\n 47 mL\n 53 mL\n Blood products:\n Total out:\n 240 mL\n 50 mL\n Urine:\n 240 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -193 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 70%\n ABG: ////\n Physical Examination\n General: Patient with agonal breathing laying in bed, minimally\n responsive, family at bedside\n HEENT: Lips and skin blue\n Labs / Radiology\n No labs today\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia and Metastatic Breast Cancer: Currently\n comfort measures only. On morphine gtt and ativan prn.\n - Continue morphine for air hunger and comfort\n - Continue IV ativan prn\n - FU palliative care recs\n - Have dc\ned all other meds as patient not likely to benefit\n #. Mild oral and pharyngeal dysphagia: Food given for comfort only\n ICU Care\n Nutrition: As above\n Glycemic Control:\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: None\n Stress ulcer: None\n VAP: None\n Comments:\n Communication: Comments: With family, at bedside\n Code status: Comfort measures only, DNR/DNI\n Disposition: Will stay in unit with palliation\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606642,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Transfer in from 7s,pt AO X 3,denies any pain or SOB or related\n symptoms\n T max 102.5,HR 90-100 while resting and upto 120\ns with activity,NBP\n stable.placed on 100% high flow,\n Desats easily when the mask is off,Lung sounds with fine crackels on\n admission,did receive 40 mg Lasix IV prior to transfer.\n Single lumen port cath for access.\n Action:\n ABG on admission 7.51/37/94\n.O 2 weaned down to 60%\n Informed the team about temp\n.pan cultured.(no Tylenol unless pt\n physiologically uncomfortable as per team,pt did receive vicodyn on the\n floor)\n On cefipime and vanco and started on tamiflu..1^st dose given.\n Influenza A& B swab send.\n Response:\n Pt continued to deny for any resp distress.\n Sats maintained upto 95%\n Plan:\n Continue to monitor resp status\n Antibiotics as ordered.\n On droplet/seizure precautions.\n AM lab results pending.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606646,
"text": "50F w/history of Breast Ca per report metastatic to brain, bone, liver, and poss\nibly lung who was admitted from clinic on with a likely seizure episode. T\nransferred from 7s for hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transfer in from 7s,pt AO X 3,denies any pain or SOB or related\n symptoms\n T max 102.5,HR 90-100 while resting and upto 120\ns with activity,NBP\n stable.placed on 100% high flow,\n Desats easily when the mask is off,Lung sounds with fine crackels on\n admission,did receive 40 mg Lasix IV prior to transfer.\n Pt has some tremors but no seizure activity noted.\n Single lumen port cath for access.\n Action:\n ABG on admission 7.51/37/94\n.O 2 weaned down to 60%\n Informed the team about temp\n.pan cultured.(no Tylenol unless pt\n physiologically uncomfortable as per team,pt did receive vicodyn on the\n floor)\n On cefipime and vanco and started on tamiflu..1^st dose given.\n Influenza A& B swab send.\n Response:\n Pt continued to deny for any resp distress.\n Sats maintained upto 95%\n Plan:\n Continue to monitor resp status\n Antibiotics as ordered.\n On droplet/seizure precautions.\n AM lab results pending.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606651,
"text": "TITLE: PHYSICIAN RESIDENT PROGRESS NOTE\n Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 12:19 AM\n PAN CULTURE - At 03:00 AM\n FEVER - 102.5\nF - 02:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 119 mL\n PO:\n TF:\n IVF:\n 119 mL\n Blood products:\n Total out:\n 0 mL\n 480 mL\n Urine:\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.51/37/94./26/5\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Using accessory muscles of breathing. Taking in word\n sentences.\n HEENT: Normocephalic, atraumatic. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: + rhonchi diffusely bilaterally.\n ABDOMEN: +BS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength\n throughout. 2+ reflexes, equal BL.\n Labs / Radiology\n 386 K/uL\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 96 mEq/L\n 135 mEq/L\n 27.5 %\n 14.2 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TCO2\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -dose of vancomycin given prior to transfer to floor, continue\n vancomycin\n -change ceftriaxone to cefepime for better pseudomonas coverage\n -send flu swab, place on precautions\n -empiric tx with tamiflu\n -urine legionella pending\n -trend WBC and fever curve\n -got lasix 20 IV x1, monitor urine output\n -appreciate pulm recs, will consider diagnostic thoracentesis\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n .\n # UTI: Treat as above.\n -change ceftriaxone to cefepime\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure ppx w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n increase in liver enzymes could be due to liver mets.\n -follow daily\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -check iron studies\n -guiac all stools\n .\n # FEN/GI:\n -NPO until respiratory status improves\n .\n # PROPHY:\n -SC heparin\n -bowel regimen\n .\n # ACCESS: Port\n .\n # CODE: FULL confirmed with patient\n .\n # COMM: patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 606661,
"text": "TITLE:\n Chief Complaint:\n Respiratory distress\n HPI:\n The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on . I was called to evaluate her for\n respiratory distress.\n .\n Pt was on 2L NC in the AM. Then this PM was 81% on 4L. On 6L NC o2\n sats improved to 85-86%. Pt then placed on NRB with sats 97-98% with\n RR 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt reports her\n shortness of breath has gradually gotten worse over the last few weeks.\n .\n Currently, patient denies any symptoms of nausea, vomiting, chest pain,\n dysuria, hematuria.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Home medications:\n Atenolol 25mg po daily\n Vicodin Q4 hr prn pain\n Neurontin 300mg TID - not taking\n Effexor XR 112.5mg daily\n Prilosec 20mg daily\n Pilocarpine 5mg TID\n Claritin prn allergy symptoms\n .\n Past medical history:\n Family history:\n Social History:\n Her oncological problems began in when she felt an\n egg size mass in her left breast. She underwent an open biopsy\n of the left breast that showed infiltrating lobular carcinoma, ER\n negative, and Her2/neu positive. She underwent a left modified\n radical mastectomy by , M.D. on that showed\n the same pathology. There were 14/16 lymph nodes positive for\n tumor. She then received 4 cycles of neoadjuvant\n cyclophosphamide and Adriamycin, followed by 4 cycles of\n Taxotere. She then completed chest irradiation by Dr. at\n Hospital, which she completed on .\n .\n Her neurological problems began in mid- when she\n experienced gradually worsening headaches. Head CT and MRI\n showed a mass in the left cerebellum. , M.D. performed\n a suboccipital craniotomy on . The pathology was\n consistent with metastatic breast cancer. She then received\n stereotactic radiosurgery to the resection bed on to\n 1,500 cGy, followed by another surgical resection of the previous\n site on and another radiation boost to 4,000 cGy from\n to . She then received Cyberknife radiosurgery\n to a right cerebellar metastasis (1,800 cGy) and a right superior\n cerebellar metastasis (1,600 cGy) on in one fraction,\n followed by a suboccipital craniotomy on for removal of\n right paramedian cerebellar metastasis. Since , she has\n been getting bevacizumab (every 2 weeks) and Herceptin (weekly).\n Her father died of lymphoma while her mother passed away from coronary\n artery disease. Her sister has some sort of cancer that metastasized to\n lungs and brain. Her children are healthy.\n No ETOH/cig/illicits\n Review of systems:\n Currently, patient denies any symptoms of nausea, vomiting, chest pain,\n dysuria, hematuria.\n Flowsheet Data as of 08:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 135 mL\n PO:\n TF:\n IVF:\n 135 mL\n Blood products:\n Total out:\n 0 mL\n 520 mL\n Urine:\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -385 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.51/37/94./26/5\n PaO2 / FiO2: 157\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 386 K/uL\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 7 mg/dL\n 26 mEq/L\n 96 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 27.5 %\n 14.2 K/uL\n [image002.jpg]\n \n 2:33 A11/24/ 12:13 AM\n \n 10:20 P11/24/ 02:57 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TC02\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.1 mg/dL\n STUDIES:\n CTA :\n CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arteries opacify\n normally. There is no evidence of pulmonary embolism. The thoracic\n aorta is normal in course and caliber, without dissection. There are\n calcifications of the aortic arch. There is trace pericardial fluid.\n The heart is enlarged.\n Diffuse ill-defined patchy ground-glass opacities are present\n throughout the lungs bilaterally, most severely affecting the lower\n lobes. Focal consolidations of the right middle lobe (3:48) and of the\n left upper lobe (3:18) are new from previous studies. Intralobular\n septal thickening affects both lungs, basilar and apical predominant.\n There are small bilateral layering pleural effusions. The airways are\n patent bilaterally to the subsegmental level.\n There are multiple sclerotic lesions within the thoracic spine and\n involving the sternum, which are similar to CT .\n .\n IMPRESSION:\n 1. No pulmonary embolism. No aortic dissection.\n 2. Diffuse ground-glass opacities and septal thickening and small\n bilateral effusions. Cardiomegaly. The constellation of findings is\n most likely due to pulmonary edema. However, lymphangitic\n carcinomatosis cannot be excluded. A followup chest CT following\n treatment and resolution of symptoms is recommended.\n 3. Focal consolidation of the right middle and left upper lobes\n concerning for superimposed infection.\n .\n CXR : Worsening bilateral opacities.\n .\n CXR :\n There is interval development of extensive interstitial prominence and\n parenchymal opacities, findings consistent with interval development of\n pulmonary edema superimposed on chronic abnormalities within the chest.\n There is bilateral small pleural effusion present. The\n cardiomediastinal silhouette is unchanged. The consolidation seen in\n the right middle lobe and right lower lobe are redemonstrated, and it\n is unclear if represents focus of infection or metastatic deposits to\n the lungs.\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -dose of vancomycin given prior to transfer to floor, continue\n vancomycin\n -change ceftriaxone to cefepime for better pseudomonas coverage\n -send flu swab, place on precautions\n -empiric tx with tamiflu\n -urine legionella pending\n -trend WBC and fever curve\n -got lasix 20 IV x1, monitor urine output\n -appreciate pulm recs, will consider diagnostic thoracentesis\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n .\n # UTI: Treat as above.\n -change ceftriaxone to cefepime\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure ppx w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n increase in liver enzymes could be due to liver mets.\n -follow daily\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -check iron studies\n -guiac all stools\n .\n # FEN/GI:\n -NPO until respiratory status improves\n .\n # PROPHY:\n -SC heparin\n -bowel regimen\n .\n # ACCESS: Port\n .\n # CODE: FULL confirmed with patient\n .\n # COMM: patient and her husband\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: patient and her husband\n status: FULL confirmed with patient\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606667,
"text": "TITLE: PHYSICIAN RESIDENT PROGRESS NOTE\n Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 12:19 AM\n PAN CULTURE - At 03:00 AM\n FEVER - 102.5\nF - 02:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 119 mL\n PO:\n TF:\n IVF:\n 119 mL\n Blood products:\n Total out:\n 0 mL\n 480 mL\n Urine:\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.51/37/94./26/5\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Using accessory muscles of breathing. Taking in word\n sentences.\n HEENT: Normocephalic, atraumatic. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: + rhonchi diffusely bilaterally.\n ABDOMEN: +BS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength\n throughout. 2+ reflexes, equal BL.\n Labs / Radiology\n 386 K/uL\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 96 mEq/L\n 135 mEq/L\n 27.5 %\n 14.2 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TCO2\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -continue vancomycin, cefepime\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -appreciate pulm recs, will consider diagnostic thoracentesis\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n .\n # UTI: Treat as above.\n -change ceftriaxone to cefepime\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure ppx w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n increase in liver enzymes could be due to liver mets.\n -follow daily\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -check iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606668,
"text": "TITLE: PHYSICIAN RESIDENT PROGRESS NOTE\n Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 12:19 AM\n PAN CULTURE - At 03:00 AM\n FEVER - 102.5\nF - 02:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 119 mL\n PO:\n TF:\n IVF:\n 119 mL\n Blood products:\n Total out:\n 0 mL\n 480 mL\n Urine:\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.51/37/94./26/5\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Using accessory muscles of breathing. Taking in word\n sentences.\n HEENT: Normocephalic, atraumatic. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: + rhonchi diffusely bilaterally.\n ABDOMEN: +BS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength\n throughout. 2+ reflexes, equal BL.\n Labs / Radiology\n 386 K/uL\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 96 mEq/L\n 135 mEq/L\n 27.5 %\n 14.2 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TCO2\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -continue vancomycin, cefepime\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -appreciate pulm recs, will consider diagnostic thoracentesis\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure ppx w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n increase in liver enzymes could be due to liver mets.\n -follow daily\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -check iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 606671,
"text": "Chief Complaint: Respiratory Failure\n Hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient admitted with RLL opacity to hospital and treated for pneumonia\n but has had worsening hypoxemia over the past 24 hours moving to NRB\n mask and with persistent tachypnea and tachycardia paient to ICU with\n worsening respiratory distress.\n On evaluation prior to transfer-->\n 7.51/37/94\n CXR-worsening bilateral infiltrates\n On exam--patient with accessory muscle use, tachypnea, agitation\n Lungs--Diffuse ronchi bilaterally\n heart-_Tachycardic\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Breast CA--metastatic--lobular carcinoma--s/p L mastectomy, nodes\n positive\n --Left cerbellar mass found--s/p craniotomy with resection\n undertakend with cyberknife\n Continues on Herceptin\n Depression\n Non-contributory for acute presentation--father with lymphoma and\n mother with CAD\n Occupation: Not known\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough, Dyspnea, Tachypnea\n Genitourinary: Foley\n Flowsheet Data as of 09:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 144 mL\n PO:\n TF:\n IVF:\n 144 mL\n Blood products:\n Total out:\n 0 mL\n 520 mL\n Urine:\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -376 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.48/40/84./26/5\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Lungs00very signfiicant bilateral crackles which are dominant at mid\n and end inspiration. Some ronchi are present as well but are a less\n dominant finding at this time.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 386 K/uL\n 27.5 %\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 7 mg/dL\n 26 mEq/L\n 96 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 14.2 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TC02\n 31\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Lactic Acid:1.1 mmol/L, Ca++:7.5\n mg/dL, Mg++:1.8 mg/dL, PO4:2.1 mg/dL\n Fluid analysis / Other labs: 7.48/40/84--on high flow neb\n Imaging: CTA----Diffuse intra-lobular thickening, bilateral\n effusions--layering, ground glass opacities and consolidations\nthis is\n suggestive of lymphangitic carcinomatosis in the setting of new\n insult. Report says that PE was not seen.\n Assessment and Plan\n 50 yo female admitted with worsening respiratory distress and in the\n setting of CTX patient evolved substantial worsening of respiratory\n status across days. Upon admission to the ICU antibiotic coverage was\n expanded and patient was successfully weaned off of the non-repreather\n mask. Lasix was given as well. For a unifying diagnosis certainly\n infection does seem most likely given ronchi, fever, infiltrate,\n elevated WBC count. However, acute worsening needs to be accounted\n for--this may be related to worsening of pneumonia in the setting of\n single coverage of antibiotic therapy. Alternatively PE is possible\n with acute decline and significant A-a gradient hypoxia and respiratory\n alkalosis. Interstitial pneumonitis certainly may well be playing a\n role with possible infectious trigger or pneumonitis secondary to\n aspiration or other casue.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\nProminently hypoxemic\n respiratory failure\nwith interstitial pneumonitis quite\n prominently\nthere are not focal areas of consolidation to make acute\n bacterial pneumonia perhaps less likely. This leaves viral infection\n as trigger certainly possible and atypical bacteria is quite likely.\n We do have a concern for aspiration in the setting of seizure.\n For Bacterial/Viral Pneumonia-\n -vancomycin/Cefepime/Azithro\nwill have to discuss with Dr. \n concerns around seizure and role of Quinolones\n -Tamiflu\n -Swab and culture and urine legionella sent\n -Do not have capacity for bronch at this time which would inform\n alveolar hemorrhage\nwill pursue if patient intubated\n For Pneumonitis-\n -Support with IVF, O2 and do not see need for additional intervention\n as is likely reactive pneumonitis to viral infection or aspiration\n event\n For alternative sources\n PE-Not seen on initial presentation with CTA, has had slow progression\n and likely worsening yesterday would be related to increased secretions\n and need for clearance\n Alveolar Hemorrhage-will have to monitor for hemoptysis\n CHF\nnot seen on exam this morning\ninfiltrates are atypical and will\n maintain negative fluid balance\n Will continue to monitor in ICU\n Seizure-\n -Keppra\n Breast CA-\n -Will discuss with oncology team any current intervetion to aid in\n control of pulmonary metastases\n ICU Care\n Nutrition: NPO during acute illness\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 12:19 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606673,
"text": "TITLE: PHYSICIAN RESIDENT PROGRESS NOTE\n Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 12:19 AM\n PAN CULTURE - At 03:00 AM\n FEVER - 102.5\nF - 02:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.5\n Tcurrent: 38.9\nC (102\n HR: 96 (96 - 117) bpm\n BP: 115/75(85) {115/60(74) - 150/86(102)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 119 mL\n PO:\n TF:\n IVF:\n 119 mL\n Blood products:\n Total out:\n 0 mL\n 480 mL\n Urine:\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.51/37/94./26/5\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Breathing comfortably on high-flow neb but desats to mid 80s\n rapidly when she removes mask.\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse bilateral rales.\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 386 K/uL\n 9.1 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 96 mEq/L\n 135 mEq/L\n 27.5 %\n 14.2 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n WBC\n 14.2\n Hct\n 27.5\n Plt\n 386\n Cr\n 0.5\n TCO2\n 31\n Glucose\n 95\n Other labs: PT / PTT / INR:12.8//1.1, Differential-Neuts:90.3 %,\n Lymph:5.5 %, Mono:3.2 %, Eos:0.9 %, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -continue vancomycin, cefepime; could\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -consider diagnostic bronchoscopy when patient stable enough to\n tolerate exam\n -appreciate pulm recs, could consider diagnostic thoracentesis although\n patient is not stable enough for this now\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure prophylaxis w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n elevated alkphos is from liver vs. .\n -recheck LFTs, along with GGT\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -f/u iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607430,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU\n for respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very diminished, scattered rhonchi, R>L\n Continues to have high O2 requirement, desaturates easily with any\n activity\n Action:\n Changed to IV Bactrim for PCP coverage\n Response:\n Pt has maintained SpO2 or recovered from de-saturation within 15\n minutes\n Plan:\n Continue antibiotics\n Continue steroid taper\n Continue respiratory support as needed\n Consult palliative care service for possible hospice referral later\n this week\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606644,
"text": "50F w/history of Breast Ca per report metastatic to brain, bone, liver, and poss\nibly lung who was admitted from clinic on with a likely seizure episode. T\nransferred from 7s for hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transfer in from 7s,pt AO X 3,denies any pain or SOB or related\n symptoms\n T max 102.5,HR 90-100 while resting and upto 120\ns with activity,NBP\n stable.placed on 100% high flow,\n Desats easily when the mask is off,Lung sounds with fine crackels on\n admission,did receive 40 mg Lasix IV prior to transfer.\n Single lumen port cath for access.\n Action:\n ABG on admission 7.51/37/94\n.O 2 weaned down to 60%\n Informed the team about temp\n.pan cultured.(no Tylenol unless pt\n physiologically uncomfortable as per team,pt did receive vicodyn on the\n floor)\n On cefipime and vanco and started on tamiflu..1^st dose given.\n Influenza A& B swab send.\n Response:\n Pt continued to deny for any resp distress.\n Sats maintained upto 95%\n Plan:\n Continue to monitor resp status\n Antibiotics as ordered.\n On droplet/seizure precautions.\n AM lab results pending.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606876,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on NRB, SATs go from 91-94%, she desats to the 70s very\n quickly when she takes her mask off. Her resp rate is /min while\n asleep. She conts to have coarse rales throughout. The influenza swab\n was initially read as neg then the lab said that they did not have\n enough cells to diagnose\n Action:\n She was put back on influenza precautions and Tamaflu was restarted,\n given 20mg of IV lasix, dexamethasone was tapered\n Response:\n Now off influenza precautions, resp status remains tenuous\n Plan:\n There has been some discussion of talking to the pt about hospice but\n this has not happened yet, SS conts to be involved\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607426,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU\n for respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very diminished, scattered rhonchi, R>L\n Continues to have high O2 requirement, desaturates easily with any\n activity\n Action:\n Changed to IV Bactrim for PCP coverage\n Response:\n Pt has maintained SpO2 or recovered from de-saturation within 15\n minutes\n Plan:\n Continue antibiotics\n Continue steroid taper\n Continue respiratory support as needed\n Consult palliative care service for possible hospice referral later\n this week\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607431,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU\n for respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS very diminished, scattered rhonchi, R>L\n Continues to have high O2 requirement, desaturates easily with any\n activity\n Action:\n Changed to IV Bactrim for PCP coverage\n Response:\n Pt has maintained SpO2 or recovered from de-saturation within 15\n minutes\n Plan:\n Continue antibiotics\n Continue steroid taper\n Continue respiratory support as needed\n Consult palliative care service for possible hospice referral later\n this week\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606755,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. . Pt states that her shortness of\n breath has gradually gotten worse over the last few weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with crackles throughout. RR 10-16 with sao2 92-94%. Pt stating\n that resp are\nmore difficult\n Action:\n Pt on 100% NRB. Lasix 20mg ivp given with a chest x-ray done. Lasix 10\n mg given. Attempted to place pt on 60% o2 unable as sao2 dropped to 88%\n within\n hour. Attempted 80% but sao2 only went to 89%. Placed back on\n NRB.\n Response:\n On NRB sao2 in the mid to high 90\n Plan:\n Attempt to wean o2 as pt is able to tol.\n"
},
{
"category": "General",
"chartdate": "2143-11-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 607477,
"text": "TITLE:\n Clinician: Resident\n I was called by a member of the nursing staff that the patient fell out\n of bed.\n The patient was found on the floor. She was alert, oriented,\n responsive, but was unable to state how she ended up getting out of\n bed.\n A detailed neurological exam was performed.\n Pupils were round and equally reactive to light. There was a slight\n pupillary assymetry with R eye having an oval-shaped pupil, unknown if\n it's due to prior surgery. Extraocular movements were intact.\n There was no facial tenderness except over nasal bridge.\n There was no point tenderness over the spinous processes.\n Strength was throughout in extremities. Sensation was grossly\n intact to light touch. Muscle tone was normal.\n The patient was placed in a J collar. A STAT CT of the head and\n spine was ordered.\n The patient was returned to bed. Oxygen saturations returned to high\n 90s.\n"
},
{
"category": "General",
"chartdate": "2143-11-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 607478,
"text": "TITLE:\n Clinician: Resident\n I was called by a member of the nursing staff that the patient fell out\n of bed.\n The patient was found on the floor. She was alert, oriented,\n responsive, but was unable to state how she ended up getting out of\n bed.\n A detailed neurological exam was performed.\n Pupils were round and equally reactive to light. There was a slight\n pupillary assymetry with R eye having an oval-shaped pupil, unknown if\n it's due to prior surgery. Extraocular movements were intact.\n There was no facial tenderness except over nasal bridge.\n There was no point tenderness over the spinous processes.\n Strength was throughout in extremities. Sensation was grossly\n intact to light touch. Muscle tone was normal.\n The patient was placed in a J collar. A STAT CT of the head and\n C-spine was ordered. Pt. will go for CT at 7 am.\n The patient was returned to bed. Oxygen saturations returned to high\n 90s.\n The pt. was placed in Posey as a precaution. Attending was notified.\n"
},
{
"category": "General",
"chartdate": "2143-11-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 607479,
"text": "TITLE:\n Clinician: Resident\n I was called by a member of the nursing staff that the patient fell out\n of bed.\n The patient was found on the floor. She was alert, oriented,\n responsive, but was unable to state how she ended up getting out of\n bed.\n A detailed neurological exam was performed.\n Pupils were round and equally reactive to light. There was a slight\n pupillary assymetry with R eye having an oval-shaped pupil, unknown if\n it's due to prior surgery. Extraocular movements were intact.\n There was no facial tenderness except over nasal bridge.\n There was no point tenderness over the spinous processes.\n Strength was throughout in extremities. Sensation was grossly\n intact to light touch. Muscle tone was normal.\n The patient was placed in a J collar. A STAT CT of the head and\n C-spine was ordered. Pt. will go for CT at 7 am.\n The patient was returned to bed. Oxygen saturations returned to high\n 90s.\n The pt. was placed in Posey restraints as a precaution. Attending was\n notified.\n"
},
{
"category": "General",
"chartdate": "2143-11-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 607480,
"text": "TITLE:\n Clinician: Resident\n I was called by a member of the nursing staff that the patient fell out\n of bed.\n The patient was found on the floor. She was alert, oriented,\n responsive, but was unable to state how she ended up getting out of\n bed.\n A detailed neurological exam was performed.\n Pupils were round and equally reactive to light. There was a slight\n pupillary assymetry with R eye having an oval-shaped pupil, unknown if\n it's due to prior surgery. Extraocular movements were intact.\n There was no facial tenderness except over nasal bridge.\n There was no point tenderness over the cervical spinous processes.\n Strength was throughout in extremities. Sensation was grossly\n intact to light touch. Muscle tone was normal.\n The patient was placed in a J collar. A STAT CT of the head and\n C-spine was ordered. Pt. will go for CT at 7 am.\n The patient was returned to bed. Oxygen saturations returned to high\n 90s.\n The pt. was placed in Posey restraints as a precaution. Attending was\n notified.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 607536,
"text": "Chief Complaint: Respiratory Failure\n Pneumonitis\n Pulmonary Edema\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Patient with intermittent hypotension noted in the setting of\n attempted diuresis\n -PCP treatment started with IV Bactrim given persistence of substantial\n infiltrates and no reasonable capacity to test further.\n -Patient with unwitnessed fall from bed with eccymosis above left\n orbit. Patient without LOC. Patient return to bed and without\n significant deficits seen. No C-Spine tenderness noted. CT planned in\n follow up and yet to be conducted at the time of this note.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Vancomycin - 08:22 PM\n Bactrim (SMX/TMP) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:23 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 67 (54 - 78) bpm\n BP: 138/70(88) {85/39(53) - 138/88(88)} mmHg\n RR: 21 (8 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,319 mL\n 586 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,199 mL\n 586 mL\n Blood products:\n Total out:\n 1,380 mL\n 280 mL\n Urine:\n 1,380 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -61 mL\n 306 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Persistent and increased cyanosis noted in\n peri-orbital area\n Head, Ears, Nose, Throat: Normocephalic, Eccymosis above left orbit\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : dominant finding, Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 605 K/uL\n 98 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 37 mg/dL\n 98 mEq/L\n 142 mEq/L\n 29.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 88\n 614\n 605\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.4 mg/dL, PO4:4.2 mg/dL\n Imaging: CXR-\n Microbiology: No new results seen\n Assessment and Plan\n 50 yo female with history of metastatic breast cancer now with\n admission with severe hypoxemic respiratory compromise. This is in the\n setting of likely lymphangitic spread of cancer but with acute\n process--likely infectious--leading to a diffuse pattern of pulmonary\n edema and likely pneumonitis with some improvement in the setting of\n diuresis.\n 1) RESPIRATORY FAILURE, ACUTE (NOT ARDS/)--This remains a diagnostic\n challenge. We have had extensive testing for influenza and in fact\n that plus all other culture data remains negative. We have had modest\n improvement in oxygenation with diuresis but now with rising creatinine\n and falling blood pressure reasonable limit has been reached. In this\n setting with persistent and diffuse infiltrates we have added empiric\n treatment for PCP as improvement has clearly plateaued and additional\n therapeutic interventions are quite limited and although sputum samples\n have been negative for PCP in the absence of HIV these samples do have\n limited sensitivity.\n -Decadron at 4mg dose\n -Cefepime/Vanco/Bactrim IV/Azithromycin\n -Will continue to support with oxygen as needed\n 2)FALL\nPatient clearly confused but easily re-oriented. Patient had\n equal pupils and preserved reflexes and motor strength bilaterally\n -CT head and C-Spine this morning\n -Denies any tenderness of C-Spine at this time\n -Will move to D/C C-collar when CT scan completed\n 3)Breast Cancer-Discussed with Dr. \n further intervention suggested at this time\n -Will continue to discuss future care in light of improvement in\n respiratory status with hospice discussed as a possible direction\n ICU Care\n Nutrition: PO intake at this time\nis limited and will maintain calorie\n counts\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition :ICU\n Total time spent: 40\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606962,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has chronic pain in the back and the neck. This shift pt stated that\n the pain was an .\n Action:\n Yesterday the vicodan was discontinued and pt was placed on percocet\n which seems to work better for the pt.\n Response:\n Pt requested a pain pill at midnight and was sleeping within half an\n hour.\n Plan:\n Cont with perocet one or two tabs as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs have remained with coarse crackles throughout the lungs bilat.\n Sao2 93-98%.\n Action:\n Pt has remained on NRB\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607516,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU\n for respiratory distress.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607529,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Satting in mid-90s on 60% face mask, but does not tolerate any\n physical exertion.\n -Hypotensive (got Atenolol in AM, which was subsequently d/c'd), so we\n were unable to diurese further in AM> Gave 80mg IV Lasix in PM, with\n good response. However, positive as was getting extra IVF with Bactrim\n (most concentrated possible).\n -Started on empiric treatment for PCP with IV bactrim (concentrated in\n order to minimize fluids).\n -The patient fell out of bed and was found on the floor. She was alert\n and oriented, but unable to state how she ended up there. She was\n returned back to bed. O2 sats returned to high 90s. Neurological exam\n was non-focal. She was placed in Posey restraints. STAT CT head and\n C-spine were ordered (will be done at 7am) Event note was written.\n Attending was notified.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Vancomycin - 08:22 PM\n Bactrim (SMX/TMP) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:23 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (54 - 78) bpm\n BP: 120/64(78) {85/39(53) - 133/88(88)} mmHg\n RR: 20 (8 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,319 mL\n 577 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,199 mL\n 577 mL\n Blood products:\n Total out:\n 1,380 mL\n 280 mL\n Urine:\n 1,380 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -61 mL\n 297 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: ///34/\n Physical Examination\n GENERAL: Alert, responsive, NAD on 60% face mask\n CARDIAC: Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 605 K/uL\n 9.8 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 37 mg/dL\n 98 mEq/L\n 142 mEq/L\n 29.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 88\n 614\n 605\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. This is most likely due to lymphangitic spread of\n her BRCA, acc to outpatient oncologist.\n There also could be contribution from pulmonary edema diastolic\n dysfunction and possible infectious process / PNA.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 5 of a 7 day course)\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 80mg lasix x 1 if BP tolerates\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n /u all outstanding cultures\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: nectar thick liquids and soft, moist solids\n Glycemic Control: none\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n plan on family mtg later in\n PM to discuss goals of care\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607078,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pt has been here on 100% NRB since transfer with sats 95%-98% at\n rest.. She continues to desat quickly when O2 mask removed for meds,\n mouth care etc. (sats dropping to 79% quickly) Today team ordered an\n induced sputum for PCP since the one done on did not have enough\n specimen for testing. When RT did induction she coughed up some eggs\n which she had eaten for breakfast. Team has since made her NPO except\n for meds and will ask for reassessment of her swallow for tomorrow.\n Being treated with lasix for crackles thoughout all lung fields.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607315,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606622,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Transfer in from 7s,pt AO X 3,denies any pain or SOB or related\n symptoms\n T max 102.5,HR 90-100 while resting and upto 120\ns with activity,NBP\n stable.placed on 100% high flow,\n Desats easily when the mask is off,Lung sounds with fine crackels on\n admission,did receive 40 mg Lasix IV prior to transfer.\n Single lumen port cath for access.\n Action:\n ABG on admission\n.O 2 weaned down to 60%\n Informed the team about temp\n.pan cultured.(no Tylenol unless pt\n physiologically uncomfortable a sper team)\n On cefipime and vanco and started on tamiflu..1^st dose given.\n Influenza A& B swab send.\n Response:\n Pt continued to deny for any resp distress.\n Plan:\n Continue to monitor resp status\n Antibiotics as ordered.\n On droplet precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606623,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Transfer in from 7s,pt AO X 3,denies any pain or SOB or related\n symptoms\n T max 102.5,HR 90-100 while resting and upto 120\ns with activity,NBP\n stable.placed on 100% high flow,\n Desats easily when the mask is off,Lung sounds with fine crackels on\n admission,did receive 40 mg Lasix IV prior to transfer.\n Single lumen port cath for access.\n Action:\n ABG on admission 7.51/37/94\n.O 2 weaned down to 60%\n Informed the team about temp\n.pan cultured.(no Tylenol unless pt\n physiologically uncomfortable a sper team)\n On cefipime and vanco and started on tamiflu..1^st dose given.\n Influenza A& B swab send.\n Response:\n Pt continued to deny for any resp distress.\n Plan:\n Continue to monitor resp status\n Antibiotics as ordered.\n On droplet precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606737,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has\n been 90-96%, she desaturares to the low 80s very quickly when the 02\n Action:\n ABG on 60% was 7.48/40/84, had a sputm induction for PCP and ,\n influenza A&B were resent due to not enough cells to read, to receive\n 40mg of IV dexamethasone for lymphadic spread in her lungs\n Response:\n Resp status is still tenuous\n Plan:\n Cont to follow, would try noninvasive ventilation if needed, cont abx,\n f/u on clx results, will need her Tamaflu dose increased if she does\n rule in for H1N1\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606750,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. . Pt states that her shortness of\n breath has gradually gotten worse over the last few weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with crackles throughout. RR 10-16 with sao2 92-94%. Pt stating\n that resp are\nmore difficult\n Action:\n Pt on 100% NRB. Lasix 20mg ivp given with a chest x-ray done.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607076,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607670,
"text": "Chief Complaint:\n 24 Hour Events:\n - Held family meeting. Now DNR/DNI. Plan is to get palliative care\n team to speak with patient/family tomorrow and initiate movements\n towards discharge, likely to an LTAC. Plan to give PCP treatment few\n days to work and likely discharge to facility mid-week.\n - Fluid balance was positive 1.5L at midnight so gave 80mg IV Lasix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 03:44 AM\n Bactrim (SMX/TMP) - 07:05 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 PM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.1\n HR: 66 (53 - 77) bpm\n BP: 113/44(62) {99/44(62) - 138/82(88)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,190 mL\n 627 mL\n PO:\n TF:\n IVF:\n 2,190 mL\n 627 mL\n Blood products:\n Total out:\n 670 mL\n 820 mL\n Urine:\n 670 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,520 mL\n -193 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: (S1: Normal), (S2: Normal), No murmur appreciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Bronchial: ), coarse\n breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. no rebound or guarding, nondistended.\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 605 K/uL\n 9.8 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.3 %\n 13.6 K/uL\n [image002.jpg]\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 426\n 557\n 588\n 614\n 605\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607672,
"text": "Chief Complaint:\n 24 Hour Events:\n - Held family meeting. Now DNR/DNI. Plan is to get palliative care\n team to speak with patient/family tomorrow and initiate movements\n towards discharge, likely to an LTAC. Plan to give PCP treatment few\n days to work and likely discharge to facility mid-week.\n - Fluid balance was positive 1.5L at midnight so gave 80mg IV Lasix.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:47 PM\n Cefipime - 03:44 AM\n Bactrim (SMX/TMP) - 07:05 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 PM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.1\n HR: 66 (53 - 77) bpm\n BP: 113/44(62) {99/44(62) - 138/82(88)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,190 mL\n 627 mL\n PO:\n TF:\n IVF:\n 2,190 mL\n 627 mL\n Blood products:\n Total out:\n 670 mL\n 820 mL\n Urine:\n 670 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,520 mL\n -193 mL\n Respiratory support\n O2 Delivery Device: High flow neb, 95% FiO2\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: (S1: Normal), (S2: Normal), No murmur appreciated\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Bronchial: ), coarse\n breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. no rebound or guarding, nondistended.\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 605 K/uL\n 9.8 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.3 %\n 13.6 K/uL\n [image002.jpg]\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n Plt\n 426\n 557\n 588\n 614\n 605\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n 31\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n Other labs: PT / PTT / INR:15.1/32.4/1.3, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n C Spine:\n IMPRESSION:\n 1. No acute cervical fracture or malalignment.\n 2. Known C4 metastasis. Sclerotic lesion seen on the vertebral body,\n also\n suspicious for metastasis.\n 3. Incompletely assessed posterior facets despite stable post-surgical\n appearance.\n Head CT:\n No acute intracranial injury. Stable post-surgical change in the\n posterior fossa. Fluid in the mastoid air cells.\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n .\n s/p Fall: Neurological Exam stable\n -Serial Neurological Exams\n -CT head and C-spine\n -Continue Posey restraints and fall precautions\n -Continue C-collar until negative CT C-spine\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. This is most likely due to lymphangitic spread of\n her BRCA, acc to outpatient oncologist.\n There also could be contribution from pulmonary edema diastolic\n dysfunction and possible infectious process / PNA.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 6 of a 7 day course)\n -No lung biopsy given respiratory distress and patient wishes.\n -Fluid balance goal of even today\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue PCP treatment with IV Bactrim (day 3).\n -f/u all outstanding cultures\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n CODE: DNR/DNI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607822,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt. in 80% hi flow mask at shift change, eventually desated to low 80\n unable to get sats above 86%\n Action:\n O2 was increased to 95%, still unable to raise sats, was given resp. rx\n which did not help , additional o2 5l was added via n/c. and 80mg of iv\n lasix was given\n Response:\n Pt. duiresed approx. 500cc from lasix, sats still in low 90\ns, desats\n with any activity ..turning , bed bath, changing hi-flow h20 bottle and\n it takes her quite a while compensate for it/\n Plan:\n Palliative care cons\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606811,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -was on high flow nebs all AM, but arond 1600 was placed on NRB,\n satting low to mid 90s on it.. lung exam concerning for worsening\n crackles (sounded very velcro-like on inspiration in AM exam), so got\n stat CXR, ABG and gave 20mg IV lasix x1\n -stat CXR looks like worsening volume overload- pulmn edema\n -ABG looks ok... but PaO2 94 and should expect better on NRB\n -put out well to lasix, 350cc over 1st hr, then 200cc, then 100cc\n -gave another 10mg IV lasix around 1230am\n -if acutely desats... might have to intubate\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:17 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 35.7\nC (96.3\n HR: 48 (47 - 91) bpm\n BP: 138/78(92) {91/61(70) - 150/94(103)} mmHg\n RR: 13 (9 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 937 mL\n 122 mL\n PO:\n TF:\n IVF:\n 937 mL\n 122 mL\n Blood products:\n Total out:\n 1,755 mL\n 280 mL\n Urine:\n 1,755 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -818 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: 7.43/45/94./28/4\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Breathing comfortably on high-flow neb but desats to mid 80s\n rapidly when she removes mask.\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse bilateral rales.\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 426 K/uL\n 9.5 g/dL\n 152 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 29.3 %\n 12.6 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n WBC\n 14.2\n 12.6\n Hct\n 27.5\n 29.3\n Plt\n 386\n 426\n Cr\n 0.5\n 0.5\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n Other labs: PT / PTT / INR:13.2/34.9/1.1, ALT / AST:19/35, Alk Phos / T\n Bili:233/0.3, Differential-Neuts:90.3 %, Lymph:5.5 %, Mono:3.2 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There may also be a component of\n aspiration PNA. She did have aspiration events prior to admission.\n -continue vancomycin, cefepime; could\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -consider diagnostic bronchoscopy when patient stable enough to\n tolerate exam\n -appreciate pulm recs, could consider diagnostic thoracentesis although\n patient is not stable enough for this now\n -need to discuss goals of care to find out utility of biopsy\n -diuresis prn\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n .\n #. Fever: spiked to 102.5. Likely due to worsening PNA.\n -abx as detailed above\n -f/u urine cx and blood cx\n -obtain sputum cx and flu swab\n .\n # Seizure: EEG pending. Dr. felt staring spells and tremors more\n likely related to hypotension and hypoxia.\n -Continue seizure prophylaxis w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: ALT 47 ASt 61 Alk ph 264 T bili 0.3. Unclear if\n elevated alkphos is from liver vs. .\n -recheck LFTs, along with GGT\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Small bites and sips\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -f/u iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 606847,
"text": "Chief Complaint: Respiratory Failure--Hypoxemic, Acute\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Patient weaned off of high flow O2\n Patient reports subjective improvement\n Negative fluild balance maintained overnight\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:17 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Tachypnea\n Flowsheet Data as of 11:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.2\nC (95.4\n HR: 50 (47 - 79) bpm\n BP: 134/73(90) {107/61(73) - 150/94(103)} mmHg\n RR: 8 (6 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 937 mL\n 163 mL\n PO:\n TF:\n IVF:\n 937 mL\n 163 mL\n Blood products:\n Total out:\n 1,755 mL\n 315 mL\n Urine:\n 1,755 mL\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n -818 mL\n -153 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: 7.43/45/94./28/4\n PaO2 / FiO2: 99\n Physical Examination\n General Appearance: Overweight / Obese, mildly\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Rhonchorous: lessened)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 426 K/uL\n 152 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 29.3 %\n 12.6 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n WBC\n 14.2\n 12.6\n Hct\n 27.5\n 29.3\n Plt\n 386\n 426\n Cr\n 0.5\n 0.5\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n Other labs: PT / PTT / INR:13.2/34.9/1.1, ALT / AST:19/35, Alk Phos / T\n Bili:233/0.3, Differential-Neuts:90.3 %, Lymph:5.5 %, Mono:3.2 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:4.4 mg/dL\n Fluid analysis / Other labs: ECHO--Mod PAH, Severe TR\n Imaging: CXR-No new today. From last night--worsening diffuse alveolar\n infiltrates noted with central predominance. This is concerning for\n hydrostatic pulmonary edema\n Microbiology: Influenza DFA--not interpretable\n Assessment and Plan\n 50 yo female with history of metastatic breast cancer now admitted with\n prominent hypoxemic respiratory failure. This was in the setting of\n concern for acute infectious insult which has yet to be fully defined.\n We do have viral culture pending but sample was not able to be\n evaluated for rapid test due to limited numbers of cells. This leaves\n the insult of likely lymphangitic carcinomatosis in addition to what\n may well be viral pneumonitis.\n 1)RESPIRATORY FAILURE, ACUTE (NOT ARDS/)-This is a provocative\n picture where we do see substantial worsening of the pulmonary\n infiltrates and persistence of the hypoxemia across time. This would\n lead to a conclusion that ongoing diuresis may be of benefit in regards\n to improvement in oxygenation. The elevation in the LVEDP is hard to\n postulate with only right sided compromise seen on ECHO unless\n ventricular inter-dependence is at play.\n PNEUMONIA-Will repeat viral culture and DFA\n -Vanco/Azithro/Cefepime/Tamiflu\n -Follow culture results across tiem\n PULMONARY EDEMA-\n -Maintain negative fluid balance today\ngoal is 1-2 liters negative\n today\n -Will use NIV today as tolerated if not able to improve with diuresis\n alone\n BREAST CANCER-\n -There is lymphangitic carcinomatosis present\n -Decadron as trialed\n 2)BREAST CANCER-\n -Dex 40mg and taper to 4mg QID x 2 days\n ICU Care\n Nutrition: PO Diet\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606930,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607651,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Received 80mg IV lasix @ 0300.\n Response:\n Breathing not labored overnight. Comfortable sleeping. U/o after\n lasix:\n Plan:\n Family wants discharge to inpatient (hospice) facility near .\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n 19\ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n Drew labs @ 0600. portacath drew poorly. Unable to obtain enough\n blood for PT, PTT.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607750,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. She has been diuresed and felt to be as dry\n as she is going to get. Plan is to try to keep pt even at this point.\n BP is running low 100\ns with HR 70\n Paliative care consult was made and RN has planned to see\n this pt and her husband tomorrow at 1630 to discuss options for further\n care/hospice. Husband has expressed his wishes that pt be transferred\n to hospice care closer to home when she is ready. Team wants he to\n complete the course of Bactrim which was started over the weekend and\n then they feel that every chance has been given to this pt for\n improvement..\n She is tolerating small amts PO\ns and is on aspiration precautions due\n to dysphagia. No signs of aspiration at this point. Meds are well\n tolerated mixed in applesauce.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt tolerating 95% high flow neb with O2 sat 97% or greater. Team asked\n me to wean as tolerated.\n Action:\n Weaned pt to 80% with her O2 sats dropping at times to 90%-91%.\n Response:\n Some drop in her sat with weaning O2. Will follow closely.\n Plan:\n Family meeting tomorrow at 1630 to discuss plan of care options. I have\n notified social work and case management. Continue to titrate O2 as\n tolerated and Keep O2 sat 90% or greater.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt assisted to chair by two PT with minimal problems. She has unsteady\n gait. She is forgetful but has not been seen trying to get up OOB on\n her own today.\n Action:\n Sat in chair for about one hour. Tolerated this well. Pt posied and on\n chair alarm seat while OOB to chair. Waist belt on while in bed.\n Response:\n Pt safe and assisted with all ADL\ns and hygeine\n Plan:\n Continue to assist with mobility and assess endurance.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607652,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats: 91-97% on 95% high flow neb. RR:8-33. Lungs are diminished\n @ bases w/ crackles @ upper lungs.\n Action:\n CXR done this am. Crushed meds & mixed w/applesauce. Kept on soft\n solid/nectar thick liquid diet. HOB remained 30 degrees or higher.\n Received 80mg IV lasix @ 0300.\n Response:\n Breathing not labored overnight. Comfortable sleeping. U/o after\n lasix: 650cc since 0300.\n Plan:\n Family wants discharge to inpatient (hospice) facility near .\n Alteration in mental status\n Assessment:\n Patient was oriented to self & place, not time. Thought it was . in\n 19\ns. Patient was restless, pulling off BP cuff, O2 mask.\n Action:\n Easily reoriented. Sat w/patient to remind her to keep O2 on. Pulled\n back curtains in room to observe patient. Bed alarm on. Patient\n room near nursing station to allow easy observation. Provided for\n relief of pain w/oxycodone & Tylenol. Provided for relief of anxiety\n w/ativan.\n Response:\n When left alone, patient removed O2 mask.\n Plan:\n Continue to provide sitter for patient when possible.\n Drew labs @ 0600. portacath drew poorly. Unable to obtain enough\n blood for PT, PTT.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607739,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. She has been diuresed and felt to be as dry\n as she is going to get. Plan is to try to keep pt even at this point.\n BP is running low 100\ns with HR 70\n Paliative care consult was made and RN has planned to see\n this pt and her husband tomorrow at 1630 to discuss options for further\n care. Husband has expressed his wishes that pt be transferred to\n hospice care closer to home when she is ready.\n She is tolerating small amts PO\ns and is on aspiration precautions due\n to dysphagia. No signs of aspiration at this point. Meds are well\n tolerated mixed in applesauce.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Pt tolerating 95% high flow neb with O2 sat 97% or greater. Team asked\n me to wean as tolerated.\n Action:\n Weaned pt to 80%\n Response:\n Plan:\n Family meeting tomorrow at 1630 to discuss plan of care options. I have\n notified social work and case management,\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt assisted to chair by two PT with minimal problems. She has unsteady\n gait. She is forgetful but has not been seen trying to get up OOB on\n her own today.\n Action:\n Sat in chair for about one hour. Tolerated this well. Pt posied and on\n chair alarm seat while OOB to chair. Waist belt on while in bed.\n Response:\n Pt safe and assisted with all ADL\ns and hygeine\n Plan:\n Continue to assist with mobility and assess endurance.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607896,
"text": "TITLE: Resident Progress Note\n Chief Complaint: Metastatic breast cancer\n 24 Hour Events:\n - Unable wean O2 yesterday, had episode of respiratory distress with\n desats, now requiring 95% face mask plus 5L NC\n - I/O: +600 at 2100, gave lasix 80 mg IV\n - Vanc and cefepime course completed yesterday\n - Plan for family meeting today at 1630\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 03:07 PM\n Vancomycin - 08:12 PM\n Bactrim (SMX/TMP) - 06:04 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 07:47 AM\n Heparin Sodium (Prophylaxis) - 01:04 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 68 (62 - 84) bpm\n BP: 110/62(74) {90/44(56) - 121/70(80)} mmHg\n RR: 16 (6 - 22) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.7 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 2,230 mL\n 323 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,990 mL\n 323 mL\n Blood products:\n Total out:\n 1,560 mL\n 595 mL\n Urine:\n 1,560 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 670 mL\n -272 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, High flow facemask\n Cardiovascular: RRR, No murmur appreciated\n Respiratory / Chest: Coarse breath sounds with crackles at bases b/l\n Abdominal: Soft, mildly tender to deep palpation in lower quadrants\n b/l. No rebound or guarding, nondistended.\n Extremities: No peripheral edema, skin warm\n Neurologic: Attentive, follows simple commands\n Labs / Radiology\n 536 K/uL\n 9.4 g/dL\n 96 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 93 mEq/L\n 136 mEq/L\n 28.6 %\n 14.0 K/uL\n [image002.jpg]\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n 04:15 AM\n 04:00 AM\n 08:00 AM\n 04:15 AM\n WBC\n 12.6\n 21.3\n 18.1\n 16.8\n 13.6\n 16.1\n 14.0\n Hct\n 29.3\n 28.4\n 29.7\n 30.3\n 29.3\n 29.4\n 28.6\n Plt\n 426\n 557\n 588\n \n 536\n Cr\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n 0.9\n 0.9\n 1.1\n Glucose\n 152\n 165\n 142\n 129\n 108\n 99\n 98\n 98\n 96\n Other labs: PT / PTT / INR:18.0/42.3/1.6, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:93.2 %, Lymph:4.5 %, Mono:1.4 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.8 mg/dL\n 12:04 pm SPUTUM Site: INDUCED\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): BUDDING YEAST.\n RESPIRATORY CULTURE (Final ):\n Commensal Respiratory Flora Absent.\n YEAST. SPARSE GROWTH.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n Assessment and Plan\n Ms. is a 50 year-old female with metastatic breast cancer to\n , , liver and lung admitted for seizures and PNA then\n transferred to the for respiratory distress in the setting of\n worsening B/L opacities on CXR.\n .\n #. Respiratory distress/hypoxia: Some mild clinical improvement after\n aggressive diuresis but overall patient is not able to be weaned fro\n her oxygen requirement. Her distress is likely combination of\n lymphangitis spread of her breast cancer, fluid overload that is not\n being adequately mobilized from her lungs for diuresis, and possible\n infection.\n - Antibiotic 8-day course with vancomycin, cefepime ended \n - No lung biopsy given respiratory distress and patient wishes.\n - Fluid balance goal of even today, requiring 80mg IV Lasix to keep her\n even every day\n - Attempt to wean oxygen as tolerated\n - Continue PCP treatment with IV Bactrim for total 5 day course to end\n (currently on day 4)\n - F/u all outstanding cultures\n - Continue Decadron 4mg \n - Add morphine for comfort to medication regimen\n .\n #. Metastatic Breast Cancer: She was getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n - FU palliative care recs\n - Continue seizure ppx w/ keppra\n - Plan for family meeting today at 4:30pm\n .\n #. S/p Fall: Neurological exam continues to be stable, Head CT and C\n spine wnl.\n - Continue Posey restraints and fall precautions\n .\n #. Mild oral and pharyngeal dysphagia: Has reduced coordination c/w\n cerebellar mets.\n - Diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n - Pills whole with apple sauce\n - Aspiration precautions\n # Anemia: HCT currently 28.6 and stable.\n - Continue to trend daily\n - Guaiac all stools\n ICU Care\n Nutrition: Regular diet, soft\n Glycemic Control: None\n Lines: Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Likely to LTACH in next few days with hospice ?\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607820,
"text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 608002,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Family meeting with palliative care yesterday, Pt has been made comfort\n care\n Respiration / Gas Exchange, Impaired\n Assessment:\n Remains on 95% high flow with 5L NC with boarderline O2 sats.\n Desaturates with any activity and unable to stay on her side due to\n SOB/low sats.\n Action:\n Medicated with morphine and ativan\n Response:\n Continues to desat\n Plan:\n Keep pt comfortable\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607171,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs still with crackles throughout. Sao2 96-100%. WBC\ns 18.1 this am.\n Action:\n Received pt on 100% high flow neb but shortly after the beginning of\n the shift pt started to desat to the low 80 range. Instructed pt to\n take deep breaths which was not effective. Pt was placed back on the\n NRB. Pt was also given lasix 80 mg iv this am.\n Response:\n Currently pt is diuresing with the lasix. Pt has had no episodes of\n resp distress this shift.\n Plan:\n Cont to diurese and cont with antibiotics and the steroids.\n Oncology will need to update family. Family spoke this weekend about\n the hopes that the steroids and antibiotics would be effective to clear\n up the lungs. If this treatment is not successful then family would\n like to take pt home with hospice care.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607381,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Family meeting was held; Husband and Daughter want to keep the\n patient full code for now. They understand the risk of intubation and\n the patient may not be able to be extubated. They want to keep\n readdressing code status daily. They are possibly interested in\n hospice, either home or inpatient closer to their home, but want to\n keep going with antibiotics and steroids for now.\n -This AM, the patient is reporting improved breathing on 60% face\n mask. She desats to ~90% when sitting up.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 02:41 PM\n Vancomycin - 08:00 PM\n Cefipime - 03:53 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 03:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 61 (57 - 73) bpm\n BP: 131/72(87) {95/50(60) - 139/72(87)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 890 mL\n 92 mL\n PO:\n TF:\n IVF:\n 890 mL\n 92 mL\n Blood products:\n Total out:\n 2,940 mL\n 135 mL\n Urine:\n 2,940 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,050 mL\n -44 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n GENERAL: Alert, responsive, NAD on 60% face mask\n CARDIAC: Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 614 K/uL\n 9.7 g/dL\n 99 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.3 %\n 16.8 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n Plt\n 88\n 614\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n Other labs: PT / PTT / INR:14.3/33.6/1.2, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:9.0 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n # Respiratory distress/hypoxia: Some clinical improvement after\n aggressive diuresis, CXR with radiographic improvement as well compared\n to several days ago. This is most likely due to lymphangitic spread of\n her BRCA, acc to outpatient oncologist.\n There also could be contribution from pulmonary edema diastolic\n dysfunction and possible infectious process / PNA.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 5 of a 7 day course)\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 80mg lasix x 1 if BP tolerates\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n /u all outstanding cultures\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: nectar thick liquids and soft, moist solids\n Glycemic Control: none\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n plan on family mtg later in\n PM to discuss goals of care\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607501,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with crackles throughout all lobes. O2 at 80% high flow neb.\n Action:\n Pt did receive lasix 80 mg iv. Pt has also been started on Bactrim iv\n to treat PCP pna if pt is pos. received pt on 60% high flow neb but had\n to increase o2 as sao2 was decreasing after pt received the fluids in\n iv antibiotics.\n Response:\n Pt is diuresing well from the lasix. Wbc\ns 13.6 this am.\n Plan:\n Cont to monitor resp status and cont with antibiotics as ordered.\n At o430, pt pulled access line from port a cath. Iv nurse notified to\n come and reaccess port. At 0500 pt found on the floor. Pt unable to\n state how she fell but was A&Ox3, able to move all extremities and\n follow commands. Will take pt to ct for head and c-spine at 0700.\n husband was notified by MD.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607593,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished, scattered rales all fields\n Continues to have high O2 requirement, desaturates easily with any\n activity\n Action:\n Head and neck CT today\n Family meeting to discuss prognosis and plan of care\n Palliative Care consult ordered\n Response:\n Pt has maintained SpO2 > 94% with oxygen on\n Plan:\n Continue antibiotics\n Continue steroid taper\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607900,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU for\n respiratory distress.\n Current resp status felt to have improved as much as she is going to\n considering the amt of lung tumor. She was made DNR/DNI at family\n meeting over the weekend. Palliative care consult made and meeting set\n for today at 1630. with family and medical team as well as case\n management and social work.\n Her resp status has deteriorated further in the past 24hrs requiring 5L\n N/C in addition to 95% high flow neb. Boarderline sat in the 88%-91%\n range. She has poor activity tolerance and has been ordered for\n morphine PRN dyspnea, pain or anxiety due to air hunger.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606800,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. . Pt states that her shortness of\n breath has gradually gotten worse over the last few weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with crackles throughout. RR 10-16 with sao2 92-94%. Pt stating\n that resp are\nmore difficult\n Action:\n Pt on 100% NRB. Lasix 20mg ivp given with a chest x-ray done. Lasix 10\n mg given. Attempted to place pt on 60% o2 unable as sao2 dropped to 88%\n within\n hour. Attempted 80% but sao2 only went to 89%. Placed back on\n NRB.\n Response:\n On NRB sao2 in the mid to high 90\n Plan:\n Attempt to wean o2 as pt is able to tol. Cont on antibiotics and follow\n temps and wbc\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-21 00:00:00.000",
"description": "ICU Attending",
"row_id": 607041,
"text": "CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Ms. with the ICU team, whose note from today\n reflects my input. I would add/emphasize that she remains markedly\n hypoxemic; she desaturates very rapidly when NRB is removed. On exam:\n 100% on NRB, RR 14, 148/82. Tremor. Alert, interactive. Crackles to\n mid-scapulae; anterior crackles. Regular heart without S3. Soft\n abdomen. No significant edema. Labs, imaging, and medications all\n reviewed. Flu DFA (with adequate cells) negative. PCP (-). WBC up to\n 21.\n Assessment and Plan\n 50 y/o woman with widely metastatic breat cancer now with hypoxemic\n respiratory failure/distress. Differential includes lymphangitic\n carcinomatosis (perhaps most likely), pneumonia (also possible), and\n pulmonary edema (seems somewhat less likely, but treatable). We have\n negative PCP DFA 1 and negative influenza DFA with adequate cells.\n We will try to avoid intubation by:\n Diuresis\n Treatment for HCAP and CAP\n Steroids for breat cancer\n Her droplet precautions have already been discontinued based on\n negative influenza DFA with adequate cells. Since history does not\n contain other suggestive factors (such as myalgia, known exposures,\n etc.), will not resume at this point.\n Repeat sputum induction today for PCP. WBC differential.\n Our team has discussed with her/family, and they would pursue\n intubation at this point. If intubated\n bronchoscopy. Will discuss\n further with Dr. .\n SQI / PPI\n Other issues as per ICU team note. 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607049,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Changed PO pain regimen to Oxycodone 10mg Q6hrs and Tylenol 650mg\n Q6hrs standing\n -Updated the patient and family on current treatment\n -Given 20mg IV Lasix x2, still only -300cc, so gave another 40cc Lasix\n IV in late PM.\n -Stable on NRB satting 98-100%, desats immediately when she takes NRB\n off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 70 (50 - 81) bpm\n BP: 148/82(100) {107/25(54) - 148/82(100)} mmHg\n RR: 7 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 741 mL\n 127 mL\n PO:\n TF:\n IVF:\n 741 mL\n 127 mL\n Blood products:\n Total out:\n 1,095 mL\n 325 mL\n Urine:\n 1,095 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -354 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 557 K/uL\n 9.2 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 100 mEq/L\n 140 mEq/L\n 28.4 %\n 21.3 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n WBC\n 14.2\n 12.6\n 21.3\n Hct\n 27.5\n 29.3\n 28.4\n Plt\n \n Cr\n 0.5\n 0.5\n 0.6\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n Other labs: PT / PTT / INR:13.2/34.9/1.1, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:90.3 %, Lymph:5.5 %, Mono:3.2 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 3)\n -d/c droplet precautions and Tamiflu given negative Influenza DFA.\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 40mg Lasix bolus now\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n sputum induction\n -Continue Decadron taper (4mg QID today, 4mg starting tomorrow).\n .\n #. Fever: Pt. is currently afebrile. Leukocytosis today likely\n secondary to steroids. No bands on diff.\n -Abx as detailed above\n -f/u urine cx and blood cx\n -F/u sputum cx\n .\n # Seizure: ? seizure . Continue to f/u Neuro recs.\n -Continue seizure prophylaxis w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: Resolving.\n -Continue to trend\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: nectar thick liquids and soft, moist solids\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607352,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -tomorrow change steroid dosage to 4mg \n -needs family mtg w/ Drs (primary onc) & (neuro-onc)\n -RT couldn't get induced sputum because she coughed up food when they\n tried\n -Have very low urine output so gave 80mg IV lasix at 4pm, after which\n she started peeing more, then tapered off\n -Was temporarily off nonrebreather but had to be placed back on\n non-rebreather\n \n - Family meeting today; Husband and Daughter want to keep the patient\n full code for now. They understand the risk of intubation and the\n patient may not be able to be extubated. They want to keep\n readdressing code status daily. They are possibly interested in\n hospice, either home or inpatient closer to their home, but want to\n keep going with antibiotics and steroids for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 02:41 PM\n Vancomycin - 08:00 PM\n Cefipime - 03:53 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:31 AM\n Heparin Sodium (Prophylaxis) - 03:53 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 61 (57 - 73) bpm\n BP: 131/72(87) {95/50(60) - 139/72(87)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 890 mL\n 92 mL\n PO:\n TF:\n IVF:\n 890 mL\n 92 mL\n Blood products:\n Total out:\n 2,940 mL\n 135 mL\n Urine:\n 2,940 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,050 mL\n -44 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 100%\n ABG: ///35/\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 614 K/uL\n 9.7 g/dL\n 99 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 99 mEq/L\n 143 mEq/L\n 30.3 %\n 16.8 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n 04:00 PM\n 04:30 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n 16.8\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n 30.3\n Plt\n 88\n 614\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n 108\n 99\n Other labs: PT / PTT / INR:14.3/33.6/1.2, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:91.3 %, Lymph:5.7 %, Mono:2.1 %,\n Eos:0.8 %, Lactic Acid:1.1 mmol/L, LDH:548 IU/L, Ca++:9.0 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Ms. is a 50 year-old lady w/ ER- Her2+ BRCA metastatic to bone,\n brain, liver and lung admitted for seizures and PNA then x-fer to \n for respiratory distress in the setting of worsening B/L opacities on\n CXR.\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA. This is most likely due to lymphangitic spread of her\n BRCA, acc to outpatient oncologist.\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 4)\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 80mg lasix x 1\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n /u sputum cx\n -Continue Decadron taper 4mg today\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n - ct seizure ppx w/ keppra\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: NPO (since was aspirating, taking pills w/ applesauce)\n Glycemic Control: none\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n plan on family mtg later in\n PM to discuss goals of care\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607365,
"text": "Ms. is a 50 yo F with breast cancer metastatic to , ,\n liver and lung admitted for seizures/PNA and transferred to the ICU\n for respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606706,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has\n been 90-96%, she desaturares to the low 80s very quickly when the 02\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606714,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has\n been 90-96%, she desaturares to the low 80s very quickly when the 02\n Action:\n ABG on 60% was 7.48/40/84, had a sputm induction for PCP and \n Response:\n Resp status is still tenuous\n Plan:\n Cont to follow, would try noninvasive ventilation if needed, cont abx,\n f/u on clx results\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607022,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Changed PO pain regimen to Oxycodone 10mg Q6hrs and Tylenol 650mg\n Q6hrs standing\n -Updated the patient and family on current treatment\n -Given 20mg IV Lasix x2, still only -300cc, so gave another 40cc Lasix\n IV in late PM.\n -Stable on NRB satting 98-100%, desats immediately when she takes NRB\n off.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 12:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 70 (50 - 81) bpm\n BP: 148/82(100) {107/25(54) - 148/82(100)} mmHg\n RR: 7 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 741 mL\n 127 mL\n PO:\n TF:\n IVF:\n 741 mL\n 127 mL\n Blood products:\n Total out:\n 1,095 mL\n 325 mL\n Urine:\n 1,095 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -354 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 557 K/uL\n 9.2 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 100 mEq/L\n 140 mEq/L\n 28.4 %\n 21.3 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n WBC\n 14.2\n 12.6\n 21.3\n Hct\n 27.5\n 29.3\n 28.4\n Plt\n \n Cr\n 0.5\n 0.5\n 0.6\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n Other labs: PT / PTT / INR:13.2/34.9/1.1, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:90.3 %, Lymph:5.5 %, Mono:3.2 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -appreciate pulm recs, could consider diagnostic thoracentesis although\n patient is not stable enough for this now\n -need to discuss goals of care to find out utility of biopsy\n -Aggressive diuresis today with goal negative 2L (as BP tolerates)\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n .\n #. Fever: Pt. is currently afebrile with WBC trending down.\n -abx as detailed above\n -f/u urine cx and blood cx\n -F/u sputum cx and flu swab\n .\n # Seizure: ? seizure . Neuro following. Continue to f/u Neuro recs.\n -Continue seizure prophylaxis w/ keppra\n -Continue Decadron taper (4mg QID x2 days, 4mg after that).\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: Trending down today. GGT elevated , so c/w liver.\n -Continue to trend\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids. Hold for now.\n - Continue sips only for now given respiratory distress\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -f/u iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves (sips OK).\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607338,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs were somewhat clear in the upper lobes at the beginning of the\n shift but now have crackles throughout. Sao2 92-100%with RR 12-23. has\n remained afebrile. Wbc\ns 16.8.\n Action:\n Pt has been on 60% high flow neb throughout the shift. When pt is awake\n must frequently remind pt to keep her o2 on. Pt remains on Vanco and\n cefepime.\n Response:\n Pt has had no episodes of sob this thift.\n Plan:\n Cont with the antibiotics and steroids. Cont to provide o2 as needed.\n Follow temps and wbc\n Yesterday the resident spoke with family and the family has decided for\n now the pt should remain a full code as they are waiting to see if the\n steroids and the antibiotics help pts resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 606890,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -was on high flow nebs all AM, but arond 1600 was placed on NRB,\n satting low to mid 90s on it.. lung exam concerning for worsening\n crackles (sounded very velcro-like on inspiration in AM exam), so got\n stat CXR, ABG and gave 20mg IV lasix x1\n -stat CXR looks like worsening volume overload- pulmonary edema\n - PaO2 94 on NRV, otherwise ABGs OK\n -put out well to lasix, ~650 cc\n -gave another 10mg IV lasix around 1230am\n -This AM, the patient states that her breathing has improved.\n Complains of some continues head and neck pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:17 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 35.7\nC (96.3\n HR: 48 (47 - 91) bpm\n BP: 138/78(92) {91/61(70) - 150/94(103)} mmHg\n RR: 13 (9 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 937 mL\n 122 mL\n PO:\n TF:\n IVF:\n 937 mL\n 122 mL\n Blood products:\n Total out:\n 1,755 mL\n 280 mL\n Urine:\n 1,755 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -818 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: 7.43/45/94./28/4\n PaO2 / FiO2: 157\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 426 K/uL\n 9.5 g/dL\n 152 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 17 mg/dL\n 98 mEq/L\n 136 mEq/L\n 29.3 %\n 12.6 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n WBC\n 14.2\n 12.6\n Hct\n 27.5\n 29.3\n Plt\n 386\n 426\n Cr\n 0.5\n 0.5\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n Other labs: PT / PTT / INR:13.2/34.9/1.1, ALT / AST:19/35, Alk Phos / T\n Bili:233/0.3, Differential-Neuts:90.3 %, Lymph:5.5 %, Mono:3.2 %,\n Eos:0.9 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:4.4 mg/dL\n -ECHO: moderate pulmonary hypertension, dilated right ventricle,\n moderate-severe TR.\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin\n -influenza swab pending; on contact precautions\n -empiric tx with tamiflu\n -appreciate pulm recs, could consider diagnostic thoracentesis although\n patient is not stable enough for this now\n -need to discuss goals of care to find out utility of biopsy\n -Aggressive diuresis today with goal negative 2L (as BP tolerates)\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n .\n #. Fever: Pt. is currently afebrile with WBC trending down.\n -abx as detailed above\n -f/u urine cx and blood cx\n -F/u sputum cx and flu swab\n .\n # Seizure: ? seizure . Neuro following. Continue to f/u Neuro recs.\n -Continue seizure prophylaxis w/ keppra\n -Continue Decadron taper (4mg QID x2 days, 4mg after that).\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: Trending down today. GGT elevated , so c/w liver.\n -Continue to trend\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets. She aspirates thin liquids silently\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids. Hold for now.\n - Continue sips only for now given respiratory distress\n -Pills whole with apple sauce\n -aspiration precautions\n .\n # Anemia: HCT currently 28 and stable. Recent baseline 32-35.\n -f/u iron studies\n -guiac all stools\n ICU Care\n Nutrition: NPO until respiratory distress improves (sips OK).\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607004,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has chronic pain in the back and the neck. This shift pt stated that\n the pain was an .\n Action:\n Yesterday the vicodan was discontinued and pt was placed on percocet\n which seems to work better for the pt.\n Response:\n Pt requested a pain pill at midnight and was sleeping within half an\n hour.\n Plan:\n Cont with perocet one or two tabs as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs have remained with coarse crackles throughout the lungs bilat.\n Sao2 93-98%.\n Action:\n Pt has remained on NRB. Received lasix 40mg iv.\n Response:\n Pt has had no episodes of sob this shift and has diuresed minimally\n approx 300cc.\n Plan:\n Cont to diurese as needed for resp relief.\n Team and myself spoke with family last evening and family expressed\n that they would like to give the steroids and the antibiotics a chance\n to see if there would be improvement. If no improvement family is\n interested in taking pt home with hospice care.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607110,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pt has been here on 100% NRB since transfer with sats 95%-98% at\n rest.. She continues to desat quickly when O2 mask removed for meds,\n mouth care etc. (sats dropping to 79% quickly) Today team ordered an\n induced sputum for PCP since the one done on did not have enough\n specimen for testing. When RT did induction she coughed up some eggs\n which she had eaten for breakfast. Team has since made her NPO except\n for meds and will ask for reassessment of her swallow for tomorrow.\n Being treated with lasix for crackles thoughout all lung fields.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on 100% NRB. O2 sat 97% with O2 on and drops to 70\ns when\n she takes her oxygen off. Symptoms of aspiration noted with PO\ns Lungs\n with diffuse crackles throughout.\n Action:\n Pt NPO except for meds for now. Tried pt with 100% high neb to see\n if we can wean this down slowly. Given 40mg IV lasix at 0930 with poor\n response. Given 80mg IV lasix at 1700 with better response. K+ 20meq\n given for K+ 3.8 according to oncology repletion guidelines. Goal fluid\n balance is for 2L negative today. As of 1700 she was -230cc\ns. Team\n aware of this.\n Response:\n Better response from the 80mg lasix dose\n Plan:\n Follow intake output and resp distress. Diurese as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607111,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Pt has been here on 100% NRB since transfer with sats 95%-98% at\n rest.. She continues to desat quickly when O2 mask removed for meds,\n mouth care etc. (sats dropping to 79% quickly) Today team ordered an\n induced sputum for PCP since the one done on did not have enough\n specimen for testing. When RT did induction she coughed up some eggs\n which she had eaten for breakfast. Team has since made her NPO except\n for meds and will ask for reassessment of her swallow for tomorrow.\n Being treated with lasix for crackles thoughout all lung fields.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on 100% NRB. O2 sat 97% with O2 on and drops to 70\ns when\n she takes her oxygen off. Symptoms of aspiration noted with PO\ns Lungs\n with diffuse crackles throughout.\n Action:\n Pt NPO except for meds for now. Tried pt with 100% high neb to see\n if we can wean this down slowly. Given 40mg IV lasix at 0930 with poor\n response. Given 80mg IV lasix at 1700 with better response. K+ 20meq\n given for K+ 3.8 according to oncology repletion guidelines. Goal fluid\n balance is for 2L negative today. As of 1700 she was -230cc\ns. Team\n aware of this.\n Response:\n Better response from the 80mg lasix dose. Currently 1300cc\ns negative.\n Plan:\n Follow intake output and resp distress. Diurese as ordered. Continue\n antibiotics and steroids as ordered.\n"
},
{
"category": "General",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Generic Note",
"row_id": 607259,
"text": "TITLE:\n Family meeting conducted by resident. The consensus of the meeting is\n to keep the patient Full Code for now. The husband and daughter would\n like to continue to monitor the patient on antibiotics and steroids to\n see if there is any improvement. I discussed with them the risk of\n possible need for life saving measures such as intubation and\n resuscitation. I discussed the possibility that the patient may not be\n able to be extubated, and may require prolonged intubation. The family\n may be interested in hospice in the future, either inpatient or home if\n her clinical situation does not improve.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607277,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was on 100% NRB today on rounds with O2 sat 99%. Continues to\n desaturate quickly with O2 off but team asked us to try high flow neb\n and wean as tolerated. She continues to have diffuse crackles\n throughout but CXR shows slight improvement in haziness which suggests\n good effect from diuresis.\n Action:\n Pt put on 100% high flow neb and weaned down as tolerated to keep sat\n >92%. Given lasix 80mg IV at 1200.\n Response:\n Fair diuretic effect from the lasix. Able to wean her high flow neb to\n 60% with O2 sat 95% or greater. BP has come down slightly with these\n last three days of diuresis/ Currently BP 104-110/60. HR stable in the\n 60 range sinus rhythm. K+ 3.7 this evening and 20meq Kcl given IV.\n Plan:\n Continue to follow resp status and wean oxygen as tolerated.\n Family met with team for update on pt condition. They would like to\n continue with aggressive care at this time and are aware of grim\n prognosis. They will consider hospice care in the future if condition\n deteriorated.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607257,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was on 100% NRB today on rounds with O2 sat 99%. Continues to\n desaturate quickly with O2 off but team asked us to try high flow neb\n and wean as tolerated. She continues to have diffuse crackles\n throughout but CXR shows slight improvement in haziness\n Action:\n Pt put on 100% high flow neb and weaned down as tolerated to keep sat\n >92%. Given lasix 80mg IV at 1200.\n Response:\n Fair diuretic effect from the lasix.\n Plan:\n Continue to follow resp status and wean oxygen as tolerated.\n Family met with team for update on pt condition. They would like to\n continue with aggressive care at this time and are aware of grim\n prognosis.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606881,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on NRB, SATs go from 91-94%, she desats to the 70s very\n quickly when she takes her mask off. Her resp rate is /min while\n asleep. She conts to have coarse rales throughout. The influenza swab\n was initially read as neg then the lab said that they did not have\n enough cells to diagnose\n Action:\n She was put back on influenza precautions and Tamaflu was restarted,\n given 20mg of IV lasix, dexamethasone was tapered, started on PO\n bactrim for PCP prophylaxis\n Response:\n Now off influenza precautions, resp status remains tenuous\n Plan:\n There has been some discussion of talking to the pt about hospice but\n this has not happened yet, social work conts to be involved\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o back and neck pain \n Action:\n Vicodin was changed to acetaminophen and oxycodone\n Response:\n Pain presently under better control\n Plan:\n Cont to follow, follow resp status with narcotics since her resp rate\n is low\n"
},
{
"category": "Rehab Services",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Physical Therapy Contact Note",
"row_id": 606879,
"text": "Attempted to see patient for physical therapy session. Chart\n reviewed. Spoke with RN. Patient is not stable for PT at this time as\n patient has a tenuous respiratory status with limited activity\n tolerance. Will follow patient and resume therapy as appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 607230,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM . Then in the\n evening it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory status has been very tenuous since admission to MICU.\n Question of aspiration of her eggs at breakfast on . She has\n continued to require 100% NRB to maintain adequate O2 sats and drops\n quickly with her mask off.\n She tolerated getting up to chair with assist of PT today but became\n very tired quickly and only stayed up for 30 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-22 00:00:00.000",
"description": "ICU Attending",
"row_id": 607235,
"text": "CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Ms. with the ICU team, whose note from today\n reflects my input. I would add/emphasize that she remains markedly\n hypoxemic; she desaturates very rapidly when NRB is removed. Tried to\n get induced sputum yesterday but coughed up eggs. Diuresed yesterday.\n Up in chair this morning.\n On exam: 100% on NRB, RR 16. Tremor. Alert, interactive, but more\n confused today. Crackles to mid-scapulae; anterior crackles. Regular\n heart without S3. Soft abdomen. No significant edema. Labs, imaging,\n and medications all reviewed. CXR looks a little better after\n diuresis. Flu DFA (with adequate cells) negative. PCP (-). WBC up to\n 21.\n Meds -- Vanco, colace, senna, neurontin, omeprazole, effexor, keppra,\n atenolol, SQH, azithro (d4/5), cefepime, dexamethasone 4 mg IV q12h,\n Bactrim daily. Got some ativan and percocet as prns.\n Assessment and Plan\n 50 y/o woman with widely metastatic breat cancer now with hypoxemic\n respiratory failure/distress. Differential includes lymphangitic\n carcinomatosis (perhaps most likely), pneumonia (also possible), and\n pulmonary edema (seems somewhat less likely, but treatable). We have\n negative PCP DFA 1 and negative influenza DFA with adequate cells.\n We will try to avoid intubation by:\n Diuresis\n Treatment for HCAP and CAP\n Steroids for breat cancer\n Her droplet precautions have already been discontinued based on\n negative influenza DFA with adequate cells. Since history does not\n contain other suggestive factors (such as myalgia, known exposures,\n etc.), will not resume at this point.\n Try to wean down to venti mask.\n Follow up PCP. .\n Our team has discussed with her/family, and they would pursue\n intubation at this point. Will further discuss. If intubated\n bronchoscopy. Will discuss further with Dr. .\n SQI / PPI\n Other issues as per ICU team note. 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606880,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on NRB, SATs go from 91-94%, she desats to the 70s very\n quickly when she takes her mask off. Her resp rate is /min while\n asleep. She conts to have coarse rales throughout. The influenza swab\n was initially read as neg then the lab said that they did not have\n enough cells to diagnose\n Action:\n She was put back on influenza precautions and Tamaflu was restarted,\n given 20mg of IV lasix, dexamethasone was tapered, started on PO\n bactrim for PCP prophylaxis\n Response:\n Now off influenza precautions, resp status remains tenuous\n Plan:\n There has been some discussion of talking to the pt about hospice but\n this has not happened yet, social work conts to be involved\n"
},
{
"category": "Physician ",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 607211,
"text": "TITLE: PROGRESS NOTE\n Chief Complaint: respiratory distress\n 24 Hour Events:\n -change steroid dosage to 4mg \n -needs family mtg w/ Drs (primary onc) & (neuro-onc)\n -RT couldn't get induced sputum because she coughed up food when they\n tried\n -Have very low urine output so gave 80mg IV lasix at 4pm, after which\n she started peeing more, then tapered off\n -Was temporarily off nonrebreather but had to be placed back on\n non-rebreather\n Allergies: NKDA\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 02:41 PM\n Vancomycin - 07:15 PM\n Cefipime - 04:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 AM\n Furosemide (Lasix) - 04:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 63 (57 - 80) bpm\n BP: 139/76(92) {120/66(80) - 146/85(98)} mmHg\n RR: 16 (6 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 70 kg\n Total In:\n 960 mL\n 177 mL\n PO:\n 120 mL\n TF:\n IVF:\n 840 mL\n 177 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,090 mL\n Urine:\n 2,300 mL\n 1,090 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,340 mL\n -913 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///35/\n Physical Examination\n GENERAL: Breathing comfortably on NRB, able to sit up without\n desattingfrom 98-100%\n CARDIAC: Tachycardic. Normal S1, S2. No murmurs, rubs or .\n LUNGS: diffuse late inspiratory crackles\n ABDOMEN: +BS. Soft, NT, ND. No HSM.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis.\n Labs / Radiology\n 588 K/uL\n 9.4 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 101 mEq/L\n 144 mEq/L\n 29.7 %\n 18.1 K/uL\n [image002.jpg]\n 12:13 AM\n 02:57 AM\n 08:54 AM\n 08:48 PM\n 04:47 AM\n 04:04 AM\n 03:01 PM\n 03:31 AM\n WBC\n 14.2\n 12.6\n 21.3\n 18.1\n Hct\n 27.5\n 29.3\n 28.4\n 29.7\n Plt\n 88\n Cr\n 0.5\n 0.5\n 0.6\n 0.7\n 0.8\n TCO2\n 31\n 31\n 31\n Glucose\n 95\n 152\n 165\n 142\n 129\n Other labs: PT / PTT / INR:13.5/37.2/1.2, ALT / AST:16/27, Alk Phos / T\n Bili:204/0.1, Differential-Neuts:95.2 %, Lymph:2.5 %, Mono:2.2 %,\n Eos:0.1 %, Lactic Acid:1.1 mmol/L, LDH:479 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Ms. is a 50 year old female with metastatic breast cancer with\n left breast cancer (ER negative, Her2 positive) to the , ,\n liver and lung who was admitted for seizures and PNA but was\n transferred to the ICU this evening for respiratory distress in the\n setting of worsening bilateral opacities on CXR.\n .\n # Respiratory distress/hypoxia: CXR with worsening bilateral opacities\n and likely fluid overload. CTA with no PE but significant for diffuse\n ground glass opacities. CTA also with consolidation in the right\n middle lobe and right lower lobe which could represent infection or\n metastatic deposits to the lungs. There is concern for lymphangitic\n spread of her breast cancer. There also could be contribution from\n pulmonary edema diastolic dysfunction and possible infectious\n process / PNA\n -continue empiric Abx treatment with vancomycin, cefepime and\n azithromycin (day 3)\n -d/c droplet precautions and Tamiflu given negative Influenza DFA.\n -No lung biopsy given respiratory distress and patient wishes.\n -Continue aggressive diuresis today, 40mg Lasix bolus now\n -could consider non-invasive positive pressure ventillation if\n clinically worsening\n -Continue Prophylactic PCP treatment\n sputum induction\n -Continue Decadron taper (4mg QID today, 4mg starting tomorrow).\n .\n #. Fever: Pt. is currently afebrile. Leukocytosis today likely\n secondary to steroids. No bands on diff.\n -Abx as detailed above\n -f/u urine cx and blood cx\n -F/u sputum cx\n .\n # Seizure: ? seizure . Continue to f/u Neuro recs.\n -Continue seizure prophylaxis w/ keppra\n .\n # Metastatic Breast Cancer: She is getting bevacizumab and Herceptin.\n She has brain metastasis and radiation induced necrosis which likely\n explains her cerebellar dysfunction.\n -management per oncology recs\n .\n # Elevated LFTs: Resolving.\n -Continue to trend\n .\n # Mild oral and pharyngeal dysphagia: pt has reduced coordination c/w\n cerebellum mets.\n -diet of nectar thick liquids and soft, moist solids. Avoid mixed\n consistencies that contain liquids and solids.\n -Pills whole with apple sauce\n -Aspiration precautions\n .\n # Anemia: HCT currently 28 and stable.\n -Continue to trend daily\n -guiac all stools\n ICU Care\n Nutrition: nectar thick liquids and soft, moist solids\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 12:19 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with patient and husband\n status: FULL confirmed with patient\n Disposition: ICU\n"
},
{
"category": "Rehab Services",
"chartdate": "2143-11-22 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 607222,
"text": "Subjective:\n I would like to get out of bed for a little while\n Objective:\n Follow up PT visit to address goals of: .\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n With Rail\n\n\n T\n\n\n\n Supine/\n Sidelying to Sit:\n Increased HOB 30\n\n\n T\n\n\n\n Transfer:\n Step Pivot\n\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 59\n 139/63\n 24\n 96% NRB\n Activity\n Sit\n 70\n 106/92\n 28\n 89% NRB\n Recovery\n Sit\n 68\n 114/59\n 24\n 93% NRB\n Total distance walked:\n Minutes:\n Gait: Pt able to take a couple small steps to chair c I UE support\n Balance: S at EOB. for dynamic standing balance during step pivot\n transfer.\n Education / Communication: c RN RE Pt status/ BP/ SaO2\n Pt RE Pacing/DB\n Other: Pulm: Decreased R BS. MinDOE. Strong, nonproductive cough.\n Pt denied pain. Pt c/o minimal dizziness with position change\n Assessment: Pt is a 50F who presents with continued limitations in\n activity tolerance hypoxia. Pt also somewhat limited by\n orthostatic hypotension likely altered fluid balance in setting of\n aggressive diuresis. Will continue to f/u for functional mobility\n training as respiratory status allows.\n Anticipated Discharge: Home with Home PT\n : Breathing Exercises\n Asses Amb as SaO2 allows\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606608,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 606717,
"text": "The pt is a 50 yo female with metastatic breast CA (ER negative, Her2\n positive on bevacizumab and herceptin) to the , , liver, and\n lung who was admitted for seizure and hypoxia (with new RLL\n opacification) on .\n .\n On the oncology floor pt was on 2L NC in the AM. Then in the evening\n it was increased to 4L with an 02 SAT of 81%. On 6L NC o2 sats\n improved to 85-86%. Pt then placed on NRB with sats 97-98% with RR\n 28-30 HR 110-112. Pt given 20 IV lasix. CXR was done which showed\n worsening bilateral infiltrates. ABG showed 7.51/37/94. Pt states that\n her shortness of breath has gradually gotten worse over the last few\n weeks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with coarse rales throughout, 02 SAT on 60% high flow cool neb has\n been 90-96%, she desaturares to the low 80s very quickly when the 02\n Action:\n ABG on 60% was 7.48/40/84, had a sputm induction for PCP and ,\n influenza A&B were resent due to not enough cells to read, to receive\n 40mg of IV dexamethasone for lymphadema in her lungs\n Response:\n Resp status is still tenuous\n Plan:\n Cont to follow, would try noninvasive ventilation if needed, cont abx,\n f/u on clx results, will need her Tamaflu dose increased if she does\n rule in for H1N1\n"
},
{
"category": "Echo",
"chartdate": "2143-11-19 00:00:00.000",
"description": "Report",
"row_id": 74046,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate LV & RV function, Evaluate valves\nHeight: (in) 63\nWeight (lb): 150\nBSA (m2): 1.71 m2\nBP (mm Hg): 106/64\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 12:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. Normal RV\nsystolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Moderate to severe [3+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 60-70%). There is\nno ventricular septal defect. The right ventricular cavity is dilated with\nnormal free wall contractility. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. Moderate to severe [3+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: moderate pulmonary hypertension with a dilated right ventricle and\nmoderate-to-severe tricsupid regurgitation\n\n\n"
},
{
"category": "ECG",
"chartdate": "2143-11-15 00:00:00.000",
"description": "Report",
"row_id": 170905,
"text": "Sinus rhythm. Delayed precordial R wave transition. Compared to the previous\ntracing of the rate is increased. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-11-18 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1109031,
"text": " 10:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: query worsening pneumonia\n Admitting Diagnosis: PNA SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n query worsening pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with hypoxia, to assess for worsening pneumonia.\n\n COMPARISON: A chest radiograph from at 9:52 a.m. and CT of\n the chest from .\n\n SINGLE SEMI-UPRIGHT PORTABLE CHEST RADIOGRAPH: In comparison to the recent\n study, there has been interval worsening in the extensive interstitial\n opacities and parenchymal opacities and findings are consistent with interval\n worsening of the infectious pathology superimposed on chronic abnormalities of\n possible lymphangitic spread of metastatic tumor. Bilateral small pleural\n effusions, without evidence of pneumothorax, are noted. Cardiac size is in\n the top normal range. The hilar and mediastinal contours are unchanged since\n the prior study.\n\n IMPRESSION: Interval worsening of the parenchymal and interstitial opacities,\n suggesting worsening of the infectious process.\n\n\n"
}
] |
31,294 | 101,974 | Patient initially transfered from OSH with encephalopathy and concern for clotted TIPS. TIPS initially placed . Ultrasound showed patent TIPS and his mental status improved with lactulose and regular bowel movements. The patient was tapped for a large amount of ascites and it was negative for SBP. He continued to have waxing and encephalopathy, He required admission to the MICU twice for unresponsiveness, both times which he was intubated for airway protection, and given additional lactulose. His head CT on first MICU admission was negative for any acute process such as intracranial bleed. EEG findings were consistent with encephalopathy without seizure activity. An attempted Re-Do TIPS to divert blood through portal veins and not the TIPS was attempted, but technically unsuccessful and complicated by small hemoperitoneum that required transfusion but otherwise self-limited. He finally had successful TIPS revision on . He continued to receive therapeutic paracentesis. Ultrasound initially showed patent TIPS but subsequent ones showed increased velocities concerning for stenosis. He was restarted on diuretics because his sodium was improved from prior admissions, but these were held for worsening renal function. He was continued on 1500ml fluid restriction and Cipro for SBP prophylaxis. CVVHD was started. A CXR showed new right sided infiltrate and the patient had moderate growth of MRSA from his sputum with sparse growth of 2 colonies of GNR. He was treated with vancomycin and zosyn. On he underwent Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct-common bile duct anastomosis with no T-tube, branch patch (recipient) to celiac patch (donor)hepatic artery anastomosis. Surgeon was Dr. . Please see operative report for further details. EBL was 2 liters replaced with PRBC, plt, FFP, cryo and cellsaver. Two JPs were placed. He was maintained on CVVHD during the case. He received HBIG intraop and on pod . HBsAb titers were greater than 450. HBIG IM was given on pod 7 and 14. Entecavir was started immediately postop. This dose was renally dosed. Postop, he was transferred to the SICU per protocol. He was extubated on POD 2. CVVHD continue for ~ 2 days then lasix was started. He received prbc/plt/ffp on pod 0. Labs were monitored q 6 hours. US of the liver demonstrated difficulty detecting the expected hepatic arterial supply to the left lobe. Otherwise U/S was normal. LFTs trended down. The medial JP was removed on pod 5. The lateral JP continued to drain large amounts of ascites. Outputs were as high as 4.5liters per day. He received IV fluid replacements and albumin for JP outputs. Of note, creatinine started trending up off CVVHD as high as 4.3 from 2.7. Urine output averaged 1000-1200cc/day. Nephrology was consulted. It was felt that he had ATN on resolving hepatorenal syndrome. Fluconazole dose was renally dosed to 200mg qd as this was felt to increase the prograf level. Creatinine slowly trended down to 2.9. Hyperkalemia was a persistent problem that required treatment with insulin, dextrose, lasix and kayexalate. Hyperkalemia improved with improved renal function. A low potassium diet was ordered. The lateral JP was removed on for outputs of 600cc. The transplant incision remained clean, dry and intact. His abdomen appeared a little distended PT evaluated him and initially recommended rehab, but he improved significant and it was felt that he would be safe for discharge to home. He was also started on insulin for hyperglycemia. Glargine and humalog sliding scale were given. Immunosuppression consisted of cellcept 1 gram , steroids were tapered to prednisone 20mg qd per protocol, and prograf was started on pod 1. Prograf was decreased to 2.5mg per trough levels of .2. VNA services were arranged for home. | Unchanged right lung atelectasis, new left-sided opacification likely due to aspiration. Unchanged right apical paucity of lung margins is likely indicative of subpleural bleb or bulla. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is atelectasis at the lung bases, right greater than left. The right PICC line terminates within the expected region of the distal superior vena cava. Limited examination of left and right portal veins. Again noted is a coarse and nodular liver, consistent with known history of cirrhosis. The area of opacification in the right mid lung zone is again seen. Splenic artery and portal vein are patent. Edematous gallbladder wall and cholithiasis, unchanged compared to CT of . The TIPS catheter appears patent. Unchanged right atelectasis, left lung opacification likely representing aspiration is slightly worse. A nasogastric catheter is in place that extends apparently beyond the level of the ligament of Treitz. IMPRESSION: AP chest compared to and 10: Nasogastric tube passes to the distal stomach and out of view. FINDINGS: Status post removal of the nasogastric tube and the endotracheal tube. A right subclavian central venous catheter is in stable position terminating in the superior vena cava. There is a small amount of peri-transplant fluid with a 4.6-cm pocket inferior to the left lobe and a 4.4-cm pocket inferior to the right lobe. Right subclavian catheter tip is in the SVC. Hypoattenuation of the cardiac is compatible with anemia. A central venous catheter terminates in the mid superior vena cava. Splenic vein appears patent. SCOUT IMAGES: A right-sided central venous catheter terminates in the distal superior vena cava. The right central venous line tip is approximately 2 cm below the cavoatrial junction. Air near TIPS, vicarious GB excretion and urinary excretion of IV contrast from early redo TIPS. Appropriate waveforms identified in the main hepatic artery and right hepatic artery with slightly decreased velocities. A right internal jugular central venous catheter terminates at the cavoatrial junction. PORTABLE SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: Abdominal ground glass opacity suggests ascites. thrombis FINAL REPORT INDICATION: Left upper extremity swelling, evaluate for thrombus. IMPRESSION: Persistent suboptimal left hepatic artery waveforms. Mesointestinal tube terminates in the proximal jejunum. The right IJ catheter tip again extends to the upper portion of the SVC. FINAL REPORT INDICATION: Encephalopathy and question of obstruction. IMPRESSION: Sub-optimal left hepatic arterial flow and waveforms again demonstrated. Again noted is a small right pleural effusion. CXR and KUB done. VRE SWAB SENT. Continues w/ lactulose/rifaximin.Resp: Vented, pressure support. PT TO C/DB W/MIN EFFECT. Sample sent for c-dif. Lactate 3.2(3.9). : PULM HYGIENE. Hypoactive BS. CVP 8-11.GI - Abd firm and distended. CXR TAKEN. BS essentially clear bilaterally w diminished RLL. + aspiration precautions. Cipro prophylactically for SBP.Skin - Dry and jaundiced appearing. Post-pyloric tube inserted in IR. EKG OBTAINED. Continues on vanco/zosyn/flagyl. A- LINE INSERTED. focus hemodynmicsdata: very lethargic tonite. Pan cultures pending.GI/GU: Abd- firm/distended, ascites. + palp peripheral pulses. Monitor resp status. Also rx'd with thiamine. INR ^,PLATELETS & HCT TRENDING DOWN ? Right supraclavicular catheter, NG tube, and TIPS are again noted. BUN 59 Creat 1.6.ID - Afeb. abd firmly distended. ABG 7.43/37/115/25. CXR and KUB done.Neuro: Opens eyes to voice. ABG OBTAINED FOR LETHARGY, RESULTS ALL WNL.AFEBRILE. LACTATE TRENDING DOWN.GI : ABD ASCITIC, VERY DISTANT HYPOACTIVE BOWEL SOUNDS HEARD. +pp.RESP: intubated as noted above. Continues on vanco/zosyn.GI/GU: Abd-firm/very distended. crrt vs hemodialysis.gi abd firmly distended. ABD FIRM, DISTENDED, HYPO/+BS. USING IS WELLGI: ABD SOFTLY DISTENDED. Started on vanco and cefepime.GI/GU: Abd- ascites. CVP-7.ID: Temp 100.4 Rectal. LUNGS CTA, PT REF TO DO IS. GEN EDEMA, PALP PP. R IJ taken out. icteric, +fluid responsive.ID: afebrile. Atrovent neb given x1, pt refused 2nd neb.GI/GU: Abd firm and distended with pos bowel sounds. Continues on PR lactuloseID: Temp 93.9 PO. crrt tonite. K REPLETED THIS AM. Pt pulled out doboff this AM. dr from renal called and crrt stopped. tpn infusing. Awating US abdomen. +hypo BS. Assess need for ?intubation. LS-rhonchi w/ dim bases. resp care - Pt extubated w/o incident. PERRL, dialated, jaudice. MARGINAL U/O, CONCENTRATED, SOME SEDIMENT NOTED. R/T ASCITES IN ABD. need for aline given intubation. 1 unit of FFP given, now awaiting PICC placement.ID: Afebrile. limit setting contracting starting with pt.CV: sys 100's, sinus, afebrile, urine out icteric and sufficient. Lactulose q2hr as ordered. noted runs of Vtach as above. Albuterol/Atrovent nebs given x1 with +effect. CONTINUE LACTULOSE TILL CLEAR MENTALLY. See CareVue for hourly CVP, CO, CI. resp care - Pt extubated w/o incident. Cefepime and Vancomycin IV Q24hrs. TYLENOL WAS TRIED X 1 W/O EFFECT. supportive care, limit setting for pt. BM x3 this shift; liquid, stool. Abd softly distended after paracentesis. foley cath to be changed, waiting for mICU MD as ^ and low platelets. Pt with +2 BLE edema. CONTINUE TO MONITER HEMODYNAMICS. Access right subclavian central line, and one right peripheral IV. Calorie count ongoing for , , . will repeat xray at 0800 and reeval position of catheter.PAIN: c/o lower back pain, tylenol given with some result.ID: vanco. Continues on zosyn and flagyl. He receives lactulose q8hour. Continues on ciprofloxacin.GI/GU: NPO. line with good trace.ID: pipercillin and flagyl. INR 2.3.ID: Temp 97.5 Ax. Fentanyl and Versed off. ?C/O TO FLOOR IF MS STABLE. Suctioned frequently.Neuro: Withdrawing to sternal rub. Monitor lytes/ HCT/ ABG. Abd-ascites. Hypoactive BS. Most recent Cr 2.0. lactulose pngt. Chect CT done-results pending.ID: Afebrile. 2.9.Resp: LS-clear w/dim bases. Q-T interval prolongation. NEURO; RETURNED FROM O.R. ETT secured/patent/ Oxygemation stable with spo2 in the mid to upper 90s. Monitor HCT/lytes. BP 96-103/53-61. HCT 23.9, 1 unit PRBC given, repeat HCT pending. PERRL. with min residual. HCT 21.2- 1 unit PRBC given, repeat HCT 24. MAE slowly and with purpose, perlCV: sinus 90-120, maps 80's, pp intact, peripheral edema appears dependant. Monitor MS, continue lactulose Monitor UO,lytes,albumin and HCT, replete accordingly Not following commands.Resp: CPAP+PS. | 129 | [
{
"category": "Radiology",
"chartdate": "2119-01-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 996449,
"text": " 8:28 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for pneumonia\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis, encephalopathy, noted increased cough\n REASON FOR THIS EXAMINATION:\n please eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased cough, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there again are extensive\n bullous changes involving the upper half of the right lung. Some atelectatic\n changes are again seen at the right base. No evidence of acute focal\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-01-18 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 996451,
"text": " 8:36 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: eval TIPS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p TIPS on now with encephalopathy\n REASON FOR THIS EXAMINATION:\n eval TIPS\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver, gallbladder ultrasound.\n\n INDICATION: 45-year-old male status post TIPS placed on now with\n encephalopathy.\n\n COMPARISONS: Ultrasound and CT .\n\n FINDINGS: The liver is shrunken in appearance and nodular in contour\n consistent with the history of the patient's known cirrhosis. There is no\n intra or extrahepatic biliary dilatation with the common bile duct measuring 4\n mm. The gallbladder is not distended, but the wall is noted to be\n significantly thickened. There are several small hyperechoic foci within the\n gallbladder, consistent in appearance with gallstones. The appearance of the\n gallbladder has not changed significantly when compared to the CT of .\n\n Son assessment of the right lobe of the liver demonstrates the outline\n of a TIPS stent in place. Color Doppler interrogation demonstrates good wall-\n to-wall flow throughout. The main portal vein remains patent with hepatopetal\n flow. The maximal velocity through the main portal vein is 53 cm/sec. The\n velocities within the TIPS shunt in the proximal, mid, and distal portions are\n 61, 112 and 120 cm/sec, respectively. These velocities are not significantly\n changed compared to 130-180 cm/sec recorded previously. Secondary to\n technical factors and patient cooperation, the left portal vein and anterior\n right portal vein cannot be adequately assessed on this current study. The\n IVC and splenic vein flow is appropriate.\n\n There is a large volume of abdominal ascites, which has increased compared to\n the previous ultrasound examination.\n\n IMPRESSION:\n\n 1. Patent TIPS shunt. Increase in ascites compared to ultrasound of .\n Limited examination of left and right portal veins.\n\n 2. Edematous gallbladder wall and cholithiasis, unchanged compared to CT of\n .\n\n (Over)\n\n 8:36 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: eval TIPS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-01-31 00:00:00.000",
"description": "2ND ORDER OR> VENOUS SYSTEM",
"row_id": 998573,
"text": " 7:25 AM\n REDO TIPS Clip # \n Reason: TIPS patency\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ********************************* CPT Codes ********************************\n * 2ND ORDER OR> VENOUS SYSTEM PERC TRANHEP PORTOGRAPHY NO PR *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis, s/p TIPS with worsening encephalopathy\n REASON FOR THIS EXAMINATION:\n TIPS patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION OF EXAM: This is a 45-year-old man with cirrhosis status post TIPS\n placement and worsening encephalopathy.\n\n RADIOLOGISTS: The procedure was performed by Drs. and the\n attending radiologist who was present and supervised throughout the procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the\n patient's family members explaining the risks and benefits of the procedure\n the patient was placed supine on the angiographic table and general anesthesia\n was administered throughout the procedure. Using ultrasonographic guidance\n the right internal jugular vein was accessed with a 21-gauge needle and 0.018\n guidewire was placed. The needle was then exchanged for a 4.5 French sheath\n and the wire was exchanged for a 0.035 wire that was placed with tip in\n the inferior vena cava under fluoroscopic guidance. A 7-French tip\n sheath was then placed with tip in the inferior vena cava and using a\n combination of a Cobra catheter and wire access was gained into the\n TIPS. A Omniflush catheter was then placed and a portogram was performed. The\n portogram demonstrates patent TIPS and no flow through the right main portal\n vein. Based on these findings it was decided to access the portal vein\n percutaneously via transhepatic access using ultrasonographic guidance.\n Multiple attempts were made in order to catheterize the right main portal vein\n that were unsuccessful. The procedure was then terminated. Central line was\n placed with tip at the level of the distal SVC and 7-French sheath was\n removed. The patient tolerated the procedure well. The patient was\n transferred to the PACU in good condition.\n\n IMPRESSION:\n 1. TIPS portogram demonstrated patent TIPS with no flow towards the right\n main portal vein.\n 2. Unsuccessful attempt in order to catheterize the right portal vein.\n 3. Successful placement of 7-French triple-lumen central line with tip of the\n catheter to be located in the distal SVC.\n\n\n\n (Over)\n\n 7:25 AM\n REDO TIPS Clip # \n Reason: TIPS patency\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1003043,
"text": " 10:56 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PICC location\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with withdrawal of PICC 2 cm\n REASON FOR THIS EXAMINATION:\n PICC location\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n change. Both central catheters extend to the lower portion of the SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-09 00:00:00.000",
"description": "PARACENTESIS DIAG. OR THERAPEUTIC",
"row_id": 1004433,
"text": " 3:11 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: therapeutic paracentesis, maximum of 3L.Pls send for cell co\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis/end stage liver disease\n REASON FOR THIS EXAMINATION:\n therapeutic paracentesis, maximum of 3L.Pls send for cell count, cultures\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 46-year-old male with cirrhosis, end-stage liver disease.\n Perform therapeutic paracentesis and send for cell count, cultures (maximum of\n 3 liters).\n\n COMPARISON: .\n\n ULTRASOUND-GUIDED THERAPEUTIC/DIAGNOSTIC PARACENTESIS: Targeted son\n evaluation of the four quadrants demonstrates a large amount of ascites. An\n area in the left lower quadrant was marked for paracentesis. The risks and\n benefits of the procedure were explained to the patient, and written informed\n consent was obtained. A preprocedure timeout was performed to confirm the\n nature of the procedure and identify the patient by name, medical record\n number, and date of birth. The area was prepped and draped in standard\n sterile fashion. 1% lidocaine was used for local anesthesia. One pass with a\n 19-gauge catheter was made with successful removal of 2 liters of bile-\n stained ascites. There was no immediate post-procedure complication. The\n patient tolerated the procedure well.\n\n Dr. , the attending radiologist, was present during the procedure.\n\n IMPRESSION: Successful therapeutic/diagnostic paracentesis with removal of 2\n liters of bile-stained ascites. The fluid was sent for requested labs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1004136,
"text": " 4:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: CIRRHOSIS WITH MS CHANGES.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis with altered mental status.\n REASON FOR THIS EXAMINATION:\n evaluate for hemorrhage, mass effect\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: .\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\n normally midline structures. The ventricles, cisterns, and sulci are\n slightly prominent for the patient's age and likely rleated to mild\n diffuse parenchymal volume loss which may due to the underlying systemic\n disease.The - white matter differentiation is preserved. The osseous\n structures are unchanged and the visualized paranasal sinuses and mastoid air\n cells are clear. There is atherosclerotic calcification of the cavernous\n carotid arteries.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-07 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 999748,
"text": " 10:32 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: TIPS REVISION, EVALUATE TIPS WITH DOPPLERS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis s/p TIPS revision with kissing stent placement\n on \n REASON FOR THIS EXAMINATION:\n evaluate TIPS with dopplers\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 45-year-old male with cirrhosis status post TIPS revision with\n kissing stent placement on .\n\n COMPARISON: Doppler ultrasound study of .\n\n FINDINGS: There is again massive ascites, at least as large as that seen on\n the . The liver is again noted to be shrunken and nodular,\n consistent with the patient's known history of cirrhosis. There are no focal\n hepatic lesions. Marked splenomegaly is noted, greater than 20.0 cm.\n\n DOPPLER EXAMINATION: The main portal vein is patent and hepatopetal with a\n velocity of 38 cm/sec. The intra-TIPS velocities are high, ranging from 166\n cm/sec proximally to approximately 300.0 cm/sec distally (higher than can fit\n on the scale), with seeming dimunition to 80-100 cm/sec in the mid portion.\n Flow in the anterior right portal vein is reversed and flow within the left\n portal vein is not detected.\n\n IMPRESSION:\n 1. Patent TIPS but with high velocities, particularly distally where the\n velocity is higher than expected. Given that the patient is one day post-\n TIPS revision, this is of uncertain significance. Short-term followup is\n recommended, in a few days' time.\n 2. Shrunken nodular liver consistent with cirrhosis. Massive ascites and\n marked splenomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-01 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 998866,
"text": " 5:28 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: please evaluate liver with thin slices to assess for hepatic\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis s/p TIPS relook yesterday, now with 8 point Hct\n drop\n REASON FOR THIS EXAMINATION:\n please evaluate liver with thin slices to assess for hepatic vascular bleed,\n also request for multiphasic study of liver for portal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old male with cirrhosis status post TIPS, now with falling\n hematocrit. Concern for hepatic hemorrhage, possible portal venous bleeding.\n\n COMPARISON: CT of the abdomen and pelvis without contrast on ; CT\n abdomen and pelvis with contrast on and .\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis before and after\n Optiray IV contrast administration. Post-contrast images were obtained during\n the arterial, portal venous and delayed phases.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is atelectasis at the\n lung bases, right greater than left. There is a small hiatal hernia. As\n before the liver is shrunken and nodular consistent with cirrhosis. The\n patient is status post TIPS placement. A small subcentimeter focus of\n arterial enhancement of hepatic segment VIII persists on the portal venous\n phase, becoming isodense to background liver on the delayed phase. This was\n present on the pre-TIPS studies of and but is more conspicuous\n now. There is no evidence of subcapsular hematoma. The TIPS catheter appears\n patent. A small subcentimeter ill- defined focus of hypodensity of hepatic\n segment V is not fully characterized. There is a large amount of intra-\n abdominal ascites which measures low density. As before there is a tiny amount\n of high- density fluid layering in the deep pelvis unchanged. As before the\n spleen is enlarged consistent with portal hypertension. The adrenal glands,\n kidneys and pancreas are unremarkable. Vicarious excretion of contrast is\n noted in the gallbladder. The celiac trunk, main hepatic artery and left and\n right hepatic arteries are patent. The SMA, renal arteries and are patent.\n Splenic artery and portal vein are patent. There are no dilated loops of large\n or small bowel.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the\n decompressed urinary bladder. A large amount of ascites tracks into the\n pelvis. A tiny amount of hyperdense material layers in the deep pelvis as\n before.\n\n BONE WINDOWS: There are no suspicious changes. Laminectomy and post-fusion\n changes are noted of the lumbosacral spine. There is evidence of iliac bone\n graft harvest site.\n\n IMPRESSION:\n (Over)\n\n 5:28 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: please evaluate liver with thin slices to assess for hepatic\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Large amount of ascites measures low density. Tiny amount of high-\n density fluid layers in the deep pelvis consistent with blood not changed from\n prior study at 2:13 a.m. today, . No subcapsular hepatic hematoma.\n\n 2. Small subcentimeter focus of arterial enhancement of hepatic segment VIII\n becomes isodense to liver parenchyma on the delayed phase. This is more\n conspicuous compared to and . Finding is non- specific but\n given cirrhosis a small focus of hepatocellular carcinoma cannot be excluded.\n Continued imaging surveillance is recommended.\n\n 3. Cirrhosis with splenomegaly indicating portal hypertension.\n\n 4. Patent TIPS.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-01-27 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 998008,
"text": " 10:17 AM\n DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: TIPS patency, portal vein patency, Dopplers\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hep c cirrhosis s/p tips with encephalopathy\n REASON FOR THIS EXAMINATION:\n TIPS patency, portal vein patency, Dopplers\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with encephalopathy and abdominal distention\n status post TIPS.\n\n COMPARISON: Doppler ultrasound and .\n\n FINDINGS: The liver is noted to be shrunken and nodular consistent with the\n patient's known cirrhosis. There is no biliary dilatation. A massive amount\n of ascites is seen around the liver and in the right and left lower quadrants.\n\n DOPPLER EXAMINATION: The main portal vein is patent and hepatopetal with a\n velocity of 64 cm/sec. The TIPS shunt is patent with what appears to be wall-\n to-wall flow and the velocities are 173, 235, and 184 cm/sec in the proximal,\n mid, and distal portions respectively. This is a slight increase from the\n velocities of . Flow within the left portal vein and the right\n portal vein was difficult to detect but may represent bidirectional flow.\n\n IMPRESSION: Very difficult and technically limited study due to the patient's\n encephalopathy and the amount of ascites present.\n 1. Shrunken nodular liver consistent with the patient's known cirrhosis.\n 2. Patent TIPS with velocities similar to the ultrasound but\n somewhat higher in the mid portion of the TIPS. A stenosis may be present in\n this area but ultrasound is unable to definitively determine this.\n 3. Massive amount of ascites.\n\n These findings were discussed with Dr. at 11:30 a.m. on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-01-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997729,
"text": " 5:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, mental status changes. Nonfocal exam, but mental\n status changes are persistent despite treatment. Was walking alone, ? if he\n fell. No stigmata of a fall.\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 4INDICATION: 45-year-old with end-stage liver disease and mental status\n changes. Nonfocal exam. Evaluate for bleed.\n\n No prior examinations.\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage or major\n vascular territorial infarct. -white matter differentiation is preserved.\n The ventricles are normal in size and configuration. The visualized paranasal\n sinuses and mastoid air cells are clear. There is no evidence of calvarial\n fracture or soft tissue abnormality in this patient with questionable trauma\n history.\n\n IMPRESSION: No acute intracranial hemorrhage or skull fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002985,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, effusions\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Herpetic encephalopathy, to evaluate for effusions and infiltrate.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again there is low lung volume with a thick band of atelectasis at the right\n base and a large right apical bleb.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002565,
"text": " 9:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates, edema, effusions\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hepatic encephalopathy, now with cough\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates, edema, effusions\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable chest.\n\n CLINICAL INDICATION: Please evaluate for infiltrates, edema, and effusion\n with patient with cough.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . Allowing for slight differences in\n technique, there is no significant interval change. The radiolucency\n throughout the right mid and upper lung are unchanged. There is a right\n basilar linear opacity with an appearance most consistent with plate-like\n atelectasis. In addition, there is associated subtle basilar patchy opacity\n likely secondary to underlying atelectasis, a superimposed pneumonia cannot be\n entirely excluded. Left basilar streaky opacities are noted consistent with\n atelectasis. No focal airspace opacities in the left hemithorax are\n visualized. The right PICC line terminates within the expected region of the\n distal superior vena cava. The remaining supporting lines are grossly\n unchanged and in satisfactory positions. The cardiomediastinal silhouette is\n within normal limits.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-08 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1004187,
"text": " 10:09 AM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: evaluate for patency of TIPS (doppler, please).\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis, s/p TIPS, now with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for patency of TIPS (doppler, please).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male with cirrhosis status post TIPS, now with altered\n mental status. Evaluate for patency of TIPS.\n\n COMPARISON: .\n\n FINDINGS: Targeted grayscale and color Doppler of the TIPS was\n obtained. Again noted is a coarse and nodular liver, consistent with known\n history of cirrhosis. There is a large amount of ascites present. The\n gallbladder demonstrates stones, without evidence of cholecystitis. The\n spleen is enlarged.\n\n The TIPS is patent, with wall-to-wall flow. Velocities proximally measure 182\n cm/sec, 170 cm/sec in the mid portion, and 268 cm/sec in the distal segment.\n The left portal vein and right anterior portal vein demonstrate appropriate\n directional flow. The main portal vein is patent with appropriate directional\n flow with a velocity of 27 cm/sec.\n\n IMPRESSION:\n\n 1. Patent TIPS with elevated, but stable, velocities as previously seen on\n prior studies.\n\n 2. Cirrhosis and large amount of ascites.\n\n 3. Gallstones.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1003128,
"text": " 6:48 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate PICC line placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with recent PICC, was pulled out further for VTach.\n REASON FOR THIS EXAMINATION:\n please evaluate PICC line placement\n ______________________________________________________________________________\n WET READ: AHPb WED 8:59 PM\n left PICC tip visualized to at least the lower SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with recent PICC which was pulled out further for\n V-tach. Please evaluate PICC line placement.\n\n COMPARISON: Portable AP upright from .\n\n PORTABLE AP CHEST UPRIGHT: In comparison to yesterday's radiograph, the left-\n sided PICC has been pulled out approximately 1 cm and is located in the lower\n SVC. The right-sided opacification in the middle to lower lung area is still\n present and is unchanged. There is a new left-sided opacification in the lung\n base. The mediastinal and the hilar contours are unremarkable. The pleural\n surfaces are normal. There is evidence of TIPS in the abdomen.\n\n IMPRESSION:\n 1. PICC line in lower SVC.\n 2. Unchanged right lung atelectasis, new left-sided opacification likely due\n to aspiration. No other significant interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003211,
"text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, PICC placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hepatic encephalopathy, continues to be in runs of vtach -\n may be associated with PICC\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with hepatic encephalopathy continued to be in\n runs of V-tach which may be associated with PICC line, evaluate for PICC\n placement.\n\n COMPARISON: portable AP upright chest.\n\n PORTABLE AP UPRIGHT CHEST: The tip of the left PICC line is barely visible in\n this study and is likely located in the lower SVC just above the cavoatrial\n junction. The right lung opacification remains unchanged whereas the left\n lung opacification in the base is slightly worse than yesterday's examination.\n Otherwise, no other significant interval changes.\n\n IMPRESSION:\n 1. Left PICC line barely visible likely located in the lower SVC above the\n cavoatrial junction. Recommend lateral chest radiographs if position still\n needs to be precisely determined.\n 2. Unchanged right atelectasis, left lung opacification likely representing\n aspiration is slightly worse.\n\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-07 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1004013,
"text": " 12:51 PM\n RENAL U.S. Clip # \n Reason: evaluate for obstruction\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with HBV/HCV/ETOH cirrhosis and ARF\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 46-year-old male with cirrhosis and acute renal failure. Evaluate\n for obstruction.\n\n COMPARISON: CT abdomen and pelvis .\n\n RENAL : The right kidney measures 11.1 cm. The left kidney measures\n 12.7 cm. There is no evidence of stones, hydronephrosis, or focal lesion.\n Limited views of the bladder are unremarkable. There is a large amount of\n ascites.\n\n IMPRESSION:\n 1. Normal renal , without hydronephrosis.\n\n 2. Large amount of ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005109,
"text": " 11:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pre-op\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis\n REASON FOR THIS EXAMINATION:\n Pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, preop for liver transplant.\n\n FINDINGS: In comparison with the study of , there is increasing fullness\n of the pulmonary vessels consistent with overhydration. The area of\n opacification in the right mid lung zone is again seen. Increasing\n opacification is seen at the left base, consistent with atelectasis or even\n supervening pneumonia.\n\n A nasogastric catheter is in place that extends apparently beyond the level of\n the ligament of Treitz. Of incidental note is substantial enlargement of the\n splenic shadow.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 999389,
"text": " 6:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluated for interval change\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with esld\n REASON FOR THIS EXAMINATION:\n evaluated for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Intubated patient with ESLD.\n\n COMPARISON: .\n\n ET tube is in standard position. NG tube tip is out of view below the\n diaphragm. Right subclavian catheter tip is seen in the SVC. There is no\n pneumothorax or pleural effusion. Unchanged right apical paucity of lung\n margins is likely indicative of subpleural bleb or bulla. Atelectasis in the\n right base has improved. Remaining atelectasis in the left lung base\n remains.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997274,
"text": " 3:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with altered mental status, bibasilar crackles. Known liver\n disease s/p TIPS\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status with bibasilar crackles.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again, there are extensive bullous changes involving the upper half of the\n right lung with some atelectatic changes at the right base. No evidence of\n acute pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003484,
"text": " 4:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate PICC placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with HBV/HCV ETOH cirrhosis, NSVT ?PICC line advanced\n REASON FOR THIS EXAMINATION:\n evaluate PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line placement.\n\n Portable AP chest radiograph compared to .\n\n The left PICC line can be followed up to the junction of left brachiocephalic\n vein and SVC. The cardiomediastinal silhouette is stable. There is no change\n in bibasal atelectasis and large right upper lobe bulla. The TIPS is again\n noted.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002901,
"text": " 10:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for ptx, infiltrate\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, ? bleb on cxr \n REASON FOR THIS EXAMINATION:\n please eval for ptx, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, blebs seen on chest x-ray. Please\n evaluate for interval change.\n\n Portable AP chest radiograph dated is compared to the prior from\n yesterday; chest x-ray and chest CT. The nasointestinal tube has been\n removed. A right subclavian central venous catheter is in stable position\n terminating in the superior vena cava. A TIPS is seen in the right upper\n quadrant. There has been no significant interval change in the appearance of\n the heart and lungs. The heart size and hilar and mediastinal contours are\n stable. The left lung is clear. The right lung shows a large right apical\n bleb and associated compressive atelectasis at the right lung base. There is\n no pleural effusion.\n\n IMPRESSION: No significant interval change in the appearance of the heart and\n lungs. Interval removal of the nasointestinal tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 999351,
"text": " 5:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 45-year-old male with altered mental status.\n\n COMPARISON: .\n\n FINDINGS: No acute hemorrhage, mass lesion, shift of normally midline\n structures, hydrocephalus or evidence of major territorial infarct is\n apparent. The -white matter differentiation is preserved. The visualized\n paranasal sinuses and mastoid air cells are clear. The visualized orbital\n regions are grossly unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect detected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-01 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 998732,
"text": " 1:10 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: rp bleed? liver hematoma? intraperitoneal bleeding ?\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with esld etoh, hbv / hcv, now s/p tips revision (percutaneous\n and endovascular) w/ dropping hct\n REASON FOR THIS EXAMINATION:\n rp bleed? liver hematoma? intraperitoneal bleeding ?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg WED 2:34 AM\n Large amount of ascites. No evidence of bleed. Cirrhosis, splenomegaly. Air\n near TIPS, vicarious GB excretion and urinary excretion of IV contrast from\n early redo TIPS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man, status post TIPS revision (percutaneous and\n endovascular) with dropping hematocrit; evaluate for liver hematoma or\n intraperitoneal bleeding.\n\n COMPARISONS: CT of the abdomen and pelvis dated .\n\n TECHNIQUE: MDCT images of the abdomen and pelvis were obtained with oral\n contrast only. Multiplanar reformations were essential to interpretation.\n\n SCOUT IMAGES: A right-sided central venous catheter terminates in the distal\n superior vena cava. There is unchanged lucency in the left upper lobe,\n suggesting a large bulla.\n\n ABDOMEN: There is unchanged density along the minor fissure, suggesting scar.\n There is mild centrilobular emphysema in the right lung, with a medial\n subpleural bleb noted in the left upper lobe. Dependent lower lobe density\n (right greater than left) is suggestive of atelectasis. Hypoattenuation of\n the cardiac is compatible with anemia. The liver is severely\n shrunken and nodular, compatible with advanced cirrhosis. A TIPS is present.\n There is subtle linear hyperattenuation in the right lobe (2, 29), which may\n be related to recent percutaneous puncture. There is vicarious excretion of\n contrast into the gallbladder, and there is contrast in the renal collecting\n systems, compatible with recent TIPS revision. A hiatal hernia is small. The\n spleen is enlarged at 14.1 cm, compatible with portal hypertension. The\n adrenal glands, pancreas, and kidneys appear grossly normal. There is no\n bowel dilatation. There is a moderate amount of predominantly low-attenuation\n ascites in the abdomen or pelvis. However, a small hematocrit level is seen\n in the deep pelvis, compatible with layering blood products.\n\n PELVIS: The rectum and sigmoid are decompressed. A Foley catheter is seen in\n the bladder.\n\n OSSEOUS STRUCTURES: There are no suspicious lesions. There are laminectomy\n and fusion changes at L4-L5. A lumbar spinal catheter is incompletely imaged.\n (Over)\n\n 1:10 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: rp bleed? liver hematoma? intraperitoneal bleeding ?\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Gynecomastia is present.\n\n IMPRESSION:\n 1. Small amount of layering blood products within moderate ascites.\n 2. Focal high attenuation in the right hepatic lobe is likely related to\n recent percutaneous hepatic puncture.\n 3. These findings were conveyed to by at\n approximately 10 a.m. on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 999290,
"text": " 8:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: difficulty breathing\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with esld\n REASON FOR THIS EXAMINATION:\n difficulty breathing\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Difficulty in breathing in a patient with end-stage\n liver disease.\n\n Portable AP chest radiograph compared to .\n\n There is increase in linear opacities in the right lower lung most likely\n consistent with atelectasis. Bulous changes in the right upper lung and to a\n lesser extent in the left apex are stable. There is no appreciable pleural\n effusion, and there is no pneumothorax. There is also no evidence of\n congestive heart failure. The cardiomediastinal silhouette is unremarkable.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 999343,
"text": " 4:50 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for placement.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man sp ET tube placement\n REASON FOR THIS EXAMINATION:\n eval for placement.\n ______________________________________________________________________________\n WET READ: JRCi SAT 11:20 PM\n New ETT placement with tip 6.5cm from the carina. Bibasilar opacities most\n consistent with atelectasis. Bullous changes at the apices. No new regions of\n consolidation. Possible small right effusion since angle not well visualized.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Assess ET placement.\n\n ET tube tip is 6.5 cm above the carina. NG tube tip is out of view below the\n diaphragm. Right subclavian catheter tip is in the SVC. There has been mild\n interval increase in right lower lobe atelectasis. Otherwise, no acute\n interval changes from study performed 8 hrs earlier. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-06 00:00:00.000",
"description": "REVISN HEPATIC SHUNT TIPS",
"row_id": 999528,
"text": " 7:27 AM\n REDO TIPS Clip # \n Reason: re-do TIPS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Contrast: OPTIRAY Amt: 130\n ********************************* CPT Codes ********************************\n * REVISN HEPATIC SHUNT TIPS EXCH CENTRAL NON-TUNNELED *\n * -51 MULTI-PROCEDURE SAME DAY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis s/p TIPS c/b encephalopathy, no flow\n through R portal vein.\n REASON FOR THIS EXAMINATION:\n re-do TIPS\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 45-year-old man with cirrhosis status post TIPS\n placement and worsening encephalopathy.\n\n RADIOLOGISTS: Dr. , Dr. , and Dr. performed the\n procedure. Dr. , the attending radiologist, was present and supervised\n throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiographic table, and general anesthesia was administered\n throughout the procedure. wire was placed through the existing\n triple-lumen catheter in the right internal jugular vein. This was exchanged\n for a 7 French sheath over the 0.035 wire. A 0.035 Amplatz wire in\n conjunction with a C2 Cobra catheter was then used to gain access to the TIPS.\n An Omniflush catheter was then placed, and a portogram was performed. The\n portogram demonstrated a patent TIPS with no flow through the right portal\n vein. Based on these findings, it was decided to place kissing wall stents\n inside the existing TIPS. The right internal jugular vein was then punctured\n using a 21-gauge needle, approximately 3 cm superior to be the site of the\n indwelling catheter placement. After placement as a 0.018 guidewire and\n exchanged for a 4.5 French sheath and placement of a 0.035 wire through\n the inferior vena cava, a 7 French tip sheath was then placed with its tip in\n the inferior vena cava using a combination of Cobra catheter and wire to\n gain access into the TIPS. A venogram done at this time demonstrated flow\n through the TIPS and a pressure gradient of 11 mmHg between the right atrium\n and main portal vein. Two 6-mm stents were then placed simultaneously in the\n existing TIPS. The proximal and distal ends of one of the stents were then\n flared with 8 mm in diameter balloon. After the placement of the two stents,\n the gradient between the IVC and the main portal vein was 18 mmHg and slightly\n decreased flow with more prominent collaterals seen. The sheaths and wires\n were then removed, and a 7 French triple-lumen catheter was reinserted into\n the internal jugular vein through the previous site with its tip in the distal\n SVC. The patient tolerated the procedure well without immediate\n complications. Total fluoroscopy time was 14.8 minutes with a total mGy of\n 204.\n\n (Over)\n\n 7:27 AM\n REDO TIPS Clip # \n Reason: re-do TIPS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Placement of kissing stents within the TIPS demonstrating slightly\n increased pressure gradient between the main portal vein and right atrium.\n\n 2. Successful exchange of a 7 French triple-lumen central line with its tip\n in the distal SVC.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002473,
"text": " 10:06 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change in RLL opacity\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis, altered mental status\n REASON FOR THIS EXAMINATION:\n interval change in RLL opacity\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest radiograph.\n\n CLINICAL INDICATION: Assess for interval change of right lower lobe opacity\n in patient with a history of cirrhosis and altered mental status.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination earlier today at 1 a.m. demonstrating no\n significant interval change. The new ovoid opacity within the right mid lung\n persists, likely reflects underlying atelectasis and/or pneumonia. In\n addition, there is a persistent right basilar opacity again likely represents\n underlying atelectasis and/or pneumonia as well. There is a left basilar\n streaky opacity likely reflects underlying atelectasis. Low lung volumes are\n again seen. The cardiomediastinal silhouette is grossly stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-23 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1002120,
"text": " 9:32 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please replace post pyloric NG tube (fell out last night wit\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Contrast: CONRAY Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD HCV, HBV and ETOH with encephalopathy recent MICU\n admission encephalopathy, aspiration\n REASON FOR THIS EXAMINATION:\n please replace post pyloric NG tube (fell out last night with sneezing)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease secondary to HCV and HBV and ETOH, need\n of post-pyloric nasogastric tube.\n\n FINDINGS/PROCEDURE: Using fluoroscopic guidance, an 8 French -\n feeding tube was advanced through the right naris, to the distal portion of\n the duodenum near the ligament of Treitz. Position was confirmed with the\n injection of approximately 10 ml of water-soluble Conray contrast. The\n patient tolerated the procedure well and there were no immediate post-\n procedure complications. A TIPS shunt is only partially imaged on this single\n image.\n\n IMPRESSION: Successful placement of post-pyloric feeding tube with the tip in\n distal duodenum, in the region of the ligament of Treitz.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-25 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1002434,
"text": " 2:58 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: ?hydronephrosis, TIPS patency, portal vein patency\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, cirrhosis, s/p TIPS and revision, with acute\n decompensation of encephalopathy\n REASON FOR THIS EXAMINATION:\n ?hydronephrosis, TIPS patency, portal vein patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, status post TIPS and revision with acute\n decompensation and encephalopathy. Status post kissing stent placement.\n\n FINDINGS: Targeted grayscale and color Doppler son of the TIPS is\n compared to . The liver is shrunken and cirrhotic with\n abundant ascites. The gallbladder is visualized on a single image, but cannot\n be evaluated. The TIPS is patent. There is apparaent narrowing of the tips\n likely consistent with placement of kissing stent placements. Velocities\n proximally measure 240 cm/sec, 230 cm/sec in the mid portion, and 230 cm/sec\n in the distal portion. The spleen is enlarged. Splenic vein appears patent.\n The patient declined further imaging when attempts were made to image the\n intrahepatic portal veins. The velocity in the main portal vein is 30 cm/sec.\n The main hepatic artery waveform appears normal. There is no hydronephrosis\n in the left kidney. The right kidney was not imaged.\n\n IMPRESSION:\n 1. Patent TIPS with increased velocities, little changed.\n 2. Cirrhosis and ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-25 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1002522,
"text": " 7:51 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post pyloric please\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with HCV/HBV cirrhosis here with altered mental status. Pulled\n out Dobhoff. Does have known varices.\n REASON FOR THIS EXAMINATION:\n post pyloric please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with HCV/HBV cirrhosis here with altered mental\n status. Pulled out Dobbhoff.\n\n -intestinal tube placement under fluoroscopy.\n\n PROCEDURE: Using fluoroscopic guidance, an 8 French - feeding\n tube was advanced through the right naris, into the fourth portion of the\n duodenum near the ligament of Treitz. The position was then confirmed by\n injecting approximately 5 cc of water-soluble Conray contrast. The patient\n tolerated the procedure well and there were no immediate post-procedure\n complications.\n\n A TIPS shunt is partially visualized in the upper portion of the image.\n\n IMPRESSION: Successful placement of a post-pyloric feeding tube with the tip\n in the fourth portion of the duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-10 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1000284,
"text": " 9:20 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Portal flow, hepatic vein Patency, degree of TIPS patency an\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis, s/p TIPS revision had resolution of\n encephalopathy and now encephalopathic, less responsive.\n REASON FOR THIS EXAMINATION:\n Portal flow, hepatic vein Patency, degree of TIPS patency and flow\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Limited abdominal ultrasound on .\n\n CLINICAL HISTORY: Recent TIPS revision, encephalopathic, assess patency.\n\n FINDINGS: Limited ultrasound imaging of the liver and gallbladder was\n performed. The patient was somewhat uncooperative, limiting the exam. The\n liver remains shrunken and atrophic with a large quantity of perihepatic\n ascites. The main portal vein is patent with velocity slightly elevated at 46\n cm/sec, in the hepatopetal direction. The TIPS shunt reveals wall-to-wall\n color flow with elevated velocities, not significantly different from prior\n study of , with approximate measurements in the mid and distal TIPS of\n 250 cm/sec. Velocity measured in the proximal TIPS is markedly decreased,\n however, it is felt to represent distal portal vein measurements rather than\n proximal TIPS.\n\n IVC is patent. The intrahepatic veins are not well visualized. Nondistended\n gallbladder is noted without stones.\n\n IMPRESSION:\n 1. Patent TIPS with persistently increased velocities to 250 cm/sec.\n 2. Cirrhosis and ascites.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000610,
"text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with encephalopathy\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Encephalopathy, NG tube placement.\n\n Comparison is made with prior study of .\n\n NG tube tip is out of view below the diaphragm, likely in the stomach. Right\n mid discoid atelectasis is persistent. Unchanged low lung volumes and\n radiolucency of the right apex. There is no sizable pleural effusion.\n Cardiomediastinal contours are normal. Right supraclavicular catheter tip\n remains in the right atrium.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000868,
"text": " 2:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for possible asp pneumonia/pneumonitis, ? ET tub\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESRD, s/p GIB, s/p witnessed aspiration on , intubated\n REASON FOR THIS EXAMINATION:\n Please eval for possible asp pneumonia/pneumonitis, ? ET tube position.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Gastrointestinal bleeding in a patient with end-stage\n renal disease.\n\n Portable AP chest radiograph compared to , obtained at 12:10.\n\n The ET tube tip is 4 cm above the carina. The NG tube tip passes below the\n diaphragm with its tip most likely in the stomach. The right central venous\n line tip is approximately 2 cm below the cavoatrial junction. There is\n interval progression of bibasal opacities as well as perihilar haziness\n suggesting worsening of the pulmonary edema accompanied by worsening bibasal\n atelectasis. The most upper lungs are unremarkable except for emphysema.\n Bilateral pleural effusions are at least moderate. The TIPS is again noted.\n\n DL\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000237,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New NGT placement; please assess; please page with wet read\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with encephalopathy\n REASON FOR THIS EXAMINATION:\n New NGT placement; please assess; please page with wet read\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:19 A.M. \n\n HISTORY: Encephalopathy. New NG tube placement.\n\n IMPRESSION: AP chest compared to and 10:\n\n Nasogastric tube passes to the distal stomach and out of view. Pulmonary\n vascular congestion is slightly worse. Opacification in the infrahilar right\n lung is probably atelectasis given the vertical orientation of the right\n bronchial tree, and what appears to be new right middle lobe collapse. Heart\n size is normal. There is no appreciable pleural effusion. Right\n supraclavicular central venous line can be traced as far as the superior\n cavoatrial junction. A stent projecting over the left lobe of the liver is\n noted. Pleural effusion if any is small, on the right. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-15 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1005301,
"text": " 8:00 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Doppler flows and vasculature\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46M with Cirrhosis HCV HBV EtOH, Grade II varices, portal hypertension, ascites\n s/p TIPS c/b encephalopathy s/p unsuccessful TIPS revision c/b\n hemoperitoneum s/p TIPS revision with encephalopathy, hepatorenal\n syndrome on CVVH now s/p orthotopic liver transplant.\n REASON FOR THIS EXAMINATION:\n Doppler flows and vasculature\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Grayscale and Doppler evaluation liver transplant.\n\n INDICATION: 46-year-old male with hepatitis C cirrhosis, grade 2 varices, and\n portal hypertension status post transplant yesterday.\n\n GRAYSCALE IMAGING: The transplanted liver is grossly normal in appearance\n without focal lesion detected. There is a small amount of peri-transplant\n fluid with a 4.6-cm pocket inferior to the left lobe and a 4.4-cm pocket\n inferior to the right lobe. No echogenic material is detected within the main\n portal vein. No intrahepatic biliary ductal dilitation is identified.\n\n COLOR DOPPLER EVALUATION: The hepatic veins are patent with normal\n directional flow and cardiac variation within the waveforms. The portal vein\n is patent with normal hepatopetal flow. The portal venous velocity is 120\n cm/sec with normal respiratory undulation. The main hepatic artery appears\n small in caliber with a low velocity of 37 cm/sec. The resistive index of the\n main hepatic artery is 0.61 with waveform demonstrating a brisk upstroke and\n forward diastolic flow. The intrahepatic right hepatic artery was detected\n with brisk upstroke and forward diastolic flow and a peak systolic velocity of\n 67 cm/sec. The resistive index in the right hepatic artery is 0.6.\n\n Despite multiple attempts by the son and the attending radiologist\n (Dr. , the left hepatic artery was not well demonstrated. Doppler\n evaluation in the expected region of the left hepatic artery demonstrated\n faint upstrokes suggestive of an arterial waveform, however, this was not\n definitive.\n\n IMPRESSION:\n 1. Grayscale imaging demonstrates a normal postoperative appearance of the\n liver with a small amount of peri- transplant fluid.\n\n 2. Doppler evaluation demonstrated difficulty detecting the expected hepatic\n arterial supply to the left lobe. Doppler evaluation otherwise normal.\n\n Findings were discussed with Dr. and short-term followup with Doppler\n evaluation in 24 hours is recommended.\n\n\n (Over)\n\n 8:00 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Doppler flows and vasculature\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1005398,
"text": " 6:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: right IJ CVL placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with hepatorenal syndrome\n REASON FOR THIS EXAMINATION:\n right IJ CVL placement\n ______________________________________________________________________________\n WET READ: MRGe WED 10:07 PM\n Unchanged left IJ catheter coiled within the subclavian vein. ETT and NGT have\n been removed. Bibasilar atelectasis. Cardiac silhouette is stable. No PTX.\n\n\n D/W Dr at the time of the interpretation.\n\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: Status post removal of the nasogastric tube and the endotracheal\n tube. Unchanged coiling of the central venous access line left. Introduction\n sheath positioned in the right internal jugular vein. On today's examination,\n massive structure loss of the right upper lung with consecutive increase of\n parenchymal density in the right lower lung is much more obvious than on the\n previous examination. The retrocardiac lung areas are increased in\n transparency, suggesting that the retrocardiac atelectasis is decreasing. The\n size of the cardiac silhouette is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1004118,
"text": " 3:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, edema, effusions --> to be done in\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis, now with tachycardia and altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, edema, effusions --> to be done in MICU ROUNDS\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and .\n\n HISTORY: A 46-year-old man with cirrhosis, now with tachycardia and altered\n mental status, evaluate for infiltrate, effusion.\n\n FINDINGS: A right middle lobe atelectatic band is stable. Mild interstitial\n prominence is seen in the lung bases, likely representing atelectasis. Severe\n emphysematous bullous changes are noted in the upper lungs, right more than\n left. The heart size is normal. No pleural effusion.\n A left subclavian PICC line distal tip is at the SVC/brachiocephalic junction\n IMPRESSION:\n Emphysematous lung disease in the lung apices with new mild bibasilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-27 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1002786,
"text": " 4:15 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for ptx\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man ESLD with R subclavian line. CXR this AM concerning for bleb\n vs. ptx. repeat CXR unable to determine.\n REASON FOR THIS EXAMINATION:\n Please eval for ptx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, possible right upper lobe bleb versus\n pneumothorax.\n\n TECHNIQUE: Multidetector CT images were obtained through the chest without\n contrast in standard and lung algorithm. Coronal and sagittal reformatted\n images were obtained.\n\n COMPARISON: Chest radiograph .\n\n CT CHEST WITHOUT CONTRAST: There is extensive bilateral panlobular emphysema.\n Specifically, within the right upper lobe, there is destroyed lung parenchyma,\n consistent with emphysema without evidence of a pneumothorax. This\n abnormality more caudally compresses the lung parenchyma causing atelectasis\n within the right upper and right lower lobes. Additionally, atelectasis is\n seen in the left lower lobe. No evidence of pneumothorax, airspace\n consolidation, or pleural effusion.\n\n Within the trachea, mild secretions are noted. Otherwise, the\n tracheobronchial tree is normal. The heart size is normal. There is no\n pericardial effusion. There is no pathologically enlarged axillary, hilar, or\n mediastinal lymphadenopathy. A central venous catheter terminates in the mid\n superior vena cava. A nasogastric tube is seen coursing through the imaged\n portion of the esophagus.\n\n Limited images through the upper abdomen show large volume ascites. A TIPS is\n seen within the liver. The spleen is enlarged.\n\n The osseous structures show no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1. Abnormality in the right upper lobe demonstrates marked panlobular\n emphysematous changes. No evidence of pneumothorax.\n\n 2. Atelectasis within the right upper and bilateral lower lobes. No evidence\n of airspace consolidation.\n\n 3. Limited images through the upper abdomen show a large volume ascites,\n TIPS, and splenomegaly.\n\n (Over)\n\n 4:15 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for ptx\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ab\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-16 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1005516,
"text": " 2:29 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: PLEASE ASSESS FOR FLOW IN HEPATIC ARTERY\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver transplant grayscale and color Doppler evaluation.\n\n COMPARISON: Transplant ultrasound, .\n\n GRAYSCALE FINDINGS: There is no increase in perihepatic fluid collections.\n Again noted is a small right pleural effusion. The echogenicity of the liver\n is unchanged from recent comparison.\n\n LIVER DOPPLER FINDINGS: The main portal vein is patent with normal\n hepatopetal flow. The flow within the portal vein ranges from 60-90 cm/sec.\n The middle, right, and left hepatic veins are patent with normal directional\n flow and cardiac cycle variability. The main and right hepatic arteries are\n patent with brisk upstroke and forward diastolic flow. A small arterial\n waveform is again noted in the left hepatic artery with a peak velocity of\n approximately 20 cm/sec. The waveform is mildly tardus-parvus with minimal to\n no diastolic flow.\n\n IMPRESSION:\n\n Sub-optimal left hepatic arterial flow and waveforms again demonstrated. This\n suggests abnormality/injury to the known replaced/accessory left hepatic\n artery. The main and right hepatic arteries demonstrate normal flow and\n waveforms. All other hepatic vascular structures are within normal limits.\n\n Interval follow up recommended.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1005200,
"text": " 1:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line positions\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46M s/p liver transplant\n REASON FOR THIS EXAMINATION:\n eval line positions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post liver transplant, to evaluate for tube positions.\n\n FINDINGS: In comparison with the study of , there has been placement of\n an endotracheal tube with its tip approximately 3.7 cm above the carina. Left\n IJ Swan-Ganz catheter tip lies in the lower portion of the pulmonary outflow\n tract. Nasogastric tube extends to the upper stomach. Some increased\n opacification is again seen in the right mid lung zone and left base, as well\n as possibly in the left perihilar region. Much of this most likely represents\n atelectatic change, though supervening pneumonia cannot be excluded. There\n also appears to be some engorgement of pulmonary vessels consistent with\n overhydration.\n\n The right IJ catheter tip again extends to the upper portion of the SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003268,
"text": " 12:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please re-eval PICC line\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD s/p PICC with several episodes of VT.\n REASON FOR THIS EXAMINATION:\n please re-eval PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with ESLD status post PICC line after several\n episodes of VT. Please evaluate PICC line.\n\n COMPARISON: Chest AP upright portable from earlier today .\n\n CHEST AP PORTABLE UPRIGHT: The tip of the PICC line is poorly visualized\n related to the absnece of the guide wire. Tip of the PICC most likely\n terminates in the lower SVC above the cavoatrial junction. The line appears to\n have been withdrawn approximately 1 cm. The left-sided opacification is no\n longer present and the right-sided atelectatic change is similar in appearance\n to the previous study.\n\n IMPRESSION:\n 1. Tip of PICC line not well visualized, likely in the lower SVC above the\n cavoatrial junction. No pneumothorax detected.\n 2. Left lung infiltrate no longer visualized with right-sided atelectatic\n change similar in appearance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002662,
"text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for any infiltrates, edema, pleural effusions\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n evaluate for any infiltrates, edema, pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatic encephalopathy.\n\n Portable AP chest dated is compared to the prior examinations from\n , , and . Mesointestinal tube terminates in the\n proximal jejunum. A right internal jugular central venous catheter terminates\n at the cavoatrial junction. A TIPS is seen in the right upper quadrant. The\n cardiac size and hilar and mediastinal contours are stable. With the\n difference in patient positioning from the multiple prior examinations, there\n is increased conspicuity of a lucency overlying the right upper lung lobe\n which may represent a large emphysematous bulla versus pneumothorax. There is\n no sign of mediastinal shift or tension pneumothorax; however, it appears\n there is atelectasis/compression of the right lung parenchyma. There is no\n pleural effusion.\n\n IMPRESSION: Increased conspicuity of lucency overlying the right upper lung\n lobe which may represent a bulla from underlying emphysema versus a\n pneumothorax. A chest CT is recommended for further evaluation.\n\n Findings discussed over the telephone at the time of dictation with the\n physician caring for the patient, Dr. .\n\n ab\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003349,
"text": " 10:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval PICC adjustment, pull back 2cm. verify position\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis\n REASON FOR THIS EXAMINATION:\n interval PICC adjustment, pull back 2cm. verify position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man with cirrhosis, interval PICC adjustment, verify\n position.\n\n COMPARISON: Chest AP portable upright from .\n\n CHEST AP UPRIGHT PORTABLE: The PICC line has been retracted approximately 2\n cm and the tip is currently located in the upper SVC. The heart is not\n enlarged. There has been interval improvement in the right-sided mid lobe\n opacity. There is no pneumothorax.\n\n IMPRESSION: Retraction of PICC line approximately 2 cm with the tip in the\n upper SVC, mild improvement in the right-sided middle lobe opacity likely\n representing atelectasis, no other significant interval change.\n\n The IV nurse was given the results of this study at approximately 10 a.m.\n today, .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005383,
"text": " 3:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate cvl placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with left IJ cvl changed over guidewire.\n REASON FOR THIS EXAMINATION:\n evaluate cvl placement\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Left IJ placement.\n\n FINDINGS: The left IJ catheter extends to the subclavian before joining the\n IVC, then coils back on itself to lie within the subclavian vein.\n\n The area of increased opacification at the right base is less prominent,\n possibly reflecting some clearing of a mucus plug. The area behind the heart\n again is opaque. The possibility of volume loss at the left base, possibly\n with pleural effusion, must be considered.\n\n The malpositioned catheter has been related to Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003722,
"text": " 5:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulmonary edema, effusions\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD HBV, HCV, ETOH with increased dyspnea\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema, effusions\n ______________________________________________________________________________\n WET READ: FBr SUN 8:09 PM\n There is atelectasis at both lung bases which are stable. No acute intra-\n thoracic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: Increasing dyspnea.\n\n Cardiac silhouette is normal in size. Asymmetrical bullous emphysema is\n present, most pronounced at the right apex. Superimposed upon previously\n demonstrated areas of linear atelectasis and/or scarring are increasing patchy\n opacities in the perihilar regions accompanied by mild bronchial wall\n thickening, most marked on the right. Differential diagnosis includes acute\n aspiration versus an atypical presentation of pulmonary edema in a patient\n with underlying emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1004793,
"text": " 7:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Line placement, PTX\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man w/Hd line being placed in IJ\n REASON FOR THIS EXAMINATION:\n Line placement, PTX\n ______________________________________________________________________________\n WET READ: JRCi SAT 8:09 PM\n New right IJ CVL terminates at the mid svc as well as PICC. Pneumothorax\n evaluation difficult given bullous changes at the lung apices however none\n identified. Metal stent overlies the liver shadow.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 19:46\n\n COMPARISON STUDY: \n\n CLINICAL INFORMATION: Line placement, question pneumothorax.\n\n FINDINGS:\n A right IJ line terminates in the superior vena cava. There are bullous\n changes in bilateral lung apices. No pneumothorax identified. There are\n multiple opacities in the right lung consistent with atelectasis. Left lung\n relatively clear. Cardiomediastinal silhouette unremarkable.\n\n IMPRESSION:\n 1. Status post right IJ line placement. No pneumothorax. Bullous changes at\n bilateral lung apices.\n\n 2. Multifocal opacities in right lung, atelectasis versus infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002752,
"text": " 1:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx?\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cirrhosis, >ptx on am cxr\n REASON FOR THIS EXAMINATION:\n ptx?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis with possible pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, the patient has\n taken a much better inspiration. Atelectatic changes persist at the right\n base. The possibility of supervening pneumonia can certainly not be excluded.\n\n Generalized lucency of the right upper lung zone is seen. This most likely\n represents a bullous formation.\n\n Of incidental note is a large spleen, consistent with the patient's known\n cirrhosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-28 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1002932,
"text": " 2:07 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place dobhoff\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Contrast: CONRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hepatic encephalopathy\n REASON FOR THIS EXAMINATION:\n please place dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n NASOINTESTINAL TUBE PLACEMENT\n\n COMPARISON: .\n\n HISTORY: Dobbhoff tube placement for feeding.\n\n PROCEDURE: Under fluoroscopic guidance, an 8 French - feeding\n tube was placed in the right nares and advanced past the pylorus into the\n third portion of the duodenum. 10 cc of Conray contrast was injected to\n confirm placement. The patient tolerated the procedure well, and there are no\n immediate post- procedure complications.\n\n IMPRESSION: Successful placement of post-pyloric feeding tube with the tip in\n the third portion of the duodenum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1003625,
"text": " 7:43 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for aspiration pneumonitis, PNA\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, started coughing after eating, ? aspiration event\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration pneumonitis, PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 45-year-old man with end-stage liver disease.\n\n FINDINGS: Comparison is made to previous study from .\n\n Cardiac silhouette and mediastinum are normal. There are emphysematous\n changes most prominent within the right lung apex. There is atelectasis at\n both lung bases which are stable. No free intra-abdominal air is seen. TIPS\n is seen within the liver.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1003021,
"text": " 8:43 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: l dl picc 60cm\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with\n REASON FOR THIS EXAMINATION:\n l dl picc 60cm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with earlier study of this date, the patient has\n taken a much better inspiration and the atelectatic changes at the right base\n are decreased. Left subclavian PICC line extends to the lower portion of the\n SVC. This information was discussed with the person placing the PICC line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1005901,
"text": " 11:56 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for effusion and interval change\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p OLT w/ low sats\n REASON FOR THIS EXAMINATION:\n please eval for effusion and interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check followup.\n\n COMPARISON: \n\n FINDINGS: As compared to the previous radiograph, the left-sided venous\n access line, that was turned curled intravascularly, has been removed. The\n right-sided central venous access line is in unchanged position. Unchanged\n areas of emphysematous and bullous destruction, most obvious at the right lung\n apex. Hypoventilation of the right lung base, this has increased as compared\n to the previous radiograph. The retrocardiac areas of hypoventilation have\n slightly decreased. However linear areas of atelectasis are now seen at the\n left lung bases. The overall extent of the cardiac silhouette is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-23 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1006535,
"text": " 2:35 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: assess for flows and fluid collection around liver\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n assess for flows and fluid collection around liver\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, please assess vascularity and for\n fluid collection around the liver.\n\n COMPARISON: .\n\n TECHNIQUE: Duplex son imaging of the transplant liver.\n\n FINDINGS: The hepatic echotexture within the transplanted liver is within\n normal limits. No focal lesions are detected. A small amount of peri-\n transplant fluid has decreased since , with a small amount\n visualized about the posterior aspect of the right lobe. The main portal vein\n is patent with hepatopetal flow. Velocities within the portal vein proximal\n to the anastomosis, at the anastomosis, and distal to the anastomosis are\n approximately 55 cm/sec, 112 cm/sec, and 84 cm/sec, respectively. The main,\n right, and left hepatic arteries are patent with normal waveforms. The peak\n systolic velocity in the main hepatic artery is approximately 50 cm/sec with\n resistive index of 0.7. The left hepatic arterial waveform, previously\n difficult to obtain, is normal on today's examination with a resistive index\n of 0.58. The hepatic veins are patent with normal waveforms. The IVC is\n patent.\n\n IMPRESSION:\n 1. Normal Doppler examination of the transplanted liver. The left hepatic\n artery waveform is now more readily identified (previously difficult to\n detect).\n 2. Decreased peri-transplant fluid.\n\n Results discussed with Dr. at 3:53 p.m. on .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-17 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 1005610,
"text": " 8:16 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: assess hepatic vasculature (LHA), ducts\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p liver transplant for HBV/hcv AND ETOH\n REASON FOR THIS EXAMINATION:\n assess hepatic vasculature (LHA), ducts\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess hepatic vasculature in recent liver transplant.\n\n COMPARISON: Liver Doppler ultrasound .\n\n FINDINGS: Hepatopetal flow is again seen in the main portal vein, left portal\n vein and right portal vein. Appropriate flow is seen in the hepatic veins.\n Careful interrogation of the main hepatic artery shows appropriate waveforms\n with good upstroke and an RI of 0.8. Appropriate waveforms are also\n identified in the posterior right hepatic artery with an RI of 0.64. Flow\n within the right hepatic artery was more difficult to obtain on today's exam,\n and the peak velocities are slightly lower than the prior exam. Flow is again\n very difficult to obtain in the left hepatic artery. Waveforms were\n identified which again show no diastolic flow and low velocities.\n\n IMPRESSION: Persistent suboptimal left hepatic artery waveforms. Appropriate\n waveforms identified in the main hepatic artery and right hepatic artery with\n slightly decreased velocities. Patent portal veins and appropriate flow in\n the hepatic veins.\n\n These findings were conveyed to Dr. at 9:45 a.m. Friday, , .\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-17 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1005609,
"text": " 8:15 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LT ARM SWELLING W/ PICC LINE IN PLACE ? THROMBUS\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p liver transplant for HBV/hcv AND ETOH now with LUE swelling\n REASON FOR THIS EXAMINATION:\n ? thrombis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left upper extremity swelling, evaluate for thrombus.\n\n COMPARISON: No previous extremity ultrasounds for comparison.\n\n FINDINGS: Echogenic material is visualized within the left IJ. This vein\n does not compress and there is no flow detected within it. Grayscale, color\n and Doppler son of the left subclavian, axillary, brachial and basilic\n veins were performed. A PICC line is identified within the basilic, axillary\n and subclavian veins on the left. Normal flow, compression and augmentation\n is seen from the level of the subclavian through the basilic.\n\n IMPRESSION: Deep vein thrombosis in the left IJ. No evidence of thrombus in\n the remainder of the left arm vessels. The PICC line is identified in the\n left basilic, axillary and subclavian veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005292,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46M with Cirrhosis HCV HBV EtOH, Grade II varices, portal hypertension, ascites\n s/p TIPS c/b encephalopathy s/p unsuccessful TIPS revision c/b\n hemoperitoneum s/p TIPS revision with encephalopathy, hepatorenal\n syndrome on CVVH now s/p orthotopic liver transplant.\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:45 A.M., :\n\n HISTORY: Cirrhosis, hepatitis, alcoholism, varices, portal hypertension,\n ascites. Hemoperitoneum.\n\n IMPRESSION: AP chest compared to through 18:\n\n Mild pulmonary edema has improved, small-to-moderate bilateral pleural\n effusions unchanged, atelectasis in the right mid lung, largely middle lobe or\n superior segment of the right lower lobe worsened since , unchanged\n since . Heart size is normal. Swan-Ganz pulmonary flotation\n catheter, nasogastric tube, ET tube, right internal jugular line, in standard\n placements. Right upper quadrant drain is noted. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-01-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 996440,
"text": " 7:48 AM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for obstruction. Please do portable, upright an\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with encephalopathy and question of obstruction\n REASON FOR THIS EXAMINATION:\n please eval for obstruction. Please do portable, upright and supine if\n possible.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Encephalopathy and question of obstruction.\n\n COMPARISON: .\n\n PORTABLE SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: Abdominal ground glass\n opacity suggests ascites. Nondistended gas-filled bowel loops are seen.\n Patient is status post laminectomy and fusion in the lower spine, with\n residual bone graft and stimulator leads present.\n\n IMPRESSION:\n 1. Nonspecific bowel gas pattern without evidence of obstruction.\n 2. Likely ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-14 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1000783,
"text": " 11:52 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? evidence obstruction, NGT placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with GIB, s/p intubation/NGT. Now vomiting\n REASON FOR THIS EXAMINATION:\n ? evidence obstruction, NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen.\n\n INDICATION: 45-year-old male with a GI bleed status post intubation/NG tube\n placement. Assess for vomiting and NG tube placement.\n\n FINDINGS: A single portable supine view of the abdomen is submitted for\n review. The outline of a nasogastric tube is identified with a sideport well\n below the expected location of the gastroesophageal junction. There are air-\n filled loops of large bowel. No definite air is present within the rectum. No\n air-extended loops of small bowel are identified. The outline of a stent\n projects over the right upper quadrant of the abdomen. The patient is status\n post lower lumbar fixation with associated pedicle screws.\n\n IMPRESSION: NG tube in good position. No definite evidence of small-bowel\n obstruction. Recommend obtaining upright views if clinical suspicion\n persists.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000784,
"text": " 12:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement.\n\n CHEST, ONE VIEW: Comparison with , 20:10 p.m. Endotracheal\n tube is now 3.5 cm above the carina. Right internal jugular vein line is\n unchanged in position. There are low lung volumes. The left midlung zone\n vague opacity is not well seen. There is bilateral lower lobe atelectasis. No\n pneumothorax. Osseous structures are unchanged. Nasogastric tube remains in\n place.\n\n IMPRESSION:\n 1. Endotracheal tube in satisfactory position.\n 2. Lower lung volumes and increased bilateral lower lobe atelectasis.\n\n ab\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000617,
"text": " 5:59 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? acute pathology\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with altered mental status, aspirating\n REASON FOR THIS EXAMINATION:\n ? acute pathology\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Question aspiration, patient with altered mental status.\n\n Comparison is made with prior study performed three hours earlier.\n\n Essentially, this examination is unchanged with low lung volumes and right mid\n and lower lobe discoid atelectasis. There are no sizable pleural effusions.\n Radiolucency in the right apex is unchanged. Cardiomediastinal contour is\n normal. Right supraclavicular catheter, NG tube, and TIPS are again noted.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000689,
"text": " 8:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for appropriate positioning.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with new ET tube placement\n REASON FOR THIS EXAMINATION:\n eval for appropriate positioning.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:10 P.M. ON \n\n HISTORY: New ET tube placement.\n\n IMPRESSION: AP chest compared to through 18 as late as 3:19 p.m.:\n\n Tip of the new endotracheal tube ends above the thoracic inlet, at least 7 cm\n from the carina 4 cm above optimal placement. Lung volumes remain quite low\n and some of the opacification at the left lung base is probably atelectasis\n but some is also due to asymmetric edema also present at the right lung base,\n worsened slightly since earlier in the day. Nevertheless heart size and\n mediastinal vasculature are normal. There is no appreciable pleural effusion\n or indication of pneumothorax. Tip of the right jugular line projects over\n the upper SVC and a nasogastric tube passes below the diaphragm and out of\n view. Dr. covering for Dr. was paged to discuss these\n findings, at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1002427,
"text": " 12:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, encephalopathy, now responsive only to pain.\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Encephalopathy with altered mental status.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: .\n\n FINDINGS: No acute hemorrhage, mass lesion, or shift of normally midline\n structures, hydrocephalus, or evidence of major territorial infarction is\n apparent. The -white matter differentiation is preserved. The visualized\n paranasal sinuses and mastoid air cells are clear. The osseous structures are\n unremarkable.\n\n IMPRESSION: Normal non-contrast head CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-20 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1001616,
"text": " 9:47 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: post-pyloric dobhoff\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n Contrast: CONRAY Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with malnutrition, cirrhosis, ascites, and encephalopathy\n REASON FOR THIS EXAMINATION:\n post-pyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old male with malnutrition, cirrhosis, and ascites.\n Postpyloric Dobbhoff tube placement for nutrition.\n\n PROCEDURE/FINDINGS: Under fluoroscopic guidance, an 8 French -\n feeding tube was advanced to the fourth portion of the duodenum in a\n postpyloric position. Position was confirmed with the injection of\n approximately 15 cc of water-soluble Conray contrast. The patient tolerated\n the procedure well.\n\n IMPRESSION: Successful placement of a postpyloric feeding tube with tip in\n distal duodenum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002428,
"text": " 1:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, now with altered mental status, hypoxia.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: chest radiograph and chest radiograph from\n .\n\n HISTORY: 45-year-old man with end-stage liver disease, with altered mental\n status, hypoxia, rule out pneumonia.\n\n FINDINGS: There is a new oval shaped infiltration in the right mid lung. The\n right central line terminates in the right atrium and needs to be readjusted.\n The endotracheal tube has been removed. A feeding tube terminates in the\n right upper quadrant likely in the gastric antrum. A TIPS stent is noted\n overlying the right upper quadrant. The previously noted atelectasis at the\n right lung base has clarified with better visualization of the right\n hemidiaphragm. The heart is not enlarged.\n\n IMPRESSION:\n 1. New pneumonic consolidation in the right middle lung.\n 2. Resolution of the right basilar atelectasis.\n 3. The right central line still terminates in the atrium and needs to be\n pulled back by at least 3 cm. This information was given to Dr. \n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000665,
"text": " 3:10 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for development of infiltrate/consolidation\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY WITH HYPERBILIRUBENEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESLD, s/p TIPS revision, now w/ obtundation, concern for\n aspiration\n REASON FOR THIS EXAMINATION:\n eval for development of infiltrate/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for aspiration, patient with ESLD S/P TIPS revision\n now with obtundation.\n\n Comparison is made with prior study performed the same day earlier in the\n morning, nine hours earlier.\n\n New ill-defined opacity in the left lower lobe is concerning for aspiration\n given the provided clinical history.\n There are low lung volumes. Discoid atelectasis in the right mid lung is\n unchanged as is radiolucency of the right apex. There is no pneumothorax. If\n any there is small right pleural effusion. Cardiomediastinal contour is\n normal. NG tube tip is in the stomach.\n Right supraclavicular catheter remains in place.\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-13 00:00:00.000",
"description": "Report",
"row_id": 1662161,
"text": "Nsg.progress notes:\nsee flow sheet for specific:\n\nNeuro: Alert and oriented x3, for endoscopy and sleeping after that, c/o abd pain tylenol with fair effect, educated him about complication of drugs due to his liver condition.irritable on and off.\n\nCV: NSR, HR:60-76, no ectopy noted, SBP 98-115, ++PP, ++edema LE,denies CP or discomfort. TPN onflow, to stop when it finishes.1 unit Platelets given post procedure and 5mg Vit K Po.Jaundiced.Fluid balance of +400ml by 1800.\n\nResp: NC with 3L O2, LS clear and diminished at bases, ++Productive cough., pt suctioning from mouth. O2 sat 95-98%.\n\nGI: Abd distended, +++ ascitis, ++BS, BM x2 on po lactulose QID to regulate BM atleast 3/day.kept NPO after break fast for procedure, was on coloric count.feeding tube placed endoscopically at bed side by Dr. and Dr.. Tf replete started at 10ml/hr MICU MD.for US guided paracenthesis tomorrow.\n\nGU: Foley cath patent with icteric urine, 10-15ml/hr, HD started at 1745, goal fluid removel 1.5L.\n\nEndo:Bld sug wnl.\n\nID: Afebrile, on anbx, and fluconazol started today.\n\nAct: Turned in the bed frequently with minimal assist.get OOB to chair with 1 assist, tolerated well, and getting out to commode for BM.skin intact.\n\nSocial: Wife called up x1. no calls from HCP today.\n\nPlan: Cont monioting, pulm hygiene, HD. Tf goal 40ml/hr now at 10ml/hr.post transfusion plt check. US guided paracenthesis tomorrow.support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-13 00:00:00.000",
"description": "Report",
"row_id": 1662162,
"text": "focus hemodynmics\ndata: very lethargic tonite. dr called and in to see pt. pt did receive fentanyl and versed iv today for feeding tube insertion. dialysis treatment tolerated well and 1.5liters of fluid removed. abd firmly distended. stool x1 tonite. pt to receive liver transplant in the am. sister called and consent obtained. renal fellow dr called and ordered crrt to be done intraop in the am. orders placed in poe. npo after midnoc.\n\nresponse: to or in the am for liver transplant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-14 00:00:00.000",
"description": "Report",
"row_id": 1662163,
"text": "NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR DETAILS.\n\nPT REMAINS LETHARGIC SLEEPING THROUGH MAJORITY OF EVENING. AROUSES TO VOICE OR STIMULI. ORIENTED X1-3 DEPENING ON ALERTNESS WHEN AROUSED. DENIES PAIN. FOLLOWING COMMANDS. MAE.\n\nSB/NSR HR 55-75. NO VIEWED ECTOPY. SBP 88-120. ++ PP. EKG OBTAINED. LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. SOUNDING CONGESTED, SECRETIONS IN BACK OF THROAT. PT TO C/DB W/MIN EFFECT. USING YANKEUR FOR SM AMOUNTS BLD TINGED THICK SECRETIONS. SATS 98-100% 4L NC. ABG OBTAINED FOR LETHARGY, RESULTS ALL WNL.\n\nAFEBRILE. TO RECIEVE ABX PRIOR TO OR. VRE SWAB SENT. ATTEMPTING TO COLLECT URINE SPECIMEN.\n\nTO RESTART CVVHD WHILE IN OR FOR FLD LOSS OF 500-750CC, CHECKING LABS ADN REPLETING ELECTROLYTES AS NEEDED.\n\nABDOMEN FIRM, DISTENDED. + BS. NO STOOLS. TF VIA DOBHOFF HELD AT MN FOR OR. FOLEY INTACT, SCANT ICTERIC U/O, SOME SEDIMENT NOTED. SKIN JAUNDICED. UMBILICAL HERNIA.\n\nSISTER CALLED, SPOKE W/ANESTHESIA. CONSENT OBTAINED.\n\n: PULM HYGIENE. FOLLOW AND TX LABS. START CVVHD. GIVE ON-CALL MEDS/OR MEDS AS ORDERED. CONT ATTEMPT OBTAIN UA. MONITOR NEURO. PROVIDE EMOTIONAL SUPPORT TO PT/FAMILY. SCHEDULED TO GO TO OR, ANESTHESIA PICK UP APPROX 0630. CALL HO W/ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-13 00:00:00.000",
"description": "Report",
"row_id": 1662119,
"text": "Respiratory Therapy\nPt presents on .5 venti-mask, somnolent sats low 90's. BS diminished all fields. Intubated for impending respiratory failure. Orally intubated W 7.5 ETT secured @ 23 lip. Positive color change on easy-cap, Bilateral BS diminished RLL. CXR done awaiting official read. Plan: Wean FiO2 as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-14 00:00:00.000",
"description": "Report",
"row_id": 1662120,
"text": "MICU NURSING NOTES:\n\nPLEASE SEE CAREVUE FOR DETAILS.\n\nEVENTS :\nPT & INTUBATED. A- LINE INSERTED. NS BOLUSED FOR LOW BP & LOW URINE OUTPUT. PAN CULTURED.\n\nNEURO : AT THE BEGINING OF THE SHIFT PT UNRESPONSIVE TO VERBAL COMMANDS, OPENS EYES SPONTANEOUSLY, SUCCX & ETOMIDATE GIVEN PREINTUBATION & STARTED ON FENTA & VERSED GTT POST INTUBATION.DOSES TIRTATED & STOPPED TO MAINTAIN BP AS PT CONTINUED TO BE UNRESPONSIVE TO PAINFUL STIMULI. PUPILS 4 TO 5 MM, REACTING TO LIGHT BRISKLY. MOVED HIS TOES MILDLY TO PAIN ON SUTURING. CONTINUED ON LACTULOSE & RIFAXIMIN FOR HEPATIC ENCEPHALOPATHY.\n\nRESP : RECEIVED PT ON , INTUBATED & VENTED ON CPAP MODE, SEE CAREVUE FOR VENT SETTINGS & ABGS. CXR TAKEN. INITIALLY ET SECRETIONS WERE COPIUS & THIN, THEN SMALL THICK YELLOWISH OBTAINED. SPO2 96 TO 99 %. LS COARSE TO CLEAR DIMINISHED AT THE BASES.\n\nCVS : ST/NSR, NO ECTOPY SEEN. HR 90'S TO HIGH 130'S. S-NIBP 80'S TO 120'S. MAPS HIGH 50'S TO 80'S. S-ABP 100'S TO 110'S, MAPS 60'S TO 90'S. CVP 4 TO 10. TOTAL OF 250 MLS X1, 500 MLS X 3 OF NS BOLUSED. PLEASE SEE CAREVUE FOR LABS. INR ^,PLATELETS & HCT TRENDING DOWN ? & NA+ ^- ? NS BOLUSES. LACTATE TRENDING DOWN.\n\nGI : ABD ASCITIC, VERY DISTANT HYPOACTIVE BOWEL SOUNDS HEARD. NGT CLAMPED AFTER LACTULOSE ADMINISTRATION & CONNECTED TO INTERMITTENT SUCTION BEFORE THE NEXT DOSE OF LACTULOSE, BILIOUS DRAINAGE OBTAINED. CONTINUED ON LACTULOSE 60 MLS PO Q 3 HRLY & PR LACTULOSE 300 MLS QID. PASSED SOFT FORMED STOOL X 1, LOOSE SMALL STOOLS X 2.MUSHROOM CATH BLOCKS DUE TO SMALL CHUNKS. DIAPER PRESENT.\n\nGU : FOLEY DRAINING INADEQUATE AMTS OF MILDLY SEDIMENTED URINE. RESPONDED POORLY TO FLUIDS. RESIDENT AWARE. AS MD NOT TO ACTIVELY TREAT URINE OUTPUT AT PRESENT AFTER THE FLUID BOLUSES WHICH HAVE BEEN GIVEN. WILL DISCUSS ABOUT TREATMENT IN THE MORNING.\n\nID : AFEBRILE, PAN CULTURED. STARTED ON IV FLAGYL, CONTINUED ON VANCO & ZOSYN.\n\nENDO : FINGERSTICKS QID.\n\nSKIN : GROSSLY INTACT. HAS A PROTRUDING PROMINENT AREA OF BONE AT THE LOWER BACK.\n\nSOCIAL : SISTER WHO IS THE HCP CALLED, UPDATED ON STATUS.\n\nPLAN :\nCONTINUE MONITORING ABG'S ? WEAN FIO2.\nCONTINUE MONITORING LYTES/COAG/HEMATO/LACTATE/ AMMONIA.\nMONITOR URINE OUTPUT - ? ALBUMIN & LASIX.\nMONITOR FOR EFFECTIVENESS OF LACTULOSE.\nMONITOR TEMP CURVE, FOLLOW UP ON CULTURES, CONTINUE ANTIBIOTICS.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-14 00:00:00.000",
"description": "Report",
"row_id": 1662121,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV. BS essentially clear bilaterally w diminished RLL. Sx for copious amts thin green to thick yellow/green. Plan continue to provide ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-14 00:00:00.000",
"description": "Report",
"row_id": 1662122,
"text": "Resp Care\n\nPt remains intubated and currently vented on PSV 5/5 tol well with Vt around 800-900ML and MV 7-10L. BS course sxing for mod amts of thick yellow/bile like material after episodes of vomiting. WIll cont with vent support and make changes accordingly to maintain adequate oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-14 00:00:00.000",
"description": "Report",
"row_id": 1662123,
"text": "MICU Nursing progress note 0700-1900\nEvents: Vomited x2. CXR and KUB done.\n\nNeuro: Opens eyes to voice. Does not track or follow commands. Withdraws to pain. Moved L leg and head nonpurposefully. Not moving other extremities. PERRL, size . Fent/versed off for shift. Continues w/ lactulose/rifaximin.\n\nResp: Vented, pressure support. Settings 50%/5PS/5PEEP. ABG 7.43/37/115/25. TV's 700's-800's. RR 9-17. O2 sats 95-99%. Intact gag/cough. Suctioning small amts of green/yellow, thin secretions. LS-clear/dim bases.\n\nCV: NSR/ST, no ectopy. HR 89-109, periodically jumps to 120's. BP 110-129/59-75. MAP's 76-92. CVP 7-9. DP's and PT's weakly palpable. HCT 28.1(27.8), platelets 65(57). Awaiting albumin dose from pharmacy.\n\nID: Temp 97.7 ax. WBC 9.9. Lactate 3.2(3.9). Continues on vanco/zosyn/flagyl. Pan cultures pending.\n\nGI/GU: Abd- firm/distended, ascites. Hypoactive BS. Small amt of sediment in lactulose output, very sm soft BM. Vomited x2 (1 large, 1 med), undigested food/meds (whole pieces of food). Witnessed vomiting, suctioned mouth and ET tube immediately. CXR and KUB done. NGT to intermittent suction, ~400cc total out @ 1700. Foley-/clear. Output 8-35cc/hr.\n\nSkin: Intact. Freq turns/back care continued.\n\nSocial: Sister, , called updated on . Other family members referred to HCP for info.\n\nPlan: Assess neuro status and effectiveness of lactulose/rifaximin. Monitor resp status. Monitor for vomiting and aspiration. Continue monitoring labs including lytes, abg, lactate, and WBC. Monitor temp curve/continue antibiotics. No current plan to reverse TIPS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Report",
"row_id": 1662124,
"text": "MICU Nursing Note 1900-0700\nEvents: pt with large amts of stool throughout night, mental status improved with pt alert and following commands but with increased agitation and re- with Versed and Fentanyl, Hemodynamically stable, Hct down to 23.9\n\nNeuro: Increased responsiveness throughout evening, eyes open, following commands (ie: wiggling toes) , moving all extremities, several attempts to pull out tubes and lines, biting on , , attempt to mildly sedate with IV Propofol ineffective as BP drops and no change in mental status, re- with versed at 2 mg/hr and Fentanyl at 50mcgs/hr. Bilat soft wrist restraints to prevent pt from pullling at lines and tubes.\n\nCardiac: HR= 100-111 ST with no ectopy noted, Right radial aline site C/D/I and with good waveform, BP= 100-130's/50-60's, Right SC TLC site C/D/I and CVP= .\n\nResp: Lungs with coarse rhonchi throughout, prod. cough of large amts thick yellow sputum----and of large amts bilious liquid, remains intubated on CPAP+PS at 50% with PS=5 and Peep=5, MV+ , RR= , Sats= 97-98%, good ABG= 7.40-42-102.\n\nGI: Abd with large amt ascites, + hypoactive bowel sounds all quads, to ILWS draining 200ml of bilious liquid with debris, no vomiting overnight, med. with 6.25mg. of IV phenergan with good effect, able to tolerate all po meds via , Pt with Mushroom cath initially---but incontinent large amts liquid golden stool around cath so cath d/c'd. Lactulose enemas x 1 with good effect, po lactulose as ordered and held this am d/t large amts of continuous stooling all night.\n\nGU: Foley to CD draining clear urine 15-30ml/hr\n\nskin: jaundiced, intact\n\nID: Afebrile, WBC= 6, continues on IV Flagyl, Vanco, Zosyn\n\nSocial: No contact from family or friends overnight\n\nPlan: Wean sedation as tolerated, wean vent as tolerated, aggressive pulmonary toiletting, monitor labs, ? of transfusion for Hct drop to 23, Hold lactulose for large amts of stooling, support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Report",
"row_id": 1662125,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV. BS coarse diminished LLL. Sx for mod to copious amts thick, creamy yellow secretions. Placed on humidified circuit. ABG: WNL RSBI was six. Plan Wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-26 00:00:00.000",
"description": "Report",
"row_id": 1662138,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt lethargic, easily arousble to verbal stimuli. Oriented to person and occasionally place and date. MAE. PERL. Given lactulose pr and po for encephelopathy. Also rx'd with thiamine. Lido patch applied to R lumbar area for sciatica pain. Pt c/o chronic abd pain.\n\nResp - LS clear to coarse, diminished at bases. No wheezing noted. RR 7-14. 02 sat > 93% RA. Productive cough thick yellow green sputum. Sputum cx sent.\n\nC-V- HR 80-95 NSR, no ectopy noted. NBP 88-95/50's. + palp peripheral pulses. Hct 24.2 previously 26.3. INR 3.1. MD aware. CVP 8-11.\n\nGI - Abd firm and distended. +BS. Post-pyloric tube inserted in IR. NPO. + aspiration precautions. Pt c/o nausea. Medicated with 10 mg reglan iv with good effect. Mushroom catheter inserted. Pt passing copious amts liquid brown stool - ~1800ccs this shift. Sample sent for c-dif. No leakage of fluid noted from paracentesis site. Total bili 36.7. Rx's with miodrine and octreotide.\n\nF/E - Urine output slightly improved, averaging 30ccs/hr via foley - icteric in appearance. No fluid boluses administered.K 5.4 on previous shift. Given 30gms kayexelate via dubhoff. K 5.1 this am. BUN 59 Creat 1.6.\n\nID - Afeb. WBC 5.6. + contact precautions for MRSA sputum. Cipro prophylactically for SBP.\n\nSkin - Dry and jaundiced appearing. Sarna lotion applied. No areas of breakdown noted.\n\nAccess - RIJ functioning well. Awaiting PIC eval.\n\nSocial - Sister called for update on pt's condition.\n\nA+P - Continue to monitor mental status closely. Lactulose as ordered for encephelopathy. Aspiration precautions. Monitor f+e status and assess for bleeding, given elevated INR. Follow-up on cx results. Emotional support to pt and sister.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-04 00:00:00.000",
"description": "Report",
"row_id": 1662113,
"text": "resp care - Pt was intubated with #7.5ETT,19@teeth for airway protection. Initially, pt was sx'd for copious amts of thick, white secretions. After NG insertion attempt, pt was sx'd for copious amts of thick, bloody secretions. Pt transported to CT for head scan w/o incident. See carevue for more details. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-05 00:00:00.000",
"description": "Report",
"row_id": 1662114,
"text": "TSICU Progress Note 1900-0700\n Improving neuro status overnight,cont w/borderline BP/ u/o\n ROS\n Neuro- awake off Propofol, obeys commands, MAE but weak.\n CV- MP SR, BP 90-100, extrems cool/dry, pp+/SCD's.CVL in place w/bleeding at site. PLT=50's, Hct 32\n Resp-CMV14/400/40%/5- ABG=7.46-28-186-21 on 60%.LS coarse, sxn thick lt.brown. ETT advanced to 23cm\n GI- bs+, freq loose stools.\n GU-Foley in place, u/o borderline, icteric, clear\n Labs- unchanged, K=3.9\n Plan- Wean as able,pulmonary hygiene\n monitor electrolytes,LFT's\n Analgesia/esdation as needed\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-05 00:00:00.000",
"description": "Report",
"row_id": 1662115,
"text": "Respiratory Care\n\n\n Pt received on A/C FI02 decreased and then placed on PSV in A.M. RSBI 25 Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-05 00:00:00.000",
"description": "Report",
"row_id": 1662116,
"text": "resp care - Pt extubated w/o incident. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-05 00:00:00.000",
"description": "Report",
"row_id": 1662117,
"text": "Encephalopathy\n\nEvents: fluid boluses x2 for low urine output\n extubated\n\nPt is alerted and oriented. He is asking appropriate questions, wants to eat, c/o diffuse abdominal pain.\n\nVSS-no hypotension. Pneumoboots on.\n\nExtubated at 2:30pm- now on 3L NC with sats 98% RR 16-productive cough. Breath sounds coarse.\n\nFluid bolus NS 500cc x2 for u/o<10cc/hr\n\nPt taking water with meds-bowel sounds present. Continues to receive Lactulose as ordered-sm. amt. soft stool and good results from Lactulose enema.\n\nSkin intact. Pt remains afebrile. IV antibiotics discontinued.\n\nPt spoke with sister and mother by phone.\n\nPlan: Continue to monitor for encephalopathy; increase activity as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-12 00:00:00.000",
"description": "Report",
"row_id": 1662158,
"text": "condition update\nD: pt alert and follows commands. c/o neck pain after dialysis catheter insertion med. x1 with fentanyl with good response. slept and sleeepy after dialysis run.\ncardiac: pt nsr rate 60-80. sbp greater than 100. pt tolerated hd well with 1liter fluid removal. sbp remained greater than 100 during dialysis.\nresp: pt remains on 3l nc. breath sound are diminished in the bases. pt continues to cough and raise and use the tonsil tip suction.\ngi; pt tolerating liquids well. refusing food. pt taking lactulose q2 hrs and no stool yet.\ngu: minimal urine and micu team aware. pt tolerated dialysis and fluid removal. foley and urine culture sent.\nskin: no areas of breakdown note.\na: monitor for hypotension,.monitor for pain. monitor neuro for confusion and sleepiness.? transfer to floor today if doing well.\nR: pt tolerated dialyis. pt sleepy after dialysis but easily arousable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-12 00:00:00.000",
"description": "Report",
"row_id": 1662159,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT , SOMEWHAT LETHARGIC AT TIMES, FOLLOWS COMMANDS. ORIENTED TO SELF, INCONSISTENTLY TO PLACE, MUTTERING WORDS OCCASIONALLY. MIN C/O GENERALIZED PAIN. HR 50-70S, NSR/SB, DOWN TO 40S SINCE HD INITIATED, SBP 90S-110S. TRANSFUSED 1UNIT PRBCS FOR HCT 22. CRRT STARTED FOR CONT FLUID OVERLOAD PER RENAL, RUN EVEN. GEN EDEMA, PALP PP. O2 SATS 95-100% ON 3L N/C, NARD/SOB. LUNGS COARSE, DIMINISHED AT BASES. ABD FIRM, DISTENDED, HYPO/+BS. PT REFUSING MEDS/LACTULOSE, POOR PO INTAKE THIS AM, PR LACTULOSE ORDERED Q4. PT W/LGE AMT LIQUID STOOL VIA RECTAL FOLEY. TPN CONT, NGT TO BE PLACED IN ?IR, BETTER PO INTAKE THIS EVE. MARGINAL U/O, CONCENTRATED, SOME SEDIMENT NOTED. AFEBRILE, BEAR-HUGGER ON FOR COMFORT.\n\nPLAN: CONT HEMODYNAMIC MONITORING, CRRT, SERIAL LABS. MENTAL STATUS, LACTULOSE AS ORDERED FOR ENCEPHALOPATHY. PLAN FOR NGT IN IR, CHANGE TO TF ONCE NG PLACED. FAMILY/EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-13 00:00:00.000",
"description": "Report",
"row_id": 1662118,
"text": "MICU Nursing progress note 0700-1900\nEvents: Admitted from 10.\n\nNeuro: Responds to pain by withdrawing. Does not follow commands. Does not move extremities on bed. With suctioning can move L arm towards NGT. PERRL, dialated, jaudice. Roving eyes. No seizure activity noted. Continues on lactulose PO and PR.\n\nResp: On venti mask-50%. O2 sats 95-99%. RR 14-24. Gag intact. Weak cough. suctioned small amt whitish, thick secretions x2. LS-rhonchi w/ dim bases. O2 sats increases while on L side. ABG 7.49/Po2 70/PCo2 30.\n\nCV: NSR/ST w/ no ectopy. HR 89-121, periodically increases to 130's. HR decreases to high 90's while on L side. BP 102-132/57-74. DP's palpable. CVP-7.\n\nID: Temp 100.4 Rectal. WBC 15 (4). Lactate 5.7 (2.2). Continues on vanco/zosyn.\n\nGI/GU: Abd-firm/very distended. Decreasing bowel sounds throughout shift. No BM. FS:128-138. NPO. NGT- minimal residual, placement checked. Foley-/clear. Output decreasing during shift. Currently ~5cc/hr. Bladder pressure-14.\n\nSocial: Full code. Family called. Sister, , updated on .\n\nPlan: Monitor resp status/ABG/lactate/WBC/HR. Assess neuro status. Assess need for ?intubation. Continue antibiotics. Monitor BS, continue lactulose. Assess for effectiveness of lactulose.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-16 00:00:00.000",
"description": "Report",
"row_id": 1662170,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt is alert and orientated. Medicated x 2 overnight with morphine ivp with good effect. Pt assisting with turning in bed. Lungs clear o2 weaning as tolerated. Pt pulling off o2 face mask so placed on nasal cannula and abg pending, sats >95%. HR SB 50s most of night without ectopy. SBP 130-140. Continued ; please refer to carevue for details. Attempting to run pt +100cc/hr on dialysis. Minimal urine output and pt is to start on bladder irrigation q 24 hours x 3 days for yeast in urine. JP x 2 with lateral one putting out lg amounts of serosang to serous drg. Lat changed to large bulb. Medial with minimal out. Left staples oozing serous turning serosang drg in copious amounts. Drg collection bag placed and MD and MD team have been notified. This drainage is being included now in 1/2cc:cc replacements per d/t lg quantities. Abdomen is firm and hypoactive. Pt is requesting food but not feeling any flatus yet. Team will discuss on rounds. Sips of water with meds. Plan: cont CVVHDF ?will tolerate HD. ?resume diet. Physical therapy. O2 weaning. Bladder irriations . Encourage turning and repositioning. PLease refer to carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-13 00:00:00.000",
"description": "Report",
"row_id": 1662160,
"text": "focus hemodymics\ndata: neuro: moves all extremities on the bed. moves from side/side. pupils react equally and briskly. assists with personal care.\n\nresp: o2sats 95-100%. o2 on at 3liters . breath sounds diminshed and needs to take deep breaths. pt complains of abd pain when taking deep breaths.\n\ncardiac: in nsr. bradycardic to the 40's. 1unit of prbc given. hct this am 24. plts 47. k 4.4. picc line in left arm patent.\n\ngu: foley patent and draining small amts of amber-icteric urine with sediment. u.o 0-45cc q1hr. crrt tonite. tolerating well. bp > 100. pulling fluid off. potassium and calicium iv infusiing. filter clotted at 0600am. dr from renal called and crrt stopped. will dicusss plan on rounds. crrt vs hemodialysis.\n\ngi abd firmly distended. tpn infusing. stooling. lactolose po and lactolose pr given. large amt of liquid stool. mental status improved.\n\nsocial. sister called and update given. pt cooperative tonite. long talk tonite regarding importance of meds and following directions from the medical team. support given to him.\n\nresponse: mnitor closely\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-16 00:00:00.000",
"description": "Report",
"row_id": 1662171,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT, ORIENTED X3, MEDICATED WITH 2MG MS FOR PAIN Q3-4HRS WITH GOOD RELIEF.\nCV: AFEBRILE. HR 70'S NSR. SBP 110-140.\nRESP: BS CLEAR. NC AT 5 LITERS WITH SAT>95%. COUGHING AND RAISING THICK TAN SECRETIONS. USING IS WELL\nGI: ABD SOFTLY DISTENDED. STARTED ON CLEAR LIQUIDS BUT PREFERS FULL LIQUIDS.\nGU: CRRT D/C'D THIS AM. GIVEN LASIX 120MG IV X1. HUO 80-100\nENDO: BS 124-158 TX'D WITH SLIDING SCALE X2\nWOUND: LEFT SIDE OF ABD INCISION DRAINING COPIOUS AMTS SEROSANG DRAINAGE- POUCH REMOVED BY LIVER TEAM, MULT SUTURES PLACED BY LIVER TEAM AND TEAM TO STOP DRAINAGE. ABD US DONE TODAY TO ASSESS FLOW.\nA/P: CONT TO MONITOR HEMODYNAMICS, ENCOURAGE PULM TOILET, OOB TO CHAIR WITH ASSISTANCE= TOL WELL, ? TRANSFER TO FLOOR LATER TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-25 00:00:00.000",
"description": "Report",
"row_id": 1662136,
"text": "MICU NPN 2300-0700\nReview carevue for all additional data\n\nAllergy:PCN,Zofran,Trazodone,phenobarbital,compazine and oxycodone\nCode Status: Full\nAccess: Rt IJ\n\n45 yo male with h/o cirrhosis,ETOH and HCV,HBV, grade 11 esophageal varices,recurrent ascitis and s/p TIPS complicated by severe and recurrent encephalopathy. Brief MICU stay for unresponsiveness and intubation and treated with antibiotics for aspiration pneumonitis. Continued on lactulose for encephalopathy and this evening after going to bathroom patient said he is weak and become unresponsive, vital signs was stable, Patient transfered to MICU for possible intubation and CT head and further management. Since admission patient was haemodynamically stable, and later MS improved to baseline, confused, following commands. He said \"He was in deep sleep\". CT head done results pending. US abd complete study pending to reevaluate about TIPS and kidneys.\n\nNeuro: MS improved ? to baseline, Confused, following commands and MAE. Ct head done. ? continue lactulose for encephalopathy. denies pain.\n\nResp: Up on admission was on NRB and weaned O2 to room air and O2 sats 93-96%. Bilateral lung sounds clear and diminished at the base. Unproductive weak cough present. breathing unlaboured.\n\nCv: NSR without ectopy, SBP 80-90(baseline), no fluid bolus given. Cvp 6-9 ? dehydrated with loose stool. Awating US abdomen. Blood culture done with AM labs.\n\nGi/Gu: NPO, doboff placement need to be confirmed? to advance further.\nAbd firm distended. no bowel movements this shift. UO 5-15ml/hr, MD aware,^^ BUN/Creat. Abd US results pending.\n\nSkin: Intact, jaundiced.\nSocial: Sister called, updated .\nPlan: Monitor MS and continue lactulose\n Need to confirm placement of doboff or new tube to be placed.\n F/u Head Ct and US abd\n routine care and support\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-25 00:00:00.000",
"description": "Report",
"row_id": 1662137,
"text": "MICU 6 NPN 0700-1900\n\nNeuro: Pt lethargic and oriented to person and place most of the time, occasionally unable to state place. Some conversation has been inappropriate for situation, but he can be reoriented. PERL brisk. Pt follows commands. He is able to MAE with equal strength bilat.\n\nCV: NBP 86/54-96/56 with MAP 57-67. HR 83-96 NSR with no ectopy noted. PT had no c/o of CP. Most recent K 5.4 up from 5.3, team aware and will address (see carevue). No peripheral edema, pos pedal pulses, pos radial pulses. CVP 4-15 did respond to fluid bolus.\n\nResp: Pt on RA with sats 91% (when asleep)- 97%. Initially LSCTA bilat with dim bases, ?asp of fluids while taking PO meds, now RUL coarse and pt coughing more frequently. He states he can not bring up the phlegm. Atrovent neb given x1, pt refused 2nd neb.\n\nGI/GU: Abd firm and distended with pos bowel sounds. No BM this shift. Pt orderred for lactulose enema which he was refusing for few hours, will continue to encourage. Pt pulled out doboff this AM. He needs replacement in IR, team aware. Abd tapped for diagnostic purposes. Foley flushed and patent drainning insufficient amounts of icteric urine. Pt given fluid boluses and albumin x3 today with little improvement in UOP. Cr 2.2 up from 1.5, renal team consulted.\n\nAccess: R IJ tlc, PICC eval orderred\n\nID: Tmax 97.1 PO. Pt on PO cipro, ?change to IV for ?asp.\n\nSocial: RN spoke with pt's sister x2 and updated on .\n\nPlan:\nroutine ICU monitorring.\nContinue to monitor labs and lytes.\n?asp, no PO intake\nMonitor MS lactulose\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-17 00:00:00.000",
"description": "Report",
"row_id": 1662134,
"text": "MICU 6 NSG 7A-7PM\nRESP--PT CONTS ON 4L NC WITH O2 SATS ?94%. PT TO 88% ON RA. LUNGS CTA, PT REF TO DO IS. STRONG PRODUCTIVE COUGH, WHEN PROMPTED, BUT WILL REF TO COUGH AS WELL, SWALLOWS EXPECTORATED SECRETIONS.\n\nNEURO--PT ALERT AND OX 0-2 THIS SHIFT. KNEW MONTH, YEAR AND PLACE THIS AM, THIS AFTERNOON, HALLUCINATING, THINKS DAUGHTER IS HERE IN ROOM AND \"TRAINING FOR A RODEO\". REORIENTED FREQ, BUT REMAINS CONFUSED, YELLING OUT. PT OOB TO CHAIR, AND LESS RESTLESS, WHEN IN BED, CONSTANTLY TRYING TO CLIMB OUT OVER SIDE RAILS. NA 153 THIS AM, AND STARTED ON D5W AT 200CC/HR X2.5L. PT TARTED ON CLEAR LIQUIDS FOR C/O EXCESSIVE THIRST, AND TOL WATER WELL.\n\nCV--REMAINS IN SR 80-100'S, NO ECTOPY NOTED. ALINE D/C'D. K REPLETED THIS AM. PLANS FOR PM LYTES. CVP MONITORING D/C'D.\n\nGI--ABD DISTENDED ASCITES, PT C/O INTERMITTENT ABD PAIN WITH PALPATION, RESOLVES WITH REPOSITIONING, ? R/T ASCITES IN ABD. FLEXISEAL TUBE DRAINING LARGE AMOUNTS LIQUID GOLDEN STOOL, AND LEAKING COPIOUS AMOUNTS AROUND CATH. PT WITH 2L MEASURABLE STOOL OUT, PLUS COPIOUS AMOUNTS LEAKING. PER I/O PT HAS HAD 4L PLUS LEAKAGE STOOL OUT IN LAST 2 DAYS. LACTULOSE D/C'D AND TEAM WILL REEVAL LATER THIS EVENING.\n\nRENAL--FOLEY CATH IN PLACE DRAINING ICTERIC CLEAR URINE. 25-50CC/HR.\n\nSOCIAL--SISTER PHONED FOR UPDATE. STATED SHE WANTED TO SPEAK WITH MEDICAL TEAM, MESSAGE PASSED ON TO MICU AND HEPATOLOGY SERVICE.\n\nPLAN--PM LYTES\n-FREE WATER FOR HYPERNATREMIA\n--REORIENTED PRN\n--C/O TO 10 AND AWAITING BED\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-17 00:00:00.000",
"description": "Report",
"row_id": 1662135,
"text": "MICU 6 NSG 7A-7PM\naddendum--pt with bed on 10. Pt to have bedside sitter at 1900, report claaed to floor, and pt will be transferred when sitter has arrived.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-04 00:00:00.000",
"description": "Report",
"row_id": 1662112,
"text": "Nursing admit note.\n45 y/o male originally admitted from Hospital for worsening hepatic enchephalopathy with elevated ammonia levels.\n\nPMH significant for end stage liver disease, hep c, hep b, chronic pancreatitis, grade 2 esophageal varices, GERD (barretts esophagus), COPD and s/p L2L4S1 fusion and s/p incarcerated umbilical hernia repair , admitted - for concern of cellutlitis around his surgical incision, 7 day course of antibiotics given at that time\n\n\n >TIPS procedure performed ?? Failure > attempted, but failed revision > ? tips ocluding right portal vein causing retro-grade left portal vein flow > plan was to go monday for revision of TIPS again.\n\nThis morning on rounds patient was obtunded which was different from his exam the night before when he was ambulating & oriented x2. ? ability to protect airway > transferred to T/Sicu on MICU service to monitor resp and neuro status.\n\nEVENTS: patient not arousable upon admission (reason for transfer) > team made decision to electively intubate patient and obtain head CT to r/o ICH and to place NGT to administer PO lactulose. patient intubated by anesthesia without difficulty > CXR pending to confirm ETT placement. travelled to Head CT without incident, safe return to unit.\n\nROS:\n\nNEURO: pre-intubation patient minimally responsive to stimuli. moaning intermittantly> roving eye movements with ? pupils dilated to ~ 6, reactive to light. no localizing to sternal rub, + weak gag, +cough, +corneals. does not follow commands. minimal movement noted in extremities. post intubation > patient started on propofol gagging on ETT and discoordination with vent. neuro exam essentially remains the same on small amount of propofol > tolerating ETT better now.\n\nCV: HR 80s-100s, SR. slighlty hypotensive, given IVF bolus 500cc NS x2 for low urine output and hypotension. +pp.\n\nRESP: intubated as noted above. O2 sats 99-100% ~ no ABG post intubation. LS coarse t/o suctioned for copious thick brown secretions (sent for cx), now bloody secretiosn post intubation & OGT placement.\n\nGI: OGT placed for med administration. ascites. +hypo BS. lactulose enema given. results pending.\n\nGU: poor urine output. icteric, +fluid responsive.\n\nID: afebrile. started on vanco and zosyn for ?aspiration pneumonia. pan cultured today.\n\nSKIN: jaundice, otherwise intact.\n\nSOCIAL: sister, is HCP, patient also has ?exwife who visited with friend today. is hesitant to allow exwife to visit to past problems with patient's substance abuse and hospitalizations. social work involved.\n\nPLAN: administer lactulose as ordered. ? diet. ? wean vent as tolerated. CT scan results. ? need for aline given intubation. monitor & support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-15 00:00:00.000",
"description": "Report",
"row_id": 1662166,
"text": "Respiratory Care:\n\nPt remain orally intubated & , received post liver transplant on full ventilatory support. We were able to switch to minimal PSV. He is and able to nod appropriatly to questions. His respiratory effort are shallow, off sedation. Plan: wean to elective extuabation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-28 00:00:00.000",
"description": "Report",
"row_id": 1662144,
"text": "MICU Nursing progress note 0700-1900\nNeuro: Opens eyes to voice. Confused, not answering questions appropriately. Increasing confusion throughout shift. Unable to focus eyes. Not following commands consistantly. Moving extremities weakly on bed. PERRL.\n\nResp: LS-coarse w/dim bases, occational wheeze. Atrovent given w/good effect. RR 10-17. O2 sats 92-99% on 4L NC. Productive cough but not a very strong cough.\n\nCV: NSR, no ectopy noted. HR 64-75. BP 94-101/52-68. DP's palpable. HCT 21.3, 1 unit PRBC given. 1 unit of FFP given, now awaiting PICC placement.\n\nID: Afebrile. WBC 2.8. Started on vanco and cefepime.\n\nGI/GU: Abd- ascites. +BS. Liquid stool- mushroom in place. New doboff placed via fluoro s/p pt pulling tube out. TF currently off d/t nausea, given reglan w/moderate effect. Foley-icteric/sediment. Output 20-45cc/hr.\n\nSkin: Intact, jaudice throughout.\n\nSocial: Mother called. visitors.\n\nPlan: ?Bedside PICC placement. Monitor neuro/resp status. Continue lactulose. Continue antibiotics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-01 00:00:00.000",
"description": "Report",
"row_id": 1662145,
"text": "MICU NPN 1900-0700\n\nNo significant events overnight,\n\nNeuro: Some improvement in MS, oriented to place and person, encephalopathic, pulling off tubes/pulled out dobhoff, bilateral wrist restraints are in place, but still patient could bend forward. No complaints of pain, but icteric, sarna lotion applied and on lactulose\n\nResp: On O2 4L nasal canula, O2 sats 97-100%. Bilateral lung sounds coarse and diminished at the base. unproductive congested weak cough present. RR 10-14.\n\nCv: NSR 70-80's without ectopy, SBP 90-100. CVP 7-11. Awaitting AM labs. RIJ in place, for PICC line placement today. HCT 25.4, 3.3 and FFP prior to PICC line. Continued on albumin 50gm once daily.\n\nGi/GU: ABd distended, ascitis, collection bag place with old puncture site with large drain,. Mushroom cath in place large golden liquid stool. TF restarted, but patient pulled doboff and need to be replaced in IR. UO 40-80ml/hr.\n\nSkin: Jaundiced, skin intact.\nSocial: No call from family overnight.\nID: Afebrile, continued on antibiotcs.\n\nPlan: For PICC/dobhoff placement today\n Continue with lactulose/TF\n SKIN care/ position change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-01 00:00:00.000",
"description": "Report",
"row_id": 1662146,
"text": "MICU Nursing progress note 0700-1900\nNeuro: Alert. Currently ox3. Less confused throughout shift. MAE weakly on bed. PERRL. Does well w/ limit setting and encouragement. Discouraged w/ current situation. Continues on PR lactulose\n\nID: Temp 93.9 PO. Continues on antibiotics.\n\nResp: LS-clear/coarse w/ dim bases. RR 12-19. O2 sats 95-100% RA. Productive cough when encouraged.\n\nCV: NSR. HR 70's to 80's. Large amt of ectopy s/p PICC insertion, PICC pulled out back 2cm x2 by resident. R IJ taken out. DP's palpable.\n\nGI/GU: Doing well w/ thickened food and reglan. Abd-soft/distended. +BS. Mushroom cath in place.\n\nSkin: Freq position changes. Intact and jandice.\n\nSocial: Several phone calls to family/friends.\n\nPlan: Monitor MS/ continue lactulose. Support family/patient. Monitor for change in ectopy. Continue w/ antibiotics. Continue thickened food/liquids.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-09 00:00:00.000",
"description": "Report",
"row_id": 1662153,
"text": "NURSING\n VSS OVERNIGHT. NSR, NO ECTOPY. WAS ALERT AND ORIENTED AT THE BEGINNING OF THE SHIFT. REMAINS ALERT AND ORIENTED X 3, BUT BECOMING ARGUMENTATIVE, FRUSTRATED, SWEARING, CALLING OUT. PER MICU TEAM, WILL CHANGE LACTULOSE FROM 60 ML TID TO 30 ML Q 2 UNTIL CLEAR. TOTAL BILI UP AGAIN TODAY. SEE CARE VUE FOR ALL LABS. MICU TEAM AWARE OF ALL LAB ABNORMALITIES.\n LUNGS CTA ALL FIELDS, REMAINS ON ROOM AIR WITH O2 SATS 95-98%. FOLEY WITH SMALL AMOUNTS URINE OUTPUT. STOOLED 5 TIMES OVERNIGHT IN SMALL TO MEDIUM AMOUNTS.\n CONTINUE TO MONITER HEMODYNAMICS. MENTAL STATUS. CONTINUE LACTULOSE TILL CLEAR MENTALLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-09 00:00:00.000",
"description": "Report",
"row_id": 1662154,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt alert and oriented x3. Very anxious and agitated; frequently yelling out this morning and frequently on the call light. Pt very upset of ICU stay. Stated that he wants to \"go home.\" Emotional support provided. Needs much encouragement. Clear speech. Follows commands and moves all extremities. Pt frequently attempted to get out of bed this morning. Patient frequently monitored by RN and PCT. All siderails up and bed alarm on. Pt reminded to press call light before getting out of bed. Lactulose increased to q2hr; pt refused 2 doses of Lactulose. BM x3 this shift. Pt c/o abdominal pain. Tylenol given x1 without effect. Per Dr. , fentanyl 12.5mcg IV given x1 with +effect. Pt stated that abdominal pain relieved after paracentesis. Afebrile. HR 60s-90s (NSR). NBP 80s-low 100s/40s-60s. Pt with +2 BLE edema. DP/PT pulses easily palpable. Pt refused venodyne boots this morning, but agreed to put them on in the afternoon. 4units FFP and 1 platelet given prior to ultrasound-guided paracentesis (2L removed). Platelet: 58; 2.4 after 2units FFP. Pt with severe epistaxis after pt sneezed this afternoon; MICU team in room to assess pt. Left nare packed with gauze and pressure applied for 30minutes. Packing removed at 1900 d/t pt desatted during sleep. O2 sat increased to >98% after packing removed. Lungs clear; + expiratory wheezing at times. Albuterol/Atrovent nebs given x1 with +effect. O2 sat WNL on room air. Pt with weak cough; non-productive. Abdomen firmly distended and tender. Abd softly distended after paracentesis. Tolerating diet well. Pt c/o nausea; relieved without med intervention. No emesis. BM x3 this shift; liquid, stool. Pt gets out of bed to commode with 1 assist; steady gait. BS 107-146. Foley intact with icteric urine. Low urine output (see CareVue). UA sent. Bladder pressure prior to paracentesis: 28 (Dr. and Dr. aware). No pressure sores noted. Jaundiced. Pt turns independently in bed. OOB to chair with 1-2 assists. Pt frequently speaks to family on his cell phone. sister updated by this RN (over the phone) on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Lactulose q2hr as ordered. Pt needs to be monitored closely; siderails up and bed alarm on. Monitor for pain. Provide emotional support. Needs much encouragement. Update pt and family on plan of care. Continue ICU care and treatment. Transfer to floor when private room availabe (pt on contact precautions).\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-15 00:00:00.000",
"description": "Report",
"row_id": 1662167,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt on Ppf gtt for most of the night, but Ppf off at 0400 per Dr. . Off sedation, pt opens eyes spontaneously and when name is called. . +corneal reflex. Follows commands and moves all extremities. Mouths words and nods/shakes to RN's questions. Impaired gag/cough reflex. Morphine 1-2mg IV given for incisional pain with +effect. Afebrile. Warm blankets applied over pt. HR 50s-70s (sinus brady/NSR; no ectopy noted). ABP stable (see CareVue). PA#s: 28-30s/16-22. Dr. aware of decreased cardiac output this morning (CO 5.7-6). 1/2 NS increased to 90cc/hr. D5 1/2NS at 10cc/hr. Per Dr. , goal CVP 12. See CareVue for hourly CVP, CO, CI. CCO/PA line will be changed to triple lumen central line per Dr. . PICC line patent. Pt with +2 pedal edema. DP/PT pulses easily palpable. Venodyne boots on BLE. Lungs clear. Current vent setting: CPAP 40%, PEEP 5, PS 5. RR 5-7 on CPAP. Extubate today. Abdomen softly distended with hypoactive bowel sound. NPO. NGT to low continuous suction with bilious/brown output (250cc output this shift). No bowel movement. FS q6hr; BS 155-210 (treated with regular insulin sliding scale). Dr. changed RISS this morning d/t hyperglycemia. Foley intact with clear, icteric urine. Low urine output. CVVHDF continued. Per Dr. and Dr. , goal is to keep pt +100cc/hr; unable to meet goal d/t large amount of JP output (SICU and transplant HO aware). JP x2 to bulb suction. JP #1 with small amount serous output. JP#2 emptied q1hr. Output from JP #2 was serosanguinous at beginning of shift, but is now serous. No pressure sores noted. Pt turned and repositioned q2-3hrs to maintain skin integrity. Primary dsg over abdominal incision intact; moderate amount serosang drainage from incision. sister called x2 overnight; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Extubate today. CCO/PA line will be changed to triple lumen central line today per Dr. . CVVHDF; goal is to keep pt +100cc/hr. Labs q6hr while on CVVHDF. Potassium/calcium sliding scale as ordered. Monitor output from JP drains and NGT. Monitor abdominal incision for sign of infection. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-15 00:00:00.000",
"description": "Report",
"row_id": 1662168,
"text": "resp care - Pt extubated w/o incident. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-15 00:00:00.000",
"description": "Report",
"row_id": 1662169,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Extubated at 1800. alert & oriented x3, MAE, morphine prn for pain, co operative after extubation even though was very agitated with ETT .pleasant.\n\nCV: NSR- SB, HR: 56-85, no ectopy noted, SBP 130's, IVF dc'd by Dr. as + 1L from MN, cont with 1/2cc: CC replacement for lat Jp out put hrly. ++PP, + edema LE, team aware.CCO swan removed today and wired with triple lumen CVL, CXR--> kinked, pulled out 4cm by Dr., cxr rpted, waiting for confirmation from MD, 12.5gm alb for Jp output >1L per primary team.denies CP or discomfort.\n\nResp:Was on vent,extubated at 1800, on facemask now, LS clear, sxn thick yellow secretion large amt when on vent, now expectorating,ABg resp acidosis on vent,O2 sat 90-98%.\n\nGI: Abd softly distended, hypoactive Bs, initial post op dressing changed by Dr., noted some oozing SS drain from surgical site after extubation when pt coughed, Dr. informed,NGT removed after extubation per primary team.JP draining serous drainage, lateral one draining more.team aware.\n\nGU: Foley cath patent with icteric urien 5-20ml/hr, on CVVHDF, pls see flow sheet for details, replacement fluid changed to B23K2 as K+ was elevated this am,goal + 100ml.seen by renal team, started with citrate as filter pr rising up.\n\nEndo: Bld sug q6h, oN SSRI.\n\nID: Afebrile, on anbx.\n\nAct: turned in bed, skin intact.\n\nSocial;Pt;s sister called up x2, updated with her .pt is talking to the wife by telephone now .\n\nPlan: cont monitoring, cont CRRT, LABS at per renal team, support to patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Report",
"row_id": 1662130,
"text": "Resp Care\n\nPt extubated this eveing to 50% cool aerosol s/p successful SBT with good cuff leak noted. BS slightly course and pt expectorated small amts of thick yellow secretions on own with strong cough and gag noted. WIll cont to monitor for s/s fatigue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-02 00:00:00.000",
"description": "Report",
"row_id": 1662147,
"text": "1900-0700 NPN\nNEURO: long and short term memory intact. limit setting contracting starting with pt.\n\nCV: sys 100's, sinus, afebrile, urine out icteric and sufficient. jaundice, skin and oral cavity dry. if lays on left side pt. has runs of vtach, maintains mentation and bp. resolves with turn off left and onto back spont.\n\nRESP: room air, stronger cough than prev., prod for clear sputum with flecks yellow and red\n\nGU/GI: icteric urine, abd rounded BT active, tol. lactulose enema, serous drainage from puncture site on right abd. rectal pouch replaced for leakage to collect serous fluid and protect skin.\n\nACCESS pt. with . noted runs of Vtach as above. 2 pull backs and 2 xrays done. HO aware. will repeat xray at 0800 and reeval position of catheter.\n\nPAIN: c/o lower back pain, tylenol given with some result.\n\nID: vanco. trough level done. contact isolation\n\nSKIN: puncture site drainage as above, skin very dry, no breaks in skin. using barrier and sarna screen.\n\nSOCIAL: sister involved in care, pt. called and spoke with wife.\n\nPLAN: possible call out to gen. floor today. supportive care, limit setting for pt. regarding calling out and use of call bell. reassure pt. he will get care. involve in care plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-02 00:00:00.000",
"description": "Report",
"row_id": 1662148,
"text": "45 y.o. ETOH cirrhosis, Hep B&C with failed TIPS awaiting liver transplant. See admit note for full PMH.\n\nFull Code\nContact Precautions-MRSA sputum\naccess: L PICC\nAllergies: PCN, Zofran, Toradol, Tazodone, Phenobarb, Compazine, Oxycodone. Food allerg: Pineapple.\n\nNeuro: Alert and oriented x2-3. Follows commands consistently. Moves all extremities strongly. PERL. OOB ambulated around unit holding on to wheelchair handles with RPT. Sat up in recliner for several minutes and then requested to go back to bed. Balance slightly unsteady when he first stands up. Sleeping this afternoon, arousable but falls back to sleep after care/activity complete.\n\nResp: Room air, SAT 94-98%. Encouraged to cough and deep breathe. Lung sounds clear upper fields, coarse in bases. Occaisional nonproductive congested cough.\n\nCV: HR 60-70's NSR. BP 98-110/55-70. Palpable pedal pulses. HCT=26.2, plt=49, PT=31.9, PTT=75.6, =3.3. No episodes of VT this shift. Repeat CXR taken of PICC line position, unable to visualize line, so taken again with leads removed from chest. No read yet on latest CXR.\n\nGI: Noted small amount of blood in oral cavity, on palate and gums. MD ordered a vitamin C level, and vitamin C tablets for ? scurvy. Patient is also receiving Octreotide SC, and coags are as noted above. Patient tolerating Thickened liquids and soft thick solids (pudding, applesauce, cream of wheat). Encouraged to take small bites, and to cough after swallowing if he becomes congested. Taking PO meds crushed in applesauce. Calorie count ongoing for , , . Patient has pulled out several NGTs, no plan to replace at this time. Draining liquid light brown stool from mushroom cath this morning. Lactulose enema x1 @1200, enema returned but no further stool yet. Order then changed to Lactulose PO 30ml TID.\n\nGU: Foley cath draining ichteric urine, 20-80cc/hr.\n\nID: Afebrile. Cefepime and Vancomycin IV Q24hrs. Vanco dose held today for Vanco trough=25. Treating for suspected aspiration PNA, sputum cultures from MRSA, Klebsiella, Yeast, GNR. Urine and blood cultures neg, C-Diff cult neg.\n\nSocial: Patient spoke to his wife and his sister today. Now has calling card number so he can call from his room phone. need assist. Wife updated by RN. Social worker from came to see patient at RN request as he was feeling frustrated and anxious regarding his transfer to (no bed available). Limit setting with patient by RN regarding very frequent calling out and call bell use also caused him frustration and anger. Appears to be coping better this evening.\n\nPlan: Called out to tele, no bed available yet. Monitor mental status, Lactulose as ordered. Continue to mobilize OOB as tolerated. Taking PO with supervision, sitting upright, thick liquids and puddings.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-08 00:00:00.000",
"description": "Report",
"row_id": 1662149,
"text": "Focus:Adm\nData:\n45yo male with h/o cirrhosis, HCV, HBV, Grade II varices, portal hypertension, ascites,s/p TIPS with waxing and encephahalopathy who acutely decompensated on 10, becoming unresponsive even to painful stimuli.\n\nOn arrival to SICU he was awake, alert and oriented x3, moving all extremities with normal strength. Complained of abdominal pain and was given Tylenol with some relief. Head CT was done with normal preliminary findings.\n\nHe is afebrile, although at times he complains of shaking chill. Lungs are bilaterally clear on 3L NC O2 with sats 97-98%. CXR done.\n\nAbdomen is firm and distended with positive bowel sounds and tender to exam.\n\nFoley with low urine output due to renal failure, creat =3.0, urine is icteric. Albumin 25% given.\n\nPlan:\nContinue to monitor in SICU for now, may be transferred back to 10 if stable in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-08 00:00:00.000",
"description": "Report",
"row_id": 1662150,
"text": "0700-1500\nsee transfer note\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-08 00:00:00.000",
"description": "Report",
"row_id": 1662151,
"text": "\n NEURO PT A/O RELAXED IN GOOD SPIRITS SEEMS TO UNDERSTAND CARE GIVEN BRIGHT AND AWAKE\n RESP NP ALT WITH BIPAP PT REQUEST PERIODS OF AGITATION AND SOB PT STATES FEELS STRONGER NEED OF BIPAP\n HEART S1S2 NSR PAC DISTANT TONES VSS ON DILT DRIP AT 10 PLEASE SEE CAREVIEW FOR DETAILS\n GI POS B/S NOTED FAIR PO\n PLAN EVAL NEED FOR BIPAP NEED VS DEPENDENCY NEED MILD SEDATION FOR RESP ISSUES\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-08 00:00:00.000",
"description": "Report",
"row_id": 1662152,
"text": "\n NEURO PT A/O RELAXED SLEEPS SHORT PERIODS IN FAIR SPIRITS HAD PHONE CALL FROM DAUGHTER MADE HIS DAY\n RESP DIM AT BASES CLEAR PERIODS OF RHOCHI AND RALES CLEARS AFTER COUGHING\n HEART S1S2 VSS NO ISSUES PULSES POS 3 THRU OUT EDEMA/ACITIES\n PLAN TO BE TRANSFERED TO FLOORS WITH TELE SUPORTIVE CARE\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-10 00:00:00.000",
"description": "Report",
"row_id": 1662155,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Patient is alert and oriented x3, more co op today with care ,agitation x1 seen by MICU MD fentanyl 12.5 x1 and slept for 3hrs. MAE.c/o abd pain fentanyl x1 with good effect and tylenol no effect.\n\nCV: NSR, HR in 70-80, no ectopy noted. SBP 100's, K 5.8 with PM , 30gm and calcium gluconate 2 gm given, ++PP, denies CP ordiscomfort.alb 50gm given.\n\nResp: Remains on and off on O2 mask .O2 sat on RA 92-94%. + productive cough.\n\nGI: Abd distended with ascitis, + BS, Bm x3 loose stool after lactulose.tolerated renal diet, bladder pr 18 cm this pm team aware.\n\nGU: Foley cath patent with icteric urine 15-25ml/hr, team aware, s/b renal team this am, not for dialysis today,may need later if renal function cont to rise up.\n\nEndo: Bld sug wnl.\n\nID: afebrile.\n\nSocial: called up by pt's sister in the am, updated with her.\n\nAct: Getting out of bed to commode with minimal asssist,skin intact.\n\nPlan; cont monitoring, pulm hygiene, skin care, support to patient,called out to floor transfer when bed available. foley cath to be changed, waiting for mICU MD as ^ and low platelets.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-11 00:00:00.000",
"description": "Report",
"row_id": 1662156,
"text": "NPN (NOC):\n\n PROBLEM HAS BEEN PAIN CONTROL. TYLENOL WAS TRIED X 1 W/O EFFECT. IN ADDITION, PT HAS REFUSED LIDOCAINE PATCH. DR. AND SAW PT X 3. SHE ORDERED 2 LOW DOSES OF FENTYNL WHICH WERE GIVEN. PT IS CONFUSED AS TO PLACE BY 6AM HOWEVER. HE THINKS HE IS IN HOSPITAL. REORIENTED. NOT C/O PAIN SO MUCH LATER IN AM. HEMODYNAMICALLY STABLE . UO IS MARGINAL AT 20 TO 25 CC'S PER HR. AM K = 5.3, KAYEXALATE GIVEN. DID HAVE ONE LARGE LOOSE BM PRIOR TO THIS BUT LACTULOSE GIVEN IN AM W/ INCREASED CONFUSION.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-11 00:00:00.000",
"description": "Report",
"row_id": 1662157,
"text": "FOCUS: CONDITION UPDATE\nD: SEE TRANSFER NOTE FOR SPECIFICS.\nTO GO TO 10 THIS EVE AFTER PLACEMENT OF DIALYSIS CATH.\n3U FFP/DDAVP/1U PLTS/ CHECKED BEFORE CATH PLACEMENT.\nPATIENT VERY AGITATED AND IMPATIENT RE: SITUATION.\nREPORT SENT TO 10. WILL TRANSFER WHEN PROCEDURE FINISHED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Report",
"row_id": 1662131,
"text": "MICU Progress Note 0700-1900\n45 yr old admitt from 10 with hepatic encephalopahty became lethargic on floor, resp sats decreased. Pt is full code.\n\nEvents: pt extubated today, and TPN started, also team would like to start tube feeds once.\n\nNeuro: pt alert/oriented x 3, able to follow commands, verbalizes needs. moves all extremities purposful.\n\nResp: pt extubated around 1700, pt on 70% face tent, pt is able to cough, but does need reminding. lung sounds clear/course, pt is able to cough up small amounts of sputum, but needs help suctioning it out.\nRR 10-20. PaO2 of 78 while on breathing trial, resident made aware before pt was extubated but still wanted to go ahead.\n\nCardio: HR NSR rate in 80-110. SBP 110-130's. afebril. peripheral pulses easily palpable. Access right subclavian central line, and one right peripheral IV. Also has A-line. CVP 6-9.\n\nGI/GU: foley 20-35ml/hr. total of 1700ml of stool out for the shift, golden brown liquid. flexiseal in for stool collection. Pt to start TPN at 1800. Also team would like to start tube feeds but will wait to see how pt does after being extubated.\n\nPlan: Cont monitoring resp status, monitor labs, cough and deep breath, cont giving lactulose.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-17 00:00:00.000",
"description": "Report",
"row_id": 1662132,
"text": "1900-0700 npn\nNEURO: pt. increasing more alert, awake and interactive. wants to eat and drink, tries to get OOB\n\nCV: afebrile, cv otherwise stable, urine out 25-30 cc hr, oral cavity dry\n\nRESP: hypoventilation, demonstrate with good technique to 750-1000cc with contracting for behavior and reward of ice chips. on 4 liters nc, cough effort fair. lung fields coarse to clear.\n\nGU/GI:foley 25-30 cc brwn, large amt golden color liquid stool. abd distended, soft, audible BT. remains npo with ice chips only. no problems with gag or airway management. cont. lactulose. flexiseal leaks occasionally but drains large amt. am abg po2 73 pco2 38 ph 7.58. HO aware\n\nACCESS: RSC all ports avail. art line wnl, 1 piv with good return.\n\nID: pipercillin/flagyl.\n\nSKIN: dry and intact.\n\nENDO: on TPN, not started tube feeds at this time due to potential for reintubation\n\nSOCIAL: pt. spoke to sister, she was updated on plan.\n\nPLAN: pulm. toilet, mobilize, dc central and art line when appropriate, replete electolytes, start tf this am. reeval need for TPN if tol. cont. lactulose\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-17 00:00:00.000",
"description": "Report",
"row_id": 1662133,
"text": "MICU 6 NSG 7A-7PM\naddendum--pt with bed on 10. Pt to have bedside sitter at 1900, report claaed to floor, and pt will be transferred when sitter has arrived.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-14 00:00:00.000",
"description": "Report",
"row_id": 1662164,
"text": "Resp Care\nPt from OR intubated s/p Liver transplant. Current vent settings: A/C 550 x 18 5P 50%. Plan is to continue to wean. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-27 00:00:00.000",
"description": "Report",
"row_id": 1662142,
"text": "MICU Nursing progress note 0700-1900\nNeuro: Alert, ox3. Follows commands. Frequently asks same questions repeatedly. Very frustrated w/ current situation. MAE. Complains of abd pain- fentanyl 12.5 given PRN w/ good effect.\n\nCV: NSR, no ectopy noted. HR 69-75. BP 96-103/53-61. HCT 21.2- 1 unit PRBC given, repeat HCT 24. 2.9.\n\nResp: LS-clear w/dim bases. RR 8-16. O2 sats 93-97% on 2L NC. Coughing sm amts of thick/tan secretions. Chect CT done-results pending.\n\nID: Afebrile. Continues on ciprofloxacin.\n\nGI/GU: NPO. Abd-ascites. TF-40cc/hr (goal). Speech and swallow done. +BS. Mushroom cath- golden/liquid. Foley- icteric/sediment. Output ~40cc/hr.\n\nSocial: Full code. Sister, HCP, called, updated on .\n\nPlan: ? IV to put in PICC s/p 2 units of FFP tomorrow. Encourage CDB. Monitor HCT/lytes. Monitor for s/s of bleeding. Support pt/family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-28 00:00:00.000",
"description": "Report",
"row_id": 1662143,
"text": "MICU NPN 1900-0700\nReview carevue for all additional data\n\nNo significant events overnight.\n\nNeuro: Alert, oriented x3, following commands, and MAE with normal strength. Continued on lactulose po for encephalopathy. C/O abdominal and back pain, no pain meds as MD tylenol, hot pack, reposition and lidocaine patch with very less effect.Patient was nauseated after po intake and was able to sleep after reglan iv.\n\nResp: Continued on O2 2L nasal canula, O2 sats 93-98%. RR unlaboured, bilateral lung sounds clear and diminished at the base. productive cough with thick tan secreation.\n\nCv: NSR without ectopy, HR 70-80's, Sbp 90-100. CVP 4-8, Rt IJ in place, for PICC line, FFP to be transfused prior to PICC line. Albumin 25%, 50 gm given 1v daily. Awaitting AM labs.\n\nGi/Gu: Speech and swallow passed, MD order for diet, but nauseated and coughs after drinking water, good effect after iv reglan. Abdoman tensed and distended, collection bag in place over the old puncture site, draining moderate yellowish clear fluid. Mushroom cath in place draining golden color liquid stool, continued on lactulose. TF nutren 2.0 with goal 40ml/hr and UO 10-40ml/hr.\n\nSkin: Intact, jaundiced.\nAccess: Rt IJ, awaitting for PICC line placement\nSocial: NO calls overnight.\n\nPlan;? call out to floors\n PICC line placement, 2units of FFP prior to Picc.\n ? better pain management\n ? Monitor MS, continue lactulose\n Monitor UO,lytes,albumin and HCT, replete accordingly\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-03-14 00:00:00.000",
"description": "Report",
"row_id": 1662165,
"text": "NEURO; RETURNED FROM O.R. S/P LIVER TRANSPLANT, ON PROPOFOL AT 25 MCG/KG/MIN, UNRESPONSIVE MOST OF SHIFT, DOES WITHDRAW HANDS AND FEET TO NAILBED PRESSURE, DOES NOT SPONTANEOUSLY MOVE EXTREMITIES OR OPEN EYES, PROPOFOL OFF AT PER AGREEMENT OF TX TEAM TO EVALUATE NEURO STSATUS FURTHER, PERL #2 AND BRISK, POSITIVE CORNEALS, WEAK GAG,\n\nCARDIOVASCULAR; CCO SWAN IN PLACE LEFT IJ, POOR PA WAVEFORM TRACING, LINE ADVANCED BY SICU HO, C.O. , CVP 6-8 (GOAL IS 12-16 PER TX TEAM), TX RESIDENT INFORMED OF THIS,MAINTENANCE IV INCREASED TO 100CC/HR\n\nRESPIR; A/C VENT SETTING, ABGS IMPROVING FROM RESPIR ACIDOSIS WITH METAB ALKALOSIS, RTE INCREASED TO 18,\n\nRENAL; U/O SCANT MOST OF SHIFT, BUT OUTPUT HAS INCREASED TO 30CC OVER PAST HR, MACHINE MALFUNCTIONED AT 1820 AND DISCONTINUED, RENAL FELLOW IN AND STATES SHE WILL DISCUSS WITH DR. RE CONTINUING , OFF AT PRESENT, GOAL HAD BEEN TO KEEP PT EVEN, ALTHOUGH NEW GOAL WILL BE TO KEEP PT 100CC POSITIVE IF RESUMED\nK AND CALCIUM REPLETIONS VIA MACHINE SLIDING SCALE\nENDOCRINE; BS 217-COVERED WITH 6 UNITS REGULAR VIA SLIDING SCALE\n\nWOUND; SMALL-MODER SERO-SANGE DGE ABD DSG, TWO JP'S TO SELF SX,MINIMAL SERO-SANGE DGE, TUBING STRIPPED Q 4 HRS,\n\nPLAN; ? RESTART , KEEP PT 100CC POSITIVE TO AUGMENT U/ UNLESS MD'S CHANGE PLANS, SERIAL LABS Q 6 HRS, NEXT DUE 2400, NEURO CHECKS NOW THAT PT IS OFF PROPOFOL,\n\n\n\n\nWOUND; MODER LIGHT SERO-SANGE DGE ON ORIGINAL DSG, MEDIAL AND JLATERAL JP BULBS TO SELF SX, SCANT SERO-SANGE DGE, TUBING STRIPPED Q 4 HRS,\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Report",
"row_id": 1662126,
"text": "MICU Nursing Progress note 0700-1900\nEvents: Sedation off. HCT 23- one unit of PRBC given. Suctioned frequently.\n\nNeuro: Withdrawing to sternal rub. Occationally moves upper extremities when turning, otherwise not moving extremities. Fentanyl and Versed off. PERRL. Not following commands.\n\nResp: CPAP+PS. Settings 40%/5PS/5PEEP. TV 750-950. RR 6-12. O2 sats 95-99%. ABG at these settings pending. LS-coarse/rhonchi w/ diminished bases. Suctioned thick, yellow secretions q1-2 hours.\n\nCV: NSR w/ no ectopy. HR 96-114. BP 92-123/49-67, MAP's mainly 70's. CVP 6-8. HCT 23.9, 1 unit PRBC given, repeat HCT pending. Platelets 50. INR 2.3.\n\nID: Temp 97.5 Ax. WBC 6.9. Continues on zosyn and flagyl. Vanco d/c'd.\n\nGI/GU: Abd- soft, distended, ascites. Hypoactive BS. Frequent liquid stools, flexiseal inplace. NGT to ILWS, ~400cc drained during shift. High residuals w/ placement check. No vomiting. Lactulose held d/t large amt of liquid stool.\n\nSkin: Intact, jaundice. Frequent turns and skin care done.\n\nSocial: Full code. Sister, , called and updated on .\n\nPlan: Continue pulmonary toiletting. Monitor lytes/ HCT/ ABG. Assess neuro status. Monitor stool output and need for lactulose. Continue to support family/patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-15 00:00:00.000",
"description": "Report",
"row_id": 1662127,
"text": "Resp Care\n\nPt remains intubated and currently vented on PSV 5/5 40% tol well with VT 700-900ml and MV 6-8L. BS course sxing for small to mod amts of thick yellow secretions. ETT secured/patent/ Oxygemation stable with spo2 in the mid to upper 90s. WIll cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Report",
"row_id": 1662128,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV Peep increased to 8 from 5 ABG 7.44/41/61/29. RN and MD aware. BS slight coarse continues to produce copious amounts thick, creamy yellow secretions. Plan: continue ventilatory support, suggest increase in peep and/or increase in FiO2\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-16 00:00:00.000",
"description": "Report",
"row_id": 1662129,
"text": "1900-0700 NPN\nNEURO: wakes to voice or tactile stim. MAE slowly and with purpose, perl\n\nCV: sinus 90-120, maps 80's, pp intact, peripheral edema appears dependant. urine 20-30 cc average this night . tmax 99.4 oral.lactate 2.4\n\nRESP: more than copious amts of thick yellow sputum suctioning x hr. copious oral secretions same color. RLL absent BS, sats declining later evening, abg done, po2 61, increased peep 8, now bs in RLL audible and rhonchi, coarse all lobes, sats high 90's, repeat abg po2 at baseline 90. rr varies from . minute volume 3.50 to 9 liters.\n\nGU/GI:foley average 20-30cc hr, abd soft and distended with BT audible without stethescope, cont. to have mod. to large liquid stools, ngt with 10cc residuals , clamping for meds tol. with min residual. cont. lactulose pngt. flexiseal to contain stool\n\nPAIN: no appearance of pain at this time.\n\nACCESS: RSC all ports accesible, piv in right flushes easily, art. line with good trace.\n\nID: pipercillin and flagyl. sputum culture pending. HEP B and C\n\nSKIN: no breaks noted, very dry skin.\n\nSOCIAL: sister who is an ICU nurse called for update. she has a cold and will cont. to check in by phone for now.\n\nPLAN: cont. lactulose, careful watch of residuals, anticipate much stool, contain, pulm toilet, frequent mouth suctioning. nutrition consult for tpn or reassess for tube feeding now that residuals are done.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-26 00:00:00.000",
"description": "Report",
"row_id": 1662139,
"text": "MICU 6 NPN 0700-1900\n\nNo significant events this shift.\nPt Full .\nSee Carevue for objective data.\n\nNeuro: Pt started shift lethargic and oriented x person and place. Pt still lethargic but oriented to person, place, and time. MAE with equal strength bilat, able to lift and hold BUE with pos asterixes noted. Pt able to lift BLE. He follows commands. PERL brisk, pos cough. Pt with c/o abd pain was given 25mcg IV fentanyl with good effect, he has IV fentanyl PRN orderrred.\n\nCV: NBP 90s/30s-50s with MAPs 53-65. HR 76-96 NSR with no ectopy noted. No c/o CP this shift. K 5.3 (team aware). No edema noted, pos radial pulses, pos pedal pulses. Hct stable at 24.3. CVP 5-6. Pt did receive albumin 25% bolus.\n\nResp: Pt received on RA and was sleeping, sats down to 87%. Pt put on 2L O2 NC with sats 95-98%. LS coarse and are now clear bilat with dim bases. pos productive cough and sputum sent.\n\nGI/GU: Abd distended and soft with pos bowel sounds. Pt with mushroom catheter drainning golden liquid stool. He receives lactulose q8hour. Nutren 2.0 TF started at 10cc/hr via doboff. Foley patent drainning icteric urine ~20cc/hr. Most recent Cr 2.0. Bladder pressure 11.\n\nSkin: Intact and jaundiced\n\nID: Tmax 98.4 orally. WBC 5.6. Pt on PO cipro prophylactic for SBP.\n\nAccess: RIJ in place, awaiting PICC eval. Spoke with IV team today and they are awaiting pt's blood culture results.\n\nSocial: MD spoke with pt's sister (HCP) regarding pt's .\n\nPlan:\nRoutine ICU monitorring.\nContinue to monitor MS.\nMonitor pt for pain and medicate appropriately.\nAdvance tube feeds per order.\nMonitor pt's UOP.\nMonitor lytes.\nPt's INR 3.1, monitor Hct.\nProvide emotional support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-26 00:00:00.000",
"description": "Report",
"row_id": 1662140,
"text": "MICU 6 addendum to NPN 0700-1900\n\nPt's K 5.3 and was given 30gm Kayaxelate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-02-27 00:00:00.000",
"description": "Report",
"row_id": 1662141,
"text": "19:00-07:00\n\nNEURO:PT IS MOSTLY LETHARGIC,ORIENTED X3.MAE.C/O PAIN ABDOMEN.PAIN SCORE .FENTANYL 12.5MCG IV GIVEN PRN WITH GOOD EFFECT.\n\nPULM:LS CLEAR WITH DIMINISHED BASE.ON 2L O2 VIA NC.SATURATING WELL.\n\nCVS:IN NSR,NBP MOSTLY 90'S,DROPS TO 70'S WHEN ASLEEP.HAD 250CC FB AND 1UNIT ALBUMIN WITH EFFECT.HAD 1 UNIT FFP FOR 3.1.PT WAS HAVING BLEEDING GUM,ITS SUBSIDED NOW.\n\nGI: ASCITIC.POS BS.MUSHROOM CATH DRAINING GOLDEN LIQ STOOL.TF AT 20CC/HR.GOAL RATE 40CC/HR.\n\nGU:FOLEY DRAINING ICTERIC URINE 20-40CC/HR.\n\nID:AFEBRILE.ON CIPRO PROPHILACTICALLY FOR SBP.\n\nSKIN:GROSSLY INTACT.PARACENTESIS SITE DRINING SEROUS FLUID.FLUID COLLECTION BAG INSITU.\n\nPLAN:\nPT IS FOR PICC.\nMONITOR MS.\n AND S/S OF BLEEDING.\n?C/O TO FLOOR IF MS STABLE.\n"
},
{
"category": "ECG",
"chartdate": "2119-03-07 00:00:00.000",
"description": "Report",
"row_id": 105874,
"text": "Technically difficult study\nSinus rhythm\nLow lead voltages\nNormal ECG\nSince previous tracing of , rhythm more regular, and no wide complex\nbeats\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-02 00:00:00.000",
"description": "Report",
"row_id": 105875,
"text": "Probable initial run of atrial fibrillation with aberrant conduction, with\nsubsequent sinus rhythm at the end of the tracing and two premature ventricular\ncomplexes. Atrial fibrillation is conducted with aberration and with a rapid\nventricular response. There are non-specific inferior and anterolateral\nST-T wave changes. Compared to the previous tracing of atrial\nfibrillation is new. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-02-25 00:00:00.000",
"description": "Report",
"row_id": 105876,
"text": "Baseline artifact. Sinus rhythm. Generalized low voltage is non-specific\nbut clinical correlation is suggested. Compared to the previous tracing\nof QRS voltage and T wave amplitude are lower.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-13 00:00:00.000",
"description": "Report",
"row_id": 105824,
"text": "Sinus bradycardia. Q-T interval prolongation. Compared to the previous\ntracing of the rate has slowed. The Q-T interval is prolonged.\nOtherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-10 00:00:00.000",
"description": "Report",
"row_id": 105825,
"text": "Sinus rhythm\nLow limb lead QRS voltages - is nonspecific and may be normal variant\nSince previous tracing of , probably no significant change\n\n"
}
] |
55,365 | 178,102 | 32yo incarcerated man with a PMHx significant only for epilepsy who presented with breakthrough seizures and status epilepticus from an OSH where he was intubated. His neurological examination on transfer revealed following commands and moving all 4 limbs with right sided weakness. He was loaded with IV phenytpoin and continued on 110mg IV Q8H. He had a negative CT head and and . After discusison with the prison nurse he had been taking his anti-epileptics as prescribed. CT-head revealed possible mild postictal edema and no intracranial hemorrhage with no focal lesion. His initial weakness was felt to be possibly due to paralysis. LP was unremarkable with WCC 2 RBC 1 and normal Pr and Glc. He had an initial leukocytosis at the OSH up to 17.9 with a high lactate which reslved on transfer to felt likely secondary to his seizures. He was following commands and moving all 4 limbs and extubated . Following extubation, he had no apparent weakness and was A+Ox3. The etiology of his presentation is unclear and toxicology screening was unremarkable and electrolytes were stable. There was no current focus for infection (UA and CXR were unremarkable and he was afebrile). On further questioning of patient, it was discovered that he had been receiving half of his Lamictal dose at the jail and in addition may have been changed from brand name to generic preparation which may have precipitated his seizures. He remained stable and was transferred to the floor on . He was continued on his home dose of medications in addition to IV phenytoin which was latterly stopped prior to discharge. He was transferred back to jail on . | No intracranial hemorrhage. Possible mild postictal edema. There is under-pneumatization of the right frontal sinus and left mastoid. Post-pyloric placement cannot be excluded. No acute pulmonary process. IMPRESSION: Endotracheal tube in satisfactory position. The lungs are clear without consolidation or edema. No herniation or midline shift. No herniation or midline shift. A presumed nasogastric tube has also been placed with its usual course through the mediastinum, coiling in the gastric fundus with the distal tip not visualized. No consolidation or edema is noted. FINDINGS: There is no intracranial hemorrhage, mass effect, or vascular territorial infarct. No effusion or pneumothorax is noted on the supine radiograph. Normal tracing. Lung volumes are slightly diminished with elevation of the hemidiaphragms. No displaced fractures are evident. Intubated w/ sinus and nasopharyngeal fluid secretions. However, mastoid air cells and middle ear cavities are clear. The cardiac silhouette is within normal limits for size. The mediastinum is unremarkable. COMPARISON: None. However, there is no evidence of cerebral herniation or shift of the normally midline structures. Orotracheal tube courses in expected position. Sinus rhythm. Diffuse blurring of the -white matter junction is noted, suggestive of postictal cerebral edema or artifact. No contraindications for IV contrast WET READ: 11:57 PM No ICH or vasc territory infarct. There is mild mucosal thickening in both maxillary sinuses, with air-fluid level on the right. Please note details of presumed nasogastric tube placement. No prior examinations for comparison. Mild diffuse blurring of GM- jctn, suggesting postictal cerebral 5edema. Mild diffuse blurring of GM- jctn, suggesting postictal cerebral 5edema. Orbits and intraconal structures are symmetric. Sinus and nasopharyngeal secretions, secondary to intubation. WET READ VERSION #1 11:55 PM No ICH or vasc territory infarct. IMPRESSION: 1. Admitting Diagnosis: SEIZURE FINAL REPORT (Cont) No previous tracing available for comparison. Outside head CT reported as negative, but repeat exam is requested to exclude intracranial hemorrhage. Scattered fluid is present throughout the ethmoid air cells. FINDINGS: Consistent with the given history, an endotracheal tube is present approximately 5.6 cm from the carina. HISTORY: Intubation. Aerosolized secretions are also noted filling the nasopharynx. If images are received, an addendum can be issued. TECHNIQUE: Contiguous non-contrast axial images were obtained through the brain, and reconstructed at 5-mm intervals. 2. 2-mm coronal and sagittal multiplanar reformats were also generated. 10:12 PM CT HEAD W/O CONTRAST Clip # Reason: ich? (Over) 10:12 PM CT HEAD W/O CONTRAST Clip # Reason: ich? FINAL REPORT INDICATION: 32-year-old male with right-sided weakness following generalized tonic-clonic seizure, likely paralysis. Admitting Diagnosis: SEIZURE MEDICAL CONDITION: 32 year old man with status post seizures, now with right-sided weakness, likely paralysis, but neuro requests repeat CT to exclude hemorrhage REASON FOR THIS EXAMINATION: ich? | 3 | [
{
"category": "Radiology",
"chartdate": "2194-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216200,
"text": " 9:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man intubated\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 2106 HOURS.\n\n HISTORY: Intubation.\n\n COMPARISON: None.\n\n FINDINGS: Consistent with the given history, an endotracheal tube is present\n approximately 5.6 cm from the carina. A presumed nasogastric tube has also\n been placed with its usual course through the mediastinum, coiling in the\n gastric fundus with the distal tip not visualized. Post-pyloric placement\n cannot be excluded. The lungs are clear without consolidation or edema. Lung\n volumes are slightly diminished with elevation of the hemidiaphragms. No\n consolidation or edema is noted. The mediastinum is unremarkable. The\n cardiac silhouette is within normal limits for size. No effusion or\n pneumothorax is noted on the supine radiograph. No displaced fractures are\n evident.\n\n IMPRESSION: Endotracheal tube in satisfactory position. Please note details\n of presumed nasogastric tube placement. No acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-10-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1216205,
"text": " 10:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with status post seizures, now with right-sided weakness,\n likely paralysis, but neuro requests repeat CT to exclude hemorrhage\n REASON FOR THIS EXAMINATION:\n ich?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:57 PM\n No ICH or vasc territory infarct.\n Mild diffuse blurring of GM- jctn, suggesting postictal cerebral 5edema.\n No herniation or midline shift.\n Intubated w/ sinus and nasopharyngeal fluid secretions.\n WET READ VERSION #1 11:55 PM\n No ICH or vasc territory infarct.\n Mild diffuse blurring of GM- jctn, suggesting postictal cerebral 5edema.\n No herniation or midline shift.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old male with right-sided weakness following generalized\n tonic-clonic seizure, likely paralysis. Outside head CT reported as\n negative, but repeat exam is requested to exclude intracranial hemorrhage.\n\n No prior examinations for comparison. If images are received, an addendum can\n be issued.\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain, and reconstructed at 5-mm intervals. 2-mm coronal and sagittal\n multiplanar reformats were also generated.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or vascular\n territorial infarct. Diffuse blurring of the -white matter junction is\n noted, suggestive of postictal cerebral edema or artifact. However, there is\n no evidence of cerebral herniation or shift of the normally midline\n structures.\n\n Orotracheal tube courses in expected position. Scattered fluid is present\n throughout the ethmoid air cells. There is mild mucosal thickening in both\n maxillary sinuses, with air-fluid level on the right. Aerosolized secretions\n are also noted filling the nasopharynx. There is under-pneumatization of the\n right frontal sinus and left mastoid. However, mastoid air cells and middle\n ear cavities are clear. Orbits and intraconal structures are symmetric.\n\n IMPRESSION:\n 1. Possible mild postictal edema. No intracranial hemorrhage.\n 2. Sinus and nasopharyngeal secretions, secondary to intubation.\n (Over)\n\n 10:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2194-10-23 00:00:00.000",
"description": "Report",
"row_id": 248443,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
}
] |
30,087 | 144,904 | After exploratory laparatomy with LOA, appendectomy, and repair of ventral hernias, the patient recovered well on the floor. However, his post-operative course was complicated on with hyponatremia and what appeared to be acute renal failure (creatinine of 1.3, baseline hospital course 0.9-1.2). After correcting for fluid deficits, nephrology was consulted. Renal U/S did not show hydronephrosis. Per nephrology, the patient's hyponatremia is of a chronic nature and suggested that the patient follow a low sodium, high protein diet with fluid restriction. Nephrology does not want patient to follow-up with them, unless hyponatremia worsens. From a surgical standpoint, the patient had return of bowel function and tolerated his new Nephrology diet well. The case manager has obtained a place for him in Of (extended care). His JP and Foley will not be taken out. He is to empty and record his outputs. He will f/u with Dr. in approximately 2 weeks and will have his JP and Foley taken out (if the Foley already was not taken out during his stay in extended care). Medications on Admission: : amiodarone 200mg qd metoprolol 50mg qd ASA 81mg qd furosemide 40mg qd spironolactone 25mg qd atorvastatin 10mg qd omeprazole 20mg qd | CONT MARGINAL HUO, DR. PMH; CAD, A-FIB, GERD. C/o incisional pain, started on Dilaudid PCA, using appropriately w/relief.RESP: Extubated w/o event this am. PCA FOR PAIN MGMT, BOLUSES/ALBUMIN FOR CONT LOW U/O. HR 70-80.GI: Abd firm, distended. intubated and presently on neo gtt and propofol. Ascites. +BELCH/NO FLATUS PER PT, FAINT BS NOTED. PAIN WELL CONTROLLED W/DILAUDID PCA. abd firmly distended. NGT to LCWS w/bilious drainage. The right internal jugular line tip terminates in mid SVC. Right apical opacity is demonstrated , of unclear etiology. Abd JPx2 w/scant sang output.GU: Marginal CYU via foley. flagyl and cipro iv ordered. Regular rhythm - mechanism uncertain, may be atrial tachycardia wit 2:1responseLow limb lead QRS voltages - is nonspecificModest nonspecific low amplitude T wave changesClinical correlation is suggestedNo previous tracing available for comparison Cont abx. NURSING NOTEJP x2 w/scant serosang drng, Midline/Lat ABD dsg C/D/I. LUNGS CLEAR, DIMINISHED AT BASES BILAT, NARD/SOB, REMAINS ON 2-3LPM VIA N/C. focus hemodynmics and admission notedata: admitted to the sicu from the or. Fluid bolus' for low u/o. Near-complete atelectasis right middle and right lower lobes, as well as partial atelectasis of left lower lobe. pt wanting et tube out. INDICATION: Clinically fluid overload. K&CA NEED REPLETION R/T 3.2/0.92 RESPECTIVELY. ALBUMIN GIVEN X1 FOR CONT MARGINAL HUO. Follow I&Os, u/o. ABGs WNL. PERRL. AFEBRILE. AFEBRILE. pt nodding to abd pain. Central venous catheter remains in standard position, endotracheal tube and nasogastric tubes have been removed. Dr aware. AMBULATE. + BS. SBP 100-S-120S, CVP 6-9. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IVF AT KVO. FIRST DEGREE AV BLOCK. The patient is after median sternotomy and CABG. MD AWARE. Lungs clear, diminished at bases. EDGES APPROXIMATED, NO ERYTHEMA.FOLEY WITH QS URINE OUTPUT. CONT 1ST DEG AV-BLOCK, HR 60S-70S, AMIO/LOPRESSOR GIVEN. New streaky right upper lobe opacities, which may represent atelectasis or subtle area of aspiration. TPN CONTINUES. NOW PATIENT IN 1ST DEGREE AV BLOCK (NOT NEW). ABDOMEN SOFTLY DISTENDED, HYPOACTIVE BOWEL SOUNDS. SBP >90, titrate Neo. MONITER HEMODYNAMICS, MONITER AND MEDICATE FOR PAIN PRN. DRESSINGS INTACT OVER JP SITES, INCISION OTA, NO DRAINAGE. RATING ABDOM PAIN "" BUT STATING "NOT BAD". Using Dilaudid PCA w/ pain level .CV: HR 50-60's w/ 1st-degree block. MAE however stating that left hand slightly weaker w/occassional twitches; Dr aware, will cont to monitor. BILATERAL LOWER QUADRANT JPS WITH SMALL AMOUNT SEROSANG DRAINAGE. PATIENT DOZING FREQ INBETWEEN DOSES. CVP 3-7. CONTINUE WITH CURRENT MONITORING AND TREATMENT. Rare PVCs noted. npo. u.o 10cc/ at 0600 dr . Questionable opacity in right apex as described. Lasix started x 3 doses w/ good response.Resp: Lungs clear/diminished @ bases. Repeated radiograph to exclude the possibility of right apical consolidation is recommended. RARELY USING DILAUDID PCA, ENCOURAGED TO USE IT AS NEEDED. NURSING NOTEPLEASE SEE CAREVUE FOR DETAILS PT A&O X3, NEUROS INTACT, MAES. Small bilateral pleural effusions. ABD SOFT, TENDER TO PALP, R>L SIDE. update given to her.respone: monitor closely. NO EDEMA NOTED, WEAK PALP PP PT>DP. Albumin x1. 250cc normal saline iv x2 given. New small bilateral pleural effusions are evident. Subcutaneous air collection. aline via right radial and right ij multilumen catheter in place. NURSING NOTEASSESSMENT: PATIENT ORIENTED X 3 AND APPROPRIATE. 1AMP NA BICARB GIVEN FOR TOT CO2 13. NEURO ALERT ORIENTED MOVES ALL EXTREMETIES NO DEFECITS NOTEDC/V NSR 1AVB AM LOPRESSOR HELD FOR HR 60. CVP 8-11. Otherwise intact.ID: Afebrile; continue anbx.Dispo: Most likely call out tomorrow if bed available. Following closely & treating w/fluid as needed.ENDO: RISS.SKIN: Multiple areas of eccymosis on arms & chest. RESP CARE NOTE87 YO M ADMITTED THROUGHER FOR AN ACUTE ABDOMINE IS NOW POST OP APPENDECTOMY AND HERNIA REPAIR. Follows commands. Left renal cysts. Titrating Neo for goal SBP >90. SP 120's/ 50's. UOP improved with lasix. ? Left lower lobe consolidation is most likely consistent with atelectasis, although infectious process cannot be excluded. Replete electrolytes as needed. NURSING VSS OVERNIGHT. 2. 2. 2. Ascites is identified within the abdomen. NGT TO LWS W/SM AMT GREEN, BILIOUS DRNG. 3. Streaky ill-defined opacities have developed within the right upper lobe along the bronchovascular structures and to a lesser degree along the lung periphery. TRANSFER TO FLOOR TODAY. Follow Sodiums. Small bilateral pleural effusion is present. NURSING PROGRESS NOTESEE CAREVUE FOR DETAILS.NEURO: A&Ox3. ABDOMINAL DRESSING DRY & INTACT. MAE. Oral contrast material is demonstrated in the colon. iv normal saline at 75cc/hr. Original dressing on abdomen; no drainage noted.SOCIAL: Granddaughter into visit. NO CHANGE TO PCA DOSE.PLAN TRANSFER TO FLOOR. LINE PLACEMENT Clip # Reason: eval line position Admitting Diagnosis: APPENDICITIS MEDICAL CONDITION: 87M s/p appy & CVL placement REASON FOR THIS EXAMINATION: eval line position FINAL REPORT REASON FOR EXAMINATION: Evaluation of central venous line placement. NEURO; A&OX3, MAE, USING DILAUDID PCA PUMPCARDIOVASCULAR; HR 70'S-80'S, 1ST DEGREE AV BLOCK WITH OCCAS PAC'S, AFEBRILE,NEO GTT OFF SINCE LAST EVENINGRESPIR; LUNGS CLEAR, 02 SAT 98% ON N/C AT 3L/MINRENAL; U/O 30-40CC/HR MOST OF NOC, OUTPUT DECREASED TO 22-20 CC, AND PT CURRENTLY RECEIVING FLUID 250CC NSS BOLUS,SKIN; JP 1& 2 DGING SMALL AMT THICK LIGHT BILIOUS DGE, ABD DSG D/IPLAN; GET PT OOB WHEN OKAY WITH TEAM, ENCOURAGE USE OF PCA TO HELP PT PERFORM ACTIVITIES, MONITOR U/O, ? Notify HO of any changes. labs drawn as ordered. HR did intermittently dip down into 40's after getting am meds (amiodarone & lopressor); self-limited and BP tolerated. | 15 | [
{
"category": "Radiology",
"chartdate": "2103-07-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1017183,
"text": " 4:35 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line position\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87M s/p appy & CVL placement\n REASON FOR THIS EXAMINATION:\n eval line position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of central venous line placement.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The ET tube tip is high, about 9 cm above the carina. The right internal\n jugular line tip terminates in mid SVC. No pneumothorax is demonstrated but\n small amount of subcutaneous emphysema is present overlying the right apex,\n thus small amount of pleural air cannot be excluded. Right apical opacity is\n demonstrated , of unclear etiology.\n\n The NG tube tip is in the stomach. The patient is after median sternotomy and\n CABG. The cardiac size and the mediastinal contours are unremarkable. Left\n lower lobe consolidation is most likely consistent with atelectasis, although\n infectious process cannot be excluded. Small bilateral pleural effusion is\n present.\n\n Oral contrast material is demonstrated in the colon.\n\n IMPRESSION:\n 1. Too high position of the ETT tip, that should be advanced for about 3-4 cm.\n 2. Questionable opacity in right apex as described. Repeated radiograph to\n exclude the possibility of right apical consolidation is recommended.\n 3. Subcutaneous air collection. No sizable pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-07-23 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1018934,
"text": " 12:55 PM\n RENAL U.S. Clip # \n Reason: eval for hydronephrosis\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with elevated Cr\n REASON FOR THIS EXAMINATION:\n eval for hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 8:30 PM\n No hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old man with elevated creatinine, evaluate for\n hydronephrosis.\n\n COMPARISON: No previous exams for comparison.\n\n FINDINGS: The right kidney measures 10.1 cm and the left kidney measures 10.0\n cm. There is no hydronephrosis and no stones or solid masses are identified\n in either kidney. Two cysts are identified in the left kidney. The larger is\n a septated cyst which measures 3.2 x 3.5 x 4.3 cm. The septation is thin and\n demonstrates no vascular flow. The second cyst is in the upper pole of the\n left kidney and measures 1.8 x 2.3 x 1.6 cm. The bladder was not visualized\n on this exam. Ascites is identified within the abdomen.\n\n IMPRESSION:\n 1. No hydronephrosis.\n 2. Left renal cysts. Ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-07-23 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1018935,
"text": ", G. CC6A 12:55 PM\n RENAL U.S. Clip # \n Reason: eval for hydronephrosis\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with elevated Cr\n REASON FOR THIS EXAMINATION:\n eval for hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n No hydronephrosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-07-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1018746,
"text": " 12:16 PM\n CHEST (PA & LAT) Clip # \n Reason: EVAL FOR PULMONARY EDEMA\n Admitting Diagnosis: APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with s/p ex-lap, appendectomy for perforated appendicitis, now\n fluid overloaded.\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Clinically fluid overload.\n\n INDICATION: Evaluate for pulmonary edema.\n\n Lung volumes are extremely low, resulting in crowding of bronchovascular\n structures. Cardiac silhouette is difficult to assess due to partial\n obscuration by adjacent atelectasis within the right middle and both lower\n lobes. Streaky ill-defined opacities have developed within the right upper\n lobe along the bronchovascular structures and to a lesser degree along the\n lung periphery. New small bilateral pleural effusions are evident. Central\n venous catheter remains in standard position, endotracheal tube and\n nasogastric tubes have been removed.\n\n IMPRESSION:\n 1. Near-complete atelectasis right middle and right lower lobes, as well as\n partial atelectasis of left lower lobe. Small bilateral pleural effusions.\n\n 2. New streaky right upper lobe opacities, which may represent atelectasis or\n subtle area of aspiration. Attention to this area on followup radiograph\n recommended to exclude an early focus of infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-12 00:00:00.000",
"description": "Report",
"row_id": 1650635,
"text": "RESP CARE NOTE\n87 YO M ADMITTED THROUGHER FOR AN ACUTE ABDOMINE IS NOW POST OP APPENDECTOMY AND HERNIA REPAIR. PMH; CAD, A-FIB, GERD. VENT SETTINGS ARE CURRENTLY PSV 5/5, 40%MOST RECENT ABG SHOWS A METABOLIC ACIDOSIS OF727/37/154/18/-8. PLAN TO CONTINUE ON PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-12 00:00:00.000",
"description": "Report",
"row_id": 1650636,
"text": "focus hemodynmics and admission note\n\ndata: admitted to the sicu from the or. intubated and presently on neo gtt and propofol. aline via right radial and right ij multilumen catheter in place. bp dropped to the 80's and neo gtt increased to 1.75mcg/kg/min. iv normal saline at 75cc/hr. propofol gtt off due to dropping bp. pt now moving extremities on the bed and nodding to questions. pt nodding to abd pain. fentanyl 12.5mg iv x2 for pain control and effective. u.o 10cc/ at 0600 dr . 250cc normal saline iv x2 given. labs drawn as ordered. abd firmly distended. absent bowel sounds. abd dsg intact with transparent dsg intact with no drainage. bilateral drains in place and draining bloody drainage. npo. flagyl and cipro iv ordered. pt wanting et tube out. pt able to move and lift extremities off the bed. rsbi 15 pt extubated shortly after morning report. pt is alert and oriented. daughter called from and is enroute to visit dad. update given to her.\n\nrespone: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-14 00:00:00.000",
"description": "Report",
"row_id": 1650641,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED X 3 AND APPROPRIATE. RATING ABDOM PAIN \"\" BUT STATING \"NOT BAD\". RARELY USING DILAUDID PCA, ENCOURAGED TO USE IT AS NEEDED. HEART RATE 60-70'S, APPEARED IN AFIB @ BEGINNING OF THE SHIFT. NOW PATIENT IN 1ST DEGREE AV BLOCK (NOT NEW). SBP 100-120, PATIENT MAKING 20-80 CC URINE HOURLY. AFEBRILE. LUNG SOUNDS CLEAR BUT DIMINISHED, BREATHING UNLABORED AT REST. ABDOMINAL DRESSING DRY & INTACT. BILATERAL LOWER QUADRANT JPS WITH SMALL AMOUNT SEROSANG DRAINAGE. NGT WITH BILIOUS DRAINAGE, PATIENT NPO (BUT TAKING ICE CHIPS, OKAY PER DR. ).\nPLAN:\n OOB TO CHAIR TOMORROW AND ? AMBULATE. CONTINUE WITH CURRENT MONITORING AND TREATMENT. WILL NEED CASE MANAGEMENT TO DISCUSS HOME NEEDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-14 00:00:00.000",
"description": "Report",
"row_id": 1650642,
"text": "0700-1900\n\nNeuro: AAO x3. A bit forgetful when he wakes up from sleeping; easily re-orients. MAE. Follows commands. PERRL. Using Dilaudid PCA w/ pain level .\n\nCV: HR 50-60's w/ 1st-degree block. HR did intermittently dip down into 40's after getting am meds (amiodarone & lopressor); self-limited and BP tolerated. SP 120's/ 50's. CVP 8-11. Lasix started x 3 doses w/ good response.\n\nResp: Lungs clear/diminished @ bases. Hands and toes cool w/ old venous status; hard to get accurate SATs; but when he holds still, or probe changed 97-100% on NC 2 liters. No SOB/DOE. Was OOB in cardiac chair x 3 hours and tolerated well.\n\nGI/GU: Abd distended; slightly tender when getting OOB, otherwise rates pain as ache . No BS, BM or flatus. NPO x sparing ice chips and mouth swabs. UOP improved with lasix. IVF decreased to 60cc/hour; goal is to start TPN tonight and keep TPN/IVF = 60cc/hour.\n\nSkin: Dressings C/D/I; no drainage. Otherwise intact.\n\nID: Afebrile; continue anbx.\n\nDispo: Most likely call out tomorrow if bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-15 00:00:00.000",
"description": "Report",
"row_id": 1650643,
"text": "NURSING\n VSS OVERNIGHT. FIRST DEGREE AV BLOCK. AFEBRILE. USING PCA EFFECTIVELY FOR CONTROL OF PAIN. TPN CONTINUES. IVF AT KVO. DRESSINGS INTACT OVER JP SITES, INCISION OTA, NO DRAINAGE. EDGES APPROXIMATED, NO ERYTHEMA.FOLEY WITH QS URINE OUTPUT. NO STOOL, NO FLATUS. ABDOMEN SOFTLY DISTENDED, HYPOACTIVE BOWEL SOUNDS. 2 JP'S WITH SEROSANGUINES DRAINAGE, 20 ML EACH OVERNIGHT. NO ISSUES OVERNIGHT.\n MONITER HEMODYNAMICS, MONITER AND MEDICATE FOR PAIN PRN. ? TRANSFER TO FLOOR TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-15 00:00:00.000",
"description": "Report",
"row_id": 1650644,
"text": "NEURO ALERT ORIENTED MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nC/V NSR 1AVB AM LOPRESSOR HELD FOR HR 60. B/P STABLE\n\nRESP LUNGS CLEAR BASES DIMINISHED ABG AM LOW P02 OOB TO CHAIR IMPROVED PAIN CONTROL ABG WNL COUGHING AND DEEP BREATHING WITH ENCOURAGMENT.\n\nGU/GI ABD SOFT BOWEL SOUNDS HEARD. TPN INFUSING TOL SMALL SIPS WITH PILLS. ADEQUATE URINE OUT WITH LASIX.\n\nSKIN SKIN TEARS EASILY DRAINING MOD AMTS SEROUS FROM ELBOW AREA R ARM.\n\nPAIN PCA DILAUDID FOR PAIN. PATIENT MAKES FREQUENT ATTEMPTS \"TO MAKE SURE IT IS WORKING\". PT USING PCA FREQUENT AND REPORTS PAIN OF . PATIENT DOZING FREQ INBETWEEN DOSES. MD AWARE. NO CHANGE TO PCA DOSE.\n\nPLAN TRANSFER TO FLOOR. CONTINUE TO MONITOR PAIN AND RESP STATUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-12 00:00:00.000",
"description": "Report",
"row_id": 1650637,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: A&Ox3. Pleasant & cooperative. MAE however stating that left hand slightly weaker w/occassional twitches; Dr aware, will cont to monitor. C/o incisional pain, started on Dilaudid PCA, using appropriately w/relief.\nRESP: Extubated w/o event this am. ABGs WNL. Sat's 99% 3L NC. Lungs clear, diminished at bases. Productive cough, using yankeur for thick white secretions.\nCV: 1st AV block. Rare PVCs noted. Titrating Neo for goal SBP >90. CVP 3-7. Fluid bolus' for low u/o. Albumin x1. Cycling electrolytes to monitor sodiums. HR 70-80.\nGI: Abd firm, distended. + BS. No BM. NGT to LCWS w/bilious drainage. Abd JPx2 w/scant sang output.\nGU: Marginal CYU via foley. Dr aware. Following closely & treating w/fluid as needed.\nENDO: RISS.\nSKIN: Multiple areas of eccymosis on arms & chest. Original dressing on abdomen; no drainage noted.\nSOCIAL: Granddaughter into visit. Wife to come in tomorrow with daughters who are flying in from & .\n\nPOC: Pain/comfort; PCA. SBP >90, titrate Neo. Follow Sodiums. Cont abx. Follow I&Os, u/o. Replete electrolytes as needed. Emotional support to pt/family. Notify HO of any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-13 00:00:00.000",
"description": "Report",
"row_id": 1650638,
"text": "NEURO; A&OX3, MAE, USING DILAUDID PCA PUMP\n\nCARDIOVASCULAR; HR 70'S-80'S, 1ST DEGREE AV BLOCK WITH OCCAS PAC'S, AFEBRILE,\nNEO GTT OFF SINCE LAST EVENING\n\nRESPIR; LUNGS CLEAR, 02 SAT 98% ON N/C AT 3L/MIN\n\nRENAL; U/O 30-40CC/HR MOST OF NOC, OUTPUT DECREASED TO 22-20 CC, AND PT CURRENTLY RECEIVING FLUID 250CC NSS BOLUS,\n\nSKIN; JP 1& 2 DGING SMALL AMT THICK LIGHT BILIOUS DGE, ABD DSG D/I\n\nPLAN; GET PT OOB WHEN OKAY WITH TEAM, ENCOURAGE USE OF PCA TO HELP PT PERFORM ACTIVITIES, MONITOR U/O, ? FUTURE BOLUSES,KEEP SYS > 90 AND MAP >60,\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-13 00:00:00.000",
"description": "Report",
"row_id": 1650639,
"text": "NURSING NOTE\nJP x2 w/scant serosang drng, Midline/Lat ABD dsg C/D/I.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-13 00:00:00.000",
"description": "Report",
"row_id": 1650640,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT A&O X3, NEUROS INTACT, MAES. PAIN WELL CONTROLLED W/DILAUDID PCA. CONT 1ST DEG AV-BLOCK, HR 60S-70S, AMIO/LOPRESSOR GIVEN. SBP 100-S-120S, CVP 6-9. NO EDEMA NOTED, WEAK PALP PP PT>DP. ALBUMIN GIVEN X1 FOR CONT MARGINAL HUO. K&CA NEED REPLETION R/T 3.2/0.92 RESPECTIVELY. 1AMP NA BICARB GIVEN FOR TOT CO2 13. LUNGS CLEAR, DIMINISHED AT BASES BILAT, NARD/SOB, REMAINS ON 2-3LPM VIA N/C. ABD SOFT, TENDER TO PALP, R>L SIDE. +BELCH/NO FLATUS PER PT, FAINT BS NOTED. NGT TO LWS W/SM AMT GREEN, BILIOUS DRNG. CONT MARGINAL HUO, DR. AWARE.\n\n PLAN: CONT HEMODYNAMIC MONITORING, FOLLOW-UP/FREQUENT LABS. PCA FOR PAIN MGMT, BOLUSES/ALBUMIN FOR CONT LOW U/O.\n"
},
{
"category": "ECG",
"chartdate": "2103-07-12 00:00:00.000",
"description": "Report",
"row_id": 158322,
"text": "Regular rhythm - mechanism uncertain, may be atrial tachycardia wit 2:1\nresponse\nLow limb lead QRS voltages - is nonspecific\nModest nonspecific low amplitude T wave changes\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
}
] |
23,631 | 107,788 | A/P: 52 y/o F with h/o duodenal ulcers and GIB while anticoagulated for afib/pe/, initially admitted to MICU with hematemesis and significant hct drop with supratherapeutic inr, now transferred to medicine floor for further management. . 1. GI Bleed: The pt's GIB was thought likely to be resulting from her duodenal ulcers and supratheraputic INR. It was unclear if the pt was noncompliant with PPI therapy vs if her GIB was secondary to PPI resistance or failure. The pt initially required 6 units PRBCs transfusion and Vitamin K on initial admission to the MICU but her Hct had been stable since transfer to the floor and she remained hemodynamically stable. Records from hospital re: prior bx results and EGD performed in showed antral gastritis and prepyloric ulcer. GI followed the patient while in house and decided to defer EGD for now as the pt had a recent EGD and her Hct remained stable. The pt required no further transfusions while on the medical floor she remained on IV PPI until her discharge. She had very poor IV access and had a RIJ cordis in place until this was changed to a triple lumen catheter. Ultimately, the patient requested that she have EGD performed under general anesthesia and she is currently scheduled for EGD for under general anesthesia which was arranged by GI. Her coumadin will need to be held 5 days prior to her procedure. 2. ?abdominal wall fluid collection: U/S on showed a fluid collection in her abd wall which was not communicating with the bowel and likely represented a chronically inflamed or infected fluid collection. This was thought to be likely secondary to heparin or lovenox injections. NO further abdominal imaging was performed. . 3. PE/DVT: After thorough investigation into pt's history of PE, it was found that CTA from OSH records showed small subsegmental RUL and RML PE, but subsequent imaging here at had not shown PEs (CTA here at showed resolution of PE and CTA revealed no definite PE although there was decreased attenuation in subsegmental RML). We had these scans re-read by radiology on this admission and radiology confirmed that the original CTA done on at did show a very small subsegmental RML PE which had resolved on subsequent CTAs here at (in the interim, pt had been treated with heparin). The radiologist had hypothesized that it was possible that a pulmonary embolus could clear after only 3 days of therapy given how small the clot burden appeared to be on the original CTA done at . In addition, it was confirmed that the patient only had episodes of superficial thrombophlebitis and never had a confirmed DVT. The pt had been anticoagulated since for PE as well as afib and had had 2 episodes of GIB since requiring several PRBC transfusions. The medicine team on this admission had an extensive discussion with the patient re: the risk of continuing anticoagulation therapy with no current evidence of pulmonary embolus in the setting of a large duodenal ulcer. The patient was very focused on her diagnosis of pulmonary embolus and after much discussion, the decision was made to continue anticoagulation given the patient's discomfort in stopping anticoagulation. The patient was kept in house with heparin drip as bridge until her INR reached 2.0. She was discharged with instructions to follow her INR closely at her PCP's office. 4. Right pleuritic chest pain: Pt has had complaints of this several times in the past and was being treated for a PE. EKGs repeatedly remained unchanged. The etiology for this pain was unclear but was thought to be likely musculoskeletal. 5. UTI: pt had evidence of a UTI on urinalyis and was treated with Cipro for a 3 day course. . 6. Afib: Pt remained in afib, rate controlled, and anticoagulated with heparin and coumadin. She remained on a B blocker while in house and was discharged on her outpatient dose of Atenolol. 7. Chronic pain: Pt was continued on oxycontin and percocet prn per her outpatient regimen for chronic pain related to her pseudotumor cerebri. . 8. Psych: Pt had some history of psychiatric hospitalization/delusions in the past but this has never been formally evaluated by psychiatry. She definitely lacked insight into her disease process and it was often difficult to address the complex medical issues re: her GIB risk and anticoagulation for PE. She was continued on clonazepam and ativan prn. 9. Hypothyroidism - She was continued on levoxyl . 10. Code: full. 11. Access: this was extremely difficult to obtain. Pt had a RIJ cordis placed initially on ICU admission which then was changed to a triple lumen catheter and remained in place until her discharge. 12. Dispo: Patient was discharged after her INR was therapeutic with instructions to follow up the next day for a follow-up INR check. She will need to return in for EGD under general anesthesia per her request. | Right pleural effusion. IMPRESSION: Right IJ line insertion. The portal vein is patent and demonstrates normal hepatopetal flow. Linear scarring in the right costophrenic angle unchanged since prior film. There is a right pleural effusion. Medicated with DIlaudid 2mg Q2hrs, Ativan and Anzamet prn with short relief.Resp: Denies SOB, LS clear, sats high 90s on RA.CV: Chronic AF HR 70s-80s, no ectopy. CT ordered. The right IJ catheter is present terminating in the junction of the superior vena cava and right atrium. Neuro: A&Ox3, cooperative with care, c/o severe H/A occasionally accompanied by nausea and RUQ abd. The aorta is normal in caliber. Atrial fibrillationSince previous tracing of , no significant change PT ANTICOAGULATED WITH COUMADIN- NOW IS ADMITTED WITH HEMATEMESIS AND HEMATOCRIT OF 15. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS. pathology/stone FINAL REPORT INDICATION: Right upper quadrant pain. Cordis catheter is in right brachiocephalic vein. SBP > OR = TO 90 WITH NO HYPOTENSIVE OR HYPERTENSIVE CRISIS NOTED. AFIB, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. PT'S ENVIRONMENT SECURED FOR SAFETY.THIS IS A 52 Y/O F WITH H/O UGI BLEED WITH DOUDENAL ULCERS, DVT/PE AND AFIB. BS X 4 QUADRANTS. IMPRESSION: 1. GI TO RE-EVALUATE. BILATERAL CHEST EXPANSION NOTED. AFEBRILE. Common bile duct dilatation to 11 mm without stones or other abnormalities demonstrated to the level of the head of the pancreas. MAE X 4 WITHOUT DIFFICULTY- ABLE TO ASSIST WITH PERSONAL CARE. PT HAS INTRODUCER TO RT IJ. The visualized pancreas is unremarkable. soft, distended, c/o intermittent RUQ pain. The patient is status post cholecystectomy. No peripheral edema noted.GI/GU: No scope today, pt. PERRLA, 3/ BRISK. BP 110s-140s/50s-60s. DENIES ANY CHEST PAIN.GI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. NO BM THIS SHIFT. NO C/O SOB OR DIFFICULTY BREATHING. PASSING FLATUS- NO PRESENTATION OF GIB.GU: PT VOIDS ON BEDPAN WITHOUT DIFFICULTY. SPEECH CLEAR. ABDOMINAL ULTRASOUND: The liver is normal in echogenicity and contour and is without focal masses or biliary ductal dilatation. NPO AT THIS TIME. REASON FOR THIS EXAMINATION: line placement FINAL REPORT CHEST SINGLE AP FILM History of right chest pain and shortness of breath. Atrophic right kidney. pathology/stone Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED FINAL REPORT (Cont) No pleural effusions. PLEASE SEE FLOW SHEET AS NEEDED. PT HAD RECENTLY BEEN ADMITTED ON TO WITH MELENA AND INR 5.5. u/s ? bile duct dilitation, follow up abd. The pulmonary vasculature is unremarkable. PT GIVEN 2 DOSES OF ATIVAN- OBTAINED STANDING ORDER FOR ANXIETY. The lungs appear clear, and there is no pneumothorax. BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. In the setting of a normal sized left kidney, this finding may represent right renal artery stenosis or other cause of atrophy. Abd. Abd. No pneumothorax. Clinical correlation is advised. Cardiomegaly. NO ISSUES. AT THAT TIME, PT HAD EGD AND COLONOSCOPY THAT WAS SIGNIFICANT FOR A DUODENAL ULCER AND DIVERTICULOSIS. The common bile duct ranges from 9 to 11 mm, which is mildly dilated. 4. Left mid abdominal wall fluid collection with vascular capsule which likely represents an inflammatory fistula or chronically-infected fluid collection. THANK YOU! Palpable pedal pulses. GI CONSULT- PLAN FOR RESUCITATION AND WILL DISCUSS POSSIBILTY OF REPEAT SCOPE. NO C/O N,V,D. RECEIVED TOTAL OF 6U PRBCS THIS SHIFT. 3:12 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: ? No intrahepatic biliary ductal dilatation is identified. 4:16 PM CHEST PORT. 3. In the left mid abdomen in the region of the patient's palpable mass is an approximately 5 cm x 2 cm fluid collection with a thick vascularized wall which does not appear to connect to the peritoneum. (Over) 3:12 PM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: ? The left kidney measures 11 cm. The right kidney measures 8.8 cm, which is small. FOLLOWS COMMANDS WITHOUT DIFFICULTY. 2. PT HAS STANDING ORDER FOR 2MG DILAUDID IVP Q 4 HOURS- WHICH HAS GIVEN HER SLIGHT RELIEF. RR 15-20, SP02 > OR = TO 95%.CV: S1 AND S2 AS PER AUSCULTATION. This most likely represents an inflammatory or chronically-infected fluid collection in the abdominal wall. IMPRESSION: No evidence for CHF or pneumonia. Voids on commode with x1 assist, clear yellow urine noted.Skin intact.Afebrile.Hct stable at 28.Lytes repleted per orders.Social: Son and husband called, planning to visit tonight.Pt. PT ALSO RECEIVED TOTAL OF 10ML OF PERCOCET ELIXER WITH RELIEF AS WELL.RESP: ROOM AIR. The heart is slightly enlarged. MONITOR PAIN AND ANXIETY. ALL QUESTIONS ANSWERED.DISPO: FULL CODE.PLAN: MONITOR CRIT Q 6 HOURS- NEXT ONE IS DUE AT 1000. is called out to 7, being evaluated by floor team. tolerating ice chips and clears. DID NOT REQUIRE ANY BLOOD TX DURING THAT HOSPITAL COURSE. NURSING PROGRES NOTE 1900-0700REPORT RECEIVED FROM AM SHIFT. pain . Heart size is difficult to evaluate on this AP film but allowing for technique is likely within normal limits and there is no evidence for CHF. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2119-11-13 00:00:00.000",
"description": "Report",
"row_id": 1571285,
"text": "NURSING PROGRES NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 52 Y/O F WITH H/O UGI BLEED WITH DOUDENAL ULCERS, DVT/PE AND AFIB. PT ANTICOAGULATED WITH COUMADIN- NOW IS ADMITTED WITH HEMATEMESIS AND HEMATOCRIT OF 15. PT HAD RECENTLY BEEN ADMITTED ON TO WITH MELENA AND INR 5.5. AT THAT TIME, PT HAD EGD AND COLONOSCOPY THAT WAS SIGNIFICANT FOR A DUODENAL ULCER AND DIVERTICULOSIS. DID NOT REQUIRE ANY BLOOD TX DURING THAT HOSPITAL COURSE. BEGINNING LAST FRIDAY PT NOTED COFFEE GROUND EMESIS AND BLACK STOOLS. GI CONSULT- PLAN FOR RESUCITATION AND WILL DISCUSS POSSIBILTY OF REPEAT SCOPE. PT HAS SIGNIFICANT PSYCH HX- PAST EPISODES OF DELUSION (THOUGHT BODY WAS INFESTED WITH MICE) AND TRAUMA FROM HX OF DOMESTIC ABUSE. PT ALSO HAS SIGNIFICANT CHRONIC PAIN ISSUES- TAKES PERCOCET AND OXYCODONE BUT ADMITTES TO OCCASIONALLY TAKING \"EXTRA OXYCONTIN\" AT TIMES DUE TO SEVERE PAIN.\n\nNEURO: PT ALERT AND ORIENTED X 3- ALTHOUGH DOES GET ANXIOUS AT TIMES- NEEDS CONSTANT REASSURANCE OF PLAN OF CARE. PT GIVEN 2 DOSES OF ATIVAN- OBTAINED STANDING ORDER FOR ANXIETY. AFEBRILE. PERRLA, 3/ BRISK. FOLLOWS COMMANDS WITHOUT DIFFICULTY. SPEECH CLEAR. MAE X 4 WITHOUT DIFFICULTY- ABLE TO ASSIST WITH PERSONAL CARE. PT HAS SIGNIFICANT CONCERNS REGARDING PAIN- STATES THAT SHE HAS CONTINOUS H/A AND BECAUSE SHE HAS NOT BEEN ABLE TO INGEST HER MEDS AT HOME-FEARS THAT THE PAIN HAS \"GOTTEN AWAY FROM HER\". PT HAS STANDING ORDER FOR 2MG DILAUDID IVP Q 4 HOURS- WHICH HAS GIVEN HER SLIGHT RELIEF. PT ALSO RECEIVED TOTAL OF 10ML OF PERCOCET ELIXER WITH RELIEF AS WELL.\n\nRESP: ROOM AIR. BBS= ESSENTIALLY CLEAR TO ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. NO C/O SOB OR DIFFICULTY BREATHING. RR 15-20, SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. AFIB, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPOTENSIVE OR HYPERTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS. PT HAS INTRODUCER TO RT IJ. RECEIVED TOTAL OF 6U PRBCS THIS SHIFT. INITIAL CRIT OF 15- AS OF 0400- LATEST CRIT IS NOW 28- WILL CHECK Q 6 HOURS- NEXT DRAW DUE AT 1000. DENIES ANY CHEST PAIN.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NPO AT THIS TIME. NO C/O N,V,D. NO BM THIS SHIFT. PASSING FLATUS- NO PRESENTATION OF GIB.\n\nGU: PT VOIDS ON BEDPAN WITHOUT DIFFICULTY. CLEAR YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: GROSSLY INTACT.\n\nSOCIAL: HUSBAND IN TO VISIT FOR BEGINNING OF SHIFT. NO ISSUES. ALL QUESTIONS ANSWERED.\n\nDISPO: FULL CODE.\n\nPLAN: MONITOR CRIT Q 6 HOURS- NEXT ONE IS DUE AT 1000. GI TO RE-EVALUATE. MONITOR PAIN AND ANXIETY. PLEASE SEE FLOW SHEET AS NEEDED. THANK YOU!\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-13 00:00:00.000",
"description": "Report",
"row_id": 1571286,
"text": "Neuro: A&Ox3, cooperative with care, c/o severe H/A occasionally accompanied by nausea and RUQ abd. pain . Medicated with DIlaudid 2mg Q2hrs, Ativan and Anzamet prn with short relief.\nResp: Denies SOB, LS clear, sats high 90s on RA.\nCV: Chronic AF HR 70s-80s, no ectopy. BP 110s-140s/50s-60s. Palpable pedal pulses. No peripheral edema noted.\nGI/GU: No scope today, pt. tolerating ice chips and clears. Abd. soft, distended, c/o intermittent RUQ pain. Abd. u/s ? bile duct dilitation, follow up abd. CT ordered. Voids on commode with x1 assist, clear yellow urine noted.\nSkin intact.\nAfebrile.\nHct stable at 28.\nLytes repleted per orders.\nSocial: Son and husband called, planning to visit tonight.\nPt. is called out to 7, being evaluated by floor team.\n"
},
{
"category": "ECG",
"chartdate": "2119-11-16 00:00:00.000",
"description": "Report",
"row_id": 177321,
"text": "Atrial fibrillation\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 883417,
"text": " 4:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess for pneumothorax and position of TLC\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with change of cortis to TLC at RIJ, also unsuccessful\n attempt at LIJ\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax and position of TLC\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n INDICATION: Line insertion.\n\n The heart is slightly enlarged. The right IJ catheter is present terminating\n in the junction of the superior vena cava and right atrium. The lungs appear\n clear, and there is no pneumothorax.\n\n IMPRESSION: Right IJ line insertion.\n\n Cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882698,
"text": " 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with R chest pain and SOB, with h/o PE.\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM\n\n History of right chest pain and shortness of breath.\n\n Cordis catheter is in right brachiocephalic vein. No pneumothorax. Heart\n size is difficult to evaluate on this AP film but allowing for technique is\n likely within normal limits and there is no evidence for CHF. Linear scarring\n in the right costophrenic angle unchanged since prior film. No pleural\n effusions.\n\n IMPRESSION: No evidence for CHF or pneumonia. The pulmonary vasculature is\n unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-13 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 882809,
"text": " 3:12 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ? pathology/stone\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with RUQ pain\n REASON FOR THIS EXAMINATION:\n ? pathology/stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant pain.\n\n ABDOMINAL ULTRASOUND: The liver is normal in echogenicity and contour and is\n without focal masses or biliary ductal dilatation. The portal vein is patent\n and demonstrates normal hepatopetal flow. The patient is status post\n cholecystectomy. The common bile duct ranges from 9 to 11 mm, which is mildly\n dilated. No stones are identified within the common bile duct or within the\n peripancreatic region. The visualized pancreas is unremarkable. The aorta is\n normal in caliber. The right kidney measures 8.8 cm, which is small. The left\n kidney measures 11 cm. Neither kidney contains masses, stones, or\n demonstrates hydronephrosis. There is a right pleural effusion.\n\n In the left mid abdomen in the region of the patient's palpable mass is an\n approximately 5 cm x 2 cm fluid collection with a thick vascularized wall\n which does not appear to connect to the peritoneum. This most likely\n represents an inflammatory or chronically-infected fluid collection in the\n abdominal wall.\n\n IMPRESSION:\n\n 1. Common bile duct dilatation to 11 mm without stones or other abnormalities\n demonstrated to the level of the head of the pancreas. No intrahepatic\n biliary ductal dilatation is identified.\n\n 2. Left mid abdominal wall fluid collection with vascular capsule which\n likely represents an inflammatory fistula or chronically-infected fluid\n collection.\n\n 3. Atrophic right kidney. In the setting of a normal sized left kidney, this\n finding may represent right renal artery stenosis or other cause of atrophy.\n Clinical correlation is advised.\n\n 4. Right pleural effusion.\n\n Recommend CT enterography scan for evaluation of the abdominal wall\n collection.\n\n (Over)\n\n 3:12 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ? pathology/stone\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
}
] |
7,247 | 134,976 | The patient was admitted to the cardiac catheterization lab. Please see the cath lab for full details. In summary, the cath report showed aortic stenosis with an aortic valve area of .6 cm sq, a mean gradient of 50, preserved ventricular function with an EF of 50% and an RCA with an 80% mid vessel stenosis. Following her catheterization, cardiothoracic surgery was consulted. She was accepted for aortic valve replacement and on she was brought to the operating room for an aortic valve replacement and a CABG times one. Please see the OR report for full details. In summary, the patient underwent an aortic valve replacement with a #21 pericardial valve and a CABG times one with a saphenous vein graft to the RCA. She tolerated the operation well and was transferred from the operating room to the cardiothoracic Intensive Care Unit. At the time of transfer the patient had a right arterial line, a Swan Ganz catheter, ventricular and atrial pacing wires, two mediastinal and a left pleural chest tube. Her mean arterial pressure was 88, her CVP was 12. She was A-paced at a rate of 90 beats per minute and she had Propofol infusing at 20 mcg/kg/minute. The patient did well in the immediate postoperative period, however, after several hours in the cardiothoracic Intensive Care Unit she became hypotensive with increasing chest tube output and she was brought back to the operating room for re-exploration of her mediastinal bleeding at which time it was found that she had a coronary sinus injury. She tolerated the re-exploration well and was brought from the operating room back to the cardiothoracic Intensive Care Unit, after which she remained hemodynamically stable without any further bleeding. She did, however, remain intubated throughout the evening and on postoperative day #1 her sedation was discontinued, however, she was slow to awaken from her anesthesia and sedation and she remained intubated throughout the day on postoperative day #1. On postoperative day #2 the patient was more responsive and she was weaned from the ventilator to C-pap, however, she was still somewhat sluggish and therefore she remained intubated throughout postoperative day #2. In addition, the patient remained hemodynamically stable, however, somewhat hypertensive and she was begun on Nipride to control her blood pressure. Throughout postoperative day #3 the patient continued to be somewhat sedate, therefore she stayed on C-pap from a respiratory standpoint with good gas exchange. Hemodynamically she remained stable but somewhat hypertensive and therefore remained on Nipride. Captopril was added to her regime of Nipride to try to control her blood pressure. On postoperative day #5 the patient was extubated, her Lopressor and Captopril were increased, allowing us to wean her from her Nipride and by postoperative day #6 her Nipride was off and she was transferred to Far 6 for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient remained hemodynamically stable, her activity level was increased on a daily basis with the assistance of physical therapy and on postoperative day #8 it was decided that the patient would be appropriate to discharge to home with the assistance of VNA for nursing assessment and physical therapy on the following day. | Lopressor and Hydralizine started today.RESP: LS coarse throughout. CT with minimal draiange.GI/GU: + BS. TYLENOL 650 MG PO W/ GOOD EFFECT.CARDIAAC~WEANING NIPRIDE TOL WELL. PT HYPERTENSIVE ON 1 MCG SNP THIS AM. PT diuresing well -- OU this shift 1180cc. UO<30 CC/HR X 4 HR, MD AWARE (PRE-REXPLORATION). 7a-7p updateNeuro: Lethargiac, PERL, MEA, right upper extremity weakCV: SR, HR 77-97. POS PAL PEDAL PULSES BILAT.RESP~LUNGS CLEAR BILAT. good effect noted.Plan: diuresis, wean snp, wean vent REMAINS ON SNP FROM .25 - 1 MCG. BUN ^35, CREAT ^1.2. CUFF BP'S CORROLATE WITH ALINE. PT HYPOTENSIVE EARLY IN SHIFT WITH DROP IN CI DOWN TO 1.37. Resp Care: Pt continues intubated and on ventilatory support with psv 8/fio2 .4/+5 peep overnoc, decreased to psv 5 early am maintaining Vt 300's with Ve 6-9L, good abg; BS coarse, sxn yell secretions, will wean as tol. ADVANCE DIET AS TOL. WEANING OFF NIPRIDE. RESP. SBP 120-150, STILL ON .5MCG SNP. Spont vols 350- 360 with RR 14-19. TOLERATING PO'S WELL THIS AM, ORAL AGENTS STARTED. Adequate Abg's with improved PaO2. IPS DECREASED TO 5 AT 0500, STILL APPEARS TO BE COMFORTABLE, WITH RR 14-20 AND VT 310-390CC. SPUTUM C&S SENT. Bs coarse bilaterally. ABD SOFT, SL DISTENDED, HYPOACTIVE BOWEL SOUNDS, TAN OGT DRAINAGE. OG TO LCS. AFEBRILE. AFEBRILE. OU (POST REEXPLORATION) > 30CC/HR. Suctioned x 4 today. RESTART ORAL HYPOGLYCEMICS. POS BS.SKIN~DSG CHANGE TO L LEG SCANT AMT OF SEROUS FLUID BLISTERS NOTED TO LTHIGH. RESP: PT ON CPAP THIS AM WITH SATS 95-97. NEO, NIPRIDE, NITRO GTTS TITRATED FOR LABILE BP THROUGHOUT THE SHIFT. PT ON LASIX TID. PLAN TO WEAN NIPRIDE AS PT TOLERATES. COUGHED UP MOD AMTS THICK SPUTUM-HAS LESS NOW AND SOUNDS LESS COARSE. MILRINONE GTT STARTED AND DC'D WITH 1 HR FOR TACHYCARDIA AND HYPTENSION. NEO GTT UP TO 7 MCG/KG TO KEEP MAP > 60, MD AWARE, TREATED WITH COLLIODS AND CRYSTALOID. LESS HYPERTENSIVE SINCE BEING . 7.0 ET TUBE AT 21CM AT LIP.PLAN- TO WEAN AS TOLERATED TO EXTUBATION RIGHT HAND S.L PLACED. GU: DIURESED COPIOUS AMT FROM 40 LASIX THIS AM. Pt. PT . PLAN TO D/C CORDIS AND ALINE; AND TRANSFER TO . CO/CI ACCEPTABLE. Resp Care: Pt continues intubated and on ventilatory support with simv 550x10/fio2 .5/+5 peep/psv 8 with acceptable abg; BS coarse crackles, sxn thick white secretions, will attempt wean as tol, see carevue foe details. CI 1.37-2.36. PT UPDATE NEURO: PT ALERT, COOPERATIVE THIS AM. RESP ALK (7.56/26)IMV RATE DECREASED TO 10. PUPILS 2MM AND SLUGGISH BILATERIALLY.PROPROFOL OFF WITH HYPOTENSION, PT MAE AT THAT TIME.CV: SR/ST, HR 130-79. NIPRIDE WEANED TO .25 UCG/KG/MIN. BM X1 THIS AM. ECCHYMOSIS BILAT THIGHS AND L UPPER ARM.ENDO~TX W/ S/S INSULIN.A/P~WEAN NIPRIDE TO OFF. ON IMV OF 14 AND 70% FIO2. LUNGS CLEAR WITH RALES LEFT BASE. EXCELLENT DIURESIS WITH INCREASED LASIX. ABD SOFT, BOWEL SOUNDS PRESENT. K BEING REPLETED. FOLEY TO GRAVITY. TO START GLUCOTROL AND GLUCOPHAGE TODAY. PACER REMAINS ON DR 60. OTHER: MIN CT DRG. Status post CABG with moderate right pleural effusion. NOW THAT PROPOFOL IS OFF; PT SOMEWHAT MORE HYPERTENSIVE AND NOW NTG BACK ON. GIVEN UPDATE RE: PT CONDITION. HTN, NTG AND SNP TITRATED.BREATHSOUNDS CLEAR. The right pleural effusion has resolved. Rule out pneumothorax. BP REMAINS SOMEWHAT LABILE; NEO TITRATED ALL AM. CO BY FICK METHOD GOOD. Bs rhonchi bilaterally. ct dc w/o incident. NOW BS 100'S AND GTT REMAINS OFF. CI DOWN TO 1.76 THIS AM; SVO2 71 AND FICK CO 5.7/CI 3.4. Status post insertion of a right chest tube. There is retrocardiac opacity and a small left sided pleural effusion. Pt. Pt. Pt. Mild increase in the left pleural effusion. Preop for CABG. ETT SUCTIONED AND LAVAGED FOR ONE TAN/BLOODY PLUG.MAE. PERIODS OF APNEA AND OVER BREATHING. S/P chest tube removal. IMPRESSION: 1. IMPRESSION: 1. CHEST, PORTABLE: Comparison is made to a prior study from . There is a moderately sized right pleural effusion. Left lower lobe atelectasis and small bilateral pleural effusions. PAP/Plateau 29/24. AVR. GI: PT ON CARAFATE. Plan to repeat to Abg. UPDATENSR WITHOUT ECTOPY. There is mild cardiomegaly. GENERALIZED EDEMA NOTED, ESPECIALLY PERIORBITAL AREAS.STERNAL, CT AND L LEG INCISIONAL DSG/S CHANGED. RR decreasing back to 18. There is opacification of the retrocardiac region most likely due to atelectasis. ONLY CO BY FICK Q/SHIFT (UNLESS PT CONDITION CHANGES) NP . Sinus rhythmLeft axis deviationPoor R wave progressionNonspecific ST-T abnormalities NEURO: PROPOFOL WEANED OFF AND PT HAS MAE, THOUGH SLOW TO WAKE UP. A right chest tube has been inserted and the right sided effusion has complete resolved. PORTABLE CHEST: Comparison is made to a prior study of . WEANED TO CPAP WITH VARYING AMOUNTS OF PRESSURE SUPPORT. There are bilateral pleural effusions and opacification of the left lower lobe is again noted. BS CLEAR. IMPRESSION: Somewhat limited examination due to respiratory motion. There is cardiomegaly. There is cardiomegaly. updateO: Ct here for ct dc pt premedicated w mso4 4 iv & subseq midaz 2mg ivp for anxiety w gd releif. Repeated Abg showed Resp Alkalosis with Pa02 61. PLAN TO KEEP MBP <90. The aorta appears tortuous. INCREASED ALERTNESS AS SHIFT PROGRESSED.PT DENIES PAIN.URINE OUTPUT ADEQUATE. Tolerated well. PT UPDATE PT MUCH MORE STABLE TODAY AFTER RETURNING FROM O.R. Vent settings Vt 550, Simv 10, Fio2 50%, Peep 5, and Psv 8. tiring. K AND CA REPLETED. NG tube is seen, the tip of which is not depicted on this film. Tolerated well until 3:45pm. REASON FOR THIS EXAMINATION: pre-op CABG/AVR in AM FINAL REPORT INDICATION: PREOP FOR CABG AND AVR. SATS 96-98. VANCO 500MG Q 18HRS. Hilar contours and pulmonary vascularity appear unremarkable. REPEAT FICK CO PENDING LABS AT THIS TIME. | 27 | [
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1359073,
"text": "RESP NOTE\n76 YR OLD FEMALE OR COURSE CABG * 1, AVR PLACED ON SIMV 10/600/PEEP +5/ PSV 5/ FIO2 60 % NO SPONT. RESP. AT THIS TIME SAT 100%-WEANED FIO2 TO 50%. 7.0 ET TUBE AT 21CM AT LIP.\nPLAN- TO WEAN AS TOLERATED TO EXTUBATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1359074,
"text": "NEURO FROM OR SEDATED PROPOFOL INFUSING 20MCGS PUPILS PINPOINT REVERSALS STARTED WITH DECREASE IN HR AND B/P ONLY HALF DOSE GIVEN NP PROPOFOL WEANED AND DC/D PUPILS REACTIVE STARTING TO WAKE MOVING SLIGHTLY IN BED ATTEMPTING TO OPEN EYES TO VOICE SHAKES HEAD NO TO QUESTIONS LOW CI LOW MIXED VENOUS PROPOFOL BACK ON PER CI MIXED VENOUS STABLE RESEDATED WITH 20MCG OF PROPOFOL DECREASE TO 15 WITH DECREASE IN B/P CURRENTLY INFUSING AT 15 WITH GOOD SEDATION\n\nC/V ARRIVED FROM OR A PACED UNDERLYING HR 70S WITH GOOD B/P PACER SET TO 70 WITH GOOD A SENSE AND CAPTURE V WIRE NOT SENSING REVERSALS GIVEN 4PM WITH DECREASE TO SB 50S PACER ON REPACED AT 86 B/P LABILE REQUIRING SMALL NITRO AT TIMES CO/CI LOW HESPAN X2 LR 1500 IUPC INFUSED CO FICK 3.4 MIXED VENOUS 46 FOR REPEAT HOURLY PER DR WITH LACTATE UNABLE TO OBTAIN DOPPLER PEDAL PULSE F FOOT ALL OTHER PULSES PRESENT FEET COOL BILAT NP CT INCREASE DRAINGAGE ON ARRIVAL ACT 145 PROTAMINE GIVEN WITH DECREASE IN CT DRAINAGE AT PRESENT B/P DECREASE TO 80S 1830 PACER INCREASE TO 95 WITH LITTLE EFFECT PROPOFOL DECREASE TO 15 NEO STARTED AT .5 WITH SL INCREASE TO 90S NEO INCREASE TO .75 WITH B/P MAP 70S CVP 19\n\nRESP VENT UNCHANGED REMAINS ON IMV 50% SMALL THICK SECRETIONS SATS 99-100%\n\nLABS INSULIN DRIP PER PROTOCOL CURRENTLY INFUSING AT 10.5 UNITS HOUR BS 168 K CALCIUM REPLACED HCT 26 IUPC GIVEN\n\nPLAN REMAIN ON VENT UNTIL STABLE CHECK MIXED VENOUS Q1H UNTIL IMPROVED MAINTAIN B/P EVALUATE CO/CI\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-12 00:00:00.000",
"description": "Report",
"row_id": 1359075,
"text": "7PM-7AM\nNEURO: PT SEDATED ON PROPOFOL. PUPILS 2MM AND SLUGGISH BILATERIALLY.\nPROPROFOL OFF WITH HYPOTENSION, PT MAE AT THAT TIME.\n\nCV: SR/ST, HR 130-79. NO ECTOPY NOTED. MAP 122-59. CI 1.37-2.36. NEO, NIPRIDE, NITRO GTTS TITRATED FOR LABILE BP THROUGHOUT THE SHIFT. PT HYPOTENSIVE EARLY IN SHIFT WITH DROP IN CI DOWN TO 1.37. MILRINONE GTT STARTED AND DC'D WITH 1 HR FOR TACHYCARDIA AND HYPTENSION. NEO GTT UP TO 7 MCG/KG TO KEEP MAP > 60, MD AWARE, TREATED WITH COLLIODS AND CRYSTALOID. CT MILKED BY MD AT THAT TIME, SANGINOUS CT DRAIAGE NOTED WITH INCREASE IN DRAINAGE 200-300 CC/HR FROM 20-50 CC/HR. DR AWARE AND IN TO SEE PATIENT, PT BACK TO OR AT 0130 FOR REXPLORATION, POST OP HYPERTENTION TX WITH NITRO AND SNP GTTS, POST OP CI 1.98-2.36\n\nRESP: LUNGS CLEAR THROUGHOUT. SUCTIONED FOR SMALL TO MODERATE AMOUNT OF LOOSE TAN SPUTUM. ON IMV OF 14 AND 70% FIO2. RESP ALK (7.56/26)\nIMV RATE DECREASED TO 10. O2 SAT 95-100%\n\nGI/GU: BS ABSENT. OG TO LCS. OG DRAINING SMALL AMOUNT OF BROWNISH FLUID. FOLEY TO GRAVITY. UO<30 CC/HR X 4 HR, MD AWARE (PRE-REXPLORATION). OU (POST REEXPLORATION) > 30CC/HR. FOLEY DRAIANGE CLEAR YELLOW URINE.\n\nCOMFORT: MEDIACTED WITH MSO4 FOR PAIN CONTROL.\n\nPLAN: MONITOR ABG'S/VENT CHANGES AS NEEDED, TITRATED GTTS TO MAINTAIN MAP 60-90 AND CI>2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-16 00:00:00.000",
"description": "Report",
"row_id": 1359091,
"text": "NEURO~A + O X3, ABLE TO LIFT AND HOLD ALL EXTREM. UPPER BODY WEAKER THAN LOWER. C/O GEN BODY ACHE AND INCISIONAL DISCOMFORT. TYLENOL 650 MG PO W/ GOOD EFFECT.\n\nCARDIAAC~WEANING NIPRIDE TOL WELL. NSR IN 70'S. OCC PACING. ELECTROLYTES REPLENISHED. POS PAL PEDAL PULSES BILAT.\n\nRESP~LUNGS CLEAR BILAT. ON 5L SATS:95-97%.\n\nGI/GU~TOL ICE CHIPS AND WATER. POS BS.\n\nSKIN~DSG CHANGE TO L LEG SCANT AMT OF SEROUS FLUID BLISTERS NOTED TO L\nTHIGH. ECCHYMOSIS BILAT THIGHS AND L UPPER ARM.\n\nENDO~TX W/ S/S INSULIN.\n\nA/P~WEAN NIPRIDE TO OFF. ADVANCE DIET AS TOL. RESTART ORAL HYPOGLYCEMICS. TRANSFER TO 6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-16 00:00:00.000",
"description": "Report",
"row_id": 1359092,
"text": "NIPRIDE WEANED TO .25 UCG/KG/MIN. MAINTAINING MAP'S 60-90. OCC A-PACES @ 60. BUN ^35, CREAT ^1.2. TO START GLUCOTROL AND GLUCOPHAGE TODAY. PLAN~WEAN NIPRIDE TO OFF AND TRANSFER TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-16 00:00:00.000",
"description": "Report",
"row_id": 1359093,
"text": "ALERT AND ORIENTED, PLEASANT WOMAN. UPPER EXTREMITIES ARE GENERALLY WEAK, EQUALLY WEAK ABLE TO LIFT AND HOLD UP BOTH ARMS. COUGHING AND RAISING THICK TAN/YELLOW SECRETIONS WELL. WEANING OXYGEN. LUNGS CLEAR WITH RALES LEFT BASE. TOLERATING PO'S WELL THIS AM, ORAL AGENTS STARTED. FOLEY DRAINING LARGE AMOUNTS AFTER LASIX WHICH HAS BEEN DECREASED TO 20MG IVP TID. CUFF BP'S CORROLATE WITH ALINE. NSR, NO ECTOPY. WEANING OFF NIPRIDE. CAPOTEN INCREASED. RIGHT HAND S.L PLACED. BM X1 THIS AM. OOB TO CHAIR WITH 2 ASSISTS, UP SINCE 8AM AND IS COMFORTABLE. SPOKE WITH DAUGHTER WHO WAS UPDATED THIS AM. DENIES PAIN, USING TYLENOL ONLY. PRESENTLY NAPPING IN THE CHAIR. PLAN TO D/C CORDIS AND ALINE; AND TRANSFER TO .\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1359087,
"text": "EKG NSR, NO ECTOPY, BUT SOMETIMES DROPS RATE TO SB, 50S, TRANSIENTLY.. PACER ON A DEMAND AT 60, MA 15. SBP STILL LABILE BETWEEN 115 AND 180, SOMETIMES WITHOUT APPARENT STIMULUS. REMAINS ON SNP FROM .25 - 1 MCG. AFEBRILE. EXCELLENT DIURESIS WITH INCREASED LASIX. CHEST INCISION AND CT SITE DRESSING DRY. ABD SOFT, BOWEL SOUNDS PRESENT. BREATH SOUNDS CLEAR, DECREASED AT BASES. ETT SUCTIONED FOR SMALL AMTS THICK YELLOW SECRETIONS. ON CPAP ALL NIGHT, WITH 8 IPS, VT 300S. IPS DECREASED TO 5 AT 0500, STILL APPEARS TO BE COMFORTABLE, WITH RR 14-20 AND VT 310-390CC. L THIGH STILL BLISTERED, SKIN FRAGILE, NETTING DRESSING CHANGED. AWAKENS READILY TO VOICE, NODS APPROP TO QUESTIONS, FOLLOWS COMMAND, MAE EQUALLY, TRIES TO HELP WITH MOVING IN BED. USUALLY DENIES PAIN, BUT MEDICATED WITH 2 MG MSO4 X 1 WHEN SHE INDICATED DISCOMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1359088,
"text": "Resp Care: Pt continues intubated and on ventilatory support with psv 8/fio2 .4/+5 peep overnoc, decreased to psv 5 early am maintaining Vt 300's with Ve 6-9L, good abg; BS coarse, sxn yell secretions, will wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1359089,
"text": "PT UPDATE\n NEURO: PT ALERT, COOPERATIVE THIS AM. . AND IS A&O X3. CALM AND COOPERATIVE. RESP: PT ON CPAP THIS AM WITH SATS 95-97. RR 18-24. PT DID HAVE MOD AMT TAN SECRETIONS; BUT HAD GOOD STRONG COUGH. SPUTUM C&S SENT. PT . AT 1100. PO2 70 ON 40% OFM-HOWEVER-PT C/O MIST IN EYES AND CONT TO PULL ON MASK; SO CHANGED TO NP 5L, AND NOW SAT 95. APPEARS TO BE BREATHING . SOMEWHAT COARSE WHEN FIRST . COUGHED UP MOD AMTS THICK SPUTUM-HAS LESS NOW AND SOUNDS LESS COARSE. STILL DIMINISHED IN BASES AND NEEDS ENCOURAGEMENT TO COUGH. CARDIAC: HR 80'S SR WITH TWO VERY BRIEF EPISODES OF HR LESS THAN 60 AND STARTED PACING (LASTING ONLY 10 SECS OR SO). PACER REMAINS ON DR 60. PT HYPERTENSIVE ON 1 MCG SNP THIS AM. LESS HYPERTENSIVE SINCE BEING . AND ALSO LOPRESSOR HAS BEEN INCREASED. SNP WEANED DOWN TO .5 MCG. GU: DIURESED COPIOUS AMT FROM 40 LASIX THIS AM. WEIGHT DOWN 2.6KG TODAY FROM YEST; BUT STILL REMAINS UP 15 KG. PT ON LASIX TID. GU: POS BS, NO BM YET. LAB: BS 150-200 RANGE-BEING COVERED BY SS INSULIN. K BEING REPLETED. OTHER: PT ASSISTED 1330-DID FAIRLY WELL, CONSIDERING HAS NOT BEEN OOB SINCE ON . PT LOOKS GOOD IN CHAIR. DAUGHTER SITTING IN WITH PT. PLEASED WITH PT'S PROGRESS. WILL CONT TO ENCOURAGE PULMONARY TOILET AND TRY TO WEAN SNP TO OFF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1359090,
"text": "NEURO~INTACT~NO C/O PAIN~INTERMITTENT TO DAUGHTER STATED SHE THOUGHT THE WALL WAS MOVING~H/O VERY SENSITIVE TO NARCOTICS AND WOULD LIKE TYLENOL IF HAVING PAIN RATHER THATN MORPHINE. 02 AT 5L~WITH SATS 92-95%, COUGHING AND RAISING THICK YELLOW. INCREASED CAPTOPRIL DOSE GIVEN AT 1600~PT TOLERATED WELL~AND NO BRADYCARDIA THIS EVENING. SMALL AIPS OF WATER~THROAT STILL HOARSE AND PT WITH INTERMITTENT COUGHING WITH WATER~ABLE TO SWALLOW PILLS. PLAN TO WEAN NIPRIDE AS PT TOLERATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 1359080,
"text": "7a-7p update\nNeuro: Lethargiac, PERL, MEA, right upper extremity weak\n\nCV: SR, HR 77-97. No ectopy noted. CI 2.22-2.57. MAP 79-104. Remains in SNP, titrated for BP, unable to wean to off. Lopressor and Hydralizine started today.\n\nRESP: LS coarse throughout. Suctioned x 4 today. Suctioned moderate amounts of thick tan sputum. Placed on CPAP from 9am-1500. CPAP 40% with 5 PEEP and 15IPS, IPS increased to 20 d/t low TV (TV in the 300's). AT 1500 rr in the 30's, increase in BP and HR, ABG 61/24/7.61/25. Pt placed back on IMV with a rate of 10, FiO2 increased to 50% with 5 PEEP and 8 IPS -- ABG 90/35/7.49/27. PT weight up, 82 kg (62.8 pre-op) - lasix started . CT with minimal draiange.\n\nGI/GU: + BS. OG draining brown fluid. PT diuresing well -- OU this shift 1180cc. foley draining clear yellow urine.\n\nPain: pt medicated with mso4 x 4 today. good effect noted.\n\nPlan: diuresis, wean snp, wean vent\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359081,
"text": "Resp Care: Pt continues intubated and on ventilatory support with simv 550x10/fio2 .5/+5 peep/psv 8 with acceptable abg; BS coarse crackles, sxn thick white secretions, will attempt wean as tol, see carevue foe details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359082,
"text": "EKG NSR, NO ECTOPY. SBP 120-150, STILL ON .5MCG SNP. AFEBRILE. CO/CI ACCEPTABLE. ADEQUATE UO, SOME DIURESIS WITH 20MG LASIX, BUT BRISKER NOW AFTER 0600 DOSE INCREASED TO 40MG. BREATH SOUNDS COARSE THROUGHOUT, SUCTIONING SMALL AMTS THICK TAN SECRETIONS FROM ETT. RESTED ON SIMV UNTIL 0530, NOW ON CPAP, RATE 18-20, VT 350+. SMALL AMTS SEROSANG CT DRAINAGE, NO AIR LEAK. ABD SOFT, SL DISTENDED, HYPOACTIVE BOWEL SOUNDS, TAN OGT DRAINAGE. SKIN WARM AND DRY, INTACT EXCEPT FOR AREA AROUND L THIGH INCISION, WHICH IS FRAGILE AND BLISTERED, NETTING USED TO HOLD DRESSING INSTEAD OF TAPE. OPENS EYES TO VOICE, FOLLOWS ALL COMMANDS, R ARM BE SLIGHTLY SLOWER TO RESPOND, BUT FAIRLY STRONG. MSO4 2 MG X 2 FOR COMFORT, BUT HELS IN EARLY AM PENDING VENT WEAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359083,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Psv 8, Cpap 5, Fio2 50%. Spont vols 350- 360 with RR 14-19. Bs coarse bilaterally. Sx'd for sm amount of thick yellow sputum. Adequate Abg's with improved PaO2. Pt. appears comfortable on above settings. Continue with Psv and wean Fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359084,
"text": "Fio2 weaned to 40%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359085,
"text": "NEURO LETHARGIC EASILY AROUSABLE FOLLOWS COMMANDS\n\nC/V NSR NO ECT NIPRIDE WEANING SLOWLY TOL WELL CAPTOPRIL PO STARTED\nPA LINE DC/D\n\nRESP VENT ON CPAP TOL WELL ABG WNL O2 DECREASE TO 40% SATS 95% SUCTIONED MOD THICK YELLOW LUNGS UPPER COARSE IMPROVES WITH SUCTIONING CT INTACT MINIMAL DRAINAGE\n\nLABS BLOOD SUGAR 200S INSULIN PER PROTOCOL IMPROVING K CA REPLACED\n\nPLAN CONTINUE CPAP AS TOL CONTINUE LASIX FOR URINE OUTPUT\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1359086,
"text": "update\nO: Ct here for ct dc pt premedicated w mso4 4 iv & subseq midaz 2mg ivp for anxiety w gd releif. ct dc w/o incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-12 00:00:00.000",
"description": "Report",
"row_id": 1359076,
"text": "PT UPDATE\n PT MUCH MORE STABLE TODAY AFTER RETURNING FROM O.R. EARLY AM. NEURO: PROPOFOL WEANED OFF AND PT HAS MAE, THOUGH SLOW TO WAKE UP. RESP: FIO2 WEANED DOWN TO 40%; RATE DOWN TO 8 AND ABG GOOD. BS CLEAR. SATS 96-98. WILL TRY TO WEAN WHEN PT MORE AWAKE. CARDIAC: PT AP AT 80;UNDERLYING RHYTHM SB 60. BP REMAINS SOMEWHAT LABILE; NEO TITRATED ALL AM. NOW THAT PROPOFOL IS OFF; PT SOMEWHAT MORE HYPERTENSIVE AND NOW NTG BACK ON. CI DOWN TO 1.76 THIS AM; SVO2 71 AND FICK CO 5.7/CI 3.4. REPEAT FICK CO PENDING LABS AT THIS TIME. GU: GOOD U/O. WEIGHT UP ALMOST 20 KG. BUN/CR WNL (PT HAS ONE KIDNEY). VANCO 500MG Q 18HRS. GI: PT ON CARAFATE. LAB: HCT 35 THIS AM-GIVEN 1 PC AND UP TO 40. BS DOWN TO 66-GTT OFF, BUT DOWN TO 55-1 AMP D50 GIVEN. NOW BS 100'S AND GTT REMAINS OFF. K AND CA REPLETED. OTHER: MIN CT DRG. NO OOZING FROM DSD'S. PT'S DAUGHTER IN TO VISIT. GIVEN UPDATE RE: PT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-12 00:00:00.000",
"description": "Report",
"row_id": 1359077,
"text": "UPDATE\nNSR WITHOUT ECTOPY. CO BY FICK METHOD GOOD. ONLY CO BY FICK Q/SHIFT (UNLESS PT CONDITION CHANGES) NP . HTN, NTG AND SNP TITRATED.\n\nBREATHSOUNDS CLEAR. WEANED TO CPAP WITH VARYING AMOUNTS OF PRESSURE SUPPORT. PERIODS OF APNEA AND OVER BREATHING. PT RETURNED TO RESTING IMV FOR OVERNIGHT PERIOD. ETT SUCTIONED AND LAVAGED FOR ONE TAN/BLOODY PLUG.\n\nMAE. PT NODDING HEAD TO QUESTIONS AND FOLLOWING COMMANDS. INCREASED ALERTNESS AS SHIFT PROGRESSED.\n\nPT DENIES PAIN.\n\nURINE OUTPUT ADEQUATE. SOME SEDIMENT NOTED IN FOLEY TUBING. GENERALIZED EDEMA NOTED, ESPECIALLY PERIORBITAL AREAS.\n\nSTERNAL, CT AND L LEG INCISIONAL DSG/S CHANGED. ECCHYMOSIS UPPER STERNAL AREA, (OLD CATH SITE R THIGH), AND L UPPER LEG INCISION.\n\nDAUGHTER IN TO VISIT. BELONGINGS TAKEN HOME BY DAUGHTER. DAUGHTER HERE FROM AND CARING FOR THIS MOTHER ) WHILE SHE IS HERE.\n\nPLAN TO TRY CPAP TOMORROW. PLAN TO KEEP MBP <90. NEED ORAL HYPERTENSIVE TOMORROW. PLAN TO CHECK ON GLUCOSE @ 2400/HR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 1359078,
"text": "NSG NOTE\nrestless, c/o incisional pain and discomfort from ett, med with mso4 2mg iv q2hrs with good effect\nremains vented with marginal oxygenation, no cuff leak, suctioned for thick tan sputum\nhemodynamically stable, weaned off nitro, nipride weaned slightly\nmoving all extremities\nminimal chest tube output\nu/o qs\n\nA- stable\n\nP- reattempt vent wean today\n? diuresis to aid vent wean (cuff leak, oxygenation)\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 1359079,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 550, Simv 10, Fio2 50%, Peep 5, and Psv 8. PAP/Plateau 29/24. Bs rhonchi bilaterally. Sx'd for moderate amount of thick tan sputum. Pt. weaned to Psv 15, Cpap 5, with Fio2 40%. Tolerated well. Spont vols 350-400's with RR 15-19. Vols decreasing to 300's and Psv increased to 20. Tolerated well until 3:45pm. Pt. tiring. RR increasing to high 28 to 30. Repeated Abg showed Resp Alkalosis with Pa02 61. Pt. changed to Simv/Psv and Fio2 increased to 50%. RR decreasing back to 18. Plan to repeat to Abg. No further changes made. Continue with mechanical support.\n"
},
{
"category": "ECG",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 152536,
"text": "Sinus rhythm\nLeft axis deviation\nPoor R wave progression\nNonspecific ST-T abnormalities\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745684,
"text": " 12:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg, avr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with severe AS and tight RCA lesion pre-op for CABG. She had\n a significant groin bleed with hematoma and can only lie flat until 11PM.\n REASON FOR THIS EXAMINATION:\n s/p cabg, avr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 year old woman with severe AS and tight RCA lesion. Preop\n for CABG.\n\n PORTABLE CHEST: Comparison is made to a prior study of . The patient\n is status post CABG with multiple mediastinal clips and sternal wires. There\n is cardiomegaly. The mediastinal contours are unremarkable allowing for the\n supine film. The pulmonary vasculature is unremarkable. There is a\n moderately sized right pleural effusion. There is retrocardiac opacity and a\n small left sided pleural effusion. The ET tube is in satisfactory position\n approximately 4 cm from the carina. A Swan-Ganz catheter is identified with\n its tip in the right pulmonary artery. NG tube is seen, the tip of which is\n not depicted on this film.\n\n IMPRESSION:\n\n 1. Status post CABG with moderate right pleural effusion. No evidence of\n CHF.\n\n 2. Retrocardiac opacity most consitent with atelectasis, however, early\n pneumonia cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745627,
"text": " 7:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op CABG/AVR in AM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with severe AS and tight RCA lesion pre-op for CABG. She had\n a significant groin bleed with hematoma and can only lie flat until 11PM.\n REASON FOR THIS EXAMINATION:\n pre-op CABG/AVR in AM\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PREOP FOR CABG AND AVR.\n\n No comparison studies available.\n\n CHEST, SINGLE VIEW: The heart size is enlarged. The aorta appears tortuous.\n Hilar contours and pulmonary vascularity appear unremarkable. The lungs are\n clear. There are no pleural effusions.\n\n IMPRESSION: Cardiomegaly and tortuous aorta with no evidence of CHF,\n pneumonia or pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745708,
"text": " 9:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o hemo/ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cabg/avr c/b blding postop\n REASON FOR THIS EXAMINATION:\n r/o hemo/ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 year old woman status post CABG. Rule out pneumothorax.\n\n CHEST - PORTABLE: Comparison is made to a prior study from earlier the same\n day. There is mild cardiomegaly. The pulmonary vasculature is normal. A\n right chest tube has been inserted and the right sided effusion has complete\n resolved. There is no evidence for a pneumothorax. In the left hemithorax\n there is increased haziness consistent with an increase in pleural effusion.\n There is opacification of the retrocardiac region most likely due to\n atelectasis.\n\n The ET tube is in satisfactory position. The Swan-Ganz catheter is now seen\n with its tip in the main pulmonary artery.\n\n IMPRESSION:\n\n 1. Status post insertion of a right chest tube. The right pleural effusion\n has resolved. There is no evidence of a pneumothorax.\n\n 2. Mild increase in the left pleural effusion.\n\n 3. Swan-Ganz catheter with its tip now in the main pulmonary artery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745797,
"text": " 9:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cabg/avr c/b blding postop\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG. AVR. Possible infiltrate.\n\n FINDINGS: There is no significant change in the appearance of the chest since\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745864,
"text": " 8:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal, diuresis-\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cabg/avr c/b blding postop\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal, diuresis-\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76 y/o woman s/p CABG, AVR. S/P chest tube removal.\n\n CHEST, PORTABLE: Comparison is made to a prior study from . There is\n cardiomegaly. The mediastinal and hilar contours are unremarkable. The\n evaluation of the vasculature is limited due to respiratory motion. There is\n no definite evidence for CHF. There are bilateral pleural effusions and\n opacification of the left lower lobe is again noted. The patient is s/p CABG\n with multiple surgical clips. The ETT is in satisfactory position.\n\n IMPRESSION: Somewhat limited examination due to respiratory motion. No\n definite evidence of CHF. No evidence of pneumothorax. Left lower lobe\n atelectasis and small bilateral pleural effusions.\n\n"
}
] |
90,026 | 186,577 | 67yo female with incessant VT s/p multiple anti-arrythmics, ablations and sympathectomy on and repeated ablation on c/b coronary sinus perforation who returns with multiple episodes of VT without ICD discharge after altering her anti-arrhythmic medications. | Stable ventricular pacing leads. Mediastinal and hilar contours are stable. IMPRESSION: Following pericardiocentesis, moderate cardiomegaly has improved. FINDINGS: Moderate cardiomegaly has improved following pericardiocentesis. Bilateral lungs are clear. Compared to the previous tracingof the findings are similar. TECHNIQUE: Portable erect chest view was read in comparison with prior chest radiograph from . A-V sequential pacing. FINAL REPORT CHEST RADIOGRAPH. A-V sequential paced rhythm, rate 70. No substatial plueral effusion. There is no pleural effusion or pneumothorax. Compared to the previous tracing of there are nosignificant changes. No pleural effusion or pneumonia. Morphology of the QRS complex is suggested byventricular pacing. Left chest wall pacemaker and defibrillator device with leads through left transverse venous approach end into the right atrium, right ventricle, and the coronary sinus. | 3 | [
{
"category": "Radiology",
"chartdate": "2114-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221736,
"text": " 7:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process\n Admitting Diagnosis: ICD FIRING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with VT\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n WET READ: 11:37 PM\n Lungs are clear. Stable ventricular pacing leads. No substatial plueral\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n TECHNIQUE: Portable erect chest view was read in comparison with prior chest\n radiograph from .\n\n FINDINGS: Moderate cardiomegaly has improved following pericardiocentesis.\n Left chest wall pacemaker and defibrillator device with leads through left\n transverse venous approach end into the right atrium, right ventricle, and the\n coronary sinus. Mediastinal and hilar contours are stable. Bilateral lungs\n are clear. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Following pericardiocentesis, moderate cardiomegaly has improved.\n No pleural effusion or pneumonia.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-12-13 00:00:00.000",
"description": "Report",
"row_id": 144513,
"text": "A-V sequential pacing. Morphology of the QRS complex is suggested by\nventricular pacing. Compared to the previous tracing of there are no\nsignificant changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-12-15 00:00:00.000",
"description": "Report",
"row_id": 144512,
"text": "A-V sequential paced rhythm, rate 70. Compared to the previous tracing\nof the findings are similar.\n\n"
}
] |
75,615 | 115,152 | . #Septic Shock: Patient presented with hypotension, as well as bandemia and hypothermia to 35C. She was admitted to the ICU. Her blood pressure was refractory to IV fluids and she was started on vasopressors to maintain a MAP> 60 through a left femoral line. Her blood pressure medications (isosorbide mononitrate, metoprolol, lasix ) were held due to hypotension. She was started on broad spectrum antibiotics that included Vanc/Cefepime/Flagyl. Her blood culture from admission grew Acinetobacter Baumannii. Her antibiotics were changed to meropenem on . She was weaned of vasopressors by ICU day three and was transferred out to the medicine floor where she remained hemodynamically stable with systolic blood pressures ranging from 90s to 120s. | Moderate mitral annularcalcification. Moderate [2+]tricuspid regurgitation is seen. Mild (1+) aortic regurgitation is seen. Moderate tricuspidregurgitation. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is moderate pulmonary artery systolichypertension. Moderate-to-severe mitral regurgitation. Physiologic (normal) PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium is elongated. Moderate to severe(3+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The right ventricularcavity is moderately dilated with normal free wall contractility. Normal RV systolic function.Abnormal septal motion/position consistent with RV pressure/volume overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The right atrium is moderately dilated. Moderate global LVhypokinesis.RIGHT VENTRICLE: Moderately dilated RV cavity. There is moderate thickening ofthe mitral valve chordae. Moderate [2+] TR. Moderate thickening of mitral valve chordae. There isabnormal septal motion/position consistent with right ventricularpressure/volume overload. Occasional ventricular prematurebeats. Compared to the previous tracing of bradycardia and ectopic beats are absent. Themitral valve leaflets are mildly thickened. Sinus bradycardia with occasional ventricular premature beats. Moderate to severe (3+) mitral regurgitation isseen. Estimated pulmonary artery pressures are lower (which may be due toprogressive right ventricular failure). At least moderate pulmonary hypertension.Compared to prior study (images reviewed) of , left ventricularfunction has declined and there is now evidence of RV volume/pressureoverload. Tricuspid leaflets do notfully coapt. Normal sinus rhythm. LowQRS voltage in the limb leads. Sinus rhythm with first degree A-V block. There is a trivial/physiologic pericardial effusion.IMPRESSION: Severe global hypokinesis with dyskinesis of the interventricularseptum. Prolonged A-V conduction. The diameters of aorta at the sinus, ascending andarch levels are normal. Mitral valve disease.Height: (in) 61Weight (lb): 95BSA (m2): 1.38 m2BP (mm Hg): 100/70HR (bpm): 72Status: InpatientDate/Time: at 16:24Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Normal LV wall thickness and cavity size. There is moderateglobal left ventricular hypokinesis (LVEF = 30-35 %). The aortic valve leaflets are mildly thickened (?#).There is no aortic valve stenosis. Dilated cardiomyopathy. Intraventricular conduction delay, complete leftbundle-branch block. Left axis deviation. Leftventricular wall thicknesses and cavity size are normal. The tricuspid valve leaflets fail to fully coapt. Compared to the previoustracing of no diagnostic interval change.TRACING #1 Left bundle-branch block. ST-T wave changes. Leftbundle-branch block. Compared to tracing #1 no diagnostic interval change.TRACING #2 No AS. Coronary artery disease. No PS.Physiologic PR. | 4 | [
{
"category": "Echo",
"chartdate": "2103-07-09 00:00:00.000",
"description": "Report",
"row_id": 95757,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Dilated cardiomyopathy. Mitral valve disease.\nHeight: (in) 61\nWeight (lb): 95\nBSA (m2): 1.38 m2\nBP (mm Hg): 100/70\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 16:24\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate global LV\nhypokinesis.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function.\nAbnormal septal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Moderate thickening of mitral valve chordae. Moderate to severe\n(3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid leaflets do not\nfully coapt. Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Physiologic (normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. Left\nventricular wall thicknesses and cavity size are normal. There is moderate\nglobal left ventricular hypokinesis (LVEF = 30-35 %). The right ventricular\ncavity is moderately dilated with normal free wall contractility. There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The diameters of aorta at the sinus, ascending and\narch levels are normal. The aortic valve leaflets are mildly thickened (?#).\nThere is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is moderate thickening of\nthe mitral valve chordae. Moderate to severe (3+) mitral regurgitation is\nseen. The tricuspid valve leaflets fail to fully coapt. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Severe global hypokinesis with dyskinesis of the interventricular\nseptum. Moderate-to-severe mitral regurgitation. Moderate tricuspid\nregurgitation. At least moderate pulmonary hypertension.\n\nCompared to prior study (images reviewed) of , left ventricular\nfunction has declined and there is now evidence of RV volume/pressure\noverload. Estimated pulmonary artery pressures are lower (which may be due to\nprogressive right ventricular failure).\n\n\n"
},
{
"category": "ECG",
"chartdate": "2103-07-08 00:00:00.000",
"description": "Report",
"row_id": 268295,
"text": "Sinus rhythm with first degree A-V block. Left bundle-branch block. Low\nQRS voltage in the limb leads. Compared to the previous tracing of \nbradycardia and ectopic beats are absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 268296,
"text": "Sinus bradycardia with occasional ventricular premature beats. Left\nbundle-branch block. Compared to tracing #1 no diagnostic interval change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 268297,
"text": "Normal sinus rhythm. Intraventricular conduction delay, complete left\nbundle-branch block. Left axis deviation. Occasional ventricular premature\nbeats. ST-T wave changes. Prolonged A-V conduction. Compared to the previous\ntracing of no diagnostic interval change.\nTRACING #1\n\n"
}
] |
31,517 | 181,431 | Initial presentation/ICU course: In brief, Mr. is a 45 yo with h/o depression/anxiety, chronic diarrhea and chronic pain hemmorhoids who was transferred from OSH after being found unresponsive by wife after deliberate acetaminophen overdose. At the OSH, initial BP 99/56, HR 118, RR 25 with an O2 sat of 71%. ABG was 7.18/47/61. Narcan was given without effect. His acetaminophen level was found to be 186 and he was started on NAC (10 grams, then 3.5 grams IV) and treated for hyperkalemia. He was intubated with observed aspiration and transferred to for further management. . Initially received vanco/zosyn and transitioned to levofloxacin for aspiration PNA. He was extubated , but continued to have enough of an o2 requirement that he was sent for CTA which was negative for PE, and ECHO to evaluate for CHF given pulmonary edema. ECHO was wnl. His o2 requirements have now been weaned to RA prior to transfer to floor. For acetaminophen toxicity, NAC was started at 17mg/kg/hr and continued until yesterday. His LFTs, which were essentially normal on admission peaked , ~ 48-72h after ingestion, have trended down. He has been followed by psychiatry service who favor inpatient psych admission once medically cleared. Of note pt. also had 1 episode of what was noted to be irregular SVT in context of albuterol administration and thought to be atrial fibrillation. Telemmetry has not shown any similar events since that time. . On arrival to floor, pt. stating he would like to go home when medically clear rather than to psych inpt. admission. Says that SI were worse in last month since starting chantix. Denies amphetamine use, though not vehemently. Denies use of , zyban, pseudephedrine, known to cause false positive amphetamine on tox screen. Says he has not had rectal pain since rectal tube placed and would like to have it continued. . Floor course/follow-up: # Acetaminophen intoxication: intentional, now LFTs improving, now off NAC. ARF resolved, with continued pulmonary edema likely aspiration +/- pulmonary toxicity. LFTs trending down. He should have outpatient liver followup to confirm that liver function tests have normalized. . # aspiration pneumonia: Respiratory status has improved to baseline and he has finished course of levofloxacin x6 days. At discharge his O2 sat was 93-95% on room air and did not drop with ambulation. He reports having some baseline shortness of breath and felt that at time of discharge he had returned to his baseline level. He should discuss with his primary care physician if he should have a further evaluation for emphysema given his significant smoking history. . # suicide attempt: Patient denies suicidality currently however psychiatry feels he would benefit from inpatient psychiatry hospitalization. He denied SI and HI to medical team however he apparently did report suicidal intent earlier in his hospital course to psychiatry team. His psychotropic medications were stopped in consultation with the psychiatry service, in part due to concern over hepatic metabolism. He was written for PRN trazodone for sleep but did not need this medication regularly. These should be restarted under the direction of his inpatient and/or outpatient mental health providers. wife unhappy about inpatient psychiatric admission. It was explained to her that law does allow a patient to be admitted if he is felt to be a danger to himself. . # chronic diarrhea and fecal urgency: started after hemorrhoid surgery and is perhaps due to impaired rectal tone. He was C.diff negative x2 and there was a very low suscpicion for infectious cause of diarrhea. We continued his home imodium prn but believe that this is more likely a surgical issue and that he should followup with his outpatient GI surgeon as well as a gastroenterologist. He was also provided with the number for the outpatient clinic at in case he chooses to followup here (he and his wife wanted to discuss this). . #perineal irritation most likely chronic irritation from diarrhea. perineum irritated but no frank ulcers. Seen by wound care who recommended a cleanser and antibiotic cream to be used after bowel movements. Their recommendations were " Cleanse wrll after each BM with perineal cleansing foam and pat dry. Apply Critic Aid anti-fungal ointment to peri-anal skin after every 2nd - 3rd BM." Patient should continue this treatment until irritation is resolved. . # Afib with RVR: isolated event in context of intubation + albuterol. CHADS 0. no anticoagulation indicated. no further events once pulmonary issues had resolved. . # pulmonary nodules: seen on CT, likely due to inflammation from aspiration, but will need followup CT as outpatient to ensure resolution. PCP made aware of this issue by letter. Issue also discussed with patient. . # hypercholesterolemia: statin held initially given elevated LFTs, but restarted once near normal levels. . # Contact: Wife, (c: ) | Normal global and regional biventricular systolicfunction. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. Transmitral Doppler E>A and TDI E/e' <8suggesting normal diastolic function, and normal LV filling pressure(PCWP<12mmHg). Left ventricular function.Height: (in) 71Weight (lb): 160BSA (m2): 1.92 m2BP (mm Hg): 112/70HR (bpm): 83Status: InpatientDate/Time: at 13:45Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). The mitral valve appearsstructurally normal with trivial mitral regurgitation. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Mildly dilated thoracic aorta. There is mild centrilobular emphysema. Mildly dilated ascending aorta. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%) Transmitraland tissue Doppler imaging suggests normal diastolic function, and a normalleft ventricular filling pressure (PCWP<12mmHg). 5) Mild centrilobular emphysema. Left lower lobe consolidation is probably unchanged due to aspiration or hemorrhage. The portal vein is patent with normal hepatopetal flow. There is bilateral perihilar ground- glass opacity with smooth intralobular septal thickening. 4) Perihilar ground-glass attenuation with smooth interlobular septal thickening likely relates to noncardiogenic pulmonary edema, given history of recent overdose. The spleen is within normal limits. The aorta has a normal course and caliber without evidence of dissection. IMPRESSION: AP chest compared to and 3: Moderate right pleural effusion, layering posteriorly, is stable or increased. The heart size is unchanged, mildly enlarged. The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation. SUPINE CHEST: Cardiomediastinal silhouette is unremarkable. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Small right pleural effusion. Bilateral lung sounds clear but diminished, encouraged for deep breathing/cough and IS. Heart, pericardium, and great vessels are normal. Non-dedicated imaging through the upper abdomen demonstrates reflux of contrast into the hepatic veins. The gallbladder is normal without evidence of stone. There has been some interval partial clearing on the right with patchy areas of alveolar infiltrate in the left lower lung. 2) Bilateral small-to-moderate pleural effusions with associated atelectasis. FINDINGS: Pulmonary arteries enhance normally without filling defects. IMPRESSION: 1) No pulmonary embolism. 7) Right lower lobe nodular opacities, likely inflammatory; however, followup (Over) 9:04 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?PE Admitting Diagnosis: OVERDOSE Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) CT recommended to ensure resolution. F/U with SW consult.Asp Pna- On abx. NPN 7a-7pPlease see carevue for additional data.FUll CodeNKDANeuro: Pt remains lethargic, but oriented x3. Sbp 99-155.GI/GU: abd soft, distended, +BS. Foley patent draining adeq. SR w/o ectopy. Acetylcysteine gtt restarted per hepatology. cx's pnding. Lytes/enzymes pnding. Compared to the previoustracing of narrow complex tachycardia has replaced previous sinus rhythmand there are now inferior and lateral ST-T wave changes.TRACING #1 Heparin gtt stopped. Early repolarization seen in the precordialleads, likely a normal variant. CXR with diffuse bilat. Psych/SW following pt.CV: VSS. Obeys commands.Resp: LS coarse/diminished. RR ^^50, diaphoretic, and pt c/o shortness of breath. HR 92-20 NSR-SVT. ShortP-R interval. EKG obtained. Compared to tracing #1 sinus tachycardia has replacedprevious narrow complex tachycardia.TRACING #2 resolved with valsalva manuevar, and also with out intervention. CXR done showing improvement in bilateral pleural effusions and edema/aspiration.ROS:Resp: LS diminished to bilateral bases, clear to apices. Flagyl, Levoflox. Able to take pill PO with out difficulty.ID: low grade temps. 19:00-07:00EVENTS:RECIEVED THE PT IS SVT 180'S.HR DOWN TO 120'S OCCASSIONALLY.HAD FB 500CC FOLLOWED BY LOPRESSOR IV WITH SOME EFFECT.HR DOWN TO 120'S.EKG SHOWED AFIB .HAD IV DILTIAZEM TOTAL 15MG WITH EFFECT.HR DOWN TO 80'S AND IN NSR.STARTED ON HEPARIN PROPHYLACTICALLY.NEURO:PT IS LETHARGIC,ORIENTED X3,OBEYING COMMANDS.C/O CP WHEN TAKING DEEP BREATH ?PLEURITIC.PULM:LS COARSE/DIMINISHED AT THE BASE.ON HIGH FLOW O2 80%.SATS 90-99%.CXR B/L INFILTRATED AND ASP PNA.CVS:AS MENTIONED ABOVE.PT IS IN NSR NOW.NBP WITHIN LIMITS.MAINTAINENCE FLUID AT 100CC/HR. Given neb tx's x 2 today w/ good effect. Given one liter NS bolus. cont on IV abx. ?D/C HEPRAIN AFTER ROUNDS.WEAN 02 AS TOLERATED.SW CONSULT IN AM.TEAM WILL REFER FOR PSYCH EVALUATION. Sinus tachycardia with occasional atrial premature couplets. Short P-R interval. 19:00-07:00NEURO:PT LETHARGIC,ORIENTED X3.MAE.C/O PAIN WHILE DEEP BREATHING.PULM:CONT ON HIGH FLOW O2 70%.SATURATING 92-100%.LS CLEAR WITH DIMINISHED BASE.CVS:IN NSR,NBP WITHIN LIMITS.GI/GU: SOFT WITH POS BS,NO BM.PT IS NPO WILL START ON DIET IN AM.CONTINUES ON MUCOMYST.FOLLOWING LIVER ENZYMES WHICH ARE TRENDING DOWN.FOLEY DRAINING GOOD U/O.ID:AFEBRILE,ON FLAGYL AND LEVOQUIN FOR ASP PNA.PT IS ON SUICIDAL PRECAUTION.SITTER AT BEDSIDE.PLAN:WEAN O2 AS TOLERATED.CONT IV ABX. 1:1 sitter ordered. Sinus rhythm. Cont on lopressor po. Dr. made aware. He stated he has been told he likely has irritable bowel syndrome. ?C/O TO FLOOR. Pt states his breathing feels much better than this morning.Neuro: Pt w/ flat/depressed affect, appropriate. Normal sinus rhythm, rate Non-specific ST-T wave abnormalities includingJ point elevation in leads V2-V4. HEPARIN AT 13.5CC/HR.CARDIAC ENZYMES TRENDING DOWN.GI: SOFT WITH POS BS.NO BM THIS SHIFT.PT REMAINS NPO EXCEPT FOR MEDICATION.GU:FOLEY DRAINING 30-40CC/HR OF URINE.URINE SENT FOR C/S AS WCC WERE ELEVATED.ID:AFEBRILE,CONT ON FLAGYL AND LEVOQUIN.PLAN:FOLLOW CARDIAC ENZYMES.CONT ABX FOR ASP PNA. Productive cough- sputum sample collected. The initial two beats of the tracing show sinusrhythm followed by an atrial premature couplet, then the development of anarrow complex tachycardia which may be atrial tachycardia or re-entranttachycardia or rapid atrial fibrillation. F/U on cx data. Chest CT done, neg for PE. PERRLS. Wife, and children in today, updated by this RN, and MD's.A/P: Tylenol OD- Aceytclysteine gtt off. | 24 | [
{
"category": "Radiology",
"chartdate": "2147-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998241,
"text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man found unresponsive by wife this am, suspected ingestion.\n Intubated at OSH, report R aspiration pneumonia, hypoxic on vent to mid 90's.\n REASON FOR THIS EXAMINATION:\n eval for tube placement, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive by wife this morning. Suspected aspiration,\n now intubated.\n\n COMPARISON: None.\n\n SUPINE CHEST: Cardiomediastinal silhouette is unremarkable. Pulmonary\n vascular congestion is noted with likely airspace opacity in the left mid-\n lung. There are no effusions. There is no pneumothorax. The proximal side port\n of a nasogastric tube is at the gastroesophageal junction. The tip of an\n endotracheal tube projects 4.4 cm above the carina.\n\n IMPRESSION:\n 1. Vascular congesion.\n 2. Apparent airspace opacity in the lingula, question aspiration related.\n 3. Nasogastric tube should be advanced for more optimal positioning. ETT tube\n in adequate position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998284,
"text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of infiltrates\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with acetaminophen overdose, aspiration pneumonia now on\n ventilator\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW.\n\n HISTORY: Followup infiltrates.\n\n FINDINGS: The ET tube is 3 cm above the carina. The OG tube tip cannot be\n well assessed secondary to overlying hardware. There has been some interval\n partial clearing on the right with patchy areas of alveolar infiltrate in the\n left lower lung. No effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-03-06 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 998495,
"text": " 4:00 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for signs of chronic disease.\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with tylenol overdose and question of chronic liver disease\n REASON FOR THIS EXAMINATION:\n eval for signs of chronic disease.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 45-year-old male with tylenol overdose. Evaluate for sign\n of chronic liver disease.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: The liver shows no focal or textural abnormality. The\n gallbladder is normal without evidence of stone. There is no intra- or extra-\n hepatic biliary dilatation. The common bile duct measures 2 mm. The portal\n vein is patent with normal hepatopetal flow. Pancreas is obscured by bowel\n gas. A small right pleural effusion is present. The spleen is within normal\n limits.\n\n IMPRESSION:\n 1. Liver shows no focal or textural abnormality.\n 2. Small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998603,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with aspiration pna\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for aspiration pneumonia.\n\n PORTABLE AP CHEST RADIOGRAPH WAS COMPARED TO .\n\n The heart size is unchanged, mildly enlarged. Mediastinal contours are\n unremarkable. There is significant interval improvement in pulmonary edema\n with decrease in still present bilateral pleural effusions, left more than\n right, with left lower lobe opacity most likely representing residual\n pulmonary edema/aspiration.\n\n There is no pneumothorax. There are no new focal consolidations worrisome for\n pneumonia.\n\n DL\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2147-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998362,
"text": " 9:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hypoxia and chest pain with ? aspiration after tylenol od\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:17 P.M., \n\n HISTORY: Hypoxia and chest pain, Tylenol overdose.\n\n IMPRESSION: AP chest compared to and , 4:41 a.m.\n\n Moderately severe interstitial pulmonary abnormality has worsened since\n after showing some earlier improvement accompanied by increasing\n heart size, mediastinal vascular engorgement and elevation of the right lung\n base, probably due to moderate subpulmonic pleural effusion. These findings\n all point to volume overload and/or cardiac decompensation. A region of\n particularly severe opacification in the left lower lobe could represent\n pulmonary hemorrhage or aspiration. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-03-06 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 998410,
"text": " 9:04 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: OVERDOSE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with increasing o2 requirement, pleuritic chest pain\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old with pleuritic chest pain and increasing O2\n requirement. Additional history obtained from prior chest radiograph\n indicates acetaminophen overdose.\n\n COMPARISONS: Chest x-ray of .\n TECHNIQUE: Axial MDCT images of the chest with 70 cc of non-ionic Optiray\n contrast per CTA chest pain protocol with coronal and sagittal reformatted\n images.\n\n FINDINGS: Pulmonary arteries enhance normally without filling defects. The\n aorta has a normal course and caliber without evidence of dissection. There\n are multiple borderline enlarged mediastinal lymph nodes, the most prominent\n in the prevascular distribution measuring up to 8 mm in short axis likely\n reactive. Heart, pericardium, and great vessels are normal.\n\n There is mild centrilobular emphysema. There is bilateral perihilar ground-\n glass opacity with smooth intralobular septal thickening. There are small-to-\n moderate bilateral pleural effusions with associated compressive atelectasis.\n Adjacent to this, there is some more coalescent consolidation likely\n representing aspiration. On the right there is one small more discrete\n nodular opacity (3, 36) measuring 8 mm likely inflammatory but should be\n followed to resolution. A second ill-defined nodular opacity (3, 22)\n measuring 4 mm is also likely inflammatory.\n\n Non-dedicated imaging through the upper abdomen demonstrates reflux of\n contrast into the hepatic veins. No other discrete abnormality with the\n exception of calcified granulomas in the spleen. Bone windows demonstrate\n only mild degenerative changes. Coronal and sagittal reformatted images\n confirm the above findings.\n\n IMPRESSION:\n 1) No pulmonary embolism.\n 2) Bilateral small-to-moderate pleural effusions with associated atelectasis.\n 3) Bibasilar consolidation, likely related to aspiration.\n 4) Perihilar ground-glass attenuation with smooth interlobular septal\n thickening likely relates to noncardiogenic pulmonary edema, given history of\n recent overdose.\n 5) Mild centrilobular emphysema.\n 6) Mediastinal lymphadenopathy, likely reactive.\n 7) Right lower lobe nodular opacities, likely inflammatory; however, followup\n (Over)\n\n 9:04 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: OVERDOSE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT recommended to ensure resolution.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998383,
"text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with acetaminophen intoxication, respiratory distress\n (aspiration, intubation)\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:50 A.M., \n\n HISTORY: Acetaminophen overdose. Respiratory distress, aspiration.\n\n IMPRESSION: AP chest compared to and 3:\n\n Moderate right pleural effusion, layering posteriorly, is stable or increased.\n Moderately severe pulmonary edema has changed in distribution but not in\n overall severity. Left lower lobe consolidation is probably unchanged due to\n aspiration or hemorrhage. Heart size is normal, stable since late on , though increased since earlier that day and mediastinal vascular\n engorgement indicating elevated central venous pressure is still present.\n\n Dr. covering for intern Dr. , and I discussed\n these findings, at the time of dictation.\n\n"
},
{
"category": "Echo",
"chartdate": "2147-03-06 00:00:00.000",
"description": "Report",
"row_id": 85778,
"text": "PATIENT/TEST INFORMATION:\nIndication: . Shortness of breath. Left ventricular function.\nHeight: (in) 71\nWeight (lb): 160\nBSA (m2): 1.92 m2\nBP (mm Hg): 112/70\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 13:45\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Transmitral\nand tissue Doppler imaging suggests normal diastolic function, and a normal\nleft ventricular filling pressure (PCWP<12mmHg). There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nIMPRESSION: No outflow tract obstruction, intracardiac shunt, or significant\nvalvular disease seen. Normal global and regional biventricular systolic\nfunction. Mildly dilated thoracic aorta.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 1663936,
"text": "19:00-07:00\n\nTHIS IS A 45 YO M ADMITTED TO ED FROM .\nPT WAS FOUND TO BE SNORING AT 11PM BY WIFE,WHICH IS HIS USUAL SELF.IN THE MORNING AT 08:30 PT WAS STILL FOUND TO BE SNORING BUT WIFE WAS NOT ABLE TO WAKE HIM UP.WIFE CALLED EMS.THERE WAS BOTTLE OF TYLENOL AT THE BEDSIDE WITH 3 TAB MISSING.TYLENOL LEVELS WERE 183 AT THE OSH.\nAT THE OSH HIS RESP STATUS DECLINED EVEN FURTHER REQUIRING INTUBATION AND VENTILATION.CXR SHOWED PNA.WAS GIVEN AVELOX AND FLAGYL.\nPT WAS THEN TRANSFERED TO ED HERE TYLENOL LEVELS DOWN TO 79.STARTED ON MUCOMIST AND THEN TRANSFERED TO MICU FOR CLOSE MONITORING.\n\nNEURO:PT IS LETHARGIC NOT ON ANY SEDATION,OBEYING COMMANDS.NO C/O PAIN.ON WRIST RESTRAINTS.PT IS RECEIVING 155CC/HR.\n\nPULM:ON AC,ARRIVED ON 100%,CURRENTLY ON 606,550/22/12.INCREASED RR FROM 16 TO 22 AS PH WAS 7.22.SUCTIONED FOR THICK TAN SECRETIONS.LS CLEAR WITH DIMINISHED BASE.\n\nCVS:IN NSR/ST,NBP WITHIN LIMITS.HAD 1LIT FB FOR ?DEHYDRATION.\nPP PALPABLE.TWO PIVS FOR ACCESS.PT GETTING 100CC/HR OF D5.45NS.\n\nGI: SOFT WITH POS BS,NO BM THIS SHIFT.PT IS NPO.\n\nGU:FOLEY DRAINING 30-50CC/HR OF CLEAR YELLOW URINE.\n\nID:AFEBRILE,STARTED ON FLAGY AND LEVOFLOXACIN FOR PNA.\n\nSOCIAL:NO PHONE ENQUIRIES.WIFE IS THE HCP.\n\nPLAN:\nFOLLOW BLD AND SPUTUM CULTURE REPORT.CONT IV ABX.\nRSBI IN THE AM.SBT IF TOLERATES.\nROUTINE ICU CARE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-08 00:00:00.000",
"description": "Report",
"row_id": 1663945,
"text": "MICU 6 NPN 0700-1900\n\nNo significant events overnight.\nPt Full .\nSee carevue for all objective data.\n\nNeuro: Pt is A and Ox3. Follows commands and is cooperative with care. He transferred independently from bed to chair and is steady on his feet. Occ flat affect, 1:1 sitter all shift. Pt denied any further SI. Psych and social work following case.\n\nCV: VSS, HR NSR with no ectopy noted, NBP stable. No edema noted, pos pedal pulses. PT with no c/o CP, SOB, dizziness, no lightheadedness. K 3.4 was repleted with 40 mEq KCl.\n\nResp: Attempted to wean pt to RA and needed to be put back on 2L NC. sats 93-96%. Inc spirometer enc. PT with cough and has thick tan secretions. Pt stated cough and sputum is \"better\" today. LSCTA bilat.\n\nGI/GU: Abd is soft and non-tender, pos bowel sounds. Fecal bag drainning liquid brown stool, sent for c.diff. Pt has 1 neg c.diff from . Tolerating regular diet. Voiding clear yellow urine independently in urinal.\n\nAccess: PIVx1\n\nID: Tmax 99.1, IV levoquin changed to PO levaquin.\n\nSocial: wife in to see pt and was updated on POC.\n\nPlan:\n1:1 sitter at bedside.\nEmotional support to pt and family.\nMonitor labs and electrolytes.\nMonitor resp status and continue with pulm toiletting.\nCall out to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-09 00:00:00.000",
"description": "Report",
"row_id": 1663946,
"text": "MICU NPN 1900-0230\n\nNo significant events overnight\n\nNeuro: Alert, oriented x3, following commands, MAE with normal strength. Occasionally flat affect, no suiciadal ideation at present, sitter at bed side, psych and social work following.\n\nResp: Continue to be on O2 2L via nasal canula, desats to 88-90% on room air occassionaly. Bilateral lung sounds clear but diminished, encouraged for deep breathing/cough and IS. RR 20-30's. O2 sats 90-94%\n\nCv: NSR without ectopy. SBP 110-120, continued on po atenolol. Low grade temp 99.8, continued on po levofloxacin.\n\nGi/Gu: Tolerating reg diet, abd soft, Bs present, rectal bag in place for ?incontinence, liquid/greenish stool. Voiding adequate amount of urine in the urinal.\nSkin: INtact,\nSocial: NO calls from family, psych and social work following.\n\nPlan: call out to floors\n Continue sitter at bed side\n Psych evaluation once medically cleared\n Monitor temp curve\n Emotional support to patient\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 1663937,
"text": "Resp Care\nPt transferred from e.d. intubated. Vent settings are a/c 600 x 24 50% 12 of peep. Slowly improving oxygenation, abgs with met. acidosis. Suctioning thick tan purulent sputum. No rsbi done due to peep level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 1663938,
"text": "Resp Care\n\nPt weaned and extubated without incident. No stridor noted after.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-06 00:00:00.000",
"description": "Report",
"row_id": 1663941,
"text": "MICU Nurse Progress Note 0700-1900\nEvents: Psych consult done, pt admitted the ingestion of tylenol/ percocet was a suicide att. 1:1 sitter ordered. Chest CT done, neg for PE. Heparin gtt stopped. Hepatology consult done r/t elevated LFT's, Liver GB US done a/o, results pending. Acetylcysteine gtt restarted per hepatology. no further episodes of SVT or A-fib noted.\n\nROS:\nNeuro: A/Ox3 more alert, follows commands well all ext Mod/= str. PERRLS. 1:1 sitter present. no SI noted. c/o chest \"soreness\"\n\nResp: remains on FM at 70% Fi02, LS coarse/ dim bases. 02sat 93-96%\n\nCVS: SR/ST HR 80's-100's, no ectopy noted, b/p stable (see carevue). rpt cardiac enzymes neg.\n\nGI: Abd soft nontender +BS x 4quads, no stool noted this shift.\n\nGU: foley cath patent draining clear yellow urine UOP 60-100ml/hr.\n\nID: temp remains 99.2-99.8 ax. cont on IV abx. for asp PNA.\n\nsocial: family in to visit pt updated by RN r/t pt cond/ POC.\n\nplan: cont 1:1 sitter, monitor for SI.\nmonitor LFT's/ INR Q6hr.\ncont aceytlcysteine gtt., IV abx a/o\ncont routine ICU monitoring and care\nsupport pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-07 00:00:00.000",
"description": "Report",
"row_id": 1663942,
"text": "19:00-07:00\n\nNEURO:PT LETHARGIC,ORIENTED X3.MAE.C/O PAIN WHILE DEEP BREATHING.\n\nPULM:CONT ON HIGH FLOW O2 70%.SATURATING 92-100%.LS CLEAR WITH DIMINISHED BASE.\n\nCVS:IN NSR,NBP WITHIN LIMITS.\n\nGI/GU: SOFT WITH POS BS,NO BM.PT IS NPO WILL START ON DIET IN AM.CONTINUES ON MUCOMYST.FOLLOWING LIVER ENZYMES WHICH ARE TRENDING DOWN.FOLEY DRAINING GOOD U/O.\n\nID:AFEBRILE,ON FLAGYL AND LEVOQUIN FOR ASP PNA.\n\nPT IS ON SUICIDAL PRECAUTION.SITTER AT BEDSIDE.\n\nPLAN:\nWEAN O2 AS TOLERATED.\nCONT IV ABX.\n?C/O TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-07 00:00:00.000",
"description": "Report",
"row_id": 1663943,
"text": "NPN:\n\nEvents..Pt desat'd this morning into mid-80s w/ 40% FIO2 hi-flow mask. RR ^^50, diaphoretic, and pt c/o shortness of breath. LS diminished posteriorly. Productive cough- yellow/thick sputum. Repositioned pt, increased FIO2 to 70%, and gave atrov/albuterol tx w/ good effect. O2 sats ^^ 91-97% and RR down to 20s-30s. CXR done showing improvement in bilateral pleural effusions and edema/aspiration.\n\nROS:\n\nResp: LS diminished to bilateral bases, clear to apices. RR 20s-30s. Productive cough- sputum sample collected. O2 sats now 95-98% on 50% FIO2 hi-flow face tent. Given neb tx's x 2 today w/ good effect. Pt states his breathing feels much better than this morning.\n\nNeuro: Pt w/ flat/depressed affect, appropriate. Denies SI/HI. W/O c/o pain. MAE. Pt OOB to chair x 2. Generalized weakness. Cont w/ 1:1 sitter for suicide watch. Psych/SW following pt.\n\nCV: VSS. SR w/o ectopy. Cont on lopressor po. Cont to follow lytes... repleted w/ neutra phos this afternoon. Liver enzymes improving. New set of labs collected @ 1700- pending. Mucomyst d/c'd this afternoon per liver team. Liver u/s yesterday showing no abnormalities.\n\nGI/GU: Abdomen soft/BS present, incontinent of frequent liquid BMs. Pt states he normally takes immodium at home d/t his frequent stooling. He stated he has had surgery in the past for his hemorroids and that since his surgery 2 yrs ago his stools have been guiac +. He stated he has been told he likely has irritable bowel syndrome. Stools today are guiac +, stool for c.diff sent to lab. Rectal bag placed on pt this evening to prevent skin breakdown as pt often unaware when he is going to the bathroom. Urine clear/yellow via foley cath. UOP wnl. UA sent to lab this eve for protein.\n\nID: Temp max 100.0, now down to 98.9 orally. Cont on levoflox, flagyl d/c'd.\n\nSocial: pt's wife phoned this morning and updated on pt's condition and POC.\n\nPlan:\n- Cont w/ 1:1 sitter for suicide precautions.\n- follow liver enzymes q6h per liver team.\n- monitor lytes and replete as needed.\n- cont w/ neb txs q 6hrs and wean O2 as tolerated.\n- Encourage CDB.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-08 00:00:00.000",
"description": "Report",
"row_id": 1663944,
"text": "MICU Nursing Note 1900-0700\nevents: 02 weaned down to 4 L NC, stable hemodynamics, LFT's continue to trend down, sitter remains at bedside\n\nNeuro: A+Ox3, pleasant and cooperative, flat affect at times and other times smiling and appropriate, appeared \"apprehensive\" during visit with family, follows all commands, moving all extremities, indep. in bed, requiring encouragement to turn and move around a bit and to use incentive spirometer, denies SI, denies HA, Sitter remains at bedside at all times\n\nCardiac: HR= 60-70's SR with no ectopy noted, BP= 120's/70's, KPhos over 6 hour during night with am labs pending.\n\nResp: Lungs remain with scattered coarse rhonchi, prod. cough of thick tan sputum, using Yankaur, 02 initially at 50% via cool mist mask and weaned to 4 L NC with Sats 92-97%. Denies SOB. Using incentive spirometer with encouragement and able to move 750ml\n\nGI: Abd soft with + bowel sounds , denies pain, NPO maintained, LFT's continue to trend down, buttocks bag intact and pt with small amts loose brown stool.\n\nGU: Foley to CD draining clear yellow urine >80ml/hr, remains positive 5.5L for LOS\n\nskin: intact\n\nID: Tmax= 99.3, WBC= 10.7, remains on IV Levofloxacin\n\nSocial: wife and in to visit during evening hours and were updated on pt's condition\n\nPlan: Continue pulmonary toiletting, continue sitter at bedside, replace lytes as needed, start on po diet, d/c foley, wean 02 as tolerates, Support pt and family and prepare for transfer to medical floor for further management with eventual transfer to psych service.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 1663939,
"text": "NPN 7a-7p\nPlease see carevue for additional data.\nFUll Code\nNKDA\n\nNeuro: Pt remains lethargic, but oriented x3. Sleeping most of day, arouses to voice. Intermittent c/o chest tightness, but no pain. Obeys commands.\nResp: LS coarse/diminished. Rare, productive cough noted. Tan, thick secretions. Extubated with out event ~10min s/p extubation on 40% face tent sats 88%. Placed on hiflow neb 50% with resulting sats 95%. CXR with diffuse bilat. infiltrates.\nCV: Several episodes of ? SVT today up to 200. Occ. resolved with valsalva manuevar, and also with out intervention. EKG obtained. Given 25mg of PO Lopressor at 18:45. Given one liter NS bolus. Lytes/enzymes pnding. HR 92-20 NSR-SVT. Sbp 99-155.\nGI/GU: abd soft, distended, +BS. No stool. Foley patent draining adeq. clear, yellow urine. Able to take pill PO with out difficulty.\nID: low grade temps. cx's pnding. Flagyl, Levoflox. for PNA.\nSocial: Patient's daughter in law reported concern on patient coping regarding admission. Reportedly, patient was raped by a priest as a child and has resultant hemerhoids, which cause him much physical discomfort. Pt. takes pain pills for this, but daughter-in-law is concerned that emotional pain is not being addressed. Dr. made aware. SW consult obtained, plan to talk with Pt. once he is more awake. Wife, and children in today, updated by this RN, and MD's.\nA/P: Tylenol OD- Aceytclysteine gtt off. LFT's improved. F/U with SW consult.\nAsp Pna- On abx. F/U on cx data. Follow sats/abg's.\nSVT- 25mg PO Lopressor given. Adenosine x1 ordered, but not given, episodes have been self limiting and also respond to valsalva manuvers.\nCont. providing supportive care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-03-06 00:00:00.000",
"description": "Report",
"row_id": 1663940,
"text": "19:00-07:00\n\nEVENTS:RECIEVED THE PT IS SVT 180'S.HR DOWN TO 120'S OCCASSIONALLY.HAD FB 500CC FOLLOWED BY LOPRESSOR IV WITH SOME EFFECT.HR DOWN TO 120'S.EKG SHOWED AFIB .HAD IV DILTIAZEM TOTAL 15MG WITH EFFECT.HR DOWN TO 80'S AND IN NSR.STARTED ON HEPARIN PROPHYLACTICALLY.\n\nNEURO:PT IS LETHARGIC,ORIENTED X3,OBEYING COMMANDS.C/O CP WHEN TAKING DEEP BREATH ?PLEURITIC.\n\nPULM:LS COARSE/DIMINISHED AT THE BASE.ON HIGH FLOW O2 80%.SATS 90-99%.CXR B/L INFILTRATED AND ASP PNA.\n\nCVS:AS MENTIONED ABOVE.PT IS IN NSR NOW.NBP WITHIN LIMITS.MAINTAINENCE FLUID AT 100CC/HR. HEPARIN AT 13.5CC/HR.CARDIAC ENZYMES TRENDING DOWN.\n\nGI: SOFT WITH POS BS.NO BM THIS SHIFT.PT REMAINS NPO EXCEPT FOR MEDICATION.\n\nGU:FOLEY DRAINING 30-40CC/HR OF URINE.URINE SENT FOR C/S AS WCC WERE ELEVATED.\n\nID:AFEBRILE,CONT ON FLAGYL AND LEVOQUIN.\n\nPLAN:\nFOLLOW CARDIAC ENZYMES.\nCONT ABX FOR ASP PNA.\n?D/C HEPRAIN AFTER ROUNDS.\nWEAN 02 AS TOLERATED.\nSW CONSULT IN AM.\nTEAM WILL REFER FOR PSYCH EVALUATION.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-03-06 00:00:00.000",
"description": "Report",
"row_id": 213332,
"text": "Sinus rhythm. Short P-R interval. Early repolarization seen in the precordial\nleads, likely a normal variant. Compared to tracing #2 atrial premature\ncouplets are not seen on the current tracing. Otherwise, no significant\nchange.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 213333,
"text": "Sinus tachycardia with occasional atrial premature couplets. Short\nP-R interval. Compared to tracing #1 sinus tachycardia has replaced\nprevious narrow complex tachycardia.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 213334,
"text": "Supraventricular tachycardia. The initial two beats of the tracing show sinus\nrhythm followed by an atrial premature couplet, then the development of a\nnarrow complex tachycardia which may be atrial tachycardia or re-entrant\ntachycardia or rapid atrial fibrillation. Non-specific inferolateral\nST-T wave changes which are likely due to rate. Compared to the previous\ntracing of narrow complex tachycardia has replaced previous sinus rhythm\nand there are now inferior and lateral ST-T wave changes.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2147-03-05 00:00:00.000",
"description": "Report",
"row_id": 213335,
"text": "Normal sinus rhythm, rate Non-specific ST-T wave abnormalities including\nJ point elevation in leads V2-V4. Compared to the previous tracing non-specific\nST-T wave abnormalities are somewhat more marked. Clinical correlation and\nrepeat tracing are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-03-04 00:00:00.000",
"description": "Report",
"row_id": 213336,
"text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
56,873 | 198,377 | 22yo male with h/o hiatal hernia, allergies, and asthma who initially presented with two days of increasing cough and shortness of breath, likely secondary to acute on chronic asthma exacerbation in setting of infectious process. . #. Asthma Exacerbation: Patient initially treated in the MICU for presumed asthma exacerbation with nebulizers and steroids. Exacerbation likely secondary to either viral or atypical pneumonia, based on CT chest findings. CTA was done given hypoxia and respiratory distress; did not show evidence of PE but did show findings concerning for left mid-lower lung pneumonia, for which he was started on ceftriaxone and azithromycin. Of note, urine legionella antigen negative, HIV antibody and viral load negative, and respiratory viral antigen screen and viral culture negative. Patient's symptoms improved rapidly and he was transferred to the floor. He was discharged on a short prednisone taper, and instructed to start using an inhaled steroid (fluticasone) after completing taper. He was also discharged on azithromycin to complete 5 day course of treatment for presumed pneumonia. Will have outpatient pulmonology follow-up and PFTs. . #. Transaminitis: Patient noted to have mild ALT and AST elevation, which trended down during hospital course. Elevation nonspecific and perhaps part of an acute viral syndrome. Of note, patient reports history of being diagnosed with "fatty liver." If transaminitis persists, can have further workup as an outpatient. . #. Abdominal Pain: Patient reported mild abdominal pain during this admission, particularly in epigastric area, that resolved prior to discharge. Of note, patient has had previous work-up for abdominal pain including EGD and colonoscopy per report, and has been diagnosed with a hiatal hernia. Pain may be secondary to GERD symptoms in setting of hiatal hernia. Patient was started on PPI. | Cardiac and mediastinal silhouettes are stable. Normal appearance of the hilar and mediastinal structures. Normal size of the cardiac silhouette. The study is not tailored for subdiaphragmatic evaluation, only to confirm normal-appearing adrenals and severe hepatic hypoattenuation, probably representing steatosis. Normal appearance of the lung parenchyma, no acute pulmonary changes. FINDINGS: As compared to the previous radiograph, there is no relevant change. The cardiac size is normal without evidence of pericardial effusion. The lungs are clear without focal consolidation. ST-T wave abnormalities are less prominent.RSR' pattern in leads V1-V2 is not seen. No pleural effusions. IMPRESSION: No acute cardiopulmonary process. RSR' pattern in lead V1. ST-T waveabnormalities. The great vessels are normal in appearance, the pulmonary artery measures 24 mm in transverse dimension. No pneumothorax. Lower thoracic spine degenerative disease is mild. There is no pleural effusion. No pleural effusion or pneumothorax is seen. FINDINGS: There is no pathologic enlargement of the supraclavicular, mediastinal or axillary lymph nodes. Baseline artifact. IMPRESSION: 1. Multifocal well defined ground-glass opacities in the left upper, right upper, left lower and lingular lobes are small in volume. Since the previous tracingof the rate is slower. RSR' pattern in leads V1-V2. FINDINGS: Frontal and lateral views of the chest were obtained. No evidence of pulmonary embolism. The central airways are patent. Sinus tachycardia. Sinus tachycardia. Thymic tissue in the anterior mediastinum is appropriate for age (4:13). FINAL REPORT INDICATION: One-year history of dyspnea, respiratory distress, exclude pulmonary embolism or interstitial lung disease. There is no evidence of pulmonary embolism. TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was performed before and after the administration of intravenous Optiray at held maximal inspiration and shallow held inspiration respectively. pna FINAL REPORT EXAM: Chest frontal and lateral views. T waveabnormalities are more prominent. The largest lymph nodes in the mediastinum at the right hilum and subcarinal stations measure 9 mm in short axis dimension. COMPARISON: . COMPARISON: . Multifocal geographic ground-glass opacities throughout both lungs, the appearance is suggestive of foreign substance inhalation, although with an appropriate clinical history, aspiration, hemorrhage and viral pneumonia are (Over) 5:47 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE, evaluate lung parenchyma for chronic process Admitting Diagnosis: ASTHMA;COPD EXACERBATION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) also considered possible. 7:20 PM CHEST (PA & LAT) Clip # Reason: ? 2. Ground glass opacity in the left mid to lower lung fields may represent infectious process; correlate clinically. Since the previous tracing of the rate is faster. 5:47 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE, evaluate lung parenchyma for chronic process Admitting Diagnosis: ASTHMA;COPD EXACERBATION Contrast: OPTIRAY Amt: 100 MEDICAL CONDITION: 22 year old man with 1 year progressive dyspnea now admitted with acute hypoxic respiratory distress REASON FOR THIS EXAMINATION: r/o PE, evaluate lung parenchyma for chronic process No contraindications for IV contrast WET READ: TUE 6:50 PM No evidence of central pe within limitations of poor mixing bolus. The images are presented for display in the axial plane at 5- and 2.5-mm collimation. 1:53 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: ASTHMA;COPD EXACERBATION MEDICAL CONDITION: 22 year old man with persistent SOB s/p fluids REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT CHEST RADIOGRAPH INDICATION: Persistent shortness of breath, status post fluid, evaluation for interval change. pna MEDICAL CONDITION: 22 year old man with cough, diff breathing REASON FOR THIS EXAMINATION: ? Multiplanar reformation images are also submitted for review. | 5 | [
{
"category": "Radiology",
"chartdate": "2152-10-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1164330,
"text": " 7:20 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with cough, diff breathing\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 22-year-old male with history of cough, difficulty\n breathing, question pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. The lungs\n are clear without focal consolidation. No pleural effusion or pneumothorax is\n seen. Cardiac and mediastinal silhouettes are stable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-10-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1164525,
"text": " 5:47 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE, evaluate lung parenchyma for chronic process\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with 1 year progressive dyspnea now admitted with acute hypoxic\n respiratory distress\n REASON FOR THIS EXAMINATION:\n r/o PE, evaluate lung parenchyma for chronic process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 6:50 PM\n No evidence of central pe within limitations of poor mixing bolus. Ground\n glass opacity in the left mid to lower lung fields may represent infectious\n process; correlate clinically.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: One-year history of dyspnea, respiratory distress, exclude\n pulmonary embolism or interstitial lung disease.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed before and after the administration of intravenous Optiray at held\n maximal inspiration and shallow held inspiration respectively. The images are\n presented for display in the axial plane at 5- and 2.5-mm collimation.\n Multiplanar reformation images are also submitted for review.\n\n FINDINGS: There is no pathologic enlargement of the supraclavicular,\n mediastinal or axillary lymph nodes. The largest lymph nodes in the\n mediastinum at the right hilum and subcarinal stations measure 9 mm in short\n axis dimension. Thymic tissue in the anterior mediastinum is appropriate for\n age (4:13).\n\n The great vessels are normal in appearance, the pulmonary artery measures 24\n mm in transverse dimension. There is no evidence of pulmonary embolism.\n\n The cardiac size is normal without evidence of pericardial effusion. There is\n no pleural effusion. The central airways are patent.\n\n Multifocal well defined ground-glass opacities in the left upper, right upper,\n left lower and lingular lobes are small in volume.\n\n The study is not tailored for subdiaphragmatic evaluation, only to confirm\n normal-appearing adrenals and severe hepatic hypoattenuation, probably\n representing steatosis.\n\n Lower thoracic spine degenerative disease is mild.\n\n IMPRESSION:\n 1. Multifocal geographic ground-glass opacities throughout both lungs, the\n appearance is suggestive of foreign substance inhalation, although with an\n appropriate clinical history, aspiration, hemorrhage and viral pneumonia are\n (Over)\n\n 5:47 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE, evaluate lung parenchyma for chronic process\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n also considered possible.\n\n 2. No evidence of pulmonary embolism.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164360,
"text": " 1:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with persistent SOB s/p fluids\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Persistent shortness of breath, status post fluid, evaluation for\n interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Normal size of the cardiac silhouette. Normal appearance of the\n hilar and mediastinal structures. No pleural effusions. No pneumothorax.\n Normal appearance of the lung parenchyma, no acute pulmonary changes.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-10-25 00:00:00.000",
"description": "Report",
"row_id": 240663,
"text": "Sinus tachycardia. RSR' pattern in lead V1. Since the previous tracing\nof the rate is slower. ST-T wave abnormalities are less prominent.\nRSR' pattern in leads V1-V2 is not seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-10-23 00:00:00.000",
"description": "Report",
"row_id": 240900,
"text": "Sinus tachycardia. Baseline artifact. RSR' pattern in leads V1-V2. ST-T wave\nabnormalities. Since the previous tracing of the rate is faster. T wave\nabnormalities are more prominent.\n\n"
}
] |
96,083 | 189,906 | # Shock/Hypotension The patient presented with shock that did not initially respond to fluid resuscitation so she was started on norepinephrine. The intial concern was for septic versus cardiogenic versus hypovolemic. She had no fever and no obvious source of infection, making septic shock unlikely. Her CVP was low and a TTE showed a hyperdynamic left ventricle with an EF >75%, no tamponade or other evidence of cardiogenic shock. She reported essentially no PO intake for about two weeks, so hypovolemic shock seemed most likely. She has had no new medications, but her family reports that she takes numerous dietary supplements at home, though they do not know what these are. She received extensive fluid resuscitation for a total of eleven liters. She was weaned off of norepinephrine asymptomatically with systolic blood pressures in the high 90s to 120s. After having stable blood pressures off of pressors for a day, her central venous catheter was removed and she was transferred to the floor. She was hemodynamically stable for the rest of her stay. . # Acute Renal Failure The patient's baseline creatinine appears to be 1.3-1.4 but she presented with a creatinine of 4.0. Pre-renal etiology is likely given elevated BUN/Cr ratio with potential overlying ATN. Her urine output was excellent throughout her stay and her creatinine fell to 1.2. Her Cr was stable the following day. . # Hematuria After the removal of the foley catheter in the ICU, she had a small amount of gross hematuria for the 24 hours following the removal of the catheter. This was acknowledged by the team and was felt to be mild. Her Hct has been stable and the hematuria should resolve in the next few hours. She had not signs of clot, or dysuria. - Recommended urology follow up if hematuria persists . # HTN The patient has a h/o HTN, borderline, on enalapril 10mg daily and two diuretics at home, but she was hypotensive requiring pressors in the ICU, so these medications were held. Once she was hemodynamically stable and transferred to the floor, she was resumed, as recommended by the cardiology consult service, on a lower dose of her previous diuretics, furosemide and spironolactone. Her enalapril was held briefly for the concern of amyloidosis as the origin of her severe LVH on her echo, but can be resumed on discharge. . # Hypothyroidism TSH 5.8, just mildly elevated at PCP office but her home dose was continued in the acute setting. Her TSH was 2.6 in-house, which was wnl. Her levothyroxine was continued. . # Asthma No shortness of breath, lungs are clear with good air movement, and she was written for albuterol and ipratropium as needed. Her home asthma medications were continued once she went to the floor. ________________________________ Transition to Care: - The patient still has a bit of hematuria when she urinates that is likely secondary to the removal of her foley. This should clear over the next several hours. Her Hct has been stable since then and we are reassured that this is not heavy bleeding and she should be stable to go to rehab. - For primary care physician: per geriatrics consult recommendations recommendations, please follow up with the following for the patient - iron studies, B12, folate, CBC and electrolytes. Also, arrange for optho appointment annually. | There is a trivial/physiologic pericardial effusion. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild PA systolichypertension.PERICARDIUM: Trivial/physiologic pericardial effusion. Mild [1+] TR. Normal interatrial septum. Non-specificrepolarization abnormalities. No echocardiographicsigns of tamponade.Conclusions:The left atrium is elongated. Nomasses or vegetations are seen on the aortic valve. Diffuse low voltage. Low voltage. There areno echocardiographic signs of tamponade. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. No diagnostic interim change. No aortic regurgitation isseen. Small LV cavity. Theleft ventricular cavity is unusually small. No MVP. No AS. An eccentric,posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Moderate (2+) MR. LVinflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild resting LVOT gradient.Mid-cavitary gradient. There issevere symmetric left ventricular hypertrophy (? Normal RV systolicfunction.AORTA: Normal aortic diameter at the sinus level. Mildly dilated RV cavity. There is mild pulmonary artery systolichypertension. No mass orvegetation on tricuspid valve. There is no mitral valveprolapse. No TS. The right ventricular cavityis mildly dilated with normal free wall contractility. No VSD.RIGHT VENTRICLE: RV hypertrophy. Normal regional LVsystolic function. No mass orvegetation on mitral valve. Theleft ventricular inflow pattern suggests impaired relaxation. A-V conduction delay. No masses orvegetations on aortic valve. No MS. Eccentric MR jet. Regional left ventricular wallmotion is normal. Hypotension, ShockHeight: (in) 58Weight (lb): 105BSA (m2): 1.39 m2BP (mm Hg): 84/39HR (bpm): 66Status: InpatientDate/Time: at 12:08Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is no ventricular septal defect.The right ventricular free wall is hypertrophied. Sinus rhythm. Sinus rhythm. Possible anterior myocardial infarction,age undetermined. NoASD by 2D or color Doppler. Probable prioranterior wall myocardial infarction. No mass or vegetation is seen on the mitral valve. No atrial septal defect is seen by 2D or colorDoppler. Left ventricular systolic function is hyperdynamic (EF>75%).There is a mild resting left ventricular outflow tract obstruction. No previous tracing available for comparison. Cardiac Amyloidosis?). Amid-cavitary gradient is identified. Diffuse ST-T wave changes, especially inthe lateral leads, as recorded on . The mitral valve leaflets are mildly thickened. The tricuspidvalve leaflets are mildly thickened. Prolonged P-R interval. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Normal IVC diameter (>2.1cm) with <50% decreasewith sniff (estimated RA pressure (>=15 mmHg).LEFT VENTRICLE: Severe symmetric LVH. Hyperdynamic LVEF >75%. | 3 | [
{
"category": "Echo",
"chartdate": "2189-06-02 00:00:00.000",
"description": "Report",
"row_id": 98924,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Hypotension, Shock\nHeight: (in) 58\nWeight (lb): 105\nBSA (m2): 1.39 m2\nBP (mm Hg): 84/39\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 12:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter (>2.1cm) with <50% decrease\nwith sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Severe symmetric LVH. Small LV cavity. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Mild resting LVOT gradient.\nMid-cavitary gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. Normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. No MS. Eccentric MR jet. Moderate (2+) MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. No TS. Mild [1+] TR. Mild PA systolic\nhypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is at least 15 mmHg. There is\nsevere symmetric left ventricular hypertrophy (? Cardiac Amyloidosis?). The\nleft ventricular cavity is unusually small. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nThere is a mild resting left ventricular outflow tract obstruction. A\nmid-cavitary gradient is identified. There is no ventricular septal defect.\nThe right ventricular free wall is hypertrophied. The right ventricular cavity\nis mildly dilated with normal free wall contractility. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. An eccentric,\nposteriorly directed jet of moderate (2+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion. There are\nno echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2189-06-02 00:00:00.000",
"description": "Report",
"row_id": 280341,
"text": "Sinus rhythm. A-V conduction delay. Diffuse low voltage. Probable prior\nanterior wall myocardial infarction. Diffuse ST-T wave changes, especially in\nthe lateral leads, as recorded on . No diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2189-06-01 00:00:00.000",
"description": "Report",
"row_id": 280342,
"text": "Sinus rhythm. Prolonged P-R interval. Low voltage. Non-specific\nrepolarization abnormalities. Possible anterior myocardial infarction,\nage undetermined. No previous tracing available for comparison.\n\n"
}
] |
82,075 | 192,894 | Pt. arrived to the ICU intubated and sedated. His labs were notable for high alcohol level and osmolal gap. Toxicology was consulted and recommended serial EKGs to evaluate for QTc prolongation as a complication of quinolone overdose. Patient had serial EKGs and increased QTc that peaked at 490 and was down to 430 by ICU day 2. QRS was never >100. On ICU day 2 the patient was awake, alert and successfully extubated. He remained hemodynamically stable and was seen by psychiatry and social work. He denied suicidal or homicidal ideations. He was put on CIWA scale but did not have any signs of EToH withdrawl. He was given multivitamin, thiamine, and folate and did not show any signs of withdrawal. He had a CIWA scale but did not require any diazepam. He was evaluated by psychiatry and social work. He was transferred to the floor, and subsequently discharged home. The police was contact to notify them of his discahrge. | FINDINGS: There has been interval removal of an ET tube. He was intubated and given Narcan, Vecuronium, and Ativan. He was intubated and given Narcan, Vecuronium, and Ativan. He was intubated and given Narcan, Vecuronium, and Ativan. He was intubated and given Narcan, Vecuronium, and Ativan. He was intubated and given Narcan, Vecuronium, and Ativan. He was intubated and given Narcan, Vecuronium, and Ativan, then transferred to . 8:21 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Previous NG tube was coiled. # Dispo: Floor today w/ suicide precautions. --Suicide Precautions, 1:1 sitter -- Replete lytes. , MED 8:21 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Previous NG tube was coiled. --Psych C/S --Hold psychiatric meds as unclear ingestion. --Psych C/S --Hold psychiatric meds as unclear ingestion. Per Psych, patient drinks approx. Per Psych, patient drinks approx. HISTORY: Multidrug ingestion, status post extubation. # Dispo: Floor today w/ suicide precautions, 1:1 sitter. Sinus rhythmModest inferior in lead V2 - may be in part positional/normal variantSince previous tracing of , sinus bradycardia absentand the prolongedQ-Tc interval is now upper limits of normal Patient (s) to Discharge: Patient discussed with multidisciplinary team: No # Prophylaxis: PPI, heparin subq, bowel regimen. # Prophylaxis: PPI, heparin subq, bowel regimen. Plan: Psych to eval pt. PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:34 AM Coiled NG tube within the esophagus. Replaced tube, please confirm placement PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:34 AM Standard position of the NG tube with its tip in the stomach. Replaced tube, please confirm placement PFI REPORT Standard position of the NG tube with its tip in the stomach. FINAL REPORT REASON FOR EXAMINATION: Followup of a patient with overdose and intubation. # Altered mental status, resolved. # Altered mental status, resolved. --F/U Psych consult . Dialysis: Yes Referrals Recommended: Social Work Current plan: Undetermined Unclear what level of services will be required at discharge. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:36 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: --Psych C/S --Hold psychiatric meds as unclear ingestion. Neuro: Sedated. Chief Complaint: Overdose, unresponsiveness HPI: History obtained from records and verbal report from MD. need for etoh/drug rehab. --Suicide Precautions, 1:1 sitter -- Replete lytes. Altered mental status (not Delirium) Assessment: Sedated s/p etoh and multiple drug ingestion. # Dispo: Floor today w/ suicide precautions. EtOH ABUSE monitor for withdrawal, CIWA scale. Received Narcan, Ativan and Vecuronium around time of intubation. Received Narcan, Ativan and Vecuronium around time of intubation. Reported empty bottles of acyclovir, percocet, flexeril, citalopram and cipro seem to provide a poor explanation for his symptoms. # Dispo: ICU pending improved mental status and possible extubation. At the end of the interview, she asked about DSS and expressed concern about the three grandchildren, , , and . At the end of the interview, she asked about DSS and expressed concern about the three grandchildren, , , and . Assessment and Plan A/P: 37 yo M with unknown PMH with progressive altered mental status in the setting of intentional multi-drug and alcohol ingestion, intubated for airway protection. He was intubated and given Narcan, Vecuronium, and Ativan, then transferred to . While in the ED at , the patient received vecuronium, ativan and narcan. While in the ED at , the patient received vecuronium, ativan and narcan. While in the ED at , the patient received vecuronium, ativan and narcan. Per Psych, patient drinks approx. He was intubated and given Narcan, Vecuronium, and Ativan. RESPRIATORY FAILURE intubated for airway protection in context of acute ingestion, somnulance. Over course of ER evaluation, became progressively less coherent and less responsive, finally unresponsive to noxious stimuli and loss of gag reflex --> intubated. Over course of ER evaluation, became progressively less coherent and less responsive, finally unresponsive to noxious stimuli and loss of gag reflex --> intubated. HPI: 37 yo M with unknown PMH with progressive altered mental status in the setting of intentional multi-drug and alcohol ingestion, intubated for airway protection. HPI: 37 yo M with unknown PMH with progressive altered mental status in the setting of intentional multi-drug and alcohol ingestion, intubated for airway protection. HPI: 37 yo M with unknown PMH with progressive altered mental status in the setting of intentional multi-drug and alcohol ingestion, intubated for airway protection. Transported to ER, ambulated into ER under own power, noted to have VS WNL. Transported to ER, ambulated into ER under own power, noted to have VS WNL. On presentation to triage at , the patient was speaking but incoherent. | 37 | [
{
"category": "Radiology",
"chartdate": "2149-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029053,
"text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man intubated with Multidrug ingestion\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:24 PM\n PFI: Increased retrocardiac opacity likely represents atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: Multidrug ingestion, status post extubation.\n\n FINDINGS: There has been interval removal of an ET tube. There is no\n evidence of pneumothorax. There is no consolidation or effusion. Increased\n retrocardiac opacities likely due to atelectasis. The osseous structures are\n grossly unremarkable.\n\n IMPRESSION: Retrocardiac opacity likely represents atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029054,
"text": ", MED 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man intubated with Multidrug ingestion\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: Increased retrocardiac opacity likely represents atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028830,
"text": " 8:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Previous NG tube was coiled. Replaced tube, please confirm p\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with intentional overdose now intubated.\n REASON FOR THIS EXAMINATION:\n Previous NG tube was coiled. Replaced tube, please confirm placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:34 AM\n Standard position of the NG tube with its tip in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with overdose and intubation.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 05:55 a.m.\n\n The ET tube tip is 5 cm above the carina. The NG tube was repositioned with\n its tip currently in the stomach. Cardiomediastinal silhouette is\n unremarkable. Minimal atelectasis at the left lung is unchanged. No pleural\n effusion or pneumothorax present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028831,
"text": ", MED 8:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Previous NG tube was coiled. Replaced tube, please confirm p\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with intentional overdose now intubated.\n REASON FOR THIS EXAMINATION:\n Previous NG tube was coiled. Replaced tube, please confirm placement\n ______________________________________________________________________________\n PFI REPORT\n Standard position of the NG tube with its tip in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028806,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm ETT placement and evaluate for any complicati\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with intentional overdose transferred from OSH intubated.\n REASON FOR THIS EXAMINATION:\n Please confirm ETT placement and evaluate for any complications of altered\n mental status including a possible aspiration event.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:34 AM\n Coiled NG tube within the esophagus. Was demonstrated to be _____ on the\n subsequent study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The ET tube tip is 5 cm above the carina. The NG tube is coiled in the\n esophagus with its tip at the level of the oropharynx. The cardiomediastinal\n silhouette is unremarkable and the lungs are clear except for linear opacity\n in the left lower lobe consistent with atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028807,
"text": ", MED 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm ETT placement and evaluate for any complicati\n Admitting Diagnosis: ?OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with intentional overdose transferred from OSH intubated.\n REASON FOR THIS EXAMINATION:\n Please confirm ETT placement and evaluate for any complications of altered\n mental status including a possible aspiration event.\n ______________________________________________________________________________\n PFI REPORT\n Coiled NG tube within the esophagus. Was demonstrated to be _____ on the\n subsequent study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Report",
"row_id": 186230,
"text": "Sinus rhythm\nModest inferior in lead V2 - may be in part positional/normal variant\nSince previous tracing of , sinus bradycardia absentand the prolonged\nQ-Tc interval is now upper limits of normal\n\n"
},
{
"category": "ECG",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Report",
"row_id": 186231,
"text": "Sinus bradycardia at 51 beats per minute. J point elevation in\nleads I, II, III, aVF and V4-V6. T wave inversion in leads V2-V3.\nQ-T interval prolongation with a QTc interval of 516 milliseconds.\nPoor R wave progression. No previous tracing available for comparison.\nClinical correlation is suggested.\n\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 411410,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice. Pt was extubated \n and has been alert and oriented.\n Suicidality / Suicide Attempt\n Assessment:\n Pt has been pleasant, his mom has been in the room for most of the day.\n a sitter has been in the room as well, he has not made any attempts to\n leave. He has been contact by the police, bail had been\n paid and he has a court date next week, police do need to be\n called when he is to leave the hospital.\n Action:\n Seen by psych sitters remain in place.\n Response:\n He has not made any attempts to leave\n Plan:\n Police to be called when he is ready to leave, sitters until\n psych feels that he does not need them.\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411402,
"text": "Chief Complaint: Polysubstance ingestion (suicide attempt)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 09:00 AM\n EKG - At 11:00 AM\n Extubated yesterday AM, remains extubated.\n Offers no new complaints.\n ECG Qt improved.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 89 (57 - 90) bpm\n BP: 116/68(78) {108/48(61) - 146/88(134)} mmHg\n RR: 16 (9 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,408 mL\n 354 mL\n PO:\n 240 mL\n TF:\n IVF:\n 4,688 mL\n 114 mL\n Blood products:\n Total out:\n 2,475 mL\n 1,680 mL\n Urine:\n 2,025 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,933 mL\n -1,326 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 11.6 g/dL\n 153 K/uL\n 89 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n 12:15 PM\n 08:50 PM\n WBC\n 4.3\n 6.1\n Hct\n 35.9\n 32.1\n Plt\n 199\n 153\n Cr\n 1.1\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 22\n Glucose\n 80\n 83\n 89\n Other labs: PT / PTT / INR:14.3/32.9/1.2, CK / CKMB /\n Troponin-T:177/3/<0.01, ALT / AST:16/17, Alk Phos / T Bili:37/0.2,\n Amylase / Lipase:45/28, Differential-Neuts:50.5 %, Lymph:41.4 %,\n Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SUICIDE ATTEMPT -- maintain 1:1 sitter; Psychiatry to follow up.\n POLYSUBSTANCE ABUSE -- improved. Monitor ECG daily.\n EtOH -- no acute withdrawal. Continue CIWA.\n NUTRITIONAL SUPPORT\n PO.\n FLUIDS\n enrourage PO. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 411406,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice. Pt was extubated \n and has been alert and oriented.\n Suicidality / Suicide Attempt\n Assessment:\n Pt has been pleasant, sitter in the room, he has not made any attempts\n to leave. He has been contact by the police, bail had\n been paid and he has a court date next week, police do need\n to be called when he is to leave the hospital.\n Action:\n Seen by psych sitters remain in place.\n Response:\n He has not made any attempts to leave\n Plan:\n Police to be called when he is ready to leave, sitters until\n psych feels that he does not need them.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 411411,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice. Pt was extubated \n and has been alert and oriented.\n Suicidality / Suicide Attempt\n Assessment:\n Pt has been pleasant, his mom has been in the room for most of the day.\n a sitter has been in the room as well, he has not made any attempts to\n leave. He has been contact by the police, bail had been\n paid and he has a court date next week, police do need to be\n called when he is to leave the hospital.\n Action:\n Seen by psych sitters remain in place.\n Response:\n He has not made any attempts to leave\n Plan:\n Police to be called when he is ready to leave, sitters until\n psych feels that he does not need them.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ?OVERDOSE\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 83.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:78\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 55 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,293 mL\n 24h total out:\n 2,280 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 08:50 PM\n Potassium:\n 4.4 mEq/L\n 08:50 PM\n Chloride:\n 112 mEq/L\n 08:50 PM\n CO2:\n 24 mEq/L\n 08:50 PM\n BUN:\n 9 mg/dL\n 08:50 PM\n Creatinine:\n 1.1 mg/dL\n 08:50 PM\n Glucose:\n 89 mg/dL\n 08:50 PM\n Hematocrit:\n 32.1 %\n 08:50 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Social Work",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 411425,
"text": "Progress Note ():\n Pt was alert and very interactive stating that he would never again\n make a suicide attempt. Mr. does not feel that EtOH is a problem,\n stating that he may drink a beer when working outside and talking with\n neighbors; on the weekend, he may go out with friends and\ndrink a few\n beers.\n He denies illicit drug use saying that a number of years ago\n (10?) he had done cocaine, but no longer. Mr. feels that being in\n psychotherapy would be of value, saying that he and his wife were\n supposed to see a couple\ns therapist this evening at 7:00. He reported\n that he will contact this therapist and see if he can schedule to meet\n with him individually. The pt says that he wants no more contact with\n his wife; he only wants to be involved with his children.\n Assessment:\n Pt quite energetic; his response to his suicide attempt is to see it as\n something in the past and that he will just move on from here. Based on\n his brother\ns report of EtOH/drug use, it would appear that Mr. is\n unable to accept the seriousness of his substance use and the effects\n that it has on his behavior/actions. His willingness to be involved in\n psychotherapy was experienced by this worker as something that he\n should say. From the pt\ns presentation, it does not appear that there\n is any reason to feel that his sense of personal responsibility/or\n insight has changed or that there is a reason to feel that it might in\n the near future.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 411404,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice. Pt was extubated \n and has been alert and oriented.\n Suicidality / Suicide Attempt\n Assessment:\n Pt has been pleasant, sitter in the room, he has not made any attempts\n to leave. He has been contact by the police, bail had\n been paid and he has a court date next week, police do need\n to be called when he is to leave the hospital.\n Action:\n Seen by psych, he remains off of his antidepressants due to his recent\n OD of them.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 411405,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice. Pt was extubated \n and has been alert and oriented.\n Suicidality / Suicide Attempt\n Assessment:\n Pt has been pleasant, sitter in the room, he has not made any attempts\n to leave. He has been contact by the police, bail had\n been paid and he has a court date next week, police do need\n to be called when he is to leave the hospital.\n Action:\n Seen by psych, he remains off of his antidepressants due to his recent\n OD of them.\n Response:\n He has not made any attempts to leave\n Plan:\n Police to be called when he is ready to leave, sitters until\n psych feels that he does not need them.\n"
},
{
"category": "Case Management ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 411397,
"text": "Insurance information\n Primary insurance: BLUE CARE ELECT EAST\n Secondary insurance: SELF PAY\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. lives with his wife and 3 Children in . He is\n independent with all ADL's. There is a reported hx of domestic\n violence as recent as the evening prior to admission involving the\n patient and his wife. police and DSS now involved.\n Primary Contact(s): (brother) at \n Health Care Proxy: .\n Dialysis: Yes\n Referrals Recommended: Social Work\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs.\n ## PER family request only contact his brother regarding\n the patient at ##\n Police have requested that they be informed of the patient's\n TX and Dc plans. Please contact Detective (\n Police /(c) ) when dc plans are being\n finalized. Per SW note the pt is being charged with intimidation of a\n witness, domestic assault and battery, and assault (or attempted\n assault\nnot clear) with a deadly weapon.\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411398,
"text": "Chief Complaint:\n 24 Hour Events:\n Yesterday, the patient was extubated. He remained alert and oriented.\n QTc down to 430s. QRS never >100, down to 82 this AM. Seen by Social\n work. Psych saw patient yesterday when he was still somnolent so will\n see again today. Denies SI this morning.\n EKG - At 09:00 AM\n EKG - At 11:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:50 AM\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 57 (50 - 86) bpm\n BP: 133/77(89) {85/48(60) - 140/88(97)} mmHg\n RR: 12 (9 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,408 mL\n 64 mL\n PO:\n TF:\n IVF:\n 4,688 mL\n 64 mL\n Blood products:\n Total out:\n 2,475 mL\n 930 mL\n Urine:\n 2,025 mL\n 930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,933 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 265 (265 - 308) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 11.8 L/min\n Physical Examination\n Gen: Well appearing, sitting in bed\n CV: RRR. No M/R/G.\n Lungs: CTAB\n Neurologic: CN 2-12 grossly intact. Strength 5/5 upper and lower\n extremity. Mood is\ngood\n, denies SI.\n Labs / Radiology\n 153 K/uL\n 11.6 g/dL\n 89 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n 12:15 PM\n 08:50 PM\n WBC\n 4.3\n 6.1\n Hct\n 35.9\n 32.1\n Plt\n 199\n 153\n Cr\n 1.1\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 22\n Glucose\n 80\n 83\n 89\n Other labs: PT / PTT / INR:14.3/32.9/1.2, CK / CKMB /\n Troponin-T:177/3/<0.01, ALT / AST:16/17, Alk Phos / T Bili:37/0.2,\n Amylase / Lipase:45/28, Differential-Neuts:50.5 %, Lymph:41.4 %,\n Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan\n A/P: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, now\n extubated and medically stable.\n # Altered mental status, resolved. Secondary to ingestion of multiple\n substances including acyclovir, cipro, citalopram and alcohol. Patient\n was intubated for airway protection, and was successfully extubated\n yesterday. Patient had increased QTc, which has decreased to 430 this\n morning. QRS was never >100.\n -- Toxicology consulted, would be concerned if QT>550 but no role for\n prophylactic Mg, no role for charcoal >1hr after ingestion, no role for\n Bicarb(only if QRS is prolonged).\n -- Continue AM EKG to evaluate for QTc prolongation as a complication\n of quinolone overdose or other TCA toxicity findings including widening\n of the PR, QRS, and QT intervals; block within the His-Purkinje system;\n and intra- or interventricular conduction delays (bundle branch\n blocks), arrhythmias or tachycardia.\n --F/U Psych consult . Section 12'd by verbal report from psychiatry at\n . Patient too drowsy for Psych to eval yesterday, will see\n him again this AM to determine status.\n --Suicide Precautions, 1:1 sitter\n -- Replete lytes.\n -- F/U TCA screen (send out lab)\n # EtOH abuse. EtOH level of >240 at the outside hospital prior to\n transfer. Per Psych, patient drinks approx. 8 beers/day and uses\n cocaine.\n - Banana bag yesterday, continue, MVI, thiamine and folate.\n - CIWA scale, monitor closely for signs of withdrawl as tonight()\n it will be approx 48 hourse since last drink.\n - Social work and Psych C/S\n #Depression. Per family, patient has been despondent in the past few\n months. There is a history of suicide in the family (uncles,\n grandparent?).\n --Psych C/S\n --Hold psychiatric meds as unclear ingestion.\n .\n # Domestic abuse/assault: Per Social Work, Pt. has multiple charges.\n They would like to be made aware when his discharge is pending. Has\n posted bail so will not be arrested in house.\n - Upon discharge from the hospital, contact police at\n to notify of release.\n .\n # FEN: Tolerating PO\n .\n # Prophylaxis: PPI, heparin subq, bowel regimen.\n .\n # Access: Peripheral IV.\n .\n # Contact: (h) , (w) and \n .\n .\n # Code: Presumed full.\n .\n # Dispo: Floor today w/ suicide precautions, 1:1 sitter. Section 12'd\n by psychiatry at . Psych has not decided on section 12\n status yet.\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411385,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early morning on .\n The pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan, then transferred to .\n Pt was extubated and awake by 1600.\n Altered mental status (not Delirium)\n Assessment:\n Pt had dinner last eve, fell asleep and slept almost the whole noc. Pt\n A&Ox3 when awake, cooperative. HR occ drops <60, serial EKGs done.\n Stable BP. Mother at bedside until 10pm.\n Action:\n Sitter at bedside. Repleted w 2 gms magnesium sulfate.\n Response:\n BP stable. Large u/o clear, lt yellow urine. Sleepy during noc, but\n alert this am.\n Plan:\n Monitor for changes in LOC.\n Suicidality / Suicide Attempt\n Assessment:\n Pt asking when he can go home. Psych has not yet evaluated pt as he\n was intubated yesterday when they visited.\n Action:\n Monitor pt w sitter at bedside.\n Response:\n Pt reports felling well, not depressed. Alert this am.\n Plan:\n _Psych to eval pt. police needs to be informed when\n discharge is imminent, note and phone # on front of chart. Cont to\n monitor for SI.\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411387,
"text": "Chief Complaint:\n 24 Hour Events:\n Yesterday, the patient was extubated. He remained alert and oriented.\n QTc down to 430s. Seen by Social work and Psych.\n EKG - At 09:00 AM\n EKG - At 11:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:50 AM\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 57 (50 - 86) bpm\n BP: 133/77(89) {85/48(60) - 140/88(97)} mmHg\n RR: 12 (9 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,408 mL\n 64 mL\n PO:\n TF:\n IVF:\n 4,688 mL\n 64 mL\n Blood products:\n Total out:\n 2,475 mL\n 930 mL\n Urine:\n 2,025 mL\n 930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,933 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 265 (265 - 308) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 11.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 153 K/uL\n 11.6 g/dL\n 89 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n 12:15 PM\n 08:50 PM\n WBC\n 4.3\n 6.1\n Hct\n 35.9\n 32.1\n Plt\n 199\n 153\n Cr\n 1.1\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 22\n Glucose\n 80\n 83\n 89\n Other labs: PT / PTT / INR:14.3/32.9/1.2, CK / CKMB /\n Troponin-T:177/3/<0.01, ALT / AST:16/17, Alk Phos / T Bili:37/0.2,\n Amylase / Lipase:45/28, Differential-Neuts:50.5 %, Lymph:41.4 %,\n Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan\n A/P: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, now\n extubated and medically stable.\n # Altered mental status, resolved. Secondary to ingestion of multiple\n substances including acyclovir, cipro, citalopram and alcohol. Patient\n was intubated for airway protection, and was successfully extubated\n yesterday. Patient had increased QTc, which has decreased to 430 this\n morning.\n -- Toxicology consulted, would be concerned if QT>550 but no role for\n prophylactic Mg, no role for charcoal >1hr after ingestion, no role for\n Bicarb(only if QRS is prolonged).\n --Replete lytes.\n -- F/U TCA screen (send out lab)\n -- Continue EKG to evaluate for QTc prolongation as a complication\n of quinolone overdose or other TCA toxicity findings including widening\n of the PR, QRS, and QT intervals; block within the His-Purkinje system;\n and intra- or interventricular conduction delays (bundle branch\n blocks), arrhythmias or tachycardia.\n -- Psych consult . Section 12'd by verbal report from psychiatry at\n . Patient too drowsy for Psych to eval yesterday, will see\n him again this AM to determine status.\n --Suicide Precautions\n # EtOH abuse. EtOH level of >240 at the outside hospital prior to\n transfer. Per Psych, patient drinks approx. 8 beers/day and uses\n cocaine.\n - Banana bag yesterday, continue, MVI, thiamine and folate.\n - CIWA scale, monitor closely for signs of withdrawl as tonight it will\n be approx 48 hourse since last drink.\n - Social work and Psych C/S\n #Depression. Per family, patient has been despondent in the past few\n months. There is a history of suicide in the family (uncles,\n grandparent?).\n --Psych C/S\n --Hold psychiatric meds as unclear ingestion. When QTc is WNL,\n consider starting SSRI.\n .\n # Domestic abuse/assault: Per Social Work, Pt. has multiple charges.\n They would like to be made aware when his discharge is pending.\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n .\n # FEN: Tolerating PO\n .\n # Prophylaxis: PPI, heparin subq, bowel regimen.\n .\n # Access: Peripheral IV.\n .\n # Contact: (h) , (w) and \n .\n .\n # Code: Presumed full.\n .\n # Dispo: Floor today w/ suicide precautions. Section 12'd by\n psychiatry at .\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Social Work",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 411391,
"text": "Progress Note (Detective/ Police):\n Spoke with Detective ( Police /(c) ) who said that pt is being charged with\n intimidation of a witness, domestic assault and battery, and assault\n (or attempted assault\nnot clear) with a deadly weapon, which she could\n not identify. The police filed a report with DSS; a copy of their\n report is in the front of the chart. The detective could only provide\n limited information because there has been no arraignment. She wants\n to be contact when pt TX/DC has been decided as she expressed a\n number of times being concerned about his wife\ns safety.\n Progress Note (Pt\ns mother):\n Ms. began talking about how much her son is experiencing\nmind-torture\n because of his wife\ns treatment, which is causing him to\ngo mentally crazy.\n Additionally, she described him as having\nhigh\n anxiety\nwhich runs in the family,\n which she also stated having. \n mind goes 50 miles/hour. She believes that they were attracted to each\n other because he was handsome and she was pretty. She said,\nThey did\n not know each other.\n There were arguments and violence from the\n beginning of their relationship\nbreaking doors, throwing a vacuum\n cleaner out a window, etc. Ms. described her as\n witch\n and noted, too, that her own parents refer to her as\na bitch.\n She sees her as\ndevious\n and\na quite sneak.\n At one point, Ms. \n had her arrested for assault because she threw a phone at her and hit\n her in the nose. The pt\ns mo did not pursue things legally if \n agreed to go to anger management. She constantly\nknocks him down\n private as well as in front of his friends. calls him\ncrazy,\ndump,\n and\nstupid.\n She says that has\nno confidence\n and\n self-esteem.\n Over the past three months, has become increasingly\n more depressed. In asking how she understands his staying with her\n given these relationship difficulties, she said,\nI guess it\ns because\n he loves her.\n constantly blames himself for the difficulties he\n is experiencing because of the affair that he had. He would like\n call it even,\n because they both had affairs, and move on from there.\n When asked about EtOH/drug use, she said that they were not a problem.\n At the end of the interview, she asked about DSS and expressed concern\n about the three grandchildren, , , and . The middle\n child is\nquick to anger.\n She is concerned about the eldest because\n she does not talk about what she is feeling/thinking. Ms. is\n hoping that DSS will have leave the home so that both grandmothers\n can stay there (the maternal grandmother already lives there) and take\n care of the children. , she said, does not care about the children\n but only having the house:\nShe wants her cake and eat it too.\n Assessment:\n \ns report of his mo\ns own EtOH use may explain her minimizing\n his substance problems. Ms. spoke of being very protective of him\n and wish that she and her two sons could return to the way it used to\n be when just the three of them lived together. \n , with whom\n he was close, died of AIDS 13 years ago; he was addicted to crack\n cocaine. The pt\ns mo description of his\nhigh anxiety,\n impulsiveness,\n and his\nracing mind,\n raise the question of whether pt might be\n bipolar.\n Plan:\n 1. Interview pt\n 2. Continue to be available to pt\ns mo and son.\n \n"
},
{
"category": "Social Work",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 411392,
"text": "Family Information\n Next of : pt's brother's request, she should not be\n given any information or allowed to call or see him.\n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: --Brother (C) \n Communication or visitation restriction: wife is to have no\n contact\n Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: None\n Past psychiatric history: reports that pt has been depressed over\n the past weeks--quiet, starring into space, out all night and sleeping\n all day, and tearful. \ns wife said that was crying\n yesterday when working on their deck.\n Past addictions history: There is an extensive family HX of EtOH and\n drug use, with drinking dating back to his youth. thinks he\n probably drinks a six-pack on weekdays and gets\nhammered\n on the\n weekends. He also misuses Percocet and Klonopin, in addition to\n marijuana and cocaine, which he and his wife have been using heavily\n over the past few months. Pt' stopped EtOH misuse and quit cocaine\n use approximately nine years ago. Pt\ns brother, grandfather, and at\n least two uncles have misused EtOH. Pt\ns grandfather and two uncles\n both committed suicide.\n Employment status: Employed as a labor at a company where his \n works.\n Legal involvement: Currently under arrest following incident of\n physically assaulting his wife last night, but do not know the specific\n charges. During his adolescents, pt also had a number of arrests, but\n did not say for what.\n Mandated Reporting Information: Police filed with DSS.\n Additional Information:\n Patient / Family Assessment: Pt and his wife, , have been married\n for 16-17 years and have three children, a y/o daughter, an y/o\n son, and a 12 y/o daughter, all three of whom live with their mo. Pt\n does visit his children. expressed concern that the children\n are experiencing the\nbrunt\n of their parents\n behavior. There is a HX\n of domestic violence dating back, possibly, to the beginning of their\n relationship. They are both verbally and physically assaultive of each\n other. It appears that one of the precipitants for the heightened\n tension in their relationship is that pt\ns wife has been involved with\n another man (or men) for the past 1\n years. earlier had an affair.\n His wife, according to , has said that she\ndoes not love him,\n possibly dating back to his affair. Over the past months, pt has lived\n between his home with his wife, friends, and is now currently with his\n brother and his wife. said that last night when speaking with\n via telephone, that he said it would be their last call because he\n was going to die. It took approximately three hours for the police to\n locate him after leaving his wife\ns house. The police found him in\n , unconscious and in his pick-up truck. and his wife\n have stopped communicating with \ns wife (other than a hello)\n approximately 12 years ago because of spiteful and sneaky behavior,\n just\ngetting under your skin.\n Assessment: Pt\ns impulsive and angry/violent behavior is of concern,\n behavior fueled by his EtOH and drug use, which may need to be need the\n primary focus of TX, in addition to concurrent psychotherapy. \n feels that when his brother gives deep thought to issues that it may\n lead to him taking responsibility for his behavior, but typically, he\n blames others raising the question of some type of personality\n disorder.\n Communication with Team:\n RN: \n Attending: \n Plan / Follow up:\n 1. To be available to pt\ns brother and , as well as with pt\n when extubated.\n 2. Contact police to inquire if they filed a report\n with DSS.\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411395,
"text": "Chief Complaint: Polysubstance ingestion (suicide attempt)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 09:00 AM\n EKG - At 11:00 AM\n Extubated yesterday AM, remains extubated.\n Offers no new complaints.\n ECG Qt improved.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 89 (57 - 90) bpm\n BP: 116/68(78) {108/48(61) - 146/88(134)} mmHg\n RR: 16 (9 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,408 mL\n 354 mL\n PO:\n 240 mL\n TF:\n IVF:\n 4,688 mL\n 114 mL\n Blood products:\n Total out:\n 2,475 mL\n 1,680 mL\n Urine:\n 2,025 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,933 mL\n -1,326 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 11.6 g/dL\n 153 K/uL\n 89 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n 12:15 PM\n 08:50 PM\n WBC\n 4.3\n 6.1\n Hct\n 35.9\n 32.1\n Plt\n 199\n 153\n Cr\n 1.1\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 22\n Glucose\n 80\n 83\n 89\n Other labs: PT / PTT / INR:14.3/32.9/1.2, CK / CKMB /\n Troponin-T:177/3/<0.01, ALT / AST:16/17, Alk Phos / T Bili:37/0.2,\n Amylase / Lipase:45/28, Differential-Neuts:50.5 %, Lymph:41.4 %,\n Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SUICIDE ATTEMPT -- maintain 1:1 sitter; Psychiatry to follow up.\n POLYSUBSTANCE ABUSE -- improved.\n EtOH -- no acute withdrawal. Continue CIWA.\n NUTRITIONAL SUPPORT -- PO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411396,
"text": "Chief Complaint:\n 24 Hour Events:\n Yesterday, the patient was extubated. He remained alert and oriented.\n QTc down to 430s. QRS never >100, down to 82 this AM. Seen by Social\n work. Psych saw patient yesterday when he was still somnolent so will\n see again today. Denies SI this morning.\n EKG - At 09:00 AM\n EKG - At 11:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:50 AM\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 57 (50 - 86) bpm\n BP: 133/77(89) {85/48(60) - 140/88(97)} mmHg\n RR: 12 (9 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,408 mL\n 64 mL\n PO:\n TF:\n IVF:\n 4,688 mL\n 64 mL\n Blood products:\n Total out:\n 2,475 mL\n 930 mL\n Urine:\n 2,025 mL\n 930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,933 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 265 (265 - 308) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SpO2: 97%\n ABG: ///24/\n Ve: 11.8 L/min\n Physical Examination\n Gen: Well appearing, sitting in bed\n CV: RRR. No M/R/G.\n Lungs: CTAB\n Neurologic: CN 2-12 grossly intact. Strength 5/5 upper and lower\n extremity. Mood is\ngood\n, denies SI.\n Labs / Radiology\n 153 K/uL\n 11.6 g/dL\n 89 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 9 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.1 %\n 6.1 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n 12:15 PM\n 08:50 PM\n WBC\n 4.3\n 6.1\n Hct\n 35.9\n 32.1\n Plt\n 199\n 153\n Cr\n 1.1\n 1.0\n 1.1\n TropT\n <0.01\n TCO2\n 22\n Glucose\n 80\n 83\n 89\n Other labs: PT / PTT / INR:14.3/32.9/1.2, CK / CKMB /\n Troponin-T:177/3/<0.01, ALT / AST:16/17, Alk Phos / T Bili:37/0.2,\n Amylase / Lipase:45/28, Differential-Neuts:50.5 %, Lymph:41.4 %,\n Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan\n A/P: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, now\n extubated and medically stable.\n # Altered mental status, resolved. Secondary to ingestion of multiple\n substances including acyclovir, cipro, citalopram and alcohol. Patient\n was intubated for airway protection, and was successfully extubated\n yesterday. Patient had increased QTc, which has decreased to 430 this\n morning. QRS was never >100.\n -- Toxicology consulted, would be concerned if QT>550 but no role for\n prophylactic Mg, no role for charcoal >1hr after ingestion, no role for\n Bicarb(only if QRS is prolonged).\n -- F/U TCA screen (send out lab)\n -- Continue AM EKG to evaluate for QTc prolongation as a complication\n of quinolone overdose or other TCA toxicity findings including widening\n of the PR, QRS, and QT intervals; block within the His-Purkinje system;\n and intra- or interventricular conduction delays (bundle branch\n blocks), arrhythmias or tachycardia.\n -- Psych consult . Section 12'd by verbal report from psychiatry at\n . Patient too drowsy for Psych to eval yesterday, will see\n him again this AM to determine status.\n --Suicide Precautions, 1:1 sitter\n -- Replete lytes.\n # EtOH abuse. EtOH level of >240 at the outside hospital prior to\n transfer. Per Psych, patient drinks approx. 8 beers/day and uses\n cocaine.\n - Banana bag yesterday, continue, MVI, thiamine and folate.\n - CIWA scale, monitor closely for signs of withdrawl as tonight it will\n be approx 48 hourse since last drink.\n - Social work and Psych C/S\n #Depression. Per family, patient has been despondent in the past few\n months. There is a history of suicide in the family (uncles,\n grandparent?).\n --Psych C/S\n --Hold psychiatric meds as unclear ingestion. When QTc is WNL,\n consider starting SSRI.\n .\n # Domestic abuse/assault: Per Social Work, Pt. has multiple charges.\n They would like to be made aware when his discharge is pending.\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n .\n # FEN: Tolerating PO\n .\n # Prophylaxis: PPI, heparin subq, bowel regimen.\n .\n # Access: Peripheral IV.\n .\n # Contact: (h) , (w) and \n .\n .\n # Code: Presumed full.\n .\n # Dispo: Floor today w/ suicide precautions. Section 12'd by\n psychiatry at .\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:36 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411384,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early morning on .\n The pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan, then transferred to .\n Pt was extubated and awake by 1600.\n Altered mental status (not Delirium)\n Assessment:\n Pt had dinner last eve, fell asleep and slept almost the whole noc. Pt\n A&Ox3 when awake, cooperative. HR occ drops <60, serial EKGs done.\n Stable BP. Mother at bedside until 10pm.\n Action:\n Sitter at bedside. Repleted w 2 gms magnesium sulfate.\n Response:\n BP stable. Large u/o clear, lt yellow urine. Sleepy during noc, but\n alert this am.\n Plan:\n Monitor for changes in LOC.\n Suicidality / Suicide Attempt\n Assessment:\n Pt asking when he can go home. Psych has not yet evaluated pt as he\n was intubated yesterday when they visited.\n Action:\n Monitor pt w sitter at bedside.\n Response:\n Pt reports felling well, not depressed. Alert this am.\n Plan:\n _Psych to eval pt. Police needs to be informed when discharge is\n imminent as pt is under arrest.\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 411350,
"text": "Chief Complaint: Overdose, unresponsiveness\n HPI:\n History obtained from records and verbal report from MD.\n Contact numbers for are not currently accepting calls.\n .\n HPI: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, intubated\n for airway protection.\n .\n The patient was reportedly involved in a domestic violence dispute with\n his wife. The wife called the police due to his violent behavior\n towards her. Initially police were unable to find the patient.\n Subsequently he was reportedly found in a car with empty alcohol\n containers and numerous empty pill bottles. Reportedly, the empty\n bottles reviewed by the staff included 4 bottles of\n acyclovir, percocet, flexeril, citalopram and ciprofloxacin. The\n patient was taken by police to Hospital because of altered\n mental status described as alert and oriented but 'not making sense'.\n He was able to walk to the ambulance in the field. On presentation to\n triage at , the patient was speaking but incoherent.\n Presentation vitals at 97.6 90 121/74 20 97% 3L. He was\n noted to have equal and responsive pupils. Quickly the patient became\n obtunded and unresponsive. He was noted to have no gag reflex and to\n have no response to noxious salts. The patient received narcan 2mg\n without any response. He was intubated for airway protection. He had\n normal vital signs throughout his ICU stay, with max heartrate of 101\n otherwise 50-80 and mild relative bp decline from sbp 120 to 90's after\n intubation. Head CT was negative. Tox screen was remarkable for an EtOH\n level of 240, otherwise negative urine tox and negative tylenol level.\n The patient is transferred for further management due to no available\n ICU beds at Hospital. While in the ED at , the\n patient received vecuronium, ativan and narcan.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Unknown\n Past medical history:\n Family history:\n Social History:\n Unable to obtain\n Unable to obtain\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Unable to obtain\n Review of systems: Unable to obtain.\n Flowsheet Data as of 05:58 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 53 (51 - 67) bpm\n BP: 106/65() {106/65() - 106/65()} mmHg\n RR: 19 (16 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -450 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n Ve: 12.2 L/min\n Physical Examination\n Gen: Intubated and sedated.\n HEENT: PERRL approximately 2-3mm bilaterally.\n CV: RRR. Normal S1 and S2. No M/R/G.\n Pulm: CTA bilaterally.\n Abd: Soft, nontender, nondistended.\n Ext: No edema.\n Neuro: Sedated. Spontaneously moved all extremities in response to OG\n tube placement. Reflexes 1+ patellar bilaterally. No clonus.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na 140, K 4.3, Cl 103, Bicarb 24, BUN/Cr\n 16/1.18, Glucose 106, Ca 9.3, T Prot 7.7, Alb 5.1.\n .\n WBC 5.8, Hct 41.5, platelets 209.\n .\n ALT 21, AST 24, Alk Phos 51, T Bili 0.2\n .\n Urine tox screen: Negative for benzos, cocaine, amphetamines,\n canabinoid, opiates and barbituates.\n .\n Serum tox screen:\n EtOH 245, Acetaminophen <1, Salicylate <3, Tricyclic antidepressant\n pending (will not be done until tomorrow due to send out lab at\n ).\n Imaging: CT head (): Verbal report negative for hemorrhage.\n .\n CXR (): Pending.\n Microbiology: None\n ECG: (): Sinus rhythm at a rate of 51. Normal axis. PR interval\n 170, QRS approximately 100, QTc 490. Downgoing T's in V1-2. Compared to\n prior earlier in the day reveals slightly prolonged PR interval by\n 20msec and slight prolongation of QRS with extended repolarization\n phase in II-III.\n Assessment and Plan\n A/P: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, intubated\n for airway protection.\n .\n # Altered mental status. Presumed secondary to ingestion. Exact\n substances of ingestion not entirely clear. Reported empty bottles of\n acyclovir, percocet, flexeril, citalopram and cipro seem to provide a\n poor explanation for his symptoms. The only finding on urine toxicology\n screen was a positive EtOH level. It is possible this represents\n synergistic respiratory depression from alcohol, flexeril and oxycodone\n component of percocet. Tylenol level negative at the outside hospital.\n TCA screen not yet completed due to outside hospital lab requiring\n send-out. EKG and exam (no clonus or hyperreflexia) not diagnostic of\n changes associated with TCA intoxication.\n - Toxicology consult.\n - Maintain intubation until able to protect airway.\n - Banana bag, MVI, thiamine, folate for EtOH use. No other toxicology\n treatment indicated.\n - Repeat blood and urine tox screen. Awaiting result of TCA screen.\n - Trend EKG to evaluate for QTc prolongation as a complication of\n quinolone overdose or other TCA toxicity findings including widening of\n the PR, QRS, and QT intervals; block within the His-Purkinje system;\n and intra- or interventricular conduction delays (bundle branch\n blocks), arrhythmias or tachycardia.\n - To consider EEG for persistent altered mental status as ciprofloxacin\n can lower seizure threshold.\n - Psych consult when extubated. Currently section 12'd by verbal report\n from psychiatry at .\n .\n # EtOH abuse. EtOH level of >240 at the outside hospital prior to\n transfer. Alcohol history unknown.\n - Banana bag, MVI, thiamine and folate.\n - CIWA scale with valium via OG tube.\n .\n # Domestic abuse. Upon discharge from the hospital, please contact\n police at to notify of release.\n .\n # FEN: NPO pending improved mental status and possible extubation, meds\n via OG tube.\n .\n # Prophylaxis: PPI, heparin subq, bowel regimen.\n .\n # Access: Peripheral IV.\n .\n # Contact: (h) , (w) \n .\n # Code: Presumed full.\n .\n # Dispo: ICU pending improved mental status and possible extubation.\n Section 12'd by psychiatry at .\n - Upon discharge from the hospital, please contact police at\n to notify of release.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:36 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411352,
"text": "History obtained from records and verbal report from MD.\n Contact numbers for are not currently accepting calls.\n .\n HPI: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, intubated\n for airway protection.\n .\n The patient was reportedly involved in a domestic violence dispute with\n his wife. The wife called the police due to his violent behavior\n towards her. Initially police were unable to find the patient.\n Subsequently he was reportedly found in a car with empty alcohol\n containers and numerous empty pill bottles. Reportedly, the empty\n bottles reviewed by the staff included 4 bottles of\n acyclovir, percocet, flexeril, citalopram and ciprofloxacin. The\n patient was taken by police to Hospital because of altered\n mental status described as alert and oriented but 'not making sense'.\n He was able to walk to the ambulance in the field. On presentation to\n triage at , the patient was speaking but incoherent.\n Presentation vitals at 97.6 90 121/74 20 97% 3L. He was\n noted to have equal and responsive pupils. Quickly the patient became\n obtunded and unresponsive. He was noted to have no gag reflex and to\n have no response to noxious salts. The patient received narcan 2mg\n without any response. He was intubated for airway protection. He had\n normal vital signs throughout his ICU stay, with max heartrate of 101\n otherwise 50-80 and mild relative bp decline from sbp 120 to 90's after\n intubation. Head CT was negative. Tox screen was remarkable for an EtOH\n level of 240, otherwise negative urine tox and negative tylenol level.\n The patient is transferred for further management due to no available\n ICU beds at Hospital. While in the ED at , the\n patient received vecuronium, ativan and narcan.\n Problem - Description In Comments\n Assessment:\n Pt responsive to painful stimuli only, impaired cough and gag,\n breathing with vent, currently not sedated, PERRLA\n Action:\n Monitoring pt, blood and urine cultures sent, OGT placed, EKG obtained\n indicating QT prolongation, ABG obtained, CIWA scale initiated although\n as noted above pt minimally responsive\n Response:\n Pt continues to be minimally responsive despite no additional sedation\n from that received at \n Plan:\n Banana bag ordered, continue to monitor MS, CIWA scale when applicable,\n f/u culture data, f/u ABG, continue mechanical vent until MS improves\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411353,
"text": "History obtained from records and verbal report from MD.\n Contact numbers for are not currently accepting calls.\n .\n HPI: 37 yo M with unknown PMH with progressive altered mental status in\n the setting of intentional multi-drug and alcohol ingestion, intubated\n for airway protection.\n .\n The patient was reportedly involved in a domestic violence dispute with\n his wife. The wife called the police due to his violent behavior\n towards her. Initially police were unable to find the patient.\n Subsequently he was reportedly found in a car with empty alcohol\n containers and numerous empty pill bottles. Reportedly, the empty\n bottles reviewed by the staff included 4 bottles of\n acyclovir, percocet, flexeril, citalopram and ciprofloxacin. The\n patient was taken by police to Hospital because of altered\n mental status described as alert and oriented but 'not making sense'.\n He was able to walk to the ambulance in the field. On presentation to\n triage at , the patient was speaking but incoherent.\n Presentation vitals at 97.6 90 121/74 20 97% 3L. He was\n noted to have equal and responsive pupils. Quickly the patient became\n obtunded and unresponsive. He was noted to have no gag reflex and to\n have no response to noxious salts. The patient received narcan 2mg\n without any response. He was intubated for airway protection. He had\n normal vital signs throughout his ICU stay, with max heartrate of 101\n otherwise 50-80 and mild relative bp decline from sbp 120 to 90's after\n intubation. Head CT was negative. Tox screen was remarkable for an EtOH\n level of 240, otherwise negative urine tox and negative tylenol level.\n The patient is transferred for further management due to no available\n ICU beds at Hospital. While in the ED at , the\n patient received vecuronium, ativan and narcan.\n Problem - Description In Comments\n Assessment:\n Pt responsive to painful stimuli only, impaired cough and gag,\n breathing with vent, currently not sedated, PERRLA\n Action:\n Monitoring pt, blood and urine cultures sent, OGT placed, EKG obtained\n indicating QT prolongation, ABG obtained, CIWA scale initiated although\n as noted above pt minimally responsive\n Response:\n Pt continues to be minimally responsive despite no additional sedation\n from that received at \n Plan:\n Banana bag ordered, continue to monitor MS, CIWA scale when applicable,\n f/u culture data, f/u ABG, continue mechanical vent until MS improves\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 411356,
"text": "Chief Complaint: Respiratory failure\n HPI:\n 37 yom reportedly otherwise healthy, reportely ingested multiple pills\n and EtOH in context of domestic dispute with wife. Pt. found by police\n in parked car in garage, awake but incoherent. Transported to\n ER, ambulated into ER under own power, noted to have VS WNL.\n Over course of ER evaluation, became progressively less coherent and\n less responsive, finally unresponsive to noxious stimuli and loss of\n gag reflex --> intubated. Evaluation revealed negative urine & serum\n tox screen, EtOH = 240. Received Narcan, Ativan and Vecuronium around\n time of intubation. Lack of ICU beds @ prompted transfer to\n MICU.\n Upon arrival to , remained intubated. Not requiring sedation.\n Slowly awakening, responding to voice. Denies pain. Received charcoal\n via NGT.\n At home, in addition to empty EtOH bottles, EMS found empty bottles of\n Citalopram, Flexeril, Percocet, Acyclovir, Ciprofloxicin.\n History obtained from Family / Medical records\n Patient unable to provide history: ETT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Reportedly without significant PMHx\n Occupation: Unknown\n Drugs: Cocaine, marijuana\n Tobacco: Yes\n Alcohol: EtOH daily\n Other: Married, currently marital tensions\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, OG / NG tube, ETT\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n mechanical ventilation\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:25 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 64 (50 - 67) bpm\n BP: 98/72(72) {87/52(60) - 106/72(72)} mmHg\n RR: 21 (16 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,512 mL\n PO:\n TF:\n IVF:\n 1,512 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 932 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 308 (308 - 308) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/35/209/20/-1\n Ve: 11.7 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,\n Endotracheal tube, No(t) NG tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 199 K/uL\n 35.9 %\n 12.2 g/dL\n 80 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 20 mEq/L\n 108 mEq/L\n 4.3 mEq/L\n 141 mEq/L\n 4.3 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n WBC\n 4.3\n Hct\n 35.9\n Plt\n 199\n Cr\n 1.1\n TC02\n 22\n Glucose\n 80\n Other labs: CK / CKMB / Troponin-T:177//, ALT / AST:18/19, Alk Phos / T\n Bili:41/0.2, Amylase / Lipase:45/28, Differential-Neuts:50.5 %,\n Lymph:41.4 %, Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Multi-substance ingestion.\n RESPRIATORY FAILURE --\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 05:36 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 75 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411366,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt weaned and extuabted this morning without incident to 2 L NC satting\n >98%\n"
},
{
"category": "Respiratory ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411347,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt admitted from OSH with ? OD and etoh. Intubated for airway\n protection. Will cont to monitor resp status\n"
},
{
"category": "Respiratory ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411348,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: ABG drawn from L radial artery. Bleeding controlled .\n"
},
{
"category": "Social Work",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 411360,
"text": "Family Information\n Next of : pt's brother's request, she should not be\n given any information or allowed to call or see him.\n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: --Brother (C) \n Communication or visitation restriction: wife is to have no\n contact\n Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: None\n Past psychiatric history: reports that pt has been depressed over\n the past weeks--quite, starring into space, out all night and sleeping\n all day, and tearful.\n Past addictions history: There is an extensive family HX EtOH of drug\n for pt dating back to his youth. Pt' \n Employment status:\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
},
{
"category": "Social Work",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 411361,
"text": "Family Information\n Next of : pt's brother's request, she should not be\n given any information or allowed to call or see him.\n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: --Brother (C) \n Communication or visitation restriction: wife is to have no\n contact\n Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: None\n Past psychiatric history: reports that pt has been depressed over\n the past weeks--quite, starring into space, out all night and sleeping\n all day, and tearful. \ns wife said that was crying\n yesterday when working on their deck.\n Past addictions history: There is an extensive family HX of EtOH and\n drug use, with drinking dating back to his youth. thinks he\n probably drinks a six-pack on weekdays and gets\nhammered\n on the\n weekends. He also misuses Percocet and Klonopin, in addition to\n marijuana and cocaine, which he and his wife have been using heavily\n over the past few months. Pt' stopped EtOH misuse and quit cocaine\n use approximately nine years ago. Pt\ns brother, grandfather, and at\n least two uncles have misused EtOH. Pt\ns grandfather and two uncles\n both committed suicide.\n Employment status: Employed as a labor at a company where his \n works.\n Legal involvement: Currently under arrest following incident of\n physically assaulting his wife last night, but do not know the specific\n charges. During his adolescents, pt also had a number of arrests, but\n did not say for what.\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Pt and his wife, , have been married\n for 16-17 years and have three children, a y/o daughter, an y/o\n son, and a 12 y/o daughter, all three of whom live with their mo. Pt\n does visit his children. expressed concern that the children\n are experiencing the\nbrunt\n of their parents\n behavior. There is a HX\n of domestic violence dating back, possibly, to the beginning of their\n relationship. They are both verbally and physically assaultive of each\n other. It appears that one of the precipitants for the heightened\n tension in their relationship is that pt\ns wife has been involved with\n another man (or men) for the past 1\n years. earlier had an affair.\n His wife, according to , has said that she\ndoes not love him,\n possibly dating back to his affair. Over the past months, pt has lived\n between his home with his wife, friends, and is now currently with his\n brother and his wife. said that last night when speaking with\n via telephone, that he said it would be their last call because he\n was going to die. It took approximately three hours for the police to\n locate after leaving his wife\ns house. The police found him in\n in his pick-up truck. and his wife have stopped\n communicating with \ns wife (other than a hello) approximately 12\n years ago because of spiteful and sneaky behavior, just\ngetting under\n your skin.\n Assessment: Pt\ns impulsive and angry/violent behavior is of concern,\n behavior fueled by his EtOH and drug use, which may be need to be the\n primary focus on TX, in addition to concurrent psychotherapy. \n feels that when his brother gives deep thought to issues that it may\n lead to him taking responsibility for his behavior, but typically, he\n blames others raising the question of some type of personality\n disorder.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n 1. To be available to pt\ns brother and , as well as with pt\n when extubated.\n 2. Contact police to inquire if they filed a report\n with DSS.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411363,
"text": "HPI: 37 year old male with an unknown PHM s/p ingestion of multiple\n drugs and ETOH admitted from to MICU early this morning. The\n pt was reportedly in a domestic abuse situation with wife when she\n called the police and he proceeded to leave the scene and ingest\n multiple drugs and ETOH including acyclovir, percocet, flexeril,\n citalopram, and ciproflaxicin. The police reportedly found and arrested\n the pt whom was then transported to the ED. While at\n the pt was initially coherent and self ventilating then\n quickly became unresponsive and without a gag. He was intubated and\n given Narcan, Vecuronium, and Ativan. Upon arrival to the MICU the pt\n remained sedated and responding only to voice.\n Suicidality / Suicide Attempt\n Assessment:\n Per brother the pt openly admitted to trying to attempt suicide after\n ingestion of drugs and etoh. Recent increase in consumption of etoh and\n drugs per brother. Family history of successful suicide attempts. Need\n for mechanical ventilation after suicide attempt. Domestic abuse\n present at home.\n Action:\n Fluid boluses, banana bag and activated charcoal administered. Patient\n observer present at bedside. Social work involved with police and\n family.\n Response:\n Currently safe from self harm resting comfortably in bed expressing no\n intent to harm self.\n Plan:\n Continue to observe for SI and keep patient observer/RN/family at\n bedside.\n Altered mental status (not Delirium)\n Assessment:\n Sedated s/p etoh and multiple drug ingestion. Responding to stimuli\n Pupils equal and sluggishly reactive. Ventilated on AC with no\n spontaneous breaths. Systolic BP 80\ns with HR in 50\n Action:\n Rest, Fluid boluses, serial ECG\n Response:\n Increase in systolic BP to 100\ns and HR to 70\ns. Breathing spontaneous\n with Sp02 of 99% on 2L.\n Plan:\n Continue to monitor LOC. Cardiac monitoring with serial ECG\ns and\n respiratory monitoring.\n Mother and brother at bedside. Wife called but hung up once the brother\n was put on phone. Mother in law called after and was given pt info from\n brother. Psych and social work involved ? need for etoh/drug rehab.\n police aware pt extubated and planning on taking him into\n custody after discharge r/t domestic abuse situation.\n"
},
{
"category": "Social Work",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 411365,
"text": "Progress Note (Detective/ Police):\n Spoke with Detective ( Police /(c) ) who said that pt is being charged with\n intimidation of a witness, domestic assault and battery, and assault\n (or attempted assault\nnot clear) with a deadly weapon, which she could\n not identify. The police filed a report with DSS; a copy of their\n report is in the front of the chart. The detective could only provide\n limited information because there has no arraignment. She wants to be\n contact when pt TX/DC has been decided as she expressed a number of\n times being concerned about his wife\ns safety.\n Progress Note (Pt\ns mother):\n Ms. began talking about how much her son is experiencing\nmind-torture\n because of his wife\ns treatment, which is causing him to\ngo mentally crazy.\n Additionally, she described him as having\nhigh\n anxiety\nwhich runs in the family,\n which she too said that she had.\n \ns mind goes 50 miles/hour. She believes that they were attracted\n to each other because he was handsome and she was pretty. She said,\nThey did not know each other.\n There were arguments and violence from\n the beginning of their relationship\nbreaking doors, throwing a vacuum\n cleaner out a window, etc. Ms. described her as\n witch\n and noted, too, that her own parents refer to her as\na bitch.\n She sees her as\ndevious\n and\na quite sneak.\n At one point, Ms. \n had her arrested for assault because she threw a phone at her and hit\n her in the nose. The pt\ns mo did not pursue things legally if \n agreed to go to anger management. She constantly\nknocks him down\n private as well as in front of his friends. calls him\ncrazy,\ndump,\n and\nstupid.\n She says that has\nno confidence\n and\n self-esteem.\n Over the past three months, has become increasingly\n more depressed. In asking how she understands his staying with her\n given these relationship difficulties, she said,\nI guess it\ns because\n he loves her.\n constantly blames himself for the difficulties he\n is experiencing because of the affair that he had. He would like\n call it even,\n because they both had affairs, and move on from there.\n When asked about EtOH/drug use, she said that they were not a problem.\n At the end of the interview, she asked about DSS and expressed concern\n about the three grandchildren, , , and . The middle\n child is\nquick to anger.\n She is concerned about the eldest because\n she does not talk about what she is feeling/thinking. Ms. is\n hoping that DSS will have leave the home so that both grandmothers\n can stay there (the maternal grandmother already lives there) and take\n care of the children. , she said, does not care about the children\n but only having the house:\nShe wants her cake and eat it too.\n Assessment:\n \ns report of his mo\ns own EtOH use may explain her minimizing\n his substance problems. Ms. spoke of being very protective of him\n and wish that she and her two sons could return to the way it used to\n be when just the three of them lived together. \n , with whom\n he was close, died of AIDS 13 years ago; he was addicted to crack\n cocaine. The pt\ns mo description of his\nhigh anxiety,\n impulsiveness,\n and his\nracing mind,\n raise the question of whether pt might be\n bipolar.\n Plan:\n 1. Interview pt\n 2. Continue to be available to pt\ns mo and son.\n \n"
},
{
"category": "Physician ",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 411368,
"text": "Chief Complaint: Respiratory failure\n HPI:\n 37 yom reportedly otherwise healthy, reportely ingested multiple pills\n and EtOH in context of domestic dispute with wife. Pt. found by police\n in parked car in garage, awake but incoherent. Transported to\n ER, ambulated into ER under own power, noted to have VS WNL.\n Over course of ER evaluation, became progressively less coherent and\n less responsive, finally unresponsive to noxious stimuli and loss of\n gag reflex --> intubated. Head CT reportedly normal. Evaluation\n revealed negative urine & serum tox screen, EtOH = 240. Received\n Narcan, Ativan and Vecuronium around time of intubation. Lack of ICU\n beds @ prompted transfer to MICU.\n Upon arrival to , remained intubated. Not requiring sedation.\n Slowly awakening, responding to voice. Denies pain. Received charcoal\n via NGT.\n At home, in addition to empty EtOH bottles, EMS found empty bottles of\n Citalopram, Flexeril, Percocet, Acyclovir, Ciprofloxicin.\n History obtained from Family / Medical records\n Patient unable to provide history: ETT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:50 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Reportedly without significant PMHx\n Unobrtainable\n Occupation: Unknown\n Drugs: Cocaine, marijuana\n Tobacco: Yes\n Alcohol: EtOH daily\n Other: Married, currently marital tensions\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, OG / NG tube, ETT\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze,\n mechanical ventilation\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:25 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 64 (50 - 67) bpm\n BP: 98/72(72) {87/52(60) - 106/72(72)} mmHg\n RR: 21 (16 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,512 mL\n PO:\n TF:\n IVF:\n 1,512 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 932 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 308 (308 - 308) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/35/209/20/-1\n Ve: 11.7 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,\n Endotracheal tube, No(t) NG tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 199 K/uL\n 35.9 %\n 12.2 g/dL\n 80 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 20 mEq/L\n 108 mEq/L\n 4.3 mEq/L\n 141 mEq/L\n 4.3 K/uL\n [image002.jpg]\n 05:16 AM\n 06:06 AM\n WBC\n 4.3\n Hct\n 35.9\n Plt\n 199\n Cr\n 1.1\n TC02\n 22\n Glucose\n 80\n Other labs: CK / CKMB / Troponin-T:177//, ALT / AST:18/19, Alk Phos / T\n Bili:41/0.2, Amylase / Lipase:45/28, Differential-Neuts:50.5 %,\n Lymph:41.4 %, Mono:5.1 %, Eos:2.3 %, Albumin:4.3 g/dL, LDH:156 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Multi-substance ingestion.\n RESPRIATORY FAILURE\n intubated for airway protection in context of\n acute ingestion, somnulance. Hope to be able to work towards\n extubation upon awakening. CXR without evidence for acute disease.\n ACUTE INGESTION -- monitor vital signs, mechanical ventilation, serial\n ECG (check Qt). Toxicology Concultation.\n SUICIDE ATTEMPT\n Provide 1:1 24-hr sitter, Psychiatry evaluation.\n EtOH ABUSE\n monitor for withdrawal, CIWA scale.\n NUTRITIONAL SUPPORT\n s/p charcoal. Otherwise NPO pending extubation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 05:36 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 75 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411370,
"text": "1500-1900 NURSING COVERAGE NOTE.\n Fully awake by 1600. A&O x3. Cooperative. OOB to commode. Passed lg\n charcoal looking stool. Good weight bearing. Needs assist with lines\n and cables. Tol cl liqs. Has begun to autodiurese w/UO > 200cc/hr.\nYellow bag\n infusing. Brother in all day. Mother visited as well\n as \ns wife. Denies pain or SOB. Gd O2sats on 2L N/C. Plan to be\n seen by psych as he was too sedated for interview when psych was here\n earlier. 1:1 sitter at bedside until cleared by psych. \n police need to be notified before pt is discharged as he is currently\n under arrest.\n"
}
] |
60,106 | 136,013 | This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia, progressive neuromuscular weakness followed by neurology now s/p trach after intubation for aspiration pneumonia and persistent difficulty weaning from vent. | Felt to have laryngeal reflux. Felt to have laryngeal reflux. Currently afebrile but is tachycardic. Currently afebrile but is tachycardic. Tracheostomy tube noted as before. Myasthenia is in the differential diagnosis. Myasthenia is in the differential diagnosis. # Prophylaxis: Pneumoboots, PPI. # Prophylaxis: Pneumoboots, PPI. There is electrophysiologic evidence for a mild proximally predominant myopathy with some denervating features. concerning for Pneumomediastium. # Leukocytosis: In the setting of peridistress. There is a small left pleural effusion and retrocardiac opacity consistent with volume loss/infiltrate/effusion. This again extends to the pancreatic head, which itself is poorly visualized. # Dysphagia. # Dysphagia. Mild (1+) mitral regurgitation is seen. - Continue eye drops/antibiotic ointments Q2H - need definitive management (i.e. - Continue eye drops/antibiotic ointments Q2H - need definitive management (i.e. Erythromycin ointment ordered QHS. Pneumomedst on CXR: Appears to have resolved on CXR, may be manipulation of trach, no crepitus on exam. Tube feed on hold since MN ?nerve biopsy in am. propofol Tracheal bleed: Check Hct q6h. Action: Pt had peditube in right nare; did have TF running prior to tracheal bleed and OR procedure. Tracheal reconstruction (Tracheobronchial) Assessment: Ptremiansintubated via ETT from OR with old trach site packed with xeroform and covered with DSD. Developed aspiration pneumonia and resp failure requiring trach on . Now s/p stitch placed in arterial bleed, awaiting trach revision. Please replace Dobbhoff tube. Developed aspiraiton pneumonia and resp failure requiring trach on . Trach inner cannula cleaned. Pt to have LP and additional testing once stable from respiratory/airway point of view. - Continue eye drops/antibiotic ointments Q2H - need definitive management (i.e. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. Erythromycin ointment ordered QHS. Felt to have laryngeal reflux. Felt to have laryngeal reflux. Tracheal reconstruction (Tracheobronchial) Assessment: Ptremiansintubated via ETT from OR with old trach site packed with xeroform and covered with DSD. # Dysphagia: seen by neuro and ENT as well as S&S eval in . nebs -speech c/s for PMV Corneal abrasion: -cont. Myasthenia is in the differential diagnosis. During that procedure, trach tube was removed and pt is currently orally intubated. # Disposition: pending above ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 04:50 PM 20 Gauge - 12:58 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: - Continue eye drops/antibiotic ointments Q2H - need definitive management (i.e. Pt seen by ENT, thought to have laryngeal reflexDophoff placed. - trend leukocytosis -vanc as above . Alteration in Nutrition Assessment: Pt remains NPO with hx of dysphagia Action: Remains NPO. Alteration in Nutrition Assessment: Pt remains NPO with hx of dysphagia Action: Remains NPO. # Prophylaxis: - pneumoboots - PPI and H2 blocker . Felt to have laryngeal reflux. Felt to have laryngeal reflux. # Prophylaxis: Pneumoboots, PPI. Tube feed on hold since MN ?nerve biopsy in am. Myopathy, other (not of critical illness) Assessment: Progressive neuromuscular weakness now s/p with trach. - Continue eye drops/antibiotic ointments Q2H - need definitive management (i.e. # Prophylaxis: - pneumoboots - PPI . Per OSH ICU attd, Dr. , call for bx results (or can page Dr. ) - continue nebs given hx asthma . # Dysphagia: seen by neuro and ENT as well as S&S eval in . - trend leukocytosis -vanc as above . Felt to have laryngeal reflux. Felt to have laryngeal reflux. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. # Prophylaxis: Pneumoboots, PPI. Tracheal reconstruction (Tracheobronchial) Assessment: Ptremiansintubated via ETT from OR with old trach site packed with xeroform and covered with DSD. propofol for now Tracheal bleed: Check Hct q6h. Alteration in Nutrition Assessment: Pt remains NPO with hx of dysphagia Action: Remains NPO. Alteration in Nutrition Assessment: Pt remains NPO with hx of dysphagia Action: Remains NPO. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. # Prophylaxis: - pneumoboots - PPI . # Prophylaxis: - pneumoboots - PPI . # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. # Hypoxic respiratory failure: She now has resolving resp failure from PNA/ARDS now s/p trach today at OSH. Chief Complaint: 24 Hour Events: Events: - stopped reglan per neuro recs - optho c/s done started cipro eye drops and Q1H lacrilube administration for significant corneal abrasion without thinning - nsurg - OR for sural nerve bx - HIT Ab PF4 sent - dopof tube placed - echo - The left atrium is moderately dilated. | 138 | [
{
"category": "Physician ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 661546,
"text": "Chief Complaint:\n 24 Hour Events:\n - spiked fever, hypotensive to high 70's, tachy to 120's. Given 2\n liters NS, vancomycin 1 g given dirty line placement.\n - Blood cx x 2, urine culture sent\n - UA with pyruria (seen previously, likely related to candiduria) ->\n foley changed\n - Cordis removed, catheter tip sent for culture\n - Hct drop from 29 to 24 -> transfused 1 unit PRBC's\n - NPO after MN for trach revision\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:50 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Midazolam (Versed) - 10:37 PM\n Fentanyl - 03:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.7\nC (98.1\n HR: 101 (91 - 126) bpm\n BP: 121/64(86) {93/50(66) - 166/89(113)} mmHg\n RR: 18 (12 - 35) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,135 mL\n 691 mL\n PO:\n TF:\n IVF:\n 8,265 mL\n 341 mL\n Blood products:\n 750 mL\n 350 mL\n Total out:\n 2,560 mL\n 510 mL\n Urine:\n 1,560 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,575 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 399 (359 - 399) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 63\n PIP: 15 cmH2O\n Plateau: 6 cmH2O\n SpO2: 99%\n ABG: 7.41/42/63/25/1\n Ve: 7 L/min\n PaO2 / FiO2: 126\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 9.4 g/dL\n 112 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 112 mEq/L\n 139 mEq/L\n 26.1 %\n 23.4 K/uL\n [image002.jpg]\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n 01:24 PM\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n WBC\n 6.6\n 16.1\n 23.4\n Hct\n 34.0\n 31.5\n 29.4\n 28.9\n 24.3\n 24.0\n 26.1\n Plt\n 140\n 149\n 134\n Cr\n 0.3\n 0.3\n 0.3\n 0.3\n TCO2\n 30\n 28\n Glucose\n 108\n 95\n 149\n 112\n Other labs: PT / PTT / INR:14.5/31.7/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:19/66, Alk Phos / T Bili:111/2.1,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 55 y/o lady with history HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness now s/p trach after intubation for\n aspiration pneumonia and persistant difficulty weaning from vent is\n admitted to MICU after bleeding around trach site.\n .\n # Current Respiratory distress: Current episode is secondary to\n bleeding aroung the trach site. Though to be secondary to small vessel\n in that area. ETT placed for ventilation and went to OR where she was\n found to have small vessel bleed and received stitches. Also had\n electrocautery to cauterize any other superficial bleeders. Thoracics\n is planning for revision on . She was ET intubated by anesthesia\n during the code.\n - Trach revision on \n - trend HCT\n - 2 typed and crossed pRBCs available currently\n .\n # s/p trach: Secondary to pneumonia and hypoxic respiratory distress as\n above. Completed 10 day course of antibiotics. Received trials of PMV\n on the floor.\n - Continue nebs\n .\n # Fever/Leukocytosis: In the setting of peridistress. ? aspiration PNA\n on CXR left base. Also may have ? small pneumo mediatstium per\n radiology, no urgency but needs to be followed. Currently afebrile but\n is tachycardic.\n - IVF\n - trend leukocytosis\n - repeat CXR to look at possible pneumomediatinum\n .\n # Decreased HCT:\n - ? CT abd/pelvis\n .\n # Left femoral hematoma: In the setting of attempted fem line. No\n need for urgent transfusion\n - trend HCT\n - T&C blood as above\n .\n # Myopathy/Neuropathy: Myopathy/neuropathy felt possibly mixed\n cryoglobulinemia associated with HCV and possible myopathy from\n interferon. Muscle biopsy showed nonspecific inflammation. Per recent\n neurology outpatient visit, EMG showed a mild sensorimotor\n polyneuropathy as well as a myopathic process in several proximal\n muscles (IP, biceps, infraspinatus, and prominently in L3 paraspinals).\n Additional nerve biopsy may be helpful, but currently holding off.\n - F/U cryo levels\n - Appreciate neurology input; further management per them\n - MRI brain w/ contrast is ordered per Neurology recs\n .\n # Bulbar weakness: Unclear why bulbar weakness is worsening and the\n rest of weakness is stable on exam. Myasthenia is in the\n differential diagnosis.\n - Follow up AChR antibodies (currently pending)\n - Possible Tensilon test\n .\n # Conjunctivitis: S/p corneal abrasion secondary to orbicularis\n weakness and inability to close eye. Ophthalmology following.\n - Continue eye drops/antibiotic ointments Q2H\n - need definitive management (i.e. taping eye) after resolution of\n bacterial infection\n .\n # HCV: Currently off interferon, with undetectable viral loads. On\n nadolol.\n .\n # Dysphagia. Seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. TF via Dobhoff, continue PPI.\n - will PEG placement\n .\n # Thrombocytopenia: Baseline in last 6 months 50-70's. At OSH,\n platelets were in the 20's; heparin stopped for concern for HIT; HIT\n antibody now negative. Platelets improved to 100's. Thrombocytopenia\n thought secondary to liver disease.\n .\n # NSTEMI: History of NSTEMI (at OSH), though likely demand ischemia. On\n beta blocker at this time.\n .\n # HCP blood exposure: Needs paperwork signed for check up once she is\n awake.\n .\n # FEN. Holding on IVF for now. Monitor/replete electrolytes. Tube\n feeds.\n .\n # Prophylaxis: Pneumoboots, PPI.\n .\n # Access: Fem cortis placed under nonsterile condition, will attemp to\n place peripheral IVs and then remove the fem line\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband . .\n - She does not wish for extended family to know about HCV status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 661403,
"text": "Chief Complaint: Trach Bleed\n HPI:\n Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Other medications:\n Meds on Transfer:\n Ipratropium Bromide MDI 6 puff IH QID\n Lorazepam 1mg IV Q3H:PRN\n Albuterol Inhaler 4puff IN Q4H:PRN\n Artificial Tear Ointment 1 Appl Both Eyes Q2H\n Miconazole 2% Cream 1 Appl TP \n Artificial Tears 1-2 Drop Both Eyes Q2H\n Morphine Sulfate 2-4 mg IV Q4H:PRN\n Multivitamins 1 Tab PO daily\n Ciprofloxacin 0.3% Ophth Soln 1-2 Drop Both Eyes Q6H\n Nadolol 20mg PO daily\n Duloxetine 60mg PO daily\n Nicotine Patch 14mg TD daily\n Erythromycin 0.5% Ophth Oint\n Pantoprazole 40mg Q24H\n Folic Acid 1mg PO daily\n Heparin 5000 Units SC TID\n Vitamin B Complex w/C 1 TAB PO daily\n Insulin Sliding Scale\n .\n Home Medications:\n ALBUTEROL 1 -2 puff by mouth twice a day\n DULOXETINE [CYMBALTA] 60 mg once a day\n GABAPENTIN 600 mg TID\n HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN\n MONTELUKAST [SINGULAIR]\n NADOLOL 20 mg daily\n OMEPRAZOLE 20 mg \n PEGINTERFERON ALFA-2B Q week\n RANITIDINE 300 mg QHS\n ZOLPIDEM 12.5 mg qhs prn\n .\n Past medical history:\n Family history:\n Social History:\n #) Active hepatitis C.\n - Diagnosed genotype 1a, \n - Treated with PEG interferon and ribavirin x 48 weeks ending in \n - Virologic relapse after 4 weeks leading to low dose PEG interferon\n starting in x 4 years, finished in \n - In had a cryocrit of 6% so maintenance PEG interferon restarted\n - known cirrhosis\n - known varices\n #) Asthma.\n #) Recent hoarseness which was evaluated by Dr. in ENT\n and was felt to be due to reflux esophagitis.\n #) s/p choly\n #) s/p appendectomy\n #) hx venous thrombophlebitis 25 yrs ago\n #) : NSTEMI at \n .\n Her mother has diabetes with neuropathy. She does not have any muscle\n problems or dysphagia in the family. Her mother had a three-vessel\n CABG. There is no evidence of Parkinson's, MS, strokes, seizures, or\n other neurologic diagnoses in the family.\n The patient has smoked 2 packs a day for the past 30 years. She does\n not use alcohol. She is married and has two sons. She does not use any\n herbal medicines or supplements. She denies any drug use.\n Review of systems:\n Flowsheet Data as of 01:25 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.6\n HR: 126 (105 - 126) bpm\n BP: 158/84(107) {117/63(79) - 172/91(123)} mmHg\n RR: 20 (12 - 20) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,929 mL\n PO:\n TF:\n IVF:\n 6,179 mL\n Blood products:\n 750 mL\n Total out:\n 0 mL\n 1,860 mL\n Urine:\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,069 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.29/59/75/31/0\n Ve: 7.2 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General: sedated and no acute distress, on propofol drip\n HEENT: Right eye with conjunctival injection/erythema, both eyes with\n substantial ointment, mucus membranes dry, otherwise clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Coarse breath sounds b/l, no wheezes, rales, rhonchi\n CV: Tachycardia, normal S1 + S2\n Abdomen: Soft, non-distended, absent bowel sounds present\n Ext: Warm, well perfused\n Neuro: limited by sedation\n .\n Labs / Radiology\n 149 K/uL\n 11.1 g/dL\n 149 mg/dL\n 0.3 mg/dL\n 8 mg/dL\n 31 mEq/L\n 106 mEq/L\n 3.1 mEq/L\n 140 mEq/L\n 31.5 %\n 16.1 K/uL\n [image002.jpg]\n \n 2:33 A2/16/ 10:13 PM\n \n 10:20 P2/16/ 11:55 PM\n \n 1:20 P2/17/ 03:13 AM\n \n 11:50 P2/17/ 05:08 PM\n \n 1:20 A2/18/ 03:55 AM\n \n 7:20 P2/19/ 03:28 AM\n 1//11/006\n 1:23 P2/19/ 09:56 PM\n \n 1:20 P2/20/ 03:23 AM\n \n 11:20 P2/24/ 08:24 AM\n \n 4:20 P2/24/ 08:43 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n 16.1\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n 31.5\n Plt\n 76\n 80\n 107\n 118\n 140\n 149\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TC02\n 27\n 30\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n 149\n Other labs: PT / PTT / INR:14.5/29.6/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.3 mg/dL, PO4:3.2 mg/dL\n Micro:\n HCV viral load 374 IU/mL\n HCV viral load less than 30 IU/mL\n Conjunctival swabs: Coagulase negative Staph\n Urine culture: Pending\n .\n Pathology (per report): There was evidence for a chronic myopathic\n process with a small amount of inflammation, but nothing striking to\n suggest a major ongoing inflammatory process.\n .\n Images:\n EMG: Abnormal study. There is electrophysiologic evidence for a\n mild proximally predominant myopathy with some denervating features.\n There is also evidence for a mild to moderate, chronic, sensorimotor,\n generalized polyneuropathy which is axonal in nature and appears\n symmetric. Compared with the prior study of , the polyneuropathy is\n new and the myopathy is more clearly present.\n .\n ECG: Sinus tachycardia. Poor R wave progression. No previous\n tracing available for comparison.\n .\n Port CXR: In comparison with the study of , there is now a\n tracheostomy tube in place with no evidence of complication. Right IJ\n catheter extends to the mid portion of the SVC. There is increased\n opacification at the left base with suggestion of shift of the\n mediastinal contents to that side, consistent with volume loss.\n Ill-defined area of increased opacification in the left mid lung zone\n that could represent an area of aspiration. Some indistinctness of the\n pulmonary vessels raises the possibility of elevated pulmonary venous\n pressure.\n .\n Abd Ultrasound: 1. Coarse hepatic echotexture consistent with\n cirrhosis without focal lesions. 2. Stable dilation of CBD. 3. Trace\n ascites, without sufficient fluid for safe bedside paracentesis.\n .\n Echo: The left atrium is moderately dilated. No atrial septal\n defect is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n .\n Port CXR: In comparison with the earlier study of this date, there\n has been placement of a Dobbhoff tube that extends to the distal\n stomach. Continued congestive failure or fluid overload with left\n pleural effusion.\n .\n Port CXR: Overall the appearance is of worsening CHF/fluid\n overload. However the asymmetric nature as well as the nodular focal\n infiltrate in the right lung also raises the possibility of infection.\n .\n Port CXR: In comparison with the study of , there is little\n overall change in the appearance of the heart and lungs. Continued\n vascular congestion with probable left pleural effusion. More\n coalescence in the left perihilar and lower lung region could reflect\n some supervening consolidation. Monitoring support devices remain in\n place.\n .\n :\n Erythema in the gastroesophageal junction compatible with esophagitis\n Granularity, friability, congestion and mosaic appearance in the whole\n stomach compatible with portal hypertensive gastropathy\n Normal mucosa in the duodenum\n Otherwise normal EGD to second part of the duodenum\n .\n Assessment and Plan\n 55 y/o lady with history HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness now s/p trach after intubation for\n aspiration pneumonia and persistant difficulty weaning from vent is\n admitted to MICU after bleeding around trach site.\n .\n # Current Respiratory distress: Current episode is secondary to\n bleeding aroung the trach site. Though to be secondary to small vessel\n in that area. ETT placed for ventilation and went to OR where she was\n found to have small vessel bleed and received stitches. Also had\n electrocautery to cauterize any other superficial bleeders. Thoracics\n is planning for revision on . She was ET intubated by anesthesia\n during the code.\n - Trach revision on \n - trend HCT\n - 2 typed and crossed pRBCs available currently\n .\n # s/p trach: Secondary to pneumonia and hypoxic respiratory distress as\n above. Completed 10 day course of antibiotics. Received trials of PMV\n on the floor.\n - Continue nebs\n .\n # Leukocytosis: In the setting of peridistress. ? aspiration PNA on\n CXR left base. Also may have ? small pneumo mediatstium per radiology,\n no urgency but needs to be followed. Currently afebrile but is\n tachycardic.\n - IVF\n - trend leukocytosis\n - repeat CXR to look at possible pneumomediatinum\n .\n # Left femoral hematoma: In the setting of attempted fem line. No\n need for urgent transfusion\n - trend HCT\n - T&C blood as above\n .\n # Myopathy/Neuropathy: Myopathy/neuropathy felt possibly mixed\n cryoglobulinemia associated with HCV and possible myopathy from\n interferon. Muscle biopsy showed nonspecific inflammation. Per recent\n neurology outpatient visit, EMG showed a mild sensorimotor\n polyneuropathy as well as a myopathic process in several proximal\n muscles (IP, biceps, infraspinatus, and prominently in L3 paraspinals).\n Additional nerve biopsy may be helpful, but currently holding off.\n - F/U cryo levels\n - Appreciate neurology input; further management per them\n - MRI brain w/ contrast is ordered per Neurology recs\n .\n # Bulbar weakness: Unclear why bulbar weakness is worsening and the\n rest of weakness is stable on exam. Myasthenia is in the\n differential diagnosis.\n - Follow up AChR antibodies (currently pending)\n - Possible Tensilon test\n .\n # Conjunctivitis: S/p corneal abrasion secondary to orbicularis\n weakness and inability to close eye. Ophthalmology following.\n - Continue eye drops/antibiotic ointments Q2H\n - need definitive management (i.e. taping eye) after resolution of\n bacterial infection\n .\n # HCV: Currently off interferon, with undetectable viral loads. On\n nadolol.\n .\n # Dysphagia. Seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. TF via Dobhoff, continue PPI.\n - will PEG placement\n .\n # Thrombocytopenia: Baseline in last 6 months 50-70's. At OSH,\n platelets were in the 20's; heparin stopped for concern for HIT; HIT\n antibody now negative. Platelets improved to 100's. Thrombocytopenia\n thought secondary to liver disease.\n .\n # NSTEMI: History of NSTEMI (at OSH), though likely demand ischemia. On\n beta blocker at this time.\n .\n # HCP blood exposure: Needs paperwork signed for check up once she is\n awake.\n .\n # FEN. Holding on IVF for now. Monitor/replete electrolytes. Tube\n feeds.\n .\n # Prophylaxis: Pneumoboots, PPI.\n .\n # Access: Fem cortis placed under nonsterile condition, will attemp to\n place peripheral IVs and then remove the fem line\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband . .\n - She does not wish for extended family to know about HCV status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 07:59 AM\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 661401,
"text": "Subjective\n Pt intubated\n Objective\n Labs:\n Value\n Date\n Glucose\n 149 mg/dL\n 08:24 AM\n Glucose Finger Stick\n 143\n 12:00 PM\n BUN\n 8 mg/dL\n 08:24 AM\n Creatinine\n 0.3 mg/dL\n 08:24 AM\n Sodium\n 140 mEq/L\n 08:24 AM\n Potassium\n 3.1 mEq/L\n 08:24 AM\n Chloride\n 106 mEq/L\n 08:24 AM\n TCO2\n 31 mEq/L\n 08:24 AM\n PO2 (arterial)\n 75 mm Hg\n 08:43 AM\n PCO2 (arterial)\n 59 mm Hg\n 08:43 AM\n pH (arterial)\n 7.29 units\n 08:43 AM\n pH (urine)\n 7.0 units\n 01:12 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 08:43 AM\n Albumin\n 2.2 g/dL\n 10:13 PM\n Calcium non-ionized\n 7.1 mg/dL\n 08:24 AM\n Phosphorus\n 3.2 mg/dL\n 08:24 AM\n Magnesium\n 1.3 mg/dL\n 08:24 AM\n ALT\n 18 IU/L\n 10:13 PM\n Alkaline Phosphate\n 104 IU/L\n 10:13 PM\n AST\n 69 IU/L\n 10:13 PM\n Amylase\n 113 IU/L\n 10:13 PM\n Total Bilirubin\n 1.0 mg/dL\n 10:13 PM\n WBC\n 16.1 K/uL\n 08:24 AM\n Hgb\n 11.1 g/dL\n 08:24 AM\n Hematocrit\n 31.5 %\n 08:24 AM\n Current diet order / nutrition support: NPO, PPN Rx (): 1L(50g\n dex,42.5gaa)\n GI:\n Assessment of Nutritional Status\n 55 y/o F admitted to OSH for peg placement. Developed aspiraiton\n pneumonia and resp failure requiring trach on .\n Monitoring neuro status on the floor, tx to ICU this am d/t bleed at\n the trach site. Intubated on the floor, now planning to re-trach today.\n Pt w/ NGT w/ TF on hold d/t procedure today.\n Possibly PEG if no contraindications.\n On propofol drip, current rate provides ~600kcals/day\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Restart TF after procedure, if PEG not placed, rec post\n pyloric or NJT\n 2. Start w/ FS Fibersource HN @10cc/hr and adv to goal of 55cc/hr\n to provide 1584kcals and 70g prot/day to meet 100% est. nutrition\n needs.\n 3. No residuals w/ PPFT, monitor tol w/ abd exam, bowel fxn.\n 4. c/w lyte mngt as you are\n Following closely, please pge w/ questions #\n 12:47\n"
},
{
"category": "Echo",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Report",
"row_id": 69383,
"text": "PATIENT/TEST INFORMATION:\nIndication: Murmur.\nHeight: (in) 66\nWeight (lb): 121\nBSA (m2): 1.62 m2\nBP (mm Hg): 161/90\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 12:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThe tricuspid valve leaflets are mildly thickened. There is mild pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064441,
"text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p bronchoscopy for tracheal bleeding, exploration of\n tracheal wound and repair of bleeding vessels\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bronchoscopy for tracheal bleeding, to evaluate for\n pneumothorax.\n\n FINDINGS: In comparison with the study of , there is increased\n opacification in the left mid and lower lung zones. This could relate to\n hemorrhage from the recent interventional procedure or aspiration pneumonia.\n\n The outer margin of the mediastinum on the left is very sharply seen, raising\n the possibility of pneumomediastinum.\n\n The tracheostomy tube has been removed and replaced with an endotracheal tube\n with its tip approximately 2.5 cm above the carina. Dobbhoff tube extends at\n least into the second portion of the duodenum.\n\n No evidence of pneumothorax.\n\n This information was telephoned to Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063356,
"text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infection, overload\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with trach, difficult wean\n REASON FOR THIS EXAMINATION:\n ?infection, overload\n ______________________________________________________________________________\n FINAL REPORT\n CXR SINGLE PORTABLE FILM\n\n HISTORY: 55-year-old patient with tracheostomy, difficult to wean. Question\n infection, question fluid overload.\n\n FINDINGS: Compared to the examination of there is slight worsening of\n the hazy opacity in the left hemithorax throughout and also a left pleural\n effusion. Poorly marginated nodular density noted in the right mid lung field\n which is more obvious compared to the examination from two days ago.\n Tracheostomy tube noted as before.\n\n CONCLUSION: Overall the appearance is of worsening CHF/fluid overload.\n However the asymmetric nature as well as the nodular focal infiltrate in the\n right lung also raises the possibility of infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064557,
"text": " 3:02 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please check for interval change.\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with neuropathy/myopathy, bled around trach this morning, s/p\n ET tube placed. ? concerning for Pneumomediastium. Please check for interval\n change.\n REASON FOR THIS EXAMINATION:\n Please check for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for consolidation.\n\n FINDINGS: In comparison with earlier study of this date, there is little\n change in the patchy opacification involving the lower half of the left\n hemithorax. There is also some suggestion of opacification in the right\n infrahilar region. This could also represent either atelectasis or aspiration\n or even a small amount of pulmonary hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063498,
"text": " 5:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess placement - please aim low enough.\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with new dopoff NG/J tube\n REASON FOR THIS EXAMINATION:\n assess placement - please aim low enough.\n ______________________________________________________________________________\n WET READ: FBr WED 8:53 PM\n Dubhoff projects inthe expected location of the stomach. No other change since\n 2 hours ago.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a Dobbhoff tube that extends to the distal stomach. Continued\n congestive failure or fluid overload with left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063721,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pre op for nerve biopsy today\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with myopathy, on chronic trach\n REASON FOR THIS EXAMINATION:\n pre op for nerve biopsy today\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chronic tracheostomy, preop for nerve biopsy.\n\n FINDINGS: In comparison with the study of , there is little overall\n change in the appearance of the heart and lungs. Continued vascular\n congestion with probable left pleural effusion. More coalescence in the left\n perihilar and lower lung region could reflect some supervening consolidation.\n\n Monitoring support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1063288,
"text": " 2:09 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for ascites, liver pathology, if ascites ple\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hepatitis C, cryoglobulinemia a/w myopathy, aspiration\n pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for ascites, liver pathology, if ascites please mark for tap\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc TUE 4:08 PM\n Trace ascites without sufficient fluid for safe bedside paracentesis. Stable\n enlarged CBD. Coarsened liver c/w cirrhosis, without focal lesions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man with hepatitis C and aspiration pneumonia. Please\n evaluate for ascites or liver pathology.\n\n COMPARISON: Multiple prior abdominal ultrasounds, most recently and .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is again diffusely coarse in\n echotexture, although without discrete focal lesions. There is no\n intrahepatic biliary ductal dilatation. The common duct remains stably\n enlarged, measuring up to 12 mm. This again extends to the pancreatic head,\n which itself is poorly visualized.\n\n Main portal vein demonstrates normal hepatopetal flow. The spleen measures\n approximately 10.5 cm. Only a trace amount of ascites is present. A safe\n spot for bedside paracentesis is not identified.\n\n IMPRESSION:\n\n 1. Coarse hepatic echotexture consistent with cirrhosis without focal\n lesions.\n\n 2. Stable dilation of CBD.\n\n 3. Trace ascites, without sufficient fluid for safe bedside paracentesis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1063289,
"text": ", F. MED MICU 2:09 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for ascites, liver pathology, if ascites ple\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hepatitis C, cryoglobulinemia a/w myopathy, aspiration\n pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for ascites, liver pathology, if ascites please mark for tap\n ______________________________________________________________________________\n PFI REPORT\n Trace ascites without sufficient fluid for safe bedside paracentesis. Stable\n enlarged CBD. Coarsened liver c/w cirrhosis, without focal lesions.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Report",
"row_id": 164822,
"text": "Sinus rhythm. Possible anteroseptal myocardial infarction. Compared to the\nprevious tracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Report",
"row_id": 164823,
"text": "Sinus tachycardia. Compared to the previous tracing of no diagnostic\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-01-25 00:00:00.000",
"description": "Report",
"row_id": 164824,
"text": "Sinus tachycardia. Poor R wave progression. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064506,
"text": " 12:18 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with tracheal bleed, ? infiltrate\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pneumonia and tracheal bleed.\n\n FINDINGS: In comparison with earlier study of this date, there is some\n decrease in the opacification at the left base. The unusual sharpness of the\n left heart border is no longer appreciated.\n\n The tip of the endotracheal tube now lies approximately 3.2 cm above the\n carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-01 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1064276,
"text": " 11:41 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place Dobhoff in this patient for medications and nut\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with h/o HepC who presents with neuropathy/myopathy.\n REASON FOR THIS EXAMINATION:\n Please place Dobhoff in this patient for medications and nutrition.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman, with history of hepatitis C, now presenting with\n neuropathy and myopathy. Request to place Dobbhoff feeding tube for\n medication and nutrition.\n\n TECHNIQUE: An 8-French nasointestinal tube was inserted via\n the right nostril without complication. Under fluoroscopic guidance, the tip\n of the tube was maneuvered distal to the pylorus, with confirmation of a post-\n pyloric position by injection of 5 cc of Conray oral contrast. The patient\n tolerated the procedure well.\n\n IMPRESSION: Successful placement of post-pyloric nasointestinal Dobbhoff\n feeding tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064005,
"text": " 12:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for evidence of pulmonary hemorrhage\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with h/o myopathy/neuropathy, and tracheostomy who presents\n s/p attempted Dobhoff placement with cough and bloody sputum.\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of pulmonary hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Attempted Dobbhoff placement with cough and bloody sputum and\n question pulmonary hemorrhage.\n\n REFERENCE EXAM: .\n\n FINDINGS: The stomach is distended with gas. There is a small left pleural\n effusion and retrocardiac opacity consistent with volume\n loss/infiltrate/effusion. There are increased interstitial markings, but\n overall the appearance is improved compared to the study from the previous\n day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-02 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1064593,
"text": " 9:13 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please assess for any structural abnormalities or masses\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55yF with neuropathy/myopathy and bulbar weakness\n REASON FOR THIS EXAMINATION:\n please assess for any structural abnormalities or masses\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE BRAIN WITH GADOLINIUM ENHANCEMENT.\n\n HISTORY: 55-year-old white female with neuropathy/myopathy and bulbar\n weakness. Please assess for any structural abnormalities.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted pre- and post-gadolinium enhanced\n brain imaging was obtained.\n\n COMPARISON IMAGING STUDIES ON PACS: None.\n\n FINDINGS:\n\n There is no sign for the presence of an intracranial mass, hydrocephalus, or\n shift of normally midline structures. Diffusion- and susceptibility-weighted\n images of the brain are within normal limits.\n\n The principal vascular flow patterns are identified.\n\n There is extensive mucosal thickening within the maxillary sinuses, and to\n only a minimal extent within the ethmoid sinuses. There is moderate mucosal\n thickening and possibly air-fluid levels present within both mastoid sinuses.\n The fluid levels could raise the question of an acute inflammatory process, as\n opposed to the mucosal thickening representing chronic inflammatory disease.\n\n Finally, encompassed only on the coronal post-contrast MP-RAGE as well as\n sagittal pre-contrast T1- weighted images is an ovoid, likely non-enhancing 4\n x 14 mm lesion within the caudal aspect of the left parotid gland, near the\n parotid tail. As there is no T2 sequence encompassing this area, complete\n characterization of this abnormality is not possible at this time. These\n supplemental sequences could be obtained as part of a follow up MRI scan of\n the neck, to include the parotid glands in their entirety. Given its T1\n hypointensity, it may represent some sort of cystic mass.\n\n CONCLUSION: No definite brain abnormalities. Other extracranial findings and\n recommended follow up studies as noted above.\n\n\n (Over)\n\n 9:13 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please assess for any structural abnormalities or masses\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064843,
"text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp failure s/p bleeding trach\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing opacity in\n the left lung has decreased. The transparency of the left lung parenchyma has\n increased. The pre-existing left retrocardiac atelectasis is unchanged. Also\n unchanged in extent is the right perihilar opacity. No evidence of newly\n appeared parenchymal opacities. Borderline size of the azygos vein indicates\n mild fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064759,
"text": ", A. MED MICU-7 3:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for placement\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p tracheostomy placement\n REASON FOR THIS EXAMINATION:\n Eval for placement\n ______________________________________________________________________________\n PFI REPORT\n Tracheostomy tip terminates 61 mm above carina. Clear right lung. Left lung\n base opacification is worse. Increased left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-03 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1064758,
"text": " 3:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for placement\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p tracheostomy placement\n REASON FOR THIS EXAMINATION:\n Eval for placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 5:34 PM\n Tracheostomy tip terminates 61 mm above carina. Clear right lung. Left lung\n base opacification is worse. Increased left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old female status post tracheostomy placement. Evaluate for\n placement.\n\n COMPARISON: Prior chest radiograph dated at 3:39 a.m.\n\n PORTABLE AP CHEST RADIOGRAPH\n\n FINDINGS: Tracheostomy tube is in place with tip terminating 61 mm above the\n carina. NG tube is in place. Right lung is clear. Unchanged appearance of\n the opacification of the left lung base. Interval worsening of the left\n pleural effusion. Heart size is within normal limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-09 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1065841,
"text": " 2:48 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: pls place NG if fails video swallow\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with trach s/p ARDS, video swallow today at 1pm\n REASON FOR THIS EXAMINATION:\n pls place NG if fails video swallow\n ______________________________________________________________________________\n WET READ: JKSd TUE 4:33 PM\n PFI: Post pyloric position of feeding tube. Ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55 year old woman with trach status post ARDS. Please place NG\n tube if fails video swallow study.\n\n -INTESTINAL TUBE PLACEMENT: An 8 French - feeding tube was\n passed through the left naris into the fourth portion of the duodenum.\n Approximately 10 cc of Conray contrast was injected into the tube to confirm\n placement.\n\n IMPRESSION: Successful post-pyloric nasointestinal tube placement. The tube is\n ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063150,
"text": " 10:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for pulm dysfunction\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with progressive weakness, aspiration pna, now s/p trach\n REASON FOR THIS EXAMINATION:\n pls eval for pulm dysfunction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration, status post tracheostomy.\n\n FINDINGS: In comparison with the study of , there is now a\n tracheostomy tube in place with no evidence of complication. Right IJ\n catheter extends to the mid portion of the SVC. There is increased\n opacification at the left base with suggestion of shift of the mediastinal\n contents to that side, consistent with volume loss. Ill-defined area of\n increased opacification in the left mid lung zone that could represent an area\n of aspiration. Some indistinctness of the pulmonary vessels raises the\n possibility of elevated pulmonary venous pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-31 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1064163,
"text": " 5:21 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please assess for ascites\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with HCV cirrhosis\n REASON FOR THIS EXAMINATION:\n please assess for ascites\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 7:15 PM\n No ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with hepatitis C cirrhosis. Please evaluate\n for ascites.\n\n LIMITED ABDOMINAL ULTRASOUND: -scale images of all four quadrants of the\n abdomen were obtained and no ascites was visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-31 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1064164,
"text": ", B. MED FA10 5:21 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please assess for ascites\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with HCV cirrhosis\n REASON FOR THIS EXAMINATION:\n please assess for ascites\n ______________________________________________________________________________\n PFI REPORT\n No ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1065962,
"text": " 10:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for possible progression of infiltrates on prior xray\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with HCV, cryoglobulinemia admitted intubated with\n neuromuscular weakness please evaluate for progression of PNA.\n REASON FOR THIS EXAMINATION:\n Eval for possible progression of infiltrates on prior xray\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:33 A.M. \n\n HISTORY: Progressive pneumonia. Neuromuscular weakness, previous pneumonia.\n\n IMPRESSION: AP chest compared to through 26:\n\n Only a small residue of peribronchial opacification at the lung bases\n persists, was previously extensive with bibasilar consolidation and\n interstitial infiltration that extended to the level of both hila. Given the\n previous distention of the pulmonary circulation and mediastinal veins there\n may have been a component of edema previously, but none is present today.\n Very small left pleural effusion persists. Heart size is normal.\n Tracheostomy tube is in standard placement and a feeding tube passes into the\n stomach and out of view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1064601,
"text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with resp arrest intubated bleed around trach,\n leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:39 A.M., \n\n HISTORY: Respiratory arrest. Intubated. Bleeding around the tracheostomy\n tube. High white count.\n\n IMPRESSION: AP chest compared to -24:\n\n Increasing heterogeneous opacification in the right mid and lower lung zones,\n and failure to clear the abnormality from the left lung since \n consistent with worsening pulmonary edema, global aspiration, or persistent\n pulmonary hemorrhage. Heart is normal size. In the absence of pleural\n effusion or mediastinal vascular engorgement suggest that cardiogenic edema is\n not the explanation. ET tube in standard placement. Nasogastric tube passes\n below the diaphragm and out of view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-11 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1066245,
"text": " 3:43 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place Dobhoff tube.\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with HCV, idiopathic neuromuscular weakness, dysphagia with\n recent Dobhoff that was clogged now is out.\n REASON FOR THIS EXAMINATION:\n Please place Dobhoff tube.\n ______________________________________________________________________________\n WET READ: 5:04 PM\n PFI: Successful postpyloric placement of feeding tube. tube is ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with HCV, idiopathic neuromuscular weakness,\n and dysphasia with recent Dobbhoff tube placement that was clogged and now is\n out. Please replace Dobbhoff tube.\n\n -INTESTINAL TUBE PLACEMENT: An 8-French - feeding tube was\n passed through the left naris into the fourth portion of the duodenum.\n Approximately 10 ml of Conray contrast injected into the tube to confirm\n placement. The feeding tube was subsequently flushed with water.\n\n IMPRESSION: Successful post-pyloric -intestinal tube placement. The tube\n is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-09 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1065840,
"text": " 2:47 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for silent aspiration\n Admitting Diagnosis: CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with HCV, cryo, s/p trach for aspiration PNA\n REASON FOR THIS EXAMINATION:\n eval for silent aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with HCV, cryo, status post tracheostomy for\n aspiration pneumonia. Evaluate for silent aspiration.\n\n TECHNIQUE: Oropharyngeal video fluoroscopic swallowing evaluation.\n\n FINDINGS: A limited oral and pharyngeal swallowing videofluoroscopy was\n performed in collaboration with speech and swallow pathology.\n\n ORAL PHASE: Tongue weakness contributed to delayed bolus transport. Only\n nectar thick barium and ice chips coated in powdered barium were given.\n\n PHARYNGEAL PHASE: Pharyngeal phase demonstrated incomplete laryngeal valve\n closure. There was no epiglottic deflection. About 90% of the bolus remained\n within the patient's pharynx with minimal amounts of the bolus observed to\n pass through the upper esophageal sphincter.\n\n There was penetration of most of all the boluses. Material was usually\n cleared by two spontaneous coughs. Chin tuck was not effective in reducing\n penetration. No aspiration was seen.\n\n IMPRESSION: Severe dysphagia with significant amount of laryngeal\n penetration. Cough cleared penetration; no aspiration.\n\n For further details, please refer to the speech and swallow pathologist's note\n of the same day.\n\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660744,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Recvd the pt on 40% trach collor,satting 95-100%,ronchorous breath\n sounds,thick yellow secretions coming around the trach,\n Action:\n No further changes in fi02,trach care given MDI\ns by RT,suctioned as\n needed.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suctioned prn\n Myopathy, other (not of critical illness)\n Assessment:\n Known myopathy very restless and agitated,poor sleep,seems very\n anxious,c/o pain at trach site,now with severe eye infection. As per\n the family pt is a heavy smoker\n Action:\n Received ativan 1 mg x4 doses in this shift alsong with morphine 2 mg\n x3,contd all eye drops/ointments as per opthal, A nicotine patch has\n been applied.\n Response:\n Improvement noted in the eyes,contd to have restlessness and pulling\n out wires and tubes,pt has pulled out the mushroom cath x2 in this\n shift,seems better after 0400am.\n Plan:\n Continue to monitor ,?increase the ativan dose or add a different drug\n regimen.\n Impaired Skin Integrity\n Assessment:\n Excoriated perineum,pt has pulled out the mushroom cath x2 in this\n shift,\n Action:\n Skin protectant applied ,turned and respositioned q2h,\n Response:\n Pt cont to have restlessness which prevents the successful drainage of\n the stool and infact lead to leaking,explained the pt but contd the\n same behavior,reinserted mushroom cath , diaper in place.\n Plan:\n Cont local skin care,turn and reposition ,\n T max 100.1 in this shift,urine cx sent,T current 97.8.\n Tube feed on hold since MN ?nerve biopsy in am.\n Received 15mmol k phos .\n Hr 85-120,sbp 130-160,received ns fluid bolus 1000cc x2 in this shift.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660669,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach mask. Moderate amt of yellow blood tinged\n sputum from around trach site. Small amt\ns suctioned from trach. O2\n sats 97-100%.\n Action:\n Suctioned prn. Trach inner cannula cleaned. Fio2 down to 40%. Speech\n and swallow in to eval pt and attempted passey-euir valve placement.\n Pt had too many secretions and it was unsuccessful.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suction prn and wean down fio2.\n Alteration in Nutrition\n Assessment:\n Received pt on 35ml/hr Fibersource HN via doboff.\n Action:\n TF\ns weaned up to goal of 55cc/hr.\n Response:\n Tolerating TF well. Currently at goal.\n Plan:\n NPO after midnight for ? nerve biopsy tomorrow. Remains on RISS.\n Myopathy, other (not of critical illness)\n Assessment:\n Pt\ns strength is improving. Able to lift and hold all 4 extremities.\n Tolerating trach collar well without struggling to use muscles for\n breating. Per ENT eyes look like they are improving.\n Action:\n Currently on artificial tear drops and ointment Q 2 hours. Cipro eye\n gtts Q 6 hours. Erythromycin ointment ordered QHS.\n Response:\n Per team eyes are improving.\n Plan:\n Continue to monitor\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 661442,
"text": "Chief Complaint: Trach bleed\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y/o F admitted to OSH for peg placement. Developed aspiration\n pneumonia and resp failure requiring trach on . Transferred to\n for neuro eval and vent wean on antiobiotics, which she completed\n during her hospitalization here.\n She was weaned off to TM and PMV and transferred to the floor on\n . c/o pain near trach site yesterday, followed by brisk bleeding\n this am. Code blue was called, surgery evaluated stat. bleeding caused\n trach to occlude, hence intubated orally by anesthesia on the floor,\n and taken to OR this am. Trach site bleed controlled with digital\n pressure. In the OR, where she was flex bronched to clean distal\n airway. they examined the internal trach site, which showed no evidence\n of internal bleed. ETT was replaced. External exam of trach site\n revealed small arterial bleeder in the lower thyroid, which was sutured\n and cauterized. Good hemostasis. Patient transferred to MICU in stable\n condition. No further bleed in the MICU.\n During code, R femoral cordis placed non sterile\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Other medications:\n nebs,\n Past medical history:\n Family history:\n Social History:\n HCV hepatitis rx with interferon: family not aware of HCV infection\n Cirrhosis with hx of varices\n NSTEMI at QMC \n Cryoglobulinemia\n vasculitis\n peripheral neuropathy\n myopathy/non specific myositis\n parathesias\n dysphagia\n asthma\n GERD\n appy\n choly\n inability to close eyes due to weakness, with conjunctivitis\n DM, CAD, no neuromusc hx\n Occupation:\n Drugs: no\n Tobacco: 2ppd x 30 yrs\n Alcohol: no\n Other: 2 sons\n Review of systems:\n Flowsheet Data as of 12:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 110 (105 - 120) bpm\n BP: 166/85(113) {142/77(101) - 172/91(123)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,830 mL\n PO:\n TF:\n IVF:\n 6,080 mL\n Blood products:\n 750 mL\n Total out:\n 0 mL\n 1,860 mL\n Urine:\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,970 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.29/59/75/31/0\n Ve: 7.2 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Eyes / Conjunctiva: Bilateral conjunctivitis\n Head, Ears, Nose, Throat: Endotracheal tube, Trach site with clean dsg,\n mm dry\n Cardiovascular: (S1: Normal), (S2: Normal, Loud), (Murmur: Systolic)\n Peripheral Vascular: all present\n Respiratory / Chest: (Breath Sounds: Rhonchorous: with squeaks R base\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, Large hematoma in L groin, R\n groin with cortis\n Musculoskeletal: 1+ reflexes bilaterally, plantars withdrawing\n Skin: Warm\n Neurologic: Responds to tactile stimuli\n Labs / Radiology\n 149 K/uL\n 31.5 %\n 11.1 g/dL\n 149 mg/dL\n 0.3 mg/dL\n 8 mg/dL\n 31 mEq/L\n 106 mEq/L\n 3.1 mEq/L\n 140 mEq/L\n 16.1 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n 16.1\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n 31.5\n Plt\n 76\n 80\n 107\n 118\n 140\n 149\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TC02\n 27\n 30\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n 149\n Other labs: PT / PTT / INR:14.5/29.6/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.3 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: LLL infiltrate new since , with air layering around\n heart border, ? pneumomedst which appears to have disappeared on two\n follow up CXRs today. LLL improved.\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n MoTOR FUNCTION, IMPAIRED\n POSTURE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI (tracheo-innominate) fistula per surgical team. Orotracheal\n intubation. Plan for surgical reexploration again tomorrow per\n thoracics.\n Resp: currently ETT intubated. Arterial bleeding of thyroid, ligated\n with hemostasis. Continue vent management. Minute ventilation increased\n to blow off CO2. Keep comfortable on propofol drip.\n Tracheal bleed: re-explore per surgical team tomorrow, with ? trach\n revision. Check Hct q6h.\n Leukocytosis with new LLL infiltrate: likely aspiration of blood.\n Afebrile. Follow clinically and with repeat imaging and WBC. No\n indication for antibiotics.\n ? Pneumomedst on CXR: repeat, not bagged thru trach during code, per\n report\n no pneumomediast on repeat xray\n L groin hematoma: pressure was applied, pressure dressing in place\n R groin code cordis: has good peripherals. Can remove cordis\n Conjunctivitis: Tears, cipro and erythromycin topical in eyes, ophthal\n following\n Neuropathy/myopathy: f/u with neuro. Rec: MRI with contrast for bulbar\n and facial weakness. Needs LP later. Anticholinergic receptor Ab\n pending. d/w neuro reg prognosis and whether she needs peg placement\n for nutrition during OR tomorrow\n CAD/NSTEMI: No acute issues. Check EKG.\n Rest per resident note\n ICU Care\n Nutrition: npo\n Glycemic Control:\n Lines / Intubation:\n Cordis/Introducer - 07:59 AM\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36 min\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661443,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661444,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661453,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site\n overnoc. Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt received intubated via ETT from OR with old\n trach site packed with xeroform and covered with DSD.\n Action:\n Dressing reinforced x several, then packing changed by thoracic \n team this evening. Moderate amt sanguinous drainage saturating through\n dressing.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt with hx of 35 lb weight gain since /. Pt unable to eat \n muscle weakness. Per husband, would vomit anything taken orally. Mg\n 1.3, K+ 3.1 today.\n Action:\n Pt had peditube in right nare; did have TF running prior to tracheal\n bleed and OR procedure. Repleted with 4gm Mg+ and 80 mEq K+ today. TF\n continue OFF for OR procedure in AM.\n Response:\n K+ improved to 3.8 and Mg+ improved to 2.2 post repletions today.\n Plan:\n NPO until post procedure tomorrow. Then likely will restart TF and\n replete electrolytes as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned OFF for wake up this evening. Pt unable to squeeze\n hands bilaterally but able to follow commands to open mouth and move\n feet. Pt being followed by neuro. S/P muscle biopsy to right thigh and\n right forearm.\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy results.\n Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661506,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD.\n Action:\n Dressing intact . HCT dropped to 24 from 28\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cordis line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2.\n folye changed d/t yeast infection\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n K repleted with 20meq iv\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 661398,
"text": "Chief Complaint: Trach bleed\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y/o F admitted to OSH for peg placement. Developed aspiraiton\n pneumonia and resp failure requiring trach on . Transferred to\n for neuro eval and vent wean on antiobiotics, which she completed\n during her hospitalization here. She was weaned off to TM and PMV and\n transferred to the floor on . c/o pain near trach site\n yesterday, followed by brisk bleeding this am. Code blue was called,\n surgery evaluated stat. bleeding caused trach to occlude, hence\n intubated orally by anesthesia on the floor, and taken to OR this am.\n Trach site bleed controlled with digital pressure. In the OR, where she\n was flex bronched to clean distal airway. they examined the internal\n trach site, which showed no evidence of internal bleed. ETT was\n replaced. External exam of trach site revealed small arterial bleeder\n in the lower thyroid, which was sutured and cauterized. Good\n hemostasis. Patient transferred to MICU in stable condition. No further\n bleed in the MICU.\n During code, R femoral cortis placed non sterile\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Other medications:\n nebs,\n Past medical history:\n Family history:\n Social History:\n HCV hepatitis rx with interferon: family not aware of HCV infection\n Cirrhosis with hx of varices\n NSTEMI at QMC \n Cryoglobulinemia\n vasculitis\n peripheral neuropathy\n myopathy/non specific myositis\n parathesias\n dysphagia\n asthma\n GERD\n appy\n choly\n inability to close eyes due to weakness, with conjunctivitis\n DM, CAD, no neuromusc hx\n Occupation:\n Drugs: no\n Tobacco: 2ppd x 30 yrs\n Alcohol: no\n Other: 2 sons\n Review of systems:\n Flowsheet Data as of 12:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 110 (105 - 120) bpm\n BP: 166/85(113) {142/77(101) - 172/91(123)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,830 mL\n PO:\n TF:\n IVF:\n 6,080 mL\n Blood products:\n 750 mL\n Total out:\n 0 mL\n 1,860 mL\n Urine:\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,970 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.29/59/75/31/0\n Ve: 7.2 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Eyes / Conjunctiva: Bilateral conjunctivitis\n Head, Ears, Nose, Throat: Endotracheal tube, Trach site with clean dsg,\n mm dry\n Cardiovascular: (S1: Normal), (S2: Normal, Loud), (Murmur: Systolic)\n Peripheral Vascular: all present\n Respiratory / Chest: (Breath Sounds: Rhonchorous: with squeaks R base\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, Large hematoma in L groin, R\n groin with cortis\n Musculoskeletal: 1+ reflexes bilaterally, plantars withdrawing\n Skin: Warm\n Neurologic: Responds to tactile stimuli\n Labs / Radiology\n 149 K/uL\n 31.5 %\n 11.1 g/dL\n 149 mg/dL\n 0.3 mg/dL\n 8 mg/dL\n 31 mEq/L\n 106 mEq/L\n 3.1 mEq/L\n 140 mEq/L\n 16.1 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n 16.1\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n 31.5\n Plt\n 76\n 80\n 107\n 118\n 140\n 149\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TC02\n 27\n 30\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n 149\n Other labs: PT / PTT / INR:14.5/29.6/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.3 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: LLL infiltrate new since , with air layering around\n heart border, ? pneumomedst\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n POSTURE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI fistula per surgical team. Orotracheal intubation. Plan for\n surgical reexploration again in few days.\n Resp: Continue vent management. Minute ventilation increased to blow\n off CO2. Kep comfortable on propofol drip.\n Tracheal bleed: reexplore per surgical team tomorrow, with ? trach\n revision. Check Hct q6h.\n Leukocytosis with new LLL infiltrate: likely blood aspiration.\n Afebrile. Follow clinically and with repeat imaging and WBC.\n ? Pneumomedst on CXR: repeat, not bagged thru trach during code, per\n report\n L groin hematoma: pressure\n R groin code cortis: change to neck CVL today if no peripherals\n available\n Conjunctivitis: Tears, cipro and erythromycin topical in eyes, ophthal\n following\n Neuropathy/myopathy: f/u with neuro. Rec: MRI with contrast for bulbar\n and facial weakness. Needs LP later. Anticholinergic receptor Ab\n pending. d/w neuro reg prognosis and whether she needs peg placement\n for nutrition during OR tomorrow\n CAD/NSTEMI: No acute issues. Check EKG.\n Rest per resident note\n ICU Care\n Nutrition:\n npo\n Glycemic Control:\n Lines / Intubation:\n Cordis/Introducer - 07:59 AM\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 661545,
"text": "Chief Complaint:\n 24 Hour Events:\n - spiked fever, hypotensive to high 70's, tachy to 120's. Given 2\n liters NS, vancomycin 1 g given dirty line placement.\n - Blood cx x 2, urine culture sent\n - UA with pyruria (seen previously, likely related to candiduria) ->\n foley changed\n - Cordis removed, catheter tip sent for culture\n - Hct drop from 29 to 24 -> transfused 1 unit PRBC's\n - NPO after MN for trach revision\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:50 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Midazolam (Versed) - 10:37 PM\n Fentanyl - 03:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.7\nC (98.1\n HR: 101 (91 - 126) bpm\n BP: 121/64(86) {93/50(66) - 166/89(113)} mmHg\n RR: 18 (12 - 35) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,135 mL\n 691 mL\n PO:\n TF:\n IVF:\n 8,265 mL\n 341 mL\n Blood products:\n 750 mL\n 350 mL\n Total out:\n 2,560 mL\n 510 mL\n Urine:\n 1,560 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,575 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 399 (359 - 399) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 63\n PIP: 15 cmH2O\n Plateau: 6 cmH2O\n SpO2: 99%\n ABG: 7.41/42/63/25/1\n Ve: 7 L/min\n PaO2 / FiO2: 126\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 9.4 g/dL\n 112 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 112 mEq/L\n 139 mEq/L\n 26.1 %\n 23.4 K/uL\n [image002.jpg]\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n 01:24 PM\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n WBC\n 6.6\n 16.1\n 23.4\n Hct\n 34.0\n 31.5\n 29.4\n 28.9\n 24.3\n 24.0\n 26.1\n Plt\n 140\n 149\n 134\n Cr\n 0.3\n 0.3\n 0.3\n 0.3\n TCO2\n 30\n 28\n Glucose\n 108\n 95\n 149\n 112\n Other labs: PT / PTT / INR:14.5/31.7/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:19/66, Alk Phos / T Bili:111/2.1,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 661555,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y/o f with HCV, Cirrhosis p/w PNA, s/p trach, course c/b acute\n arterial bleed from trach site. Now s/p stitch placed in arterial\n bleed, awaiting trach revision.\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 AM\n BLOOD CULTURED - At 09:08 PM\n URINE CULTURE - At 09:08 PM\n CORDIS/INTRODUCER - STOP 09:18 PM\n MAGNETIC RESONANCE IMAGING - At 10:01 PM\n head MRI\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:50 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Midazolam (Versed) - 10:37 PM\n Fentanyl - 03:24 AM\n Lansoprazole (Prevacid) - 07:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.3\nC (99.1\n HR: 101 (91 - 126) bpm\n BP: 121/64(86) {93/50(66) - 166/85(113)} mmHg\n RR: 18 (14 - 35) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,135 mL\n 782 mL\n PO:\n TF:\n IVF:\n 8,265 mL\n 372 mL\n Blood products:\n 750 mL\n 350 mL\n Total out:\n 2,560 mL\n 630 mL\n Urine:\n 1,560 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,575 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 399 (359 - 399) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 63\n PIP: 15 cmH2O\n Plateau: 6 cmH2O\n SpO2: 99%\n ABG: 7.41/42/63/25/1\n Ve: 7 L/min\n PaO2 / FiO2: 126\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 134 K/uL\n 112 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 112 mEq/L\n 139 mEq/L\n 26.1 %\n 23.4 K/uL\n [image002.jpg]\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n 01:24 PM\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n WBC\n 6.6\n 16.1\n 23.4\n Hct\n 34.0\n 31.5\n 29.4\n 28.9\n 24.3\n 24.0\n 26.1\n Plt\n 140\n 149\n 134\n Cr\n 0.3\n 0.3\n 0.3\n 0.3\n TCO2\n 30\n 28\n Glucose\n 108\n 95\n 149\n 112\n Other labs: PT / PTT / INR:14.5/31.7/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:19/66, Alk Phos / T Bili:111/2.1,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI (tracheo-innominate) fistula per surgical team. Orotracheal\n intubation. Plan for surgical reexploration again tomorrow per\n thoracics. Developed GPC bacteremia overnight.\n Resp: currently ETT intubated. Arterial bleeding of thyroid, ligated\n with hemostasis. Continue vent management. Keep comfortable on propofol\n drip. Plan for trach revision today.\n -possible SBT after trach revision\n -cont. propofol\n Tracheal bleed: Check Hct q6h. Hct goal 26%, no active bleed now\n Leukocytosis: Suspect from dirty fem line placed during code, pulled\n yesterday. F/u cx. Cont. Vanco q12h.\n ? Pneumomedst on CXR: Appears to have resolved on CXR, may be \n manipulation of trach, no crepitus on exam.\n L groin hematoma: pressure was applied, pressure dressing in place\n HCV with cirrhosis: Following up with liver.\n Conjunctivitis: Tears, cipro and erythromycin topical in eyes,\n ophthal following\n Neuropathy/myopathy: f/u with neuro. Follow up MRI brain. LP when off\n the vent. Anticholinergic receptor Ab pending. Will consult IR for\n eventually for PEG given ascites.\n CAD/NSTEMI: No symptoms currently, no wall motion abnormalities on\n TTE.\n FEN: Restart TF after trach. Goal even.\n Access: PIVs\n Vent: HOB 30 degress, mouth care\n Ppx: PPI, pneumoboots\n Code: Full code\n Comm: husband\n ICU \n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 661745,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 cuffed\n fenestrated portex trach.\n ACCESS: Right #22G PIV, Right #18G PIV\n CODE: FULL\n SOCIAL: Husband very involved in care. FAMILY (PARENTS) DOES NOT KNOW\n PT HAS HCV!!\n ROS:\n *Neuro- A&Ox3, able to communicate needs by mouthing words or writing;\n c/o incisional neck pain, can receive Tylenol and oxycodone via NGT.\n * pt with #7 cuffed fenestrated portex trach (green), tolerating\n trach mask with 40% O2 but can probably weaned off O2 in AM. Able to\n cough up some secretions and will ask to be suctioned when necessary.\n Thick blood tinged secretions being suctioned from trach. Satting\n 98-100% with RR teens-20s.\n *CV- HR 80s-90s, SR; SBP 100s-140s. Pt with outlined hematoma to left\n groin from attempted cortis placement. Old cortis site with DSD to\n right groin.\n *GI/GU- TF restarted today (Fibersource HN @ 35cc/hr)- TF initially\n causing diarrhea/incontinence so gave 2 packets banana flakes per\n nutrition. Pt to get 4 packets banana flakes per day, still needs two\n more today. Abd S/NT/ND, no notable ascites. Foley with lg amts CYU.\n * Pt worked with PT/OT today. OOB to chair and commode with 1\n assist. Steady on feet but needs 1 assist.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube.\n Action:\n Pt tolerating trach collar at 50%. Changed to 40% this evening.\n Response:\n Tolerating trach collar. Sats 99-100%. Pt with thick serosanguinous\n secretions via trach.\n Plan:\n Monitor resp status. Pt to see S&S tomorrow. Can probably come off O2\n in AM. Cont to suction as needed. Cont trach care.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaining of pain at trach site.\n Action:\n Given fentanyl 1mg IVx1 this am with effect, then pain meds changed to\n oxycodone and Tylenol.\n Response:\n Oxycodone working well, Tylenol will little response.\n Plan:\n Continue to monitor for pain and medicate PRN.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 661746,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 cuffed\n fenestrated portex trach.\n ACCESS: Right #22G PIV, Right #18G PIV\n CODE: FULL\n SOCIAL: Husband very involved in care. FAMILY (PARENTS) DOES NOT KNOW\n PT HAS HCV!!\n ROS:\n *Neuro- A&Ox3, able to communicate needs by mouthing words or writing;\n c/o incisional neck pain, can receive Tylenol and oxycodone via NGT.\n * pt with #7 cuffed fenestrated portex trach (green), tolerating\n trach mask with 40% O2 but can probably weaned off O2 in AM. Able to\n cough up some secretions and will ask to be suctioned when necessary.\n Thick blood tinged secretions being suctioned from trach. Satting\n 98-100% with RR teens-20s.\n *CV- HR 80s-90s, SR; SBP 100s-140s. Pt with outlined hematoma to left\n groin from attempted cortis placement. Old cortis site with DSD to\n right groin.\n *GI/GU- TF restarted today (Fibersource HN @ 35cc/hr)- TF initially\n causing diarrhea/incontinence so gave 2 packets banana flakes per\n nutrition. Pt to get 4 packets banana flakes per day, still needs two\n more today. Abd S/NT/ND, no notable ascites. Foley with lg amts CYU.\n * Pt worked with PT/OT today. OOB to chair and commode with 1\n assist. Steady on feet but needs 1 assist.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube.\n Action:\n Pt tolerating trach collar at 50%. Changed to 40% this evening.\n Response:\n Tolerating trach collar. Sats 99-100%. Pt with thick serosanguinous\n secretions via trach.\n Plan:\n Monitor resp status. Pt to see S&S tomorrow. Can probably come off O2\n in AM. Cont to suction as needed. Cont trach care.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaining of pain at trach site.\n Action:\n Given fentanyl 1mg IVx1 this am with effect, then pain meds changed to\n oxycodone and Tylenol.\n Response:\n Oxycodone working well, Tylenol will little response.\n Plan:\n Continue to monitor for pain and medicate PRN.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n Admission weight:\n 55 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Asthma\n CV-PMH:\n Additional history: Active hepatitis, HCV, known cirrhosis, known\n varices, recent horseness which was evaluated by ENT, s/p choly, s/p\n appendectomy and hx of venous thrombophlebitis.\n Surgery / Procedure and date: Trach , s/p tracheal bleed with flex\n bronch in OR \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:78\n Temperature:\n 98.8\n Arterial BP:\n S:143\n D:74\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 40% %\n 24h total in:\n 1,179 mL\n 24h total out:\n 1,675 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:02 AM\n Potassium:\n 3.7 mEq/L\n 02:02 AM\n Chloride:\n 108 mEq/L\n 02:02 AM\n CO2:\n 26 mEq/L\n 02:02 AM\n BUN:\n 7 mg/dL\n 02:02 AM\n Creatinine:\n 0.3 mg/dL\n 02:02 AM\n Glucose:\n 85 mg/dL\n 02:02 AM\n Hematocrit:\n 25.0 %\n 10:05 AM\n Finger Stick Glucose:\n 127\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 782\n Transferred to: 226\n Date & time of Transfer: @ 2120\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-02-02 00:00:00.000",
"description": "PMV Follow Up",
"row_id": 661379,
"text": "TITLE: DEFERRED REPEAT PMV TRIAL\n We returned today to again attempt PMV placement. Pt was taken to OR\n this morning due to tracheostomy bleeding for bronch and wound\n exploration. During that procedure, trach tube was removed and pt is\n currently orally intubated. It appears that plan at this time includes\n return to OR for replacement of trach tube on .\n Please reconsult for PMV evaluation when trach tube is in place and pt\n is managing secretions such that PMV trial might be indicated. Typical\n protocol includes minimum 24 hour wait after trach change (e.g.\n downsize) and minimum 48 hour wait after new trach to allow time for\n surgical site to heal. Surgical team may wish to wait longer in this\n case, given recent h/o wound at trach site.\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 15 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 661415,
"text": "Chief Complaint: Trach bleed\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y/o F admitted to OSH for peg placement. Developed aspiraiton\n pneumonia and resp failure requiring trach on . Transferred to\n for neuro eval and vent wean on antiobiotics, which she completed\n during her hospitalization here. She was weaned off to TM and PMV and\n transferred to the floor on . c/o pain near trach site\n yesterday, followed by brisk bleeding this am. Code blue was called,\n surgery evaluated stat. bleeding caused trach to occlude, hence\n intubated orally by anesthesia on the floor, and taken to OR this am.\n Trach site bleed controlled with digital pressure. In the OR, where she\n was flex bronched to clean distal airway. they examined the internal\n trach site, which showed no evidence of internal bleed. ETT was\n replaced. External exam of trach site revealed small arterial bleeder\n in the lower thyroid, which was sutured and cauterized. Good\n hemostasis. Patient transferred to MICU in stable condition. No further\n bleed in the MICU.\n During code, R femoral cortis placed non sterile\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Other medications:\n nebs,\n Past medical history:\n Family history:\n Social History:\n HCV hepatitis rx with interferon: family not aware of HCV infection\n Cirrhosis with hx of varices\n NSTEMI at QMC \n Cryoglobulinemia\n vasculitis\n peripheral neuropathy\n myopathy/non specific myositis\n parathesias\n dysphagia\n asthma\n GERD\n appy\n choly\n inability to close eyes due to weakness, with conjunctivitis\n DM, CAD, no neuromusc hx\n Occupation:\n Drugs: no\n Tobacco: 2ppd x 30 yrs\n Alcohol: no\n Other: 2 sons\n Review of systems:\n Flowsheet Data as of 12:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 110 (105 - 120) bpm\n BP: 166/85(113) {142/77(101) - 172/91(123)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 6,830 mL\n PO:\n TF:\n IVF:\n 6,080 mL\n Blood products:\n 750 mL\n Total out:\n 0 mL\n 1,860 mL\n Urine:\n 860 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,970 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.29/59/75/31/0\n Ve: 7.2 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Eyes / Conjunctiva: Bilateral conjunctivitis\n Head, Ears, Nose, Throat: Endotracheal tube, Trach site with clean dsg,\n mm dry\n Cardiovascular: (S1: Normal), (S2: Normal, Loud), (Murmur: Systolic)\n Peripheral Vascular: all present\n Respiratory / Chest: (Breath Sounds: Rhonchorous: with squeaks R base\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, Large hematoma in L groin, R\n groin with cortis\n Musculoskeletal: 1+ reflexes bilaterally, plantars withdrawing\n Skin: Warm\n Neurologic: Responds to tactile stimuli\n Labs / Radiology\n 149 K/uL\n 31.5 %\n 11.1 g/dL\n 149 mg/dL\n 0.3 mg/dL\n 8 mg/dL\n 31 mEq/L\n 106 mEq/L\n 3.1 mEq/L\n 140 mEq/L\n 16.1 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n 16.1\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n 31.5\n Plt\n 76\n 80\n 107\n 118\n 140\n 149\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TC02\n 27\n 30\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n 149\n Other labs: PT / PTT / INR:14.5/29.6/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.3 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: LLL infiltrate new since , with air layering around\n heart border, ? pneumomedst\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n POSTURE, IMPAIRED\n TRANSFERS, IMPAIRED\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI fistula per surgical team. Orotracheal intubation. Plan for\n surgical reexploration again in few days.\n Resp: currently ETT intubated. Arterial bleeding of thyroid, ligated\n with hemostasis. Continue vent management. Minute ventilation increased\n to blow off CO2. Kep comfortable on propofol drip.\n Tracheal bleed: re-explore per surgical team tomorrow, with ? trach\n revision. Check Hct q6h.\n Leukocytosis with new LLL infiltrate: likely aspiration of blood.\n Afebrile. Follow clinically and with repeat imaging and WBC.\n ? Pneumomedst on CXR: repeat, not bagged thru trach during code, per\n report\n no pneumomediast on repeat xray\n L groin hematoma: pressure was applied, pressure dressing in place\n R groin code cordis: has good peripherals. Can remove cordis\n Conjunctivitis: Tears, cipro and erythromycin topical in eyes, ophthal\n following\n Neuropathy/myopathy: f/u with neuro. Rec: MRI with contrast for bulbar\n and facial weakness. Needs LP later. Anticholinergic receptor Ab\n pending. d/w neuro reg prognosis and whether she needs peg placement\n for nutrition during OR tomorrow\n CAD/NSTEMI: No acute issues. Check EKG.\n Rest per resident note\n ICU Care\n Nutrition: npo\n Glycemic Control:\n Lines / Intubation:\n Cordis/Introducer - 07:59 AM\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36 min\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 661427,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: no\n Procedure location: Intubated on floors\n Reason: emergent code\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean on PSV as tol.\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Cannot protect airway\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661535,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD. Pt c/o pain \n Action:\n Dressing intact . HCT dropped to 24 from 28, given fentanyl 50mg x2\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement. HCT morning\n 26\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities. Overnight pt\n more awake, follows commands, able to write in white board, appeared\n oreineted. Moves all extremities, lift and hold arms.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, during MRI pt required fentanyl\n 50mg and versed fro seadation 1mg result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cordis line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2.\n folye changed d/t yeast infection\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n K 3.8 repleted with 20meq iv.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 661738,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 cuffed\n fenestrated portex trach.\n ACCESS: Right #22G PIV, Right #18G PIV\n CODE: FULL\n SOCIAL: Husband very involved in care. FAMILY (PARENTS) DOES NOT KNOW\n PT HAS HCV!!\n ROS:\n *Neuro- A&Ox3, able to communicate needs by mouthing words or writing;\n c/o incisional neck pain, can receive Tylenol and oxycodone via NGT.\n * pt with #7 cuffed fenestrated portex trach (green), tolerating\n trach mask with 40% O2 but can probably weaned off O2 in AM. Able to\n cough up some secretions and will ask to be suctioned when necessary.\n Thick blood tinged secretions being suctioned from trach. Satting\n 98-100% with RR teens-20s.\n *CV- HR 80s-90s, SR; SBP 100s-140s. Pt with outlined hematoma to left\n groin from attempted cortis placement. Old cortis site with DSD to\n right groin.\n *GI/GU- TF restarted today (Fibersource HN @ 35cc/hr)- TF initially\n causing diarrhea/incontinence so gave 2 packets banana flakes per\n nutrition. Pt to get 4 packets banana flakes per day, still needs two\n more today. Abd S/NT/ND, no notable ascites. Foley with lg amts CYU.\n * Pt worked with PT/OT today. OOB to chair and commode with 1\n assist. Steady on feet but needs 1 assist.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube.\n Action:\n Pt. tolerating PSV overnight, changed to trach collar this am.\n Response:\n Tolerating trach collar. Sats 99%. Pt with thick serosanginous\n secretions via trach.\n Plan:\n Monitor response to trach collar. Pt will need eventual evaluation by\n speech and swallow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. complaining of pain at trach site.\n Action:\n Given fentanyl 1mg IVx1 this am with effect, then pain meds changed to\n oxycodone\n Response:\n Plan:\n Continue to monitor for pain and medicate PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 661739,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 cuffed\n fenestrated portex trach.\n ACCESS: Right #22G PIV, Right #18G PIV\n CODE: FULL\n SOCIAL: Husband very involved in care. FAMILY (PARENTS) DOES NOT KNOW\n PT HAS HCV!!\n ROS:\n *Neuro- A&Ox3, able to communicate needs by mouthing words or writing;\n c/o incisional neck pain, can receive Tylenol and oxycodone via NGT.\n * pt with #7 cuffed fenestrated portex trach (green), tolerating\n trach mask with 40% O2 but can probably weaned off O2 in AM. Able to\n cough up some secretions and will ask to be suctioned when necessary.\n Thick blood tinged secretions being suctioned from trach. Satting\n 98-100% with RR teens-20s.\n *CV- HR 80s-90s, SR; SBP 100s-140s. Pt with outlined hematoma to left\n groin from attempted cortis placement. Old cortis site with DSD to\n right groin.\n *GI/GU- TF restarted today (Fibersource HN @ 35cc/hr)- TF initially\n causing diarrhea/incontinence so gave 2 packets banana flakes per\n nutrition. Pt to get 4 packets banana flakes per day, still needs two\n more today. Abd S/NT/ND, no notable ascites. Foley with lg amts CYU.\n * Pt worked with PT/OT today. OOB to chair and commode with 1\n assist. Steady on feet but needs 1 assist.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube.\n Action:\n Pt tolerating trach collar at 50%. Changed to 40% this evening.\n Response:\n Tolerating trach collar. Sats 99-100%. Pt with thick serosanguinous\n secretions via trach.\n Plan:\n Monitor resp status. Pt to see S&S tomorrow. Can probably come off O2\n in AM. Cont to suction as needed. Cont trach care.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaining of pain at trach site.\n Action:\n Given fentanyl 1mg IVx1 this am with effect, then pain meds changed to\n oxycodone and Tylenol.\n Response:\n Oxycodone working well, Tylenol will little response.\n Plan:\n Continue to monitor for pain and medicate PRN.\n"
},
{
"category": "General",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Generic Note",
"row_id": 661734,
"text": "TITLE: Respiratory Care Shift Note: Pt remains w/ a 7.0 Portex\n Fen-Trach Tube in place. Pt has remained on a 50 % Trach Collar all day\n and appears comfortable and no c/o dyspnea. Will probably go to floor\n later this evening. Will monitor respiratory status.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 661735,
"text": "Chief Complaint: Resp Failure\n Weakness\n Tracheal Bleed\n Line Infection\n HPI:\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI fistula per surgical team. Orotracheal intubation. Just had\n revision of trach yesterday. Planning to wean now. Neuro following for\n neuromusc weakness w/u.\n 24 Hour Events:\n 7.0 Portex placed yesterday, started TF, myasthenia w/u undergone, BCx\n with GPCs after fem line pulled.\n INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:30 AM\n Lansoprazole (Prevacid) - 08:10 AM\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.2\nC (99\n HR: 92 (86 - 109) bpm\n BP: 190/144(163) {96/46(65) - 190/144(163)} mmHg\n RR: 21 (11 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,234 mL\n 300 mL\n PO:\n TF:\n IVF:\n 1,824 mL\n 300 mL\n Blood products:\n 350 mL\n Total out:\n 1,058 mL\n 660 mL\n Urine:\n 1,008 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,176 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 332 (307 - 360) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 57\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.37/49/135/26/2\n Ve: 5.3 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: R pupil 6mm L pupil 4mm both reactive\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 137 K/uL\n 85 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 138 mEq/L\n 25.2 %\n 12.7 K/uL\n [image002.jpg]\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n 12:29 PM\n 12:41 PM\n 05:01 PM\n 02:02 AM\n 02:26 AM\n WBC\n 23.4\n 12.7\n Hct\n 28.9\n 24.3\n 24.0\n 26.1\n 25.7\n 26.3\n 25.2\n Plt\n 134\n 137\n Cr\n 0.3\n 0.3\n TCO2\n 28\n 27\n 29\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:14.2/32.0/1.2, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/51, Alk Phos / T Bili:109/1.2,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI (tracheo-innominate) fistula per surgical team. Orotracheal\n intubation, now with revised trach. Growing GNR in BAL, being treated\n for CNS bacteremia\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n CNS from BCx and old line which is out. F/u blood cultures negative so\n far\n -14 days of IV vanco for Bacteremia\n New GNRs in BAL . Will need to be followed up and treated if not\n felt to be colonization. Low grade temp overnight Tm 100, WBC improved\n from 25\n 12. This will need to be followed up.\n TRACHEAL RECONSTRUCTION (TRACHEOBRONCHIAL)\n s/p cautery of trach bleed, s/p new trach, no recent bleeding\n -f/u BAL\n -cont. TM today\n -cont. nebs\n -speech c/s for PMV\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n As above\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n -bulbar and facial weakness, extremity weakness improved\n -MRI OK no brainstem lesion\n -neuro wanted LP, can have as an outpatient to w/u for myasthenia\n -Ab pending\n FEN: Swallow eval, tube feeds\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor. Will likely need rehab / long term care\n facility\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660683,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach mask. Moderate amt of yellow blood tinged\n sputum from around trach site. Small amt\ns suctioned from trach. O2\n sats 97-100%.\n Action:\n Suctioned prn. Trach inner cannula cleaned. Fio2 down to 40%. Speech\n and swallow in to eval pt and attempted passey-euir valve placement.\n Pt had too many secretions and it was unsuccessful.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suction prn and wean down fio2.\n Alteration in Nutrition\n Assessment:\n Received pt on 35ml/hr Fibersource HN via doboff.\n Action:\n TF\ns weaned up to goal of 55cc/hr.\n Response:\n Tolerating TF well. Currently at goal.\n Plan:\n NPO after midnight for ? nerve biopsy tomorrow. Remains on RISS.\n Myopathy, other (not of critical illness)\n Assessment:\n Pt\ns strength is improving. Able to lift and hold all 4 extremities.\n Tolerating trach collar well without struggling to use muscles for\n breating. Per ENT eyes look like they are improving.\n Action:\n Currently on artificial tear drops and ointment Q 2 hours. Cipro eye\n gtts Q 6 hours. Erythromycin ointment ordered QHS.\n Response:\n Per team eyes are improving.\n Plan:\n Continue to monitor\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 661727,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: cirrhosis / 571.40\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 55 yo F with Hep C\n cirrhosis with 6 month h/o neuromuscular and bulbar weakness admitted\n on from OSH with pneumonia where she required intubation/trach on\n , extubated on , developed respiratory distress bleeding\n around the trach site requiring re-intubation followed by revision of\n trach. Re-extubated early . Tolerating trach collar and work-up\n for myopathy/polyneuropathy in progress.\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, ciprofloxacin, fentanyl, nadolol, tylenol,\n propofol, vancomycin\n Radiology: CXR - Clear right lung. Left lung base opacification is\n worse. Increased left pleural effusion.\n Labs:\n 25.0\n 8.5\n 137\n 12.7\n [image002.jpg]\n Other labs:\n pO2 135\n pCO2 49\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert & oriented x3,\n unable to verbalize trach but able to mouth words to make needs\n met. Following all commands. Writing effectively.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 93\n 146/77\n 22\n 94% on TM\n Sit\n /\n Activity\n 93\n 132/80\n 28\n 97% on TM\n Stand\n /\n Recovery\n 90\n 143/74\n 22\n 97% on TM\n Total distance walked: feet\n Minutes:\n Pulmonary Status: non-labored breathing, lungs cta, no cough noted; on\n 60% FIO2 via trach mask\n Integumentary / Vascular: erythema L eye; R radial a-line, #7 portex\n trach with trach mask, B PIV, foley, tele\n Sensory Integrity: intact to light touch B UE's, intact to light touch\n through L3 on LLE and through L2 on RLE, absent below. Diminished\n proprioception B great toes, R worse then left. Facial sensation\n intact.\n Pain / Limiting Symptoms: denies pain\n Posture: cachectic appearance, mild kyphotic\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly 4+/5 throughout\n R shoulder flexion \n L shoulder flexion \n R elbow flexion \n L elbow flexion \n R elbow extension \n L elbow extension 3+/5\n R wrist extension 3+/5\n L wrist extension \n strong grip bilaterally\n Motor Function: brisk patella reflexes L>R. Symmetrical smile, tongue\n to midline, normal saccades, visual fields intact. Unable to close\n eyes.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several small steps from edge of bed to\n chair, decr step length bilaterally, limited by multiple lines. Denies\n SOB or lightheadedness.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static/dynamic sitting balance, CG static standing, CG/min A\n dynamic activities- eyes closed x 5 sec, perturbations in all\n directions with LOB backward, unable to assume narrow BOS.\n Education / Communication: Reviewed PT and encouraged OOB and deep\n breathing. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis: 5j\n 1.\n Transfers/gait, impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Impaired pulmonary function\n 5.\n Impaired endurance\n 6.\n Clinical impression / Prognosis: 55 yo F with cirrhosis and muscle\n weakness p/w above impairments a/w CNS disorder. She is most limited\n by muscle weakness UE\ns>LE\ns as well as general weakness and\n deconditioning a/w prolonged hospital stay. She is well below her\n baseline level however is making excellent progress in PT in the past\n week. Would continue to anticipate STR upon d/c as she has new\n tracheostomy however if she remains an inpatient could potentially\n reach a functional level of mobility and possibly d/c home. PT to\n continue to follow up daily, she is good rehab candidate at this time.\n Goals\n Time frame: 1 week\n 1.\n CG stand step transfers, assess gait\n 2.\n No LOB with mobility/gait\n 3.\n Tolerates daily strengthening/therex\n 4.\n Maintains appropriate O2 sat with mobility\n 5.\n Tolerates OOB >2hrs/day\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: bed mobility, transfers, ambulation, balance,\n strengthening, endurance, education, d/c planning\n Frequency / Duration: daily\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-29 00:00:00.000",
"description": "ICU Attending Addendum",
"row_id": 660802,
"text": "CRITICAL CARE STAFF\n 11a\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. The ICU team\ns note\n from today reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Yesterday, she did not tolerate PMV trial due to coughing. Remained off\n ventilator. Neuro and ophtho continue to follow.\n On exam, she is comfortable on PSV. Eyes are injected; Heart is\n regular. Today there is no murmur. Lungs are coarse. Abdomen is soft\n and nontender. She is up in a chair and moving a bit more today.\n Still cannot close eyes.\n Labs, imaging, and medications reviewed in today\ns ICU team note.\n Platelets continue to improve.\n Assessment and Plan\n 55-year-old woman with\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n o Tolerating trach mask now\n o Speech to revisit today\n Myopathy and neuropathy\n o Appreciate neuro\ns help.\n o Awaiting results of recent muscle biopsy\n o Holding off on nerve biopsy pending results of muscle biopsy.\n Ophthalmologic issues\n o Greatly appreciate ophtho\ns help\n o On eye gtt and topical abx\n o Will need corneal protective strategy if strength unimproved\n Access\n o PIVs adequate for now\n HCV\n o Hold interferon\n o nadolol\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Improving\n Nutrition\n o On TF\n Other issues as per ICU team note above.\n From a respiratory standpoint, she is ready for the floor. We will\n review whether her eye-care needs can be met outside of a critical care\n setting.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660756,
"text": "Chief Complaint:\n 24 Hour Events:\n - speech and swallow eval today, could not handle Passy-Muir valve yet,\n will try again on Friday\n - tachycardic in afternoon; appeared dry perhaps from autodiuresis with\n low K/Phos - given IVFs, tachycardia improved overnight\n - optho recs continued cipro gtts, spaced out lacrilube to q2 hrs,\n added erythromycin drops at night to L eye\n - neurosurg preop completed with type and screen, UA, CXR\n - waiting for OSH path prior to nerve biopsy, because if specimen is\n inadequate would like to do both muscle and nerve biopsy at the same\n time; plan would be for Monday if not tomorrow - need to touch base\n with both neuro and neurosurg today about finalized plan\n - aggitated overnight and slept very little, did not respond to\n morphine or ativan; can consider adding sleeping medicine tomorrow\n night like trazadone\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Lorazepam (Ativan) - 02:49 AM\n Morphine Sulfate - 06:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 99 (89 - 118) bpm\n BP: 157/91(108) {124/79(90) - 169/121(126)} mmHg\n RR: 27 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,657 mL\n 1,516 mL\n PO:\n TF:\n 952 mL\n 10 mL\n IVF:\n 1,225 mL\n 1,505 mL\n Blood products:\n Total out:\n 4,025 mL\n 1,335 mL\n Urine:\n 3,725 mL\n 1,135 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n -1,368 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 140 K/uL\n 11.4 g/dL\n 95 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 109 mEq/L\n 138 mEq/L\n 34.0 %\n 6.6 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n Plt\n 76\n 80\n 107\n 118\n 140\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n Other labs: PT / PTT / INR:14.7/31.5/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n 20 Gauge - 12:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660757,
"text": "Chief Complaint:\n 24 Hour Events:\n - speech and swallow eval today, could not handle Passy-Muir valve yet,\n will try again on Friday\n - tachycardic in afternoon; appeared dry perhaps from autodiuresis with\n low K/Phos - given IVFs, tachycardia improved overnight\n - optho recs continued cipro gtts, spaced out lacrilube to q2 hrs,\n added erythromycin drops at night to L eye\n - neurosurg preop completed with type and screen, UA, CXR\n - waiting for OSH path prior to nerve biopsy, because if specimen is\n inadequate would like to do both muscle and nerve biopsy at the same\n time; plan would be for Monday if not tomorrow - need to touch base\n with both neuro and neurosurg today about finalized plan\n - aggitated overnight and slept very little, did not respond to\n morphine or ativan; can consider adding sleeping medicine tomorrow\n night like trazadone\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Lorazepam (Ativan) - 02:49 AM\n Morphine Sulfate - 06:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 99 (89 - 118) bpm\n BP: 157/91(108) {124/79(90) - 169/121(126)} mmHg\n RR: 27 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,657 mL\n 1,516 mL\n PO:\n TF:\n 952 mL\n 10 mL\n IVF:\n 1,225 mL\n 1,505 mL\n Blood products:\n Total out:\n 4,025 mL\n 1,335 mL\n Urine:\n 3,725 mL\n 1,135 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n -1,368 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n Not cooperating with neuro exam this morning, moving all 4 extremities\n against gravity but not pushing against resistance, reflexes continue\n to be 3+\n Labs / Radiology\n 140 K/uL\n 11.4 g/dL\n 95 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 109 mEq/L\n 138 mEq/L\n 34.0 %\n 6.6 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n Plt\n 76\n 80\n 107\n 118\n 140\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n Other labs: PT / PTT / INR:14.7/31.5/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n 20 Gauge - 12:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660760,
"text": "Chief Complaint:\n 24 Hour Events:\n - speech and swallow eval today, could not handle Passy-Muir valve yet,\n will try again on Friday\n - tachycardic in afternoon; appeared dry perhaps from autodiuresis with\n low K/Phos - given IVFs, tachycardia improved overnight\n - optho recs continued cipro gtts, spaced out lacrilube to q2 hrs,\n added erythromycin drops at night to L eye\n - neurosurg preop completed with type and screen, UA, CXR\n - waiting for OSH path prior to nerve biopsy, because if specimen is\n inadequate would like to do both muscle and nerve biopsy at the same\n time; plan would be for Monday if not tomorrow - need to touch base\n with both neuro and neurosurg today about finalized plan\n - aggitated overnight and slept very little, did not respond to\n morphine or ativan; can consider adding sleeping medicine tomorrow\n night like trazadone\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Lorazepam (Ativan) - 02:49 AM\n Morphine Sulfate - 06:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 99 (89 - 118) bpm\n BP: 157/91(108) {124/79(90) - 169/121(126)} mmHg\n RR: 27 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,657 mL\n 1,516 mL\n PO:\n TF:\n 952 mL\n 10 mL\n IVF:\n 1,225 mL\n 1,505 mL\n Blood products:\n Total out:\n 4,025 mL\n 1,335 mL\n Urine:\n 3,725 mL\n 1,135 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n -1,368 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n Not cooperating with neuro exam this morning, moving all 4 extremities\n against gravity but not pushing against resistance, reflexes continue\n to be 3+\n Labs / Radiology\n 140 K/uL\n 11.4 g/dL\n 95 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 109 mEq/L\n 138 mEq/L\n 34.0 %\n 6.6 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n Plt\n 76\n 80\n 107\n 118\n 140\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n Other labs: PT / PTT / INR:14.7/31.5/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities. Working diagnosis is an INF\n related primary myopathy with an underlying secondary neuropathy\n related to cyroglobulemiia. Neuro and neurosurg following\n - cryo levels pending\n - plan to review OSH muscle biopsies with neuro. OSH doctor is Dr. ,\n call for bx results (or can page Dr. )\n - neuro would like to hold on nerve biopsy pending the muscle biopsy\n results; Dr. is following and she is scheduled for OR today\n - appreciate neuro and neurosurg recs\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Completed course of cefepime on . Given that her weakness preceeded\n her critical illness, I suspect cryoglobulinemia as primary process.\n - completed 10 day of cefepime on \n - doing well on trach mask trial\n - continue nebs given hx asthma\n .\n # HCV: stable, viral load undetectable\n - appreciate liver recs, abd US done and showed minimal ascites\n - dobhoff placed, starting nutrition; will have to follow up long term\n nutrition plans\n - holding INF as it may be possible cause of weakness\n - cryo levels pending\n .\n # Corneal abrasion and conjunctivitis\n opthamology following;\n - tx with lacrilube ointment q 1hr, lacrilube drops q2 hr and cipro\n gtts q 6hrs\n - at risk for worsening corneal damage in setting of muscle weakness\n and inability to close eyes; will need close eye care for now and\n follow up with ophthalmology\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, requiring less and less medicine\n - starting tube feeds now that dobhoff placed\n - transitioned back to nadolol for varices; can titrate up as needed\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. Failed PMV trial \n coughing/secretions.\n - continue PMV trials\n - NPO\n - continuing PPI, stopped ranitidine\n - dobhoff in place\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab - negative\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - nadolol as above for tachycardia\n .\n # FEN:\n - on tube feeds, stopping maintenance fluids\n - replete electrolytes\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n - no HIT\n starting SQ heparin after nerve biopsy, will hold AM of\n surgery\n .\n # Access:\n - RIJ from OSH removed, now with PIVs\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n 20 Gauge - 12:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 661696,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: cirrhosis / 571.40\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 55 yo F with Hep C\n cirrhosis with 6 month h/o neuromuscular and bulbar weakness admitted\n from OSH with pneumonia requiring intubation, extubated on ,\n developed respiratory distress bleeding around the trach site\n requiring re-intubation followed by revision of trach. Re-extubated\n early .\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, ciprofloxacin, fentanyl, nadolol, tylenol,\n propofol, vancomycin\n Radiology: CXR - Clear right lung. Left lung base opacification is\n worse. Increased left pleural effusion.\n Labs:\n 25.0\n 8.5\n 137\n 12.7\n [image002.jpg]\n Other labs:\n pO2 135\n pCO2 49\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert & oriented x3,\n unable to verbalize trach but able to mouth words to make needs\n met. Following all commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 93\n 146/77\n 22\n 94% on TM\n Sit\n /\n Activity\n 93\n 132/80\n 28\n 97% on TM\n Stand\n /\n Recovery\n 90\n 143/74\n 22\n 97% on TM\n Total distance walked: feet\n Minutes:\n Pulmonary Status: non-labored breathing, lungs cta, no cough noted; on\n 60% FIO2 via trach mask\n Integumentary / Vascular: erythema L eye; R radial a-line, #7 portex\n trach with trach mask, B PIV, foley, tele\n Sensory Integrity: intact to light touch B UE's, intact to light touch\n through L3 on LLE and through L2 on RLE, absent below. Diminished\n proprioception B great toes, R worse then left.\n Pain / Limiting Symptoms: denies pain\n Posture: cachectic appearance, mild kyphotic\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly 4+/5 throughout\n R shoulder flexion \n L shoulder flexion \n R elbow flexion \n L elbow flexion \n R elbow extension \n L elbow extension 3+/5\n R wrist extension 3+/5\n L wrist extension \n strong grip bilaterally\n Motor Function: brisk patella reflexes L>R\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several small steps from edge of bed to\n chair, decr step length bilaterally, limited by multiple lines. Denies\n SOB or lightheadedness.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static/dynamic sitting balance, CG static standing, CG/min A\n dynamic activities- eyes closed x 5 sec, perturbations in all\n directions with LOB backward, unable to assume narrow BOS.\n Education / Communication: Reviewed PT and encouraged OOB and deep\n breathing. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performace, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Posture, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame: 1 week\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 661703,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: cirrhosis / 571.40\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 55 yo F with Hep C\n cirrhosis with 6 month h/o neuromuscular and bulbar weakness admitted\n from OSH with pneumonia requiring intubation, extubated on ,\n developed respiratory distress bleeding around the trach site\n requiring re-intubation followed by revision of trach. Re-extubated\n early .\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, ciprofloxacin, fentanyl, nadolol, tylenol,\n propofol, vancomycin\n Radiology: CXR - Clear right lung. Left lung base opacification is\n worse. Increased left pleural effusion.\n Labs:\n 25.0\n 8.5\n 137\n 12.7\n [image002.jpg]\n Other labs:\n pO2 135\n pCO2 49\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert & oriented x3,\n unable to verbalize trach but able to mouth words to make needs\n met. Following all commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 93\n 146/77\n 22\n 94% on TM\n Sit\n /\n Activity\n 93\n 132/80\n 28\n 97% on TM\n Stand\n /\n Recovery\n 90\n 143/74\n 22\n 97% on TM\n Total distance walked: feet\n Minutes:\n Pulmonary Status: non-labored breathing, lungs cta, no cough noted; on\n 60% FIO2 via trach mask\n Integumentary / Vascular: erythema L eye; R radial a-line, #7 portex\n trach with trach mask, B PIV, foley, tele\n Sensory Integrity: intact to light touch B UE's, intact to light touch\n through L3 on LLE and through L2 on RLE, absent below. Diminished\n proprioception B great toes, R worse then left.\n Pain / Limiting Symptoms: denies pain\n Posture: cachectic appearance, mild kyphotic\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly 4+/5 throughout\n R shoulder flexion \n L shoulder flexion \n R elbow flexion \n L elbow flexion \n R elbow extension \n L elbow extension 3+/5\n R wrist extension 3+/5\n L wrist extension \n strong grip bilaterally\n Motor Function: brisk patella reflexes L>R\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several small steps from edge of bed to\n chair, decr step length bilaterally, limited by multiple lines. Denies\n SOB or lightheadedness.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static/dynamic sitting balance, CG static standing, CG/min A\n dynamic activities- eyes closed x 5 sec, perturbations in all\n directions with LOB backward, unable to assume narrow BOS.\n Education / Communication: Reviewed PT and encouraged OOB and deep\n breathing. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis: 5j\n 1.\n Transfers/gait, impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Impaired pulmonary function\n 5.\n Impaired endurance\n 6.\n Clinical impression / Prognosis: 55 yo F with cirrhosis and muscle\n weakness p/w above impairments a/w CNS disorder. She is most limited\n by muscle weakness UE\ns>LE\ns as well as general weakness and\n deconditioning a/w prolonged hospital stay. She is well below her\n baseline level however is making excellent progress in PT in the past\n week. Would continue to anticipate STR upon d/c as she has new\n tracheostomy however if she remains an inpatient could potentially\n reach a functional level of mobility and possibly d/c home. PT to\n continue to follow up daily, she is good rehab candidate at this time.\n Goals\n Time frame: 1 week\n 1.\n CG stand step transfers, assess gait\n 2.\n No LOB with mobility/gait\n 3.\n Tolerates daily strengthening/therex\n 4.\n Maintains appropriate O2 sat with mobility\n 5.\n Tolerates OOB >2hrs/day\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: bed mobility, transfers, ambulation, balance,\n strengthening, endurance, education, d/c planning\n Frequency / Duration: daily\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 661705,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient had trach placed, 7-0 fenestrated portex, needs suture\n removal around the trach which needs to be removed in one week, bronch\n during this procedure showed increased mucus from left lower lobe, mini\n BAL was sent\n - ordered for tube feeds\n - Neuro recs, MRI unimpressive, wanted to check antiMUSK Ab for a rare\n type of Myasthenia \n - HCT stable\n - fem catheter tip also grwoing GPC\n - patient needs to consent for blood tests once sedation is off given\n employee blood exposure, employee health is following\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (86 - 109) bpm\n BP: 158/85(113) {96/46(65) - 159/85(114)} mmHg\n RR: 20 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,234 mL\n 78 mL\n PO:\n TF:\n IVF:\n 1,824 mL\n 78 mL\n Blood products:\n 350 mL\n Total out:\n 1,058 mL\n 660 mL\n Urine:\n 1,008 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,176 mL\n -582 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 332 (307 - 360) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 57\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.37/49/135/26/2\n Ve: 5.3 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Thin, middle-aged female, A&Ox3\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : ) CTA\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 8.5 g/dL\n 85 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 138 mEq/L\n 25.2 %\n 12.7 K/uL\n [image002.jpg]\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n 12:29 PM\n 12:41 PM\n 05:01 PM\n 02:02 AM\n 02:26 AM\n WBC\n 23.4\n 12.7\n Hct\n 28.9\n 24.3\n 24.0\n 26.1\n 25.7\n 26.3\n 25.2\n Plt\n 134\n 137\n Cr\n 0.3\n 0.3\n TCO2\n 28\n 27\n 29\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:14.2/32.0/1.2, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/51, Alk Phos / T Bili:109/1.2,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Microbiology: 8:29 pm CATHETER TIP-IV Source: R femoral\n cortiz.\n GRAM POSITIVE COCCUS(COCCI). >15 colonies.\n 8:29 pm BLOOD CULTURE Source: Line-R femoral cortiz.\n Blood cultures 2/4: GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n 55 y/o lady with history HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness now s/p trach after intubation for\n aspiration pneumonia and persistant difficulty weaning from vent is\n admitted to MICU after bleeding around trach site.\n 1) Respiratory failure: occurred secondary to bleed around trach.\n ETT was placed emergently for ventilation and small thyroid artery was\n cauterized in OR. Now s/p revised ETT and successful extubation.\n - PMV trial today\n 2) GPC bacteremia: Most likely from the nonsterile femoral cordis\n placed during code. Line discontinued on . Catheter tip also\n with GPC\n - f/u GPC speciation\n - Continue vancomycin\n - f/u surveillence cultures\n - check Vanc level in AM given low body weight\n 3) Anemia: Consider bleed from trach site vs. femoral hematoma\n - continue to trend hct\n 4) Myopathy/Neuropathy: Myopathy/neuropathy felt possibly mixed\n cryoglobulinemia associated with HCV and possible myopathy from\n interferon. Muscle biopsy showed nonspecific inflammation. Per recent\n neurology outpatient visit, EMG showed a mild sensorimotor\n polyneuropathy as well as a myopathic process in several proximal\n muscles (IP, biceps, infraspinatus, and prominently in L3 paraspinals).\n Additional nerve biopsy may be helpful, but currently holding off.\n MRI without any intracranial abnormality to explain symptoms.\n - F/U cryo levels\n - Neurology following closely\n - patient declined LP today\n - PT today\n # Bulbar weakness: Unclear why bulbar weakness is worsening and the\n rest of weakness is stable on exam. Myasthenia is in the\n differential diagnosis.\n - f/u antiMUSK ab\n - AChR antibody negative\n # Conjunctivitis: S/p corneal abrasion secondary to orbicularis\n weakness and inability to close eye.\n - Ophthalmology following.\n - Continue eye drops/antibiotic ointments Q2H\n - need definitive management (i.e. taping eye) after resolution of\n bacterial infection\n # HCV: Currently off interferon, with undetectable viral loads.\n - Continue nadolol.\n - Patient requests that HCV infection not be disclosed to extended\n family.\n # Dysphagia. Seen by Neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - S&S reevaluation today, now s/p extubation\n - will proceed with PEG placement by IR prior to discharge\n # Thrombocytopenia: Baseline in last 6 months 50-70's. At OSH,\n platelets were in the 20's; heparin stopped for concern for HIT; HIT\n antibody now negative. Platelets improved to 100's. Thrombocytopenia\n thought secondary to liver disease.\n - continue to trend\n - avoid heparin products\n # FEN:\n - Resumed tube feeds via NGT\n # Prophylaxis: Pneumoboots, Continue famotidine.\n - d/c PPI now that she\ns extubated.\n # Access: PIV\n # Code: FULL CODE.\n # Communication: Patient and husband . .\n - She does not wish for extended family to know about HCV status\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Famotidine\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: Call out to Medicine floor.\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 661706,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: cirrhosis / 571.40\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 55 yo F with Hep C\n cirrhosis with 6 month h/o neuromuscular and bulbar weakness admitted\n from OSH with pneumonia requiring intubation, extubated on ,\n developed respiratory distress bleeding around the trach site\n requiring re-intubation followed by revision of trach. Re-extubated\n early .\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, ciprofloxacin, fentanyl, nadolol, tylenol,\n propofol, vancomycin\n Radiology: CXR - Clear right lung. Left lung base opacification is\n worse. Increased left pleural effusion.\n Labs:\n 25.0\n 8.5\n 137\n 12.7\n [image002.jpg]\n Other labs:\n pO2 135\n pCO2 49\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert & oriented x3,\n unable to verbalize trach but able to mouth words to make needs\n met. Following all commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 93\n 146/77\n 22\n 94% on TM\n Sit\n /\n Activity\n 93\n 132/80\n 28\n 97% on TM\n Stand\n /\n Recovery\n 90\n 143/74\n 22\n 97% on TM\n Total distance walked: feet\n Minutes:\n Pulmonary Status: non-labored breathing, lungs cta, no cough noted; on\n 60% FIO2 via trach mask\n Integumentary / Vascular: erythema L eye; R radial a-line, #7 portex\n trach with trach mask, B PIV, foley, tele\n Sensory Integrity: intact to light touch B UE's, intact to light touch\n through L3 on LLE and through L2 on RLE, absent below. Diminished\n proprioception B great toes, R worse then left.\n Pain / Limiting Symptoms: denies pain\n Posture: cachectic appearance, mild kyphotic\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly 4+/5 throughout\n R shoulder flexion \n L shoulder flexion \n R elbow flexion \n L elbow flexion \n R elbow extension \n L elbow extension 3+/5\n R wrist extension 3+/5\n L wrist extension \n strong grip bilaterally\n Motor Function: brisk patella reflexes L>R\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several small steps from edge of bed to\n chair, decr step length bilaterally, limited by multiple lines. Denies\n SOB or lightheadedness.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static/dynamic sitting balance, CG static standing, CG/min A\n dynamic activities- eyes closed x 5 sec, perturbations in all\n directions with LOB backward, unable to assume narrow BOS.\n Education / Communication: Reviewed PT and encouraged OOB and deep\n breathing. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis: 5j\n 1.\n Transfers/gait, impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Impaired pulmonary function\n 5.\n Impaired endurance\n 6.\n Clinical impression / Prognosis: 55 yo F with cirrhosis and muscle\n weakness p/w above impairments a/w CNS disorder. She is most limited\n by muscle weakness UE\ns>LE\ns as well as general weakness and\n deconditioning a/w prolonged hospital stay. She is well below her\n baseline level however is making excellent progress in PT in the past\n week. Would continue to anticipate STR upon d/c as she has new\n tracheostomy however if she remains an inpatient could potentially\n reach a functional level of mobility and possibly d/c home. PT to\n continue to follow up daily, she is good rehab candidate at this time.\n Goals\n Time frame: 1 week\n 1.\n CG stand step transfers, assess gait\n 2.\n No LOB with mobility/gait\n 3.\n Tolerates daily strengthening/therex\n 4.\n Maintains appropriate O2 sat with mobility\n 5.\n Tolerates OOB >2hrs/day\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan: bed mobility, transfers, ambulation, balance,\n strengthening, endurance, education, d/c planning\n Frequency / Duration: daily\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 661707,
"text": "Chief Complaint: Resp Failure\n Weakness\n Tracheal Bleed\n Line Infection\n HPI:\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI fistula per surgical team. Orotracheal intubation. Just had\n revision of trach yesterday. Planning to wean now. Neuro following for\n neuromusc weakness w/u.\n 24 Hour Events:\n 7.0 Portex placed yesterday, started TF, myasthenia w/u undergone, BCx\n with GPCs after fem line pulled.\n INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:30 AM\n Lansoprazole (Prevacid) - 08:10 AM\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.2\nC (99\n HR: 92 (86 - 109) bpm\n BP: 190/144(163) {96/46(65) - 190/144(163)} mmHg\n RR: 21 (11 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,234 mL\n 300 mL\n PO:\n TF:\n IVF:\n 1,824 mL\n 300 mL\n Blood products:\n 350 mL\n Total out:\n 1,058 mL\n 660 mL\n Urine:\n 1,008 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,176 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 332 (307 - 360) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 57\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.37/49/135/26/2\n Ve: 5.3 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: R pupil 6mm L pupil 4mm both reactive\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 137 K/uL\n 85 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 138 mEq/L\n 25.2 %\n 12.7 K/uL\n [image002.jpg]\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n 12:29 PM\n 12:41 PM\n 05:01 PM\n 02:02 AM\n 02:26 AM\n WBC\n 23.4\n 12.7\n Hct\n 28.9\n 24.3\n 24.0\n 26.1\n 25.7\n 26.3\n 25.2\n Plt\n 134\n 137\n Cr\n 0.3\n 0.3\n TCO2\n 28\n 27\n 29\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:14.2/32.0/1.2, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/51, Alk Phos / T Bili:109/1.2,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n GPCs from BCx and old line\n -14 days of IV vanco for Bacteremia\n New GNRs in BAL . Will need to be followed up and treated if not\n felt to be colonization. Low grade temp overnight Tm 100, WBC improved\n from 25\n 12. This will need to be followed up.\n TRACHEAL RECONSTRUCTION (TRACHEOBRONCHIAL)\n s/p cautery of trach bleed, s/p new trach, no recent bleeding\n -f/u BAL\n -cont. TM today\n -cont. nebs\n -speech c/s for PMV\n Corneal abrasion:\n -cont. eye gtts\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n As above\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n -bulbar and facial weakness, extremity weakness improved\n -MRI OK no brainstem lesion\n -neuro wanted LP, can have as an outpatient to w/u for myasthenia\n -Ab pending\n FEN: Swallow eval, TF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 20 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 660473,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Shiley\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Plan\n Next 24-48 hours: Continue T-mask as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660480,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n \n cardiac echo done, results pending.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 10/5, 40% fio2. RR 10\ns-20\ns. LS with wheezes,\n cleared later in shift. Large amts of tan/yellow thick secretions from\n trach. O2 sats 97-100%.\n Action:\n Pt weaned off of vent. Placed on trach collar 50%. Pt to receive last\n dose of Cefepime today. MDI\ns given by RT as ordered.\n Response:\n Sats 100%, pt appears comfortable and in no resp distress.\n Plan:\n Continue to wean down fio2 and monitor resp status. Administer abx as\n ordered.Continue with frequent suctioning.\n Alteration in Nutrition\n Assessment:\n Pt remains NPO with hx of dysphagia\n Action:\n Remains NPO. Waiting to hear from GI to either place doboff today or\n PEG tomorrow. Pt has hx or varices. Currently on D5 1/2NS at 75ml/hr.\n Response:\n Consults pending. Pt remains NPO.\n Plan:\n F/U with choice of nutrition administration. Con\nt NPO.\n Impaired Skin Integrity\n Assessment:\n Yeast on coccyx with skin excoriation and redness. Pt has\n conjunctivitis in each eye, left eye appears more swollen and red.\n Action:\n Miconazole cream applied to pt\ns coccyx. Turned Q 2 hours.\n Erythromycin eye ointment applied, artificial tears and artificial\n tears ointment applied Q 2 hours as ordered.\n Response:\n Per team, eyes\nlook better today than they did yesterday\n Plan:\n Continue to apply miconazole cream to coccyx. Continue to administer\n eye medication as ordered. Turn Q 2 hours.\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. EMG shows a mild sensory motor polyneuropathy as well as a\n myopathic process in several proximal muscles. Muscle biopsy results\n from OSH pending.\n Action:\n Pt given 2-4 mg IV Morphine prn for pain in hip and legs. Repositioned\n frequently. Currently on 1mg Lorazepam IV prn for anxiety. Good\n effect with both meds.\n Response:\n Pain improved. Pt appears to be less anxious. Per team, pt\ns strength\n is better today than it was yesterday.\n Plan:\n Continue to monitor. F/U with neuron consult and biopsy from OSH.\n Per pt\ns husband, pt\ns family is not aware of her HCV status and\n requests that they are not told.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660555,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach collor,copious amount of secretions from the\n trach ,also around the trach sats mid 90\ns,ronchorous breath sounds,\n Action:\n Suctioned as needed,trach care given,MDI by RT..\n Response:\n Sats 95-100%, no resp distress.\n Plan:\n Cont trach collor,wean fi02 as tolerated\n Alteration in Nutrition\n Assessment:\n Receivd the pt NPO,had doboff placed under bronchoscopy at bedside,on\n d5/12 ns @75cc/hr\n Action:\n Started on TF-fibersource HN @ 15cc/hr,tube placement conformed by x\n ray. Recvd neutraphos.\n Response:\n Tolerating the tube feed well,\n Plan:\n Advance 10cc q4h,goal 55cc/hr,need to hold the TF since midnight for\n biopsy in am()\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. Now with eye infection,pt was restless ,trying to get oob,pulling\n wires,.\n Action:\n Recvd ativan 1 mg x 3 doses , also recvd morphine 2 mg ivp,turned and\n repositioned q2h,started on artifical tears q1h and cipro eye drops as\n per opthal reccs.\n Response:\n Pain improved. Pt appears to be less anxious for a short while after\n ativan Contd restlessness ,slides down all the time,resulting in\n displacement of flexiseal,now back to mushroom cath,also put a diaper\n .didnt sleep much in this shift.\n Plan:\n Continue to monitor.?need to increase the ativan or add different drug\n regimen Plan to to do nerve biopsy on ,biopsy from osh is\n pending.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661512,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD. Pt c/o pain \n Action:\n Dressing intact . HCT dropped to 24 from 28, given fentanyl 50mg x2\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, during MRI pt required fentanyl\n 50mg and versed fro seadation 1mg result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cordis line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2.\n folye changed d/t yeast infection\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n K 3.8 repleted with 20meq iv.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660468,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n \n cardiac echo done, results pending.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 10/5, 40% fio2. RR 10\ns-20\ns. LS with wheezes,\n cleared later in shift. Large amts of tan/yellow thick secretions from\n trach. O2 sats 97-100%.\n Action:\n Pt weaned off of vent. Placed on trach collar 50%. Pt to receive last\n dose of Cefepime today. MDI\ns given by RT as ordered.\n Response:\n Sats 100%, pt appears comfortable and in no resp distress.\n Plan:\n Continue to wean down fio2 and monitor resp status. Administer abx as\n ordered.Continue with frequent suctioning.\n Alteration in Nutrition\n Assessment:\n Pt remains NPO with hx of dysphagia\n Action:\n Remains NPO. Waiting to hear from GI to either place doboff today or\n PEG tomorrow. Pt has hx or varices. Currently on D5 1/2NS at 75ml/hr.\n Response:\n Consults pending. Pt remains NPO.\n Plan:\n F/U with choice of nutrition administration. Con\nt NPO.\n Impaired Skin Integrity\n Assessment:\n Yeast on coccyx with skin excoriation and redness. Pt has\n conjunctivitis in each eye, left eye appears more swollen and red.\n Action:\n Miconazole cream applied to pt\ns coccyx. Turned Q 2 hours.\n Erythromycin eye ointment applied, artificial tears and artificial\n tears ointment applied Q 2 hours as ordered.\n Response:\n Per team, eyes\nlook better today than they did yesterday\n Plan:\n Continue to apply miconazole cream to coccyx. Continue to administer\n eye medication as ordered. Turn Q 2 hours.\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. EMG shows a mild sensory motor polyneuropathy as well as a\n myopathic process in several proximal muscles. Muscle biopsy results\n from OSH pending.\n Action:\n Pt given 2-4 mg IV Morphine prn for pain in hip and legs. Repositioned\n frequently. Currently on 1mg Lorazepam IV prn for anxiety. Good\n effect with both meds.\n Response:\n Pain improved. Pt appears to be less anxious. Per team, pt\ns strength\n is better today than it was yesterday.\n Plan:\n Continue to monitor. F/U with neuron consult and biopsy from OSH.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 661677,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient had trach placed, 7-0 fenestrated portex, needs suture\n removal around the trach which needs to be removed in one week, bronch\n during this procedure showed increased mucus from left lower lobe, mini\n BAL was sent\n - ordered for tube feeds\n - Neuro recs, MRI unimpressive, wanted to check antiMUSK Ab for a rare\n type of Myasthenia \n - HCT stable\n - fem catheter tip also grwoing GPC\n - patient needs to consent for blood tests once sedation is off given\n employee blood exposure, employee health is following\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (86 - 109) bpm\n BP: 158/85(113) {96/46(65) - 159/85(114)} mmHg\n RR: 20 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,234 mL\n 78 mL\n PO:\n TF:\n IVF:\n 1,824 mL\n 78 mL\n Blood products:\n 350 mL\n Total out:\n 1,058 mL\n 660 mL\n Urine:\n 1,008 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,176 mL\n -582 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 332 (307 - 360) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 57\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.37/49/135/26/2\n Ve: 5.3 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : )\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 8.5 g/dL\n 85 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 138 mEq/L\n 25.2 %\n 12.7 K/uL\n [image002.jpg]\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n 12:29 PM\n 12:41 PM\n 05:01 PM\n 02:02 AM\n 02:26 AM\n WBC\n 23.4\n 12.7\n Hct\n 28.9\n 24.3\n 24.0\n 26.1\n 25.7\n 26.3\n 25.2\n Plt\n 134\n 137\n Cr\n 0.3\n 0.3\n TCO2\n 28\n 27\n 29\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:14.2/32.0/1.2, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/51, Alk Phos / T Bili:109/1.2,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Microbiology: 8:29 pm CATHETER TIP-IV Source: R femoral\n cortiz.\n GRAM POSITIVE COCCUS(COCCI). >15 colonies.\n 8:29 pm BLOOD CULTURE Source: Line-R femoral cortiz.\n Blood cultures 2/4: GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND\n CLUSTERS.\n Assessment and Plan\n 55 y/o lady with history HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness now s/p trach after intubation for\n aspiration pneumonia and persistant difficulty weaning from vent is\n admitted to MICU after bleeding around trach site.\n .\n # Current Respiratory distress: Current episode is secondary to\n bleeding aroung the trach site. Though to be secondary to small vessel\n in that area. ETT placed for ventilation and went to OR where she was\n found to have small vessel bleed and received stitches. Also had\n electrocautery to cauterize any other superficial bleeders. Thoracics\n is planning for revision today. She was ET intubated by anesthesia\n during the code.\n - Trach revision on \n - trend HCT\n - active T&C\n .\n # s/p trach: Secondary to pneumonia and hypoxic respiratory distress as\n above. Completed 10 day course of antibiotics. Received trials of PMV\n on the floor.\n - Continue nebs\n .\n # GPC bacteremia: Most likely from the nonsterile fem line placed.\n Already discontinued the fem line.\n - vancomycin\n - surveillence cultures\n .\n # Fever/Leukocytosis:? aspiration PNA on CXR left base, but\n radiologically improved. GPC bacteremia as above. Also may have ?\n small pneumo mediatstium per radiology on post code CXR but repeat CXR\n are improved.\n - trend leukocytosis\n -vanc as above\n .\n # Decreased HCT: Most likely from femoral hematoma. Currently\n hemodynamically stable.\n - trend HCT\n - ? CT abd/pelvis if continues to trend down to look for RPB\n .\n # Left femoral hematoma: In the setting of attempted fem line.\n - trend HCT\n - T&C blood as above\n .\n # Myopathy/Neuropathy: Myopathy/neuropathy felt possibly mixed\n cryoglobulinemia associated with HCV and possible myopathy from\n interferon. Muscle biopsy showed nonspecific inflammation. Per recent\n neurology outpatient visit, EMG showed a mild sensorimotor\n polyneuropathy as well as a myopathic process in several proximal\n muscles (IP, biceps, infraspinatus, and prominently in L3 paraspinals).\n Additional nerve biopsy may be helpful, but currently holding off.\n - F/U cryo levels\n - Appreciate neurology input; further management per them\n - MRI brain w/ contrast is ordered per Neurology recs\n .\n # Bulbar weakness: Unclear why bulbar weakness is worsening and the\n rest of weakness is stable on exam. Myasthenia is in the\n differential diagnosis.\n - Follow up AChR antibodies (currently pending)\n .\n # Conjunctivitis: S/p corneal abrasion secondary to orbicularis\n weakness and inability to close eye. Ophthalmology following.\n - Continue eye drops/antibiotic ointments Q2H\n - need definitive management (i.e. taping eye) after resolution of\n bacterial infection\n .\n # HCV: Currently off interferon, with undetectable viral loads. On\n nadolol.\n # Dysphagia. Seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. TF via Dobhoff, continue PPI.\n - will need PEG placement by IR\n # Thrombocytopenia: Baseline in last 6 months 50-70's. At OSH,\n platelets were in the 20's; heparin stopped for concern for HIT; HIT\n antibody now negative. Platelets improved to 100's. Thrombocytopenia\n thought secondary to liver disease.\n # NSTEMI: History of NSTEMI (at OSH), though likely demand ischemia. On\n beta blocker at this time.\n # Occupational blood exposure: Needs paperwork signed for check up\n once she is awake.\n # FEN. Holding on IVF for now. Monitor/replete electrolytes. Tube\n feeds.\n # Prophylaxis: Pneumoboots, PPI.\n # Access: Fem cortis placed under nonsterile condition, will attemp to\n place peripheral IVs and then remove the fem line\n # Code: FULL CODE\n # Communication: Patient and husband . .\n - She does not wish for extended family to know about HCV status\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661669,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 fenestrated\n portex trach.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube. Pt received on ACV, changed to PSV at\n beginning of shift.\n Action:\n Pt. tolerating PSV overnight, changed to trach collar this am.\n Response:\n Tolerating trach collar. Sats 99%. Pt with serosanginous secretions\n around new trach site.\n Plan:\n Monitor response to trach collar. Pt will need eventual evaluation by\n speech and swallow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. received on Propofol gtt at 40mcg/kg/min. Pt. complaining of pain\n at trach site.\n Action:\n Propofol d/c\nd. Given bolus Fentanyl for pain control overnight.\n Response:\n Pt. states good response to Propofol.\n Plan:\n Continue to monitor for pain and medicate PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660658,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach mask. Moderate amt of yellow blood tinged\n sputum from around trach site. Small amt\ns suctioned from trach. O2\n sats 97-100%.\n Action:\n Suctioned prn. Trach inner cannula cleaned. Fio2 down to 40%. Speech\n and swallow in to eval pt and attempted passey-euir valve placement.\n Pt had too many secretions and it was unsuccessful.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suction prn and wean down fio2.\n Alteration in Nutrition\n Assessment:\n Received pt on 35ml/hr Fibersource HN via doboff.\n Action:\n TF\ns weaned up to goal of 55cc/hr.\n Response:\n Tolerating TF well. Currently at goal.\n Plan:\n NPO after midnight for ? nerve biopsy tomorrow. Remains on RISS.\n Myopathy, other (not of critical illness)\n Assessment:\n Pt\ns strength is improving. Able to lift and hold all 4 extremities.\n Tolerating trach collar well without struggling to use muscles for\n breating. Per ENT eyes look like they are improving.\n Action:\n Currently on artificial tear drops and ointment Q 2 hours. Cipro eye\n drops changed to QHS.\n Response:\n Per team eyes are improving.\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661465,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site\n overnoc. Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt received intubated via ETT from OR with old\n trach site packed with xeroform and covered with DSD.\n Action:\n Dressing reinforced x several, then packing changed by thoracic \n team this evening. Moderate amt sanguinous drainage saturating through\n dressing.\n Response:\n HCT remain stable at this time.\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Alteration in Nutrition\n Assessment:\n Pt with hx of 35 lb weight loss since /. Pt unable to eat \n muscle weakness. Per husband, would vomit anything taken orally. Mg\n 1.3, K+ 3.1 today.\n Action:\n Pt had peditube in right nare; did have TF running prior to tracheal\n bleed and OR procedure. Repleted with 4gm Mg+ and 80 mEq K+ today. TF\n continue OFF for OR procedure in AM.\n Response:\n K+ improved to 3.8 and Mg+ improved to 2.2 post repletions today.\n Plan:\n NPO until post procedure tomorrow. Then likely will restart TF and\n replete electrolytes as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt s/p trach for failure to wean from vent muscular weakness.\n Now s/p tracheal bleed from superficial arterial bleed around trach\n site, with removal of trach, flex bronch in OR. Pt intubated s/p\n tracheal bleed.\n Action:\n Pt on AC 50%/400/14/5.\n Response:\n ABG WNL. Pt with RR 20s, O2 sat 93-100%.\n Plan:\n Cont with current vent settings. Pt to go to OR tomorrow for new trach\n placement at which time ETT will be removed. Will cont on vent post\n trach placement and OR, then will wean vent as tolerated.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned OFF for wake up this evening. Pt unable to squeeze\n hands bilaterally but able to follow commands to open mouth and move\n feet. Pt being followed by neuro. S/P muscle biopsy to right thigh and\n right forearm.\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy results.\n Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660652,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660656,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660723,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Recvd the pt on 40% trach collor,satting 95-100%,ronchorous breath\n sounds,thick yellow secretions coming around the trach,\n Action:\n No further changes in fi02,trach care given MDI\ns by RT,suctioned as\n needed.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suctioned prn\n Myopathy, other (not of critical illness)\n Assessment:\n Known myopathy very restless and agitated,poor sleep,seems very\n anxious,c/o pain at trach site,now with severe eye infection. As per\n the family pt is a heavy smoker\n Action:\n Received ativan 1 mg x4 doses in this shift alsong with morphine 2 mg\n x2,contd all eye drops/ointments as per opthal, A nicotine patch has\n been applied.\n Response:\n Improvement noted in the eyes,contd to have restlessness and pulling\n out wires and tubes,pt has pulled out the mushroom cath x2 in this\n shift,seems better after 0400am.\n Plan:\n Continue to monitor ,?increase the ativan dose or add a different drug\n regimen.\n Impaired Skin Integrity\n Assessment:\n Excoriated perineum,pt has pulled out the mushroom cath x2 in this\n shift,contd have loose bm,\n Action:\n Skin protectant applied ,turned and respositioned q2h,\n Response:\n Pt cont to have restlessness which prevents the successful drainage of\n the stool and infact lead to leaking,explained the pt but contd the\n same behavior,reinserted mushroom cath , diaper in place.\n Plan:\n Cont local skin care,turn and reposition ,\n T max 100.1 in this shift,urine cx sent,T current 97.8.\n Tube feed on hold since MN ?nerve biopsy in am.\n Received 15mmol k phos .\n Hr 85-120,sbp 130-160,received ns fluid bolus 1000cc x2 in this shift.\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 660831,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 55 yo f c h/o\n hepatitis C on interferon who was brought to by\n husband for increasing dysphagia, nausea and vomiting. Pt has h/o\n worsening weakness (over last few years) in her feet, proximal lower\n extremity muslces and hands with a few falls, trouble with stairs and\n trouble opening jars.While at OSH the patient aspirated and developed\n aspiration pneumonia , required intubation and had difficulty\n extubating secondary to known muscle weakness. The patient underwent\n tracheostomy on and was transferred to . While at \n she also underwent muscle biopsy of R quad and R forearm those results\n are pending.\n Past Medical / Surgical History: - Hepatitis C, dx , on PEG\n interferon\n - known cirrhosis and varices\n - Asthma\n - Recent hoarseness - to reflux esophagitis per ENT (DR.\n )\n - s/p appy, choly\n - hx of venous thrombophlebitis 25 yrs ago\n Medications: Duloxetine, Morphine, Lorazepam, Lorazepam\n Radiology: CXR : . Continued congestive failure or fluid overload\n with left pleural effusion. EEG : Abnormal study. There is\n electrophysiologic evidence for a mild proximally predominant myopathy\n with some denervating features. There is also evidence for a mild to\n moderate, chronic, sensorimotor, generalized polyneuropathy which is\n axonal in nature and appears symmetric. Compared with the prior study\n of , the polyneuropathy is new and the myopathy is more clearly\n present\n Labs:\n 34.0\n 11.4\n 140\n 6.6\n [image002.jpg]\n Other labs:\n Activity Orders: Ok for OOB RN\n Social / Occupational History: Married\n Living Environment: Unable to obtain hx from patient\n Prior Functional Status / Activity Level: Unable to obtain hx from\n patient\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt is lethargic supine\n in bed, pt appears more alter and is able to follow more commands when\n sitting up at EOB, even smiled occasoinally. Pt followed 70% of\n commands when supine, 100% sitting at EOB. Pt inconsistently mouth\n words and nodding head to questions. Orient to hospital and name, not\n date.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: CTAB, strong non prodcutive cough\n Integumentary / Vascular: NGT, foley, B PIV. B eyes with vasaline, R\n eye appears cloudy.\n Sensory Integrity: minimally withdrawal to painful stim B LE. withdraws\n to pain B UE\n Pain / Limiting Symptoms: Pt reports she is comfortable, no pain\n Posture: cachetic\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n Motor Function:\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance:\n Education / Communication:\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performace, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Posture, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 660842,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / cirrhosis\n Reason of referral: eval and tx\n History of Present Illness / Subjective Complaint: 55 yo f c h/o\n hepatitis C on interferon who was brought to by husband\n for increasing dysphasia, nausea and vomiting. Pt has h/o worsening\n weakness (over last few years) in her feet, proximal lower extremity\n muscles and hands with a few falls, trouble with stairs and trouble\n opening jars. While at OSH the patient aspirated and developed\n aspiration pneumonia , required intubation and had difficulty\n extubating secondary to known muscle weakness. The patient underwent\n tracheostomy on and was transferred to . While at \n she also underwent muscle biopsy of R quad and R forearm those results\n are pending.\n Past Medical / Surgical History: - Hepatitis C, dx , on PEG\n interferon\n - known cirrhosis and varices\n - Asthma\n - Recent hoarseness\n - s/p appy, choly\n - hx of venous thrombophlebitis 25 yrs ago\n Medications: Duloxetine, Morphine, Lorazepam, Lorazepam\n Radiology: CXR : . Continued congestive failure or fluid overload\n with left pleural effusion. EEG : Abnormal study. There is\n electrophysiologic evidence for a mild proximally predominant myopathy\n with some denervating features. There is also evidence for a mild to\n moderate, chronic, sensorimotor, generalized polyneuropathy which is\n axonal in nature and appears symmetric. Compared with the prior study\n of , the polyneuropathy is new and the myopathy is more clearly\n present\n Labs:\n 34.0\n 11.4\n 140\n 6.6\n [image002.jpg]\n Other labs:\n Activity Orders: Ok for OOB RN\n Social / Occupational History: Married\n Living Environment: Unable to obtain hx from patient\n Prior Functional Status / Activity Level: Unable to obtain hx from\n patient\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt is lethargic supine\n in bed, pt appears more alter and is able to follow more commands when\n sitting up at EOB, even smiled occasionally. Pt followed 70% of\n commands when supine, 100% sitting at EOB. Pt inconsistently mouth\n words and nodding head to questions. Orient to hospital and name, not\n date.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: CTAB, strong non productive cough\n Integumentary / Vascular: NGT, foley, B PIV. B eyes with Vaseline, R\n eye appears cloudy.\n Sensory Integrity: minimally withdrawal to painful stim B LE. withdraws\n to pain B UE\n Pain / Limiting Symptoms: Pt reports she is comfortable, no pain\n Posture: cachetic\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n B DF \n B knee ext > \n B hip flexion > 3-/5\n B shld flexion > 3-/5\n B elb flexion > 3-/5\n Motor Function: Pt able to track B\nly. Visual assessment limited\n however pt able to mimic finger gestures in both R and L fields\n grossly.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n x\n Supine /\n Sidelying to Sit:\n\n\n\n x\n\n Transfer:\n\n\n\n x\n\n Sit to Stand:\n\n\n\n x\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt has good sitting balance at EOB she is able to reach\n within BOS in all directions with S. Pt requires mod A x 2 to stand and\n perform marching with increased posterior bias.\n Education / Communication: Pt educated on role of PT. Pt status\n discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Posture, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 55 yo f c hep c on interferon presents\n from OSH with increase dysphagia, resp failure requiring trach and\n progressive myopathy which is still being worked up. Pt presents with\n above impairments c/w deconditioning, and connective tissue\n dysfunction. Pt is functioning below baseline limited by mental status,\n and strength deficits. Pt has potential to make gains with mobility,\n pending improvement in strength bracing options maybe considered in the\n future to assist with foot drop. Pt will require rehab upon d/c to\n optimize safety and function.\n Goals\n Time frame:\n 1.\n follow 100% of 1 step command\n 2.\n I bed mobility\n 3.\n Min A to transfer\n 4.\n Min A to maintain standing balance > 2 mins\n 5.\n Increase mmt t/o\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 660843,
"text": " MD ADMITTING NOTE:\n PT WAS ADMITTED FROM on . Pt is a 55 y/o F hx\n HCV treated with IFN, cyroglobulinemia with progressively worsening\n peripheral myopathy followed by neurology and dysphagia who was\n recently admitted to OSH for planned peg due to dysphagia, poor PO\n intake and 5 pound weight loss over past 3-4 months. During admission,\n she developed hypoxia, fever and was found to have an aspiration\n pneumonia. Sputum Cx grew serratia, E. coli, and staph. She required\n intubation and was hypotensive requiring pressors X 2 days. She is\n currently on day of cefepime and has been off pressors X 4 days.\n Per ICU attd at OSH, she was difficult to wean from vent presumably\n from neuromuscular weakness and is now s/p trach on and\n currently on PS 15/5 30%. She received daily PS trials but was not able\n to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n .\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n .\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Currently awaiting muscle bx prior to doing nerve bx. Holding\n interferon as may be cause of increasing weakness. Pt has corneal\n abrasions and sever conjunctivitis, ophthalmology following. Pt needs\n eye drops q1hr secondary to inability to blink eyes. Pt seen by ENT,\n thought to have laryngeal reflex\nDophoff placed. Seen by Speech\n therapy , unable to tolerate PMV at this time secondary to\n secretions. Pt remains on Trach mask 70%, sat\ns 95-97% at rest. Pt\n desat\ns slightly when OOB and during exertion. Pt is lethargic today\n (night shift nurse reported that pt was very restless and did NOT sleep\n last night). Lungs diminished, pt has strong cough. Pt able to bring\n thick secretions up , but needs suctioning to clear. ABd soft,\n +BS..No stool today. Restarted on TF today at 30cc/hr w/ goal of\n 55CC/hr. denies nausea.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Because eyes are swollen and pt is unable to blink, it is difficult at\n times to assess if she if focusing or tracking. Pt is able to follow\n commands about 60-75% of the time. Pt will nod head appropriately to\n yes /no questions.\n Action:\n Continues to assess neuro status and re-orient pt as needed.\n Response:\n Plan:\n Continue to assess\n Motor Function, Impaired\n Assessment:\n Pt is stiff and slightly contracted at times. Pt was able to stand on\n side of bed and pivot to chair with assist of two.\n Action:\n Pt followed by Neuro\n Response:\n Neuro feels overall pt has increased muscle tone\n Plan:\n Pt to be reassessed by speech therapy on Monday for PMV, Continues to\n work w/ PT\n Please note husband request\ns that no information be given out to\n other family memebers. All information to be filtered via husband.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n CIRRHOSIS;HEPATITIS;HEPATIC ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n Admission weight:\n 55 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma\n CV-PMH:\n Additional history: Active hepatitis, known cirrhosis,known varices,\n recent horseness which was evaluated by ENT, s/p choly, s/p\n appendectomy and hx of venous thrombophlebitis.\n Surgery / Procedure and date: Trach \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:149\n D:95\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 70% %\n 24h total in:\n 1,601 mL\n 24h total out:\n 1,785 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:23 AM\n Potassium:\n 4.0 mEq/L\n 03:23 AM\n Chloride:\n 109 mEq/L\n 03:23 AM\n CO2:\n 27 mEq/L\n 03:23 AM\n BUN:\n 6 mg/dL\n 03:23 AM\n Creatinine:\n 0.3 mg/dL\n 03:23 AM\n Glucose:\n 95 mg/dL\n 03:23 AM\n Hematocrit:\n 34.0 %\n 03:23 AM\n Finger Stick Glucose:\n 93\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU -6\n Transferred to: 10\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "General",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Generic Note",
"row_id": 660847,
"text": "TITLE: REPEAT EVALUATION\n Pt did not tolerate continuous secretions requiring shallow\n tracheal suctioning. We will reevaluate Monday for toleration.\n Please see Web OMR for complete note.\n , SLP/Student\n Pager #\n 15:52\n ------ Protected Section ------\n I was present for the above evaluation and agree with the assessment\n and recommendations.\n , MS, CCC-SLP\n Pager#\n ------ Protected Section Addendum Entered By: , M.S.,\n CCC-SLP on: 15:54 ------\n 15:54\n"
},
{
"category": "General",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Generic Note",
"row_id": 660845,
"text": "TITLE: REPEAT EVALUATION\n Pt did not tolerate continuous secretions requiring shallow\n tracheal suctioning. We will reevaluate Monday for toleration.\n Please see Web OMR for complete note.\n , SLP/Student\n Pager #\n 15:52\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660176,
"text": "Chief Complaint: OSH transfer for workup of weakness\n 24 Hour Events:\n Events:\n - overnight remained anxious and uncomfortable, received ativan and\n morphine with only mild effect\n - tachycardic to 110s\n - no PO access, consider PEG v. NG tube today\n INVASIVE VENTILATION - START 09:05 PM\n MULTI LUMEN - START 09:42 PM\n EKG - At 10:53 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 01:00 AM\n Morphine Sulfate - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.6\n HR: 104 (104 - 122) bpm\n BP: 150/87(103) {127/83(95) - 150/89(103)} mmHg\n RR: 15 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8 mL\n 583 mL\n PO:\n TF:\n IVF:\n 8 mL\n 583 mL\n Blood products:\n Total out:\n 145 mL\n 265 mL\n Urine:\n 145 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -138 mL\n 318 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.37/45/179/29/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 447\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 84 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 29.9 %\n 6.7 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n WBC\n 6.4\n 6.7\n Hct\n 29.5\n 29.9\n Plt\n 76\n 80\n Cr\n 0.3\n 0.3\n TropT\n 0.18\n TCO2\n 27\n Glucose\n 73\n 84\n Other labs: PT / PTT / INR:15.5/31.8/1.4, CK / CKMB /\n Troponin-T:98//0.18, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.5\n mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process. She\n does not appear to have had prlongued illness or steroid use.\n - continue 10 day course cefepime and moxiflox (today day )\n - continue PS with goal to wean, daily RSBI and SBT\n - try sitting upright to see if diaphragmatic paralysis\n - apprec neurology recs\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - d/w neuro re: nerve bx\n - continue nebs given hx asthma\n - repeat CXR tonight\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia.\n - neurology c/s in am\n - I will email Dr. , her outpt neurologist, tonight\n - check cryo levels\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs\n - continue IFN Q week\n - can restart nadolol if BP and HR tolerated\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continue ranitidine and PPI\n - c/s IP for peg in AM, if not possible tomorrow, would place NGT for\n tube feeds\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - check EKG and CE's\n - would start ASA\n .\n # FEN:\n - No IVF\n - replete electrolytes\n - tube feeds after NGT\n .\n # Prophylaxis:\n - pneumoboots\n - PPI and H2 blocker\n .\n # Access:\n - RIJ from OSH (placed on )\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661665,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 fenestrated\n portex trach.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube. Pt received on ACV, changed to PSV at\n beginning of shift.\n Action:\n Pt. tolerating PSV overnight, changed to trach collar this am.\n Response:\n Tolerating trach collar. Sats 99%. Pt with serosanginous secretions\n around new trach site.\n Plan:\n Monitor response to trach collar. Pt will need eventual evaluation by\n speech and swallow.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Pt awake this AM and able to follow commands. Pt with equal \n strength bilaterally, able to move all extremities. Pt being followed\n by neuro. S/P muscle biopsy to right thigh and right forearm.\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy results.\n Pt to have LP and additional testing once no longer on vent.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661666,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 fenestrated\n portex trach.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube. Pt received on ACV, changed to PSV at\n beginning of shift.\n Action:\n Pt. tolerating PSV overnight, changed to trach collar this am.\n Response:\n Tolerating trach collar. Sats 99%. Pt with serosanginous secretions\n around new trach site.\n Plan:\n Monitor response to trach collar. Pt will need eventual evaluation by\n speech and swallow.\n"
},
{
"category": "Nutrition",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 660826,
"text": "Objective\n Pertinent medications: folate, protonix, Vit B complex c/ vit C,\n multivitamin, others noted\n Labs:\n Value\n Date\n Glucose\n 95 mg/dL\n 03:23 AM\n Glucose Finger Stick\n 123\n 04:00 PM\n BUN\n 6 mg/dL\n 03:23 AM\n Creatinine\n 0.3 mg/dL\n 03:23 AM\n Sodium\n 138 mEq/L\n 03:23 AM\n Potassium\n 4.0 mEq/L\n 03:23 AM\n Chloride\n 109 mEq/L\n 03:23 AM\n TCO2\n 27 mEq/L\n 03:23 AM\n pH (urine)\n 7.0 units\n 01:12 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 11:55 PM\n Calcium non-ionized\n 7.9 mg/dL\n 03:23 AM\n Phosphorus\n 2.1 mg/dL\n 03:23 AM\n Magnesium\n 1.7 mg/dL\n 03:23 AM\n WBC\n 6.6 K/uL\n 03:23 AM\n Hgb\n 11.4 g/dL\n 03:23 AM\n Hematocrit\n 34.0 %\n 03:23 AM\n Current diet order / nutrition support: Fibersource @55mL/hr (1584\n kcas/70 graa)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n Pt had NGT placed . TF\ns advanced to goal c/ good tolerance.\n Currently on hold since midnight for planned nerve biopsy this am. PT\n did not get biopsy and plan per d/w RN to resume feeds. PO4 remains\n low despite 15mm KPO4 yesterday. Pt c/o to floor. Plan for speech to\n see for ? PMV.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Resume TF's as ordered\n Other: Residual checks q4 hr, hold if > 150mL\n Continue to replete PO4 until WNL\n Please page c/?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660181,
"text": "Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient from OSH vented via trach tube , A/C 400/../5 and 50%.\n Bilateral lung sounds rhonchorus and diminished bases. Copius amount of\n thick blood tinged secreation with suction. From OSH patient has\n difficulty in weaning is may be due to neuromuscular weakness. O2 sats\n 99-100%\n Action:\n Continued vent settings, O2 down to 40%, suctioned thick blood tinged\n secreation, CXR taken. Ativan 1mg q8hrs for agitation and morphine\n 2-4mg PRN for pain.\n Response:\n Blood gas satisfactory, O2 sats 98-100%, continue to have copious amt\n of blood tinged secreation.\n Plan:\n Daily RSBI and SBT, wean vent as tolerated, MDI\ns as ordered and\n suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n NPO tonight, D51/2 NS 100ml/hr on flow and continued PPI, finger stick\n qid\n Response:\n Plan:\n C/s IP for PEG in Am, if not NGT placement for tube feeds.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change, miconazole cream applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle and nerve biopsy are needed to help evaluate the nature\n of her myopathy and to look for evidence of a vasculitic neuropathy in\n the setting of her cryoglobulinemia.\n Action:\n Check cryo levels, morphine 2mg x2 and 4mg x1 given for pain.\n Response:\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH.\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 661655,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Fenestrated\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 4 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Able to successfully wean to trach collar\n AM RSBI 58\n Assessment of breathing comfort: comfortable\n Plan\n Next 24-48 hours: Weaned to trach collar\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660333,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient A/C 450x14, PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copius amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n Pt placed on CPAP 50% 10/5 cont freq suction of thick tan/ blood tinged\n secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change, miconazole cream applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle biopsy results from OSH pending,.\n Action:\n morphine 2mg x2 and 4mg x1 given for pain./ tachycardia 110\ns-120\ns, pt\n also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660377,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Neuro rec'd sural nerve biopsy by NSurg ()\n - Liver rec'd Dobhoff tube for nutrition, hydroxyzine for itching,\n consider plamapharesis if condition does not improve\n - RUQ U/S -> Trace ascites without sufficient fluid for safe bedside\n paracentesis. Stable enlarged CBD. Coarsened liver c/w cirrhosis,\n without focal lesions\n - tachycardia improved with fluid boluses, morphine, ativan and IV\n metoprolol 5mg IV\n MULTI LUMEN - STOP 04:46 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:50 PM\n Pantoprazole (Protonix) - 12:03 AM\n Lorazepam (Ativan) - 04:44 AM\n Metoprolol - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 88 (88 - 120) bpm\n BP: 139/81(95) {123/79(93) - 164/104(112)} mmHg\n RR: 10 (8 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,561 mL\n 438 mL\n PO:\n TF:\n IVF:\n 1,561 mL\n 438 mL\n Blood products:\n Total out:\n 1,205 mL\n 490 mL\n Urine:\n 1,205 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 356 mL\n -53 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 359 (305 - 418) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n Plateau: 19 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n NIF: -18 cmH2O\n Ve: 7 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 107 K/uL\n 10.5 g/dL\n 92 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 6 mg/dL\n 102 mEq/L\n 134 mEq/L\n 31.9 %\n 6.0 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n WBC\n 6.4\n 6.7\n 6.0\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n Plt\n 76\n 80\n 107\n Cr\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n Other labs: PT / PTT / INR:14.9/32.1/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process.\n - complete 10 day of cefepime, will get ID approval\n - continue PS with goal to wean, daily RSBI and SBT; did well with\n decrease PS this morning\n - try sitting upright to see if diaphragmatic paralysis\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult and will touch base with Dr. ; plan for possible\n nerve biopsy and / or EMG\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs\n - continue IFN Q week, although need to consider IFN as toxic cause of\n her myopathy\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - IVF boluses PRN\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopping ranitidine today\n - will discuss with liver if PEG tube can be placed\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n .\n # Access:\n - RIJ from OSH (placed on ); plan for PIVs and then d/c of RIJ if\n possible\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660700,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Recvd the pt on 40% trach color,satting 95-100%,ronchorous breath\n sounds,thick yellow secretions coming around the trach,\n Action:\n No further changes in fi02,trch care given MDI as per RT,suctioned as\n needed.\n Response:\n Pt remains comfortable on current fio2. Sats 100%. Still with\n moderate amt of secretions from trach. No resp distress noted.\n Plan:\n Continue to monitor, suctioned prn\n Myopathy, other (not of critical illness)\n Assessment:\n Known myothy very restless and agiatated,poor sleep,seems very\n anxious,c/p pain at trach site,now with severe eye infection. As per\n the family pt is a heavy smoker\n Action:\n Received ativan 1 mg x3 doses in this shift alsong with morphine 2 mg\n x2,contd all eye drops/ointments as per opthal, A nicotine patch has\n been applied.\n Response:\n Improvement noted in the eyes,contd to have reslessness and pulling\n out wires and tubes,pt has pulled out the mushroom cath x2 in this\n shift\n Plan:\n Continue to monitor ,\n Impaired Skin Integrity\n Assessment:\n Excoriated perineum,pt has pulled out the mushroom cath x2 in this\n shift,contd have loose bm,\n Action:\n Skin protectant applied ,turned and respositioned q2h,\n Response:\n Pt cont to have restlessness which prevents the successful drainage of\n the stool and infact lead to leaking,explained the pt but contd the\n same behavior\n Plan:\n Cont local skin care,turn and reposition\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "ICU Attending",
"row_id": 660514,
"text": "CRITICAL CARE STAFF\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. The ICU team\ns note\n from today reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Yesterday, we decreased her ventilatory support, which she has\n tolerated. She was seen by liver and neurology.\n On exam, she is comfortable on PSV. Eyes are injected. Heart is\n regular. Today there is a holosystolic murmur. Lungs are coarse.\n Abdomen is soft and nontender. Neurologic exam is unchanged c/w\n yesterday, though her affect is brighter today. Muscle biopsy site\n intact.\n Labs, imaging, and medications reviewed in today\ns ICU team note.\n Assessment and Plan\n 55-year-old woman with\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n o Appears to have improved substantially\n try trach mask today\n Myopathy and neuropathy\n o Appreciate neuro\ns help.\n o Awaiting results of recent muscle biopsy\n o Anticipate nerve biopsy this week, per neuro\n Conjunctivitis\n o Ophtho consult\n Access\n o PIVs adequate\n o Liver team feels Dobhoff appropriate course for enteral\n access. Will do under bronchoscopic guidance.\n HCV\n o Hold interferon\n o [image002.jpg] Beta blockers IV for now\n Tachycardia\n o Showing improvement\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Improving\n Other issues as per ICU team note above.\n She is critically ill. 45 minutes\n"
},
{
"category": "General",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Procedure Note",
"row_id": 660515,
"text": "TITLE: Resident Procedure Note - Placement of Dopoff tube\n Time: 5:30pm\n Under the visual guidance of bronchoscopy done by Dr. , dopoff\n tube was placed in right nares with stylet. It advanced easily to\n 70cms. Stylet was removed. Confirmation by air felt in abdomen. CXR\n pending. Patient tolerated the procedure well.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Small-bore feeding tube placement",
"row_id": 660524,
"text": "TITLE: Resident Procedure Note - Placement of Dopoff tube\n Time: 5:30pm\n Under the visual guidance of bronchoscopy done by Dr. , dopoff\n tube was placed in right nares with stylet. It advanced easily to\n 70cms. Stylet was removed. Confirmation by air felt in abdomen. CXR\n pending. Patient tolerated the procedure well.\n ------ Protected Section ------\n Critical Care Staff\n Present throughout entire dprocedure. Indications, risks, and benefits\n of procedure discussed with Ms. . Easy placement with real-time\n bronchoscopic visualization of airways, done to ensure avoidance of\n endotracheal placement. Advanced to ~50cm, presumptive pylorus. 20cc\n D5W instilled until loss of resistance\n advanced to 70cm. CXR\n confirmed placement.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:40 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661481,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD.\n Action:\n Dressing intact . HCT dropped to 24 from 28\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660158,
"text": "Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient from OSH vented via trach tube , A/C 400/../5 and 50%.\n Bilateral lung sounds rhonchorus and diminished bases. Copius amount of\n thick blood tinged secreation with suction. From OSH patient has\n difficulty in weaning is may be due to neuromuscular weakness. O2 sats\n 99-100%\n Action:\n Continued vent settings, O2 down to 40%, suctioned thick blood tinged\n secreation, CXR taken. Ativan 1mg q8hrs for agitation and morphine\n 2-4mg PRN for pain.\n Response:\n Blood gas satisfactory, O2 sats 98-100%, continue to have copious amt\n of blood tinged secreation.\n Plan:\n Daily RSBI and SBT, wean vent as tolerated, MDI\ns as ordered and\n suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n NPO tonight, D51/2 NS 100ml/hr on flow and continued PPI, finger stick\n qid\n Response:\n Plan:\n C/s IP for PEG in Am, if not NGT placement for tube feeds.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change, miconazole cream applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle and nerve biopsy are needed to help evaluate the nature\n of her myopathy and to look for evidence of a vasculitic neuropathy in\n the setting of her cryoglobulinemia.\n Action:\n Check cryo levels, morphine 2mg x2 and 4mg x1 given for pain.\n Response:\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660331,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660332,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient A/C 450x14, PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copius amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n Pt placed on CPAP 50% 10/5 cont freq suction of thick tan/ blood tinged\n secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change, miconazole cream applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle biopsy results from OSH pending,.\n Action:\n morphine 2mg x2 and 4mg x1 given for pain./ tachycardia 110\ns-120\ns, pt\n also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660563,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach collor,copious amount of secretions from the\n trach ,also around the trach sats mid 90\ns,ronchorous breath sounds,\n Action:\n Suctioned as needed,trach care given,MDI by RT..\n Response:\n Sats 95-100%, no resp distress.\n Plan:\n Cont trach collor,wean fi02 as tolerated\n Alteration in Nutrition\n Assessment:\n Receivd the pt NPO,had doboff placed under bronchoscopy at bedside,on\n d5/12 ns @75cc/hr,am lab shows k 3.2 mg 1.4\n Action:\n Started on TF-fibersource HN @ 15cc/hr,tube placement conformed by x\n ray. Recvd neutraphosx 2 doses,\n Response:\n Tolerating the tube feed well,\n Plan:\n Advance 10cc q4h,goal 55cc/hr,will replete k and mg as per sliding\n scale.need to hold the TF since midnight for biopsy in am()\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. Now with eye infection,pt was restless ,trying to get oob,pulling\n wires,.\n Action:\n Recvd ativan 1 mg x 4 doses , also recvd morphine 2 mg ivp,turned and\n repositioned q2h,started on artifical tears q1h and cipro eye drops as\n per opthal reccs.\n Response:\n Pain improved. Pt appears to be less anxious for a short while after\n ativan Contd restlessness ,slides down all the time,resulting in\n displacement of flexiseal,now back to mushroom cath,also put a diaper\n .didnt sleep much in this shift.\n Plan:\n Continue to monitor.?need to increase the ativan or add different drug\n regimen Plan to to do nerve biopsy on .\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661479,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site\n overnoc. Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt received intubated via ETT from OR with old\n trach site packed with xeroform and covered with DSD.\n Action:\n Dressing reinforced x several, then packing changed by thoracic \n team this evening. Moderate amt sanguinous drainage saturating through\n dressing.\n Response:\n HCT remain stable at this time.\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661480,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site\n overnoc. Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt received intubated via ETT from OR with old\n trach site packed with xeroform and covered with DSD.\n Action:\n Dressing reinforced x several, then packing changed by thoracic \n team this evening. Moderate amt sanguinous drainage saturating through\n dressing.\n Response:\n HCT remain stable at this time.\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt s/p trach for failure to wean from vent muscular weakness.\n Now s/p tracheal bleed from superficial arterial bleed around trach\n site, with removal of trach, flex bronch in OR. Pt intubated s/p\n tracheal bleed.\n Action:\n Pt on AC 50%/400/14/5.\n Response:\n ABG WNL. Pt with RR 20s, O2 sat 93-100%.\n Plan:\n Cont with current vent settings. Pt to go to OR tomorrow for new trach\n placement at which time ETT will be removed. Will cont on vent post\n trach placement and OR, then will wean vent as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661482,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD.\n Action:\n Dressing intact . HCT dropped to 24 from 28\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cortic line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661483,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD.\n Action:\n Dressing intact . HCT dropped to 24 from 28\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cordiz line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661484,
"text": "Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Ptremiansintubated via ETT from OR with old trach site packed with\n xeroform and covered with DSD.\n Action:\n Dressing intact . HCT dropped to 24 from 28\n Response:\n Given 1unit of PC\n Plan:\n Pt to go to OR tomorrow for trach revision and replacement.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Sedation turned down to 10mcg/kg/min d/t hypotensiong. Pt unable to\n squeeze hands bilaterally but able to follow commands to open mouth and\n move feet. Pt being followed by neuro. S/P muscle biopsy to right thigh\n and right forearm. MRI of head done, result pending\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy and MRI\n results. Pt to have LP and additional testing once stable from\n respiratory/airway point of view.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 101, and before MRI droped BP to 85-87., MD aware\n Action:\n Blood and urine cx sent, given Tylenol. Cordis line removed by MD,\n site intact. Given 1 dose of vanco, given fluid bolus of NS 1000cc x2\n Response:\n Temp down to 98.3. BP up to 100\n Plan:\n Cont follow temp and BP.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 661632,
"text": "Chief Complaint:\n 24 Hour Events:\n - spiked fever, hypotensive to high 70's, tachy to 120's. Given 2\n liters NS, vancomycin 1 g given dirty line placement.\n - Blood cx x 2, urine culture sent\n - UA with pyruria (seen previously, likely related to candiduria) ->\n foley changed\n - Cordis removed, catheter tip sent for culture\n - Hct drop from 29 to 24 -> transfused 1 unit PRBC's\n - NPO after MN for trach revision\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:50 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Midazolam (Versed) - 10:37 PM\n Fentanyl - 03:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.7\nC (98.1\n HR: 101 (91 - 126) bpm\n BP: 121/64(86) {93/50(66) - 166/89(113)} mmHg\n RR: 18 (12 - 35) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,135 mL\n 691 mL\n PO:\n TF:\n IVF:\n 8,265 mL\n 341 mL\n Blood products:\n 750 mL\n 350 mL\n Total out:\n 2,560 mL\n 510 mL\n Urine:\n 1,560 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,575 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 399 (359 - 399) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 63\n PIP: 15 cmH2O\n Plateau: 6 cmH2O\n SpO2: 99%\n ABG: 7.41/42/63/25/1\n Ve: 7 L/min\n PaO2 / FiO2: 126\n Physical Examination\n General: sedated and no acute distress\n HEENT: Right eye with conjunctival injection/erythema, both eyes with\n substantial ointment, mucus membranes dry, otherwise clear\n Neck: supple\n Lungs: Coarse breath sounds b/l\n CV: Tachycardia, normal S1 + S2\n Abdomen: Soft, non-distended\n Ext: Warm, well perfused\n Neuro: limited by sedation\n Labs / Radiology\n 134 K/uL\n 9.4 g/dL\n 112 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 112 mEq/L\n 139 mEq/L\n 26.1 %\n 23.4 K/uL\n [image002.jpg]\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n 01:24 PM\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n WBC\n 6.6\n 16.1\n 23.4\n Hct\n 34.0\n 31.5\n 29.4\n 28.9\n 24.3\n 24.0\n 26.1\n Plt\n 140\n 149\n 134\n Cr\n 0.3\n 0.3\n 0.3\n 0.3\n TCO2\n 30\n 28\n Glucose\n 108\n 95\n 149\n 112\n Other labs: PT / PTT / INR:14.5/31.7/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:19/66, Alk Phos / T Bili:111/2.1,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 55 y/o lady with history HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness now s/p trach after intubation for\n aspiration pneumonia and persistant difficulty weaning from vent is\n admitted to MICU after bleeding around trach site.\n .\n # Current Respiratory distress: Current episode is secondary to\n bleeding aroung the trach site. Though to be secondary to small vessel\n in that area. ETT placed for ventilation and went to OR where she was\n found to have small vessel bleed and received stitches. Also had\n electrocautery to cauterize any other superficial bleeders. Thoracics\n is planning for revision today. She was ET intubated by anesthesia\n during the code.\n - Trach revision on \n - trend HCT\n - active T&C\n .\n # s/p trach: Secondary to pneumonia and hypoxic respiratory distress as\n above. Completed 10 day course of antibiotics. Received trials of PMV\n on the floor.\n - Continue nebs\n .\n # GPC bacteremia: Most likely from the nonsterile fem line placed.\n Already discontinued the fem line.\n - vancomycin\n - surveillence cultures\n .\n # Fever/Leukocytosis:? aspiration PNA on CXR left base, but\n radiologically improved. GPC bacteremia as above. Also may have ?\n small pneumo mediatstium per radiology on post code CXR but repeat CXR\n are improved.\n - trend leukocytosis\n -vanc as above\n .\n # Decreased HCT: Most likely from femoral hematoma. Currently\n hemodynamically stable.\n - trend HCT\n - ? CT abd/pelvis if continues to trend down to look for RPB\n .\n # Left femoral hematoma: In the setting of attempted fem line.\n - trend HCT\n - T&C blood as above\n .\n # Myopathy/Neuropathy: Myopathy/neuropathy felt possibly mixed\n cryoglobulinemia associated with HCV and possible myopathy from\n interferon. Muscle biopsy showed nonspecific inflammation. Per recent\n neurology outpatient visit, EMG showed a mild sensorimotor\n polyneuropathy as well as a myopathic process in several proximal\n muscles (IP, biceps, infraspinatus, and prominently in L3 paraspinals).\n Additional nerve biopsy may be helpful, but currently holding off.\n - F/U cryo levels\n - Appreciate neurology input; further management per them\n - MRI brain w/ contrast is ordered per Neurology recs\n .\n # Bulbar weakness: Unclear why bulbar weakness is worsening and the\n rest of weakness is stable on exam. Myasthenia is in the\n differential diagnosis.\n - Follow up AChR antibodies (currently pending)\n .\n # Conjunctivitis: S/p corneal abrasion secondary to orbicularis\n weakness and inability to close eye. Ophthalmology following.\n - Continue eye drops/antibiotic ointments Q2H\n - need definitive management (i.e. taping eye) after resolution of\n bacterial infection\n .\n # HCV: Currently off interferon, with undetectable viral loads. On\n nadolol.\n .\n # Dysphagia. Seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. TF via Dobhoff, continue PPI.\n - will need PEG placement by IR\n .\n # Thrombocytopenia: Baseline in last 6 months 50-70's. At OSH,\n platelets were in the 20's; heparin stopped for concern for HIT; HIT\n antibody now negative. Platelets improved to 100's. Thrombocytopenia\n thought secondary to liver disease.\n .\n # NSTEMI: History of NSTEMI (at OSH), though likely demand ischemia. On\n beta blocker at this time.\n .\n # HCP blood exposure: Needs paperwork signed for check up once she is\n awake.\n .\n # FEN. Holding on IVF for now. Monitor/replete electrolytes. Tube\n feeds.\n .\n # Prophylaxis: Pneumoboots, PPI.\n .\n # Access: Fem cortis placed under nonsterile condition, will attemp to\n place peripheral IVs and then remove the fem line\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband . .\n - She does not wish for extended family to know about HCV status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660375,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Neuro rec'd sural nerve biopsy by NSurg ()\n - Liver rec'd Dobhoff tube for nutrition, hydroxyzine for itching,\n consider plamapharesis if condition does not improve\n - RUQ U/S -> Trace ascites without sufficient fluid for safe bedside\n paracentesis. Stable enlarged CBD. Coarsened liver c/w cirrhosis,\n without focal lesions\n - tachycardia improved with fluid boluses, morphine, ativan and IV\n metoprolol 5mg IV\n MULTI LUMEN - STOP 04:46 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:50 PM\n Pantoprazole (Protonix) - 12:03 AM\n Lorazepam (Ativan) - 04:44 AM\n Metoprolol - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 88 (88 - 120) bpm\n BP: 139/81(95) {123/79(93) - 164/104(112)} mmHg\n RR: 10 (8 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,561 mL\n 438 mL\n PO:\n TF:\n IVF:\n 1,561 mL\n 438 mL\n Blood products:\n Total out:\n 1,205 mL\n 490 mL\n Urine:\n 1,205 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 356 mL\n -53 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 359 (305 - 418) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n Plateau: 19 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n NIF: -18 cmH2O\n Ve: 7 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 107 K/uL\n 10.5 g/dL\n 92 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 6 mg/dL\n 102 mEq/L\n 134 mEq/L\n 31.9 %\n 6.0 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n WBC\n 6.4\n 6.7\n 6.0\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n Plt\n 76\n 80\n 107\n Cr\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n Other labs: PT / PTT / INR:14.9/32.1/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 661521,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer: Shiley\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 4 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n travelled to MRI for head scan\n Bedside Procedures:\n Comments:\n Respiratory Care:\n Pt remains intubated and vented. No parameter changes made this shift.\n Travelled to MRI/ head scan. Plan to go to OR for trach site revision/\n possible trach.\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 661617,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y/o f with HCV, Cirrhosis p/w PNA, s/p trach, course c/b acute\n arterial bleed from trach site. Now s/p stitch placed in arterial\n bleed, awaiting trach revision.\n 24 Hour Events:\n ARTERIAL LINE - START 08:00 AM\n BLOOD CULTURED - At 09:08 PM\n URINE CULTURE - At 09:08 PM\n CORDIS/INTRODUCER - STOP 09:18 PM\n MAGNETIC RESONANCE HEAD IMAGING - At 10:01 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:50 PM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:45 AM\n Midazolam (Versed) - 10:37 PM\n Fentanyl - 03:24 AM\n Lansoprazole (Prevacid) - 07:45 AM\n Other medications: reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.3\nC (99.1\n HR: 101 (91 - 126) bpm\n BP: 121/64(86) {93/50(66) - 166/85(113)} mmHg\n RR: 18 (14 - 35) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,135 mL\n 782 mL\n PO:\n TF:\n IVF:\n 8,265 mL\n 372 mL\n Blood products:\n 750 mL\n 350 mL\n Total out:\n 2,560 mL\n 630 mL\n Urine:\n 1,560 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,575 mL\n 152 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 399 (359 - 399) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 63\n PIP: 15 cmH2O\n Plateau: 6 cmH2O\n SpO2: 99%\n ABG: 7.41/42/63/25/1\n Ve: 7 L/min\n PaO2 / FiO2: 126\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 134 K/uL\n 112 mg/dL\n 0.3 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 6 mg/dL\n 112 mEq/L\n 139 mEq/L\n 26.1 %\n 23.4 K/uL\n [image002.jpg]\n 09:56 PM\n 03:23 AM\n 08:24 AM\n 08:43 AM\n 01:24 PM\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n WBC\n 6.6\n 16.1\n 23.4\n Hct\n 34.0\n 31.5\n 29.4\n 28.9\n 24.3\n 24.0\n 26.1\n Plt\n 140\n 149\n 134\n Cr\n 0.3\n 0.3\n 0.3\n 0.3\n TCO2\n 30\n 28\n Glucose\n 108\n 95\n 149\n 112\n Other labs: PT / PTT / INR:14.5/31.7/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:19/66, Alk Phos / T Bili:111/2.1,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI (tracheo-innominate) fistula per surgical team. Orotracheal\n intubation. Plan for surgical reexploration today and replacement of\n trach. Developed GPC bacteremia overnight.\n Resp: on rounds in AM ETT intubated. Arterial bleeding of thyroid,\n ligated with hemostasis. Continue vent management. Keep comfortable on\n propofol drip. Plan for trach revision today. SBT to be planned once\n trach revised and pt off sedation. Cont. propofol for now\n Tracheal bleed: Check Hct q6h. Hct goal 26%, no active bleed now\n Bacteremia/leukocytosis: GPC 2/2 bottles, speciation and pending.\n Suspect from dirty fem line placed during code, pulled yesterday. F/u\n cx. Cont. Vanco q12h.\n ? Pneumomedst on CXR: Appears to have resolved on CXR, may be \n manipulation of trach, no crepitus on exam.\n L groin hematoma: pressure was applied, pressure dressing in place\n HCV with cirrhosis: Following up with liver.\n Conjunctivitis: Tears, cipro and erythromycin topical in eyes,\n ophthal following\n Neuropathy/myopathy: f/u with neuro. Follow up MRI brain. LP when off\n the vent. Anticholinergic receptor Ab pending. Will consult IR for\n eventually for PEG given ascites.\n CAD/NSTEMI: No symptoms currently, no wall motion abnormalities on\n TTE.\n FEN: Restart TF after trach. Goal even.\n Access: PIVs\n Vent: HOB 30 degress, mouth care\n Ppx: PPI, pneumoboots\n Code: Full code\n Comm: husband\n ICU \n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 661725,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 fenestrated\n portex trach.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt to OR yesterday for flex bronch, BAL, and\n reinsertion of trach tube.\n Action:\n Pt. tolerating PSV overnight, changed to trach collar this am.\n Response:\n Tolerating trach collar. Sats 99%. Pt with thick serosanginous\n secretions via trach.\n Plan:\n Monitor response to trach collar. Pt will need eventual evaluation by\n speech and swallow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. complaining of pain at trach site.\n Action:\n Given fentanyl 1mg IVx1 this am with effect, then pain meds changed to\n oxycodone\n Response:\n Plan:\n Continue to monitor for pain and medicate PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660363,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient A/C 450x14, PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copius amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n Pt placed on CPAP 50% 10/5 cont freq suction of thick tan/ blood tinged\n secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Started D51/2NS 75ml/hr.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red and unable to close completely , new rashes noted on her rt hand\n Action:\n Frequent position change, miconazole cream applied, eye drops and\n ointment applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . Myopathy/neuropathy felt possibly \n mixed cryoglobulinemia associated with HCV, EMG showed a mild sensory\n motor polyneuropathy EMG showed a mild sensory motor polyneuropathy\n as well as a myopathic process in several proximal muscles Muscle\n biopsy results from OSH pending,.\n Action:\n morphine 2-4mg prn and lorazepam 1mg iv given for pain./ tachycardia\n 110\ns-120\ns, pt also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660365,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient, PSV 10/ PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copious amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n No vent changes overnight, cont freq suction of thick tan/ blood\n tinged secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Started D51/2NS 75ml/hr.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red and unable to close completely , new rashes noted on her rt hand\n Action:\n Frequent position change, miconazole cream applied, eye drops and\n ointment applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . Myopathy/neuropathy felt possibly \n mixed cryoglobulinemia associated with HCV, EMG showed a mild sensory\n motor polyneuropathy EMG showed a mild sensory motor polyneuropathy\n as well as a myopathic process in several proximal muscles Muscle\n biopsy results from OSH pending,.\n Action:\n morphine 2-4mg prn and lorazepam 1mg iv given for pain./ tachycardia\n 110\ns-120\ns, pt also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660373,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Neuro rec'd sural nerve biopsy by NSurg ()\n - Liver rec'd Dobhoff tube for nutrition, hydroxyzine for itching,\n consider plamapharesis if condition does not improve\n - RUQ U/S -> Trace ascites without sufficient fluid for safe bedside\n paracentesis. Stable enlarged CBD. Coarsened liver c/w cirrhosis,\n without focal lesions\n - tachycardia improved with fluid boluses, morphine, ativan and IV\n metoprolol 5mg IV\n MULTI LUMEN - STOP 04:46 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:50 PM\n Pantoprazole (Protonix) - 12:03 AM\n Lorazepam (Ativan) - 04:44 AM\n Metoprolol - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 88 (88 - 120) bpm\n BP: 139/81(95) {123/79(93) - 164/104(112)} mmHg\n RR: 10 (8 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,561 mL\n 438 mL\n PO:\n TF:\n IVF:\n 1,561 mL\n 438 mL\n Blood products:\n Total out:\n 1,205 mL\n 490 mL\n Urine:\n 1,205 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 356 mL\n -53 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 359 (305 - 418) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n Plateau: 19 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n NIF: -18 cmH2O\n Ve: 7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 107 K/uL\n 10.5 g/dL\n 92 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 6 mg/dL\n 102 mEq/L\n 134 mEq/L\n 31.9 %\n 6.0 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n WBC\n 6.4\n 6.7\n 6.0\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n Plt\n 76\n 80\n 107\n Cr\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n Other labs: PT / PTT / INR:14.9/32.1/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660509,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n \n cardiac echo done, results pending.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 10/5, 40% fio2. RR 10\ns-20\ns. LS with wheezes,\n cleared later in shift. Large amts of tan/yellow thick secretions from\n trach. O2 sats 97-100%.\n Action:\n Pt weaned off of vent. Placed on trach collar 50%. Pt to receive last\n dose of Cefepime today. MDI\ns given by RT as ordered.\n Response:\n Sats 100%, pt appears comfortable and in no resp distress.\n Plan:\n Continue to wean down fio2 and monitor resp status. Administer abx as\n ordered.Continue with frequent suctioning.\n Alteration in Nutrition\n Assessment:\n Pt remains NPO with hx of dysphagia\n Action:\n Remains NPO. Pt currently on D5 1/2NS at 75ml/hr. Doboff placed at\n bedside by physician with bronchoscope.\n Response:\n Pt currently has doboff in place. Waiting for x-ray for placement\n confirmation.\n Plan:\n ? start tube feeds once confirmation of correct doboff placement.\n Impaired Skin Integrity\n Assessment:\n Yeast on coccyx with skin excoriation and redness. Pt has\n conjunctivitis in each eye, left eye appears more swollen and red.\n Action:\n Miconazole cream applied to pt\ns coccyx. Turned Q 2 hours.\n Erythromycin eye ointment applied, artificial tears and artificial\n tears ointment applied Q 2 hours as ordered.\n Response:\n Per team, eyes\nlook better today than they did yesterday\n Plan:\n Continue to apply miconazole cream to coccyx. Continue to administer\n eye medication as ordered. Turn Q 2 hours.\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. EMG shows a mild sensory motor polyneuropathy as well as a\n myopathic process in several proximal muscles. Muscle biopsy results\n from OSH pending.\n Action:\n Pt given 2-4 mg IV Morphine prn for pain in hip and legs. Repositioned\n frequently. Currently on 1mg Lorazepam IV prn for anxiety. Good\n effect with both meds.\n Response:\n Pain improved. Pt appears to be less anxious. Per team, pt\ns strength\n is better today than it was yesterday.\n Plan:\n Continue to monitor. F/U with neuron consult and biopsy from OSH.\n Per pt\ns husband, pt\ns family is not aware of her HCV status and\n requests that they are not told.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660809,
"text": "Chief Complaint:\n 24 Hour Events:\n - speech and swallow eval today, could not handle Passy-Muir valve yet,\n will try again on Friday\n - tachycardic in afternoon; appeared dry perhaps from autodiuresis with\n low K/Phos - given IVFs, tachycardia improved overnight\n - optho recs continued cipro gtts, spaced out lacrilube to q2 hrs,\n added erythromycin drops at night to L eye\n - neurosurg preop completed with type and screen, UA, CXR\n - waiting for OSH path prior to nerve biopsy, because if specimen is\n inadequate would like to do both muscle and nerve biopsy at the same\n time; plan would be for Monday if not tomorrow - need to touch base\n with both neuro and neurosurg today about finalized plan\n - aggitated overnight and slept very little, did not respond to\n morphine or ativan; can consider adding sleeping medicine tomorrow\n night like trazadone\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Lorazepam (Ativan) - 02:49 AM\n Morphine Sulfate - 06:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.6\nC (97.8\n HR: 99 (89 - 118) bpm\n BP: 157/91(108) {124/79(90) - 169/121(126)} mmHg\n RR: 27 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,657 mL\n 1,516 mL\n PO:\n TF:\n 952 mL\n 10 mL\n IVF:\n 1,225 mL\n 1,505 mL\n Blood products:\n Total out:\n 4,025 mL\n 1,335 mL\n Urine:\n 3,725 mL\n 1,135 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n -1,368 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n Not cooperating with neuro exam this morning, moving all 4 extremities\n against gravity but not pushing against resistance, reflexes continue\n to be 3+\n Labs / Radiology\n 140 K/uL\n 11.4 g/dL\n 95 mg/dL\n 0.3 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 109 mEq/L\n 138 mEq/L\n 34.0 %\n 6.6 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n 09:56 PM\n 03:23 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n 6.6\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n 34.0\n Plt\n 76\n 80\n 107\n 118\n 140\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n 108\n 95\n Other labs: PT / PTT / INR:14.7/31.5/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities. Working diagnosis is an INF\n related primary myopathy with an underlying secondary neuropathy\n related to cyroglobulemiia. Neuro and neurosurg following\n - cryo levels pending\n - plan to review OSH muscle biopsies with neuro. OSH doctor is Dr. ,\n call for bx results (or can page Dr. )\n - neuro would like to hold on nerve biopsy pending the muscle biopsy\n results\n - nsurg aware of plan\n - appreciate neuro and neurosurg recs\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Completed course of cefepime on . Given that her weakness preceeded\n her critical illness, I suspect cryoglobulinemia as primary process.\n - completed 10 day of cefepime on \n - doing well on trach mask trial\n - continue nebs given hx asthma\n .\n # HCV: stable, viral load undetectable\n - appreciate liver recs, abd US done and showed minimal ascites\n - dobhoff placed, starting nutrition; will have to follow up long term\n nutrition plans\n - holding INF as it may be possible cause of weakness\n - cryo levels pending\n .\n # Corneal abrasion and conjunctivitis\n opthamology following;\n - tx with lacrilube ointment q 1hr, lacrilube drops q2 hr and cipro\n gtts q 6hrs\n - at risk for worsening corneal damage in setting of muscle weakness\n and inability to close eyes; will need close eye care for now and\n follow up with ophthalmology\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, requiring less and less medicine\n - starting tube feeds now that dobhoff placed\n - transitioned back to nadolol for varices; titrate up to 40mg \n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux. Failed PMV trial \n coughing/secretions.\n - continue PMV trials\n - NPO\n - continuing PPI, stopped ranitidine\n - dobhoff in place\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab - negative\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - nadolol as above for tachycardia\n .\n # FEN:\n - on tube feeds, stopping maintenance fluids\n - replete electrolytes\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n - no HIT\n starting SQ heparin after nerve biopsy, will hold AM of\n surgery\n .\n # Access:\n - RIJ from OSH removed, now with PIVs\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: floor if can get adequate eye treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n 20 Gauge - 12:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 661689,
"text": "Chief Complaint: Resp Failure\n Weakness\n Tracheal Bleed\n Line Infection\n HPI:\n 55 y/o F with Hep C cirrhosis with neuromusc and bulbar weakness s/p\n tracheal bleed s/p OR visit for ligation and cauterization of bleeder.\n No e/o TI fistula per surgical team. Orotracheal intubation. Just had\n revision of trach today. Planning to wean now. Neuro following for\n neuromusc weakness w/u.\n 24 Hour Events:\n 7.0 Portex placed yesterday, started TF, myasthenia w/u undergone, BCx\n with GPCs after fem line pulled.\n INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:30 AM\n Lansoprazole (Prevacid) - 08:10 AM\n Famotidine (Pepcid) - 08:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.2\nC (99\n HR: 92 (86 - 109) bpm\n BP: 190/144(163) {96/46(65) - 190/144(163)} mmHg\n RR: 21 (11 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,234 mL\n 300 mL\n PO:\n TF:\n IVF:\n 1,824 mL\n 300 mL\n Blood products:\n 350 mL\n Total out:\n 1,058 mL\n 660 mL\n Urine:\n 1,008 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,176 mL\n -361 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 332 (307 - 360) mL\n PS : 8 cmH2O\n RR (Set): 0\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 57\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.37/49/135/26/2\n Ve: 5.3 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: R pupil 6mm L pupil 4mm both reactive\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 137 K/uL\n 85 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 108 mEq/L\n 138 mEq/L\n 25.2 %\n 12.7 K/uL\n [image002.jpg]\n 01:57 PM\n 06:09 PM\n 12:17 AM\n 12:55 AM\n 05:36 AM\n 12:29 PM\n 12:41 PM\n 05:01 PM\n 02:02 AM\n 02:26 AM\n WBC\n 23.4\n 12.7\n Hct\n 28.9\n 24.3\n 24.0\n 26.1\n 25.7\n 26.3\n 25.2\n Plt\n 134\n 137\n Cr\n 0.3\n 0.3\n TCO2\n 28\n 27\n 29\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:14.2/32.0/1.2, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/51, Alk Phos / T Bili:109/1.2,\n Amylase / Lipase:113/124, Differential-Neuts:87.6 %, Lymph:9.0 %,\n Mono:2.9 %, Eos:0.4 %, Lactic Acid:1.3 mmol/L, Albumin:2.3 g/dL,\n LDH:296 IU/L, Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n GPCs from BCx and old line\n -14 days of IV vanco for bacteremia\n TRACHEAL RECONSTRUCTION (TRACHEOBRONCHIAL)\n s/p cutery of trach bleed, s/p new trach, no recent bleeding\n -f/u BAL\n -cont. TM today\n -cont. nebs\n -speech c/s for PMV\n Corneal abrasion:\n -cont. eye gtts\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n As above\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n -bulbar and facial weakness, extermity weakness improved\n -MRI OK no brainstem lesion\n -neuro wanted LP, can have as an outpatient to w/u for myasthenia\n -Ab pending\n FEN: Swallow eval, TF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 07:59 AM\n Arterial Line - 08:00 AM\n 18 Gauge - 12:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 20 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2145-02-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 661611,
"text": "Briefly, Ms. is a 55 year old woman with HCV treated with IFN,\n cryoglobulinemia, progressively worsening peripheral neuropathy and\n parasthesias (x 6 months), and dysphagia (~3-4 months), who was\n transferred to from an OSH, where she was admitted for PEG\n placement given failure to thrive over the last several months. During\n that hospitalization, she developed aspiration pneumonia and was\n intubated and hypotensive, requiring pressors for ~4 days (thought\n ?ARDS). There was difficulty weaning her from the vent, presumably\n secondary to neuromuscular weakness, and she was trached on . In\n addition, she had a muscle biopsy at the OSH (concerning for myositits)\n and was transferred to for further workup.\n .\n In the ICU, she completed a ten day course of cefepime for pneumonia.\n Neurology was consulted, and the current belief is that her myopathy is\n secondary to interferon, whereas her neurologic deficit may be\n secondary to cryoglobulinemia/vasulitis. Her interferon was stopped\n given concern for contribution to myositis. She was weaned from the\n vent and switched to trach mask on with good results; she is able\n to tolerate a PMV only for a few minutes given substantial secretions.\n A Dobhoff was placed for enteral feeding. Given orbicularis weakness,\n she is unable to close her eyes; as such, she developed a corneal\n abrasion and conjunctivitis requiring antibiotic eye drops Q2H.\n .\n On the floor, patient continued to have work-up of her myopathy for\n possible myasthenia given her pronounced bulbar weakness. On the floor\n patient pulled her dobhoff tube, and had it replaced.\n .\n On the floor prior to arrest, patient was noted to have some oozing\n around her trach site. At approximately 3am patient was patient was in\n respiratory distress. Anesthesia tubed from above, trach was removed\n due to resistance. O2 sats were adequate, but increasing pressures.\n During the code, patient got 1LNS, and 2 units PRBC's. Non-sterile\n R-cordis, L-femoral line placed unsuccesfully with large residual\n hematoma. Patient taken to OR once airway secured.\n .\n In OR, she was found to have an arterial bleeder most likely in the\n lower thyroid tissues which we controlled with 2 stitches. Also had\n electrocautery to cauterize any other superficial bleeders.\n Pt back to OR today for reinsertion of trach. Now with #7 fenestrated\n portex trach.\n Tracheal reconstruction (Tracheobronchial)\n Assessment:\n Pt s/p tracheal bleed from superficial artery around trach site overnoc\n . Taken emergently to OR for trach removal, exploration of trach\n site, and flex bronch. Pt received intubated via ETT from OR with old\n trach site packed with xeroform and covered with DSD.\n Action:\n Pt to OR @ 1330 for flex bronch, BAL, and reinsertion of trach tube.\n Response:\n Pt now with #7 fenestrated portex trach intact. Old incision with\n sutures intact. Sm amt sanguinous drainage around trach site. HCT\n stable.\n Plan:\n Wean vent as tolerated. Pt will need eventual evaluation by speech and\n swallow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt s/p trach for failure to wean from vent muscular weakness.\n Now s/p tracheal bleed from superficial arterial bleed around trach\n site, with removal of trach, flex bronch in OR. Pt intubated s/p\n tracheal bleed.\n Action:\n Pt to OR today for reinsertion of trach. Received from OR paralyzed and\n sedated on AC.\n Response:\n Trach #7 fenestrated portex in place. Allevyn trach dsg placed around\n site with small amt of sanguinous drainage. Sutures intact around old\n incision site. No s/s infection.\n Plan:\n Wean vent as tolerated and hopefully change over to trach mask in AM.\n Muscle Performace, Impaired\n Assessment:\n Pt with known hx of muscle weakness causing inability to eat/ inability\n to clear secretions. Hx of difficulty moving extremities.\n Action:\n Pt awake this AM and able to follow commands. Pt with equal \n strength bilaterally, able to move all extremities. Pt being followed\n by neuro. S/P muscle biopsy to right thigh and right forearm.\n Response:\n Pending biopsy results.\n Plan:\n Cont to follow neuro recs, cont with neuro exams, f/u biopsy results.\n Pt to have LP and additional testing once no longer on vent.\n"
},
{
"category": "Nutrition",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 660484,
"text": "Subjective\n Pt receiving Jevity @55mL/hr @ OSH per chart, 30 # wt loss per chart x\n mo\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 55 kg\n 19.6 per UBW\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 54.5\n 95% per UBW\n 52 Kg per OSH records\n 106%\n Diagnosis: cirrhosis, hepatitis, hepatic encephalopathy\n PMH :\n Active hepatitis C.diagnosed genotype 1a, treated with PEG\n interferon and ribavirin x 48 weeks ending in virologic relapse\n after 4 weeks leading to low dose PEG interferon starting in x 4\n years, finished in , In had a cryocrit of 6% so maintenance\n PEG interferon restarted, known cirrhosis, known varices\n Asthma.\n Recent hoarseness which was evaluated by Dr. in ENT and was\n felt to be due to reflux esophagitis.\n s/p choly\n s/p appendectomy\n hx venous thrombophlebitis 25 yrs ago\n Food allergies and intolerances: NKFA\n Pertinent medications: folic acid, vit B complax, protonix, abx,\n D51/2NS @75mL/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 92 mg/dL\n 03:55 AM\n Glucose Finger Stick\n 109\n 10:00 AM\n BUN\n 6 mg/dL\n 03:55 AM\n Creatinine\n 0.3 mg/dL\n 03:55 AM\n Sodium\n 134 mEq/L\n 03:55 AM\n Potassium\n 4.5 mEq/L\n 03:55 AM\n Chloride\n 102 mEq/L\n 03:55 AM\n TCO2\n 29 mEq/L\n 03:55 AM\n PO2 (arterial)\n 179 mm Hg\n 11:55 PM\n PCO2 (arterial)\n 45 mm Hg\n 11:55 PM\n pH (arterial)\n 7.37 units\n 11:55 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 11:55 PM\n Albumin\n 2.2 g/dL\n 10:13 PM\n Calcium non-ionized\n 7.4 mg/dL\n 03:55 AM\n Phosphorus\n 2.4 mg/dL\n 03:55 AM\n Magnesium\n 1.7 mg/dL\n 03:55 AM\n WBC\n 6.0 K/uL\n 03:55 AM\n Hgb\n 10.5 g/dL\n 03:55 AM\n Hematocrit\n 31.9 %\n 03:55 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/+bs/+bm\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: NPO / hypocaloric diet, Low protein stores,\n dysphagia, cirrhosis, wt loss\n Estimated Nutritional Needs\n Calories: 1295-1560 (BEE x or / 25-30 cal/kg)\n Protein: 62-78 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate NPO s/ feeding access\n Specifics:\n 55 y/o female c/ HCV, worsening peripheral myopathy and dysphagia,\n presents form OSH c/ asp. PNA, likely ARDS requiring trach c/\n persistent failure to wean. Nutrition consulted for TF recs as pt was\n receiving nutrition via NGT @ OSH worsening dysphagia. Per d/w RN,\n team awaiting GI/liver recs re ? NGT vs PEG. TF recs are the same\n regardless of what tube pt receives, please see below. Low PO4.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: ON ppft or PEG placed and ok to use, rec\n Fibersource HN @15mL/hr to increase 10 mL q4hr, to goal 55mL/hr (1584\n kcals/70 gr aa)\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n If pt c/ NGT/PEG, residual check q4 hr, hold if >150mL\n If pt c/ ppft, monitor tolerance via abd exam, pt complaints\n 2 packets neutraphos\n Please page c/ ?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660492,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n \n cardiac echo done, results pending.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP 10/5, 40% fio2. RR 10\ns-20\ns. LS with wheezes,\n cleared later in shift. Large amts of tan/yellow thick secretions from\n trach. O2 sats 97-100%.\n Action:\n Pt weaned off of vent. Placed on trach collar 50%. Pt to receive last\n dose of Cefepime today. MDI\ns given by RT as ordered.\n Response:\n Sats 100%, pt appears comfortable and in no resp distress.\n Plan:\n Continue to wean down fio2 and monitor resp status. Administer abx as\n ordered.Continue with frequent suctioning.\n Alteration in Nutrition\n Assessment:\n Pt remains NPO with hx of dysphagia\n Action:\n Remains NPO. Pt currently on D5 1/2NS at 75ml/hr. Doboff placed at\n bedside by physician.\n :\n Plan:\n Impaired Skin Integrity\n Assessment:\n Yeast on coccyx with skin excoriation and redness. Pt has\n conjunctivitis in each eye, left eye appears more swollen and red.\n Action:\n Miconazole cream applied to pt\ns coccyx. Turned Q 2 hours.\n Erythromycin eye ointment applied, artificial tears and artificial\n tears ointment applied Q 2 hours as ordered.\n Response:\n Per team, eyes\nlook better today than they did yesterday\n Plan:\n Continue to apply miconazole cream to coccyx. Continue to administer\n eye medication as ordered. Turn Q 2 hours.\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. EMG shows a mild sensory motor polyneuropathy as well as a\n myopathic process in several proximal muscles. Muscle biopsy results\n from OSH pending.\n Action:\n Pt given 2-4 mg IV Morphine prn for pain in hip and legs. Repositioned\n frequently. Currently on 1mg Lorazepam IV prn for anxiety. Good\n effect with both meds.\n Response:\n Pain improved. Pt appears to be less anxious. Per team, pt\ns strength\n is better today than it was yesterday.\n Plan:\n Continue to monitor. F/U with neuron consult and biopsy from OSH.\n Per pt\ns husband, pt\ns family is not aware of her HCV status and\n requests that they are not told.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 660227,
"text": "Chief Complaint: OSH transfer for workup of weakness\n 24 Hour Events:\n Events:\n - overnight remained anxious and uncomfortable, received ativan and\n morphine with only mild effect\n - tachycardic to 110s\n - no PO access, consider PEG v. NG tube today\n INVASIVE VENTILATION - START 09:05 PM\n MULTI LUMEN - START 09:42 PM\n EKG - At 10:53 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 01:00 AM\n Morphine Sulfate - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.6\n HR: 104 (104 - 122) bpm\n BP: 150/87(103) {127/83(95) - 150/89(103)} mmHg\n RR: 15 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8 mL\n 583 mL\n PO:\n TF:\n IVF:\n 8 mL\n 583 mL\n Blood products:\n Total out:\n 145 mL\n 265 mL\n Urine:\n 145 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -138 mL\n 318 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.37/45/179/29/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 447\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 84 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 29.9 %\n 6.7 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n WBC\n 6.4\n 6.7\n Hct\n 29.5\n 29.9\n Plt\n 76\n 80\n Cr\n 0.3\n 0.3\n TropT\n 0.18\n TCO2\n 27\n Glucose\n 73\n 84\n Other labs: PT / PTT / INR:15.5/31.8/1.4, CK / CKMB /\n Troponin-T:98//0.18, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.5\n mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process.\n - complete 10 day of cefepime, will get ID approval\n - continue PS with goal to wean, daily RSBI and SBT; did well with\n decrease PS this morning\n - try sitting upright to see if diaphragmatic paralysis\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult and will touch base with Dr. ; plan for possible\n nerve biopsy and / or EMG\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs\n - continue IFN Q week, although need to consider IFN as toxic cause of\n her myopathy\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - IVF boluses PRN\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopping ranitidine today\n - will discuss with liver if PEG tube can be placed\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n .\n # Access:\n - RIJ from OSH (placed on ); plan for PIVs and then d/c of RIJ if\n possible\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n CRITICAL CARE STAFF\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. Dr. \ns note\n above reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Overnight issues included anxiety, pain, and tachycardia.\n On exam, she is comfortable on CMV. With conversion to PSV 10/5 she\n also remains comfortable. NIF is -18. Sclerae are injected. Heart is\n regular. Lungs are coarse. Abdomen is soft and nontender. Trach site\n is oozing. Neuro exam is limited by ?cooperation and difficulty\n communicating due to trach. In general, she has paresesis of eyelids\n (mid-position), and at best antigravity strength or less. Muscle\n biopsy site intact.\n Labs, imaging, and medications reviewed.\n Assessment and Plan\n 55-year-old woman with\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n Myopathy and neuropathy\n o Discuss with her neurologist, since substantial workup\n already done\n o Get report and slides of recent muscle biopsy\n o Based on biopsy and neuro, may need further eval (e.g. rheum)\n o Will need eye gtt since can\nt keep lids closed\n Access\n o Will try for PIVs. If unable, pursue PICC.\n o CVL out after alterative access obtained.\n o Will discuss PEG with liver team\n HCV\n o Will discuss role of interferon with hepatology\n o Beta blockers IV for now\n Tachycardia\n o Try sequential diagnostic rx: pain control, fluids, beta\n blocker\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Now back closer to baseline\n Other issues as per ICU team note above.\n She is critically ill. 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 01:53 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 660284,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Shiley\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660342,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient A/C 450x14, PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copius amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n Pt placed on CPAP 50% 10/5 cont freq suction of thick tan/ blood tinged\n secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Started D51/2NS 75ml/hr.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red and unable to close completely , new rashes noted on her rt hand\n Action:\n Frequent position change, miconazole cream applied, eye drops and\n ointment applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . Myopathy/neuropathy felt possibly \n mixed cryoglobulinemia associated with HCV, EMG showed a mild sensory\n motor polyneuropathy EMG showed a mild sensory motor polyneuropathy\n as well as a myopathic process in several proximal muscles Muscle\n biopsy results from OSH pending,.\n Action:\n morphine 2-4mg prn and lorazepam 1mg iv given for pain./ tachycardia\n 110\ns-120\ns, pt also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 660345,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Shiley\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt trached and on mech vent as per Metavision. Lung sounds sl\n coarse suct mod th yellow sput. MDI given as per order. Pt in NARD on\n current vent setting; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660449,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Neuro rec'd sural nerve biopsy by NSurg ()\n - Liver rec'd Dobhoff tube for nutrition, hydroxyzine for itching,\n consider plamapharesis if condition does not improve\n - RUQ U/S -> Trace ascites without sufficient fluid for safe bedside\n paracentesis. Stable enlarged CBD. Coarsened liver c/w cirrhosis,\n without focal lesions\n - tachycardia improved with fluid boluses, morphine, ativan and IV\n metoprolol 5mg IV\n MULTI LUMEN - STOP 04:46 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:50 PM\n Pantoprazole (Protonix) - 12:03 AM\n Lorazepam (Ativan) - 04:44 AM\n Metoprolol - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 88 (88 - 120) bpm\n BP: 139/81(95) {123/79(93) - 164/104(112)} mmHg\n RR: 10 (8 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,561 mL\n 438 mL\n PO:\n TF:\n IVF:\n 1,561 mL\n 438 mL\n Blood products:\n Total out:\n 1,205 mL\n 490 mL\n Urine:\n 1,205 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 356 mL\n -53 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 359 (305 - 418) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n Plateau: 19 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n NIF: -18 cmH2O\n Ve: 7 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 107 K/uL\n 10.5 g/dL\n 92 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 6 mg/dL\n 102 mEq/L\n 134 mEq/L\n 31.9 %\n 6.0 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n WBC\n 6.4\n 6.7\n 6.0\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n Plt\n 76\n 80\n 107\n Cr\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n Other labs: PT / PTT / INR:14.9/32.1/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Nonetheless, she is on a day course abx. Given that her weakness\n preceeded her critical illness, I suspect cryoglobulinemia as primary\n process.\n - complete 10 day of cefepime, last day today\n - continue PS with goal to wean, daily RSBI and SBT; continuing to\n improve, will do trach collar trial today\n - NIF is still -18 today\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult; plan for EMG and a nerve biopsy with neurosurg (Dr.\n \n - will follow up OSH biopsy, plan is to have specimen sent to after\n it is fixed\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs, abd US done and showed no ascites; question is\n now PEG v. dobhoff\n - holding INF as it may be possible cause of weakness\n - HCV virus and cyro levels pending\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - on maintenance fluids for now\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI; will switch from IV to PO nadolol when access to gut\n is achieved\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopped ranitidine\n - will discuss with liver if PEG tube can be placed; likely can be\n placed since no ascites\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n results pending\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement per liver recs, likely should\n have PEG to avoid two procedures as likely will need long term feeding\n options\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n - no heparin problems\n .\n # Access:\n - RIJ from OSH removed, now with PIVs\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660442,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - Neuro rec'd sural nerve biopsy by NSurg ()\n - Liver rec'd Dobhoff tube for nutrition, hydroxyzine for itching,\n consider plamapharesis if condition does not improve\n - RUQ U/S -> Trace ascites without sufficient fluid for safe bedside\n paracentesis. Stable enlarged CBD. Coarsened liver c/w cirrhosis,\n without focal lesions\n - tachycardia improved with fluid boluses, morphine, ativan and IV\n metoprolol 5mg IV\n MULTI LUMEN - STOP 04:46 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 10:50 PM\n Pantoprazole (Protonix) - 12:03 AM\n Lorazepam (Ativan) - 04:44 AM\n Metoprolol - 04:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 88 (88 - 120) bpm\n BP: 139/81(95) {123/79(93) - 164/104(112)} mmHg\n RR: 10 (8 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,561 mL\n 438 mL\n PO:\n TF:\n IVF:\n 1,561 mL\n 438 mL\n Blood products:\n Total out:\n 1,205 mL\n 490 mL\n Urine:\n 1,205 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 356 mL\n -53 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 359 (305 - 418) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n Plateau: 19 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n NIF: -18 cmH2O\n Ve: 7 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 107 K/uL\n 10.5 g/dL\n 92 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 6 mg/dL\n 102 mEq/L\n 134 mEq/L\n 31.9 %\n 6.0 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n WBC\n 6.4\n 6.7\n 6.0\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n Plt\n 76\n 80\n 107\n Cr\n 0.3\n 0.3\n 0.3\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n Other labs: PT / PTT / INR:14.9/32.1/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Nonetheless, she is on a day course abx. Given that her weakness\n preceeded her critical illness, I suspect cryoglobulinemia as primary\n process.\n - complete 10 day of cefepime, last day today\n - continue PS with goal to wean, daily RSBI and SBT; continuing to\n improve, will do trach collar trial today\n - NIF is still -18 today\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult; plan for EMG and a nerve biopsy with neurosurg (Dr.\n \n - will follow up OSH biopsy, plan is to have specimen sent to after\n it is fixed\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs, abd US done and showed no ascites; question is\n now PEG v. dobhoff\n - holding INF as it may be possible cause of weakness\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - on maintenance fluids for now\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopped ranitidine\n - will discuss with liver if PEG tube can be placed; likely can be\n placed since no ascites\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n .\n # Access:\n - RIJ from OSH (placed on ); plan for PIVs and then d/c of RIJ if\n possible\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660533,
"text": "This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistent difficulty\n weaning from vent.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 50% trach collor,copious amount of secrations from the\n trach ?surrounding the trach sats mid 90\ns,ronchorous breath sounds,\n Action:\n Suctioned as needed,trch care given,MDI by RT..\n Response:\n Sats 100%, pt appears comfortable and in no resp distress.\n Plan:\n Cont trch collor,wean fi02 as tolerated\n Alteration in Nutrition\n Assessment:\n Receivd the pt NPO,had doboff placed under bronchoscopy at bedside,on\n d5/12 ns @75cc/hr\n Action:\n Started on TF-fibersource HN @ 15cc/hr,tube placement conformed by x\n ray. Recvd neutraphos.\n Response:\n Tolerating the tube feed well,\n Plan:\n Advance 10cc q4h,goal 55cc/hr,need to hold the TF since midnight for\n biopsy in am()\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach.\n Myopathy/neuropathy possibly mixed cryoglobulinemia associated with\n HCV. Now with eye infection,pt was restless ,trying to get oob,pulling\n wires,.\n Action:\n Recvd ativan 1 mg q3h also recvd morphine 2 mg ivp,turned and\n repositioned q2h,started on artifical tears q1h and cipro eye drops as\n per opthal reccs.\n Response:\n Pain improved. Pt appears to be less anxious.\n Plan:\n Continue to monitor. Plan to to do nerve biopsy on ,biopsy from\n osh is pending.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-28 00:00:00.000",
"description": "ICU attending",
"row_id": 660607,
"text": "CRITICAL CARE STAFF\n 10a\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. The ICU team\ns note\n from today reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Yesterday, she tolerated a trach collar trial. We placed a small-bore\n feeding tube, and asked ophthalmology to see her for concern about her\n corneas and conjunctivits.\n On exam, she is comfortable on PSV. Eyes are injected. Heart is\n regular. Today there is a holosystolic murmur. Lungs are coarse.\n Abdomen is soft and nontender. Neurologic exam is unchanged c/w\n yesterday, though her affect is brighter today. Muscle biopsy site\n intact.\n Labs, imaging, and medications reviewed in today\ns ICU team note.\n Platelets continue to improve.\n Assessment and Plan\n 55-year-old woman with\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n o Tolerating trach mask now\n o Speech consult today\n Myopathy and neuropathy\n o Appreciate neuro\ns help.\n o Awaiting results of recent muscle biopsy\n o Anticipate nerve biopsy this week, per neuro\n Ophthalmologic issues\n o Greatly appreciate ophtho\ns help\n o On eye gtt and topical abx\n o Will need corneal protective strategy if strength unimproved\n Access\n o PIVs adequate for now\n HCV\n o Hold interferon\n o Beta blockers IV for now\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Improving\n Other issues as per ICU team note above.\n She is critically ill. 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660267,
"text": "Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Events: weaning on CPAP 10/5 tol well, IV ativan/ morphine for anxiety/\n pain. Liver/ GI consults pending, ? nerve biopsy in AM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient A/C 450x14, PEEP 5 and 50%. LS Rhonci bilat w/ dim.\n bases. Copius amount of thick tan/ blood tinged secretions with\n suction.. O2 sats 99-100%\n Action:\n Pt placed on CPAP 50% 10/5 cont freq suction of thick tan/ blood tinged\n secretions, Ativian x2 for anxiety.\n Response:\n O2 sats 98-100%, continue to have copious amt of blood tinged\n secretions tol CPAP well,\n Plan:\n wean vent as tolerated, MDI\ns as ordered and freq. suction PRN,\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n Remains NPO today, n/s FB x1 r/t tachycardia and ? slight dehydration.\n Liver team and GI both consulted r/t PEG vs NGT. Pt has hx of varices.\n Response:\n Consults pending at the time of this note.\n Plan:\n Cont NPO r/t to trach/ +aspiration. f/u w/ consulting teams.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change, miconazole cream applied\n Response:\n unchanged\n Plan:\n Frequent position change, miconazole cream for yeast infection\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle biopsy results from OSH pending,.\n Action:\n morphine 2mg x2 and 4mg x1 given for pain./ tachycardia 110\ns-120\ns, pt\n also started on beta blocker r/t tachycardia\n Response:\n HR decreased into the 90\ns- low 100\ns, pt less anxious, pain improved.\n Unable to score pain r/t trach.\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH. And nerve\n biopsy when appropriate. Cont metoprolol for now resume home beta\n blocker after PEG/NGT placed.\n"
},
{
"category": "Rehab Services",
"chartdate": "2145-01-28 00:00:00.000",
"description": "PMV Evaluation",
"row_id": 660626,
"text": "TITLE: PASSY MUIR SPEAKING VALVE EVALUATION\n Pt seen at bedside with Respiratory Therapist for attempted PMV\n placement. Not yet tolerating. We will re-eval. Please see full note\n in OMR or paper chart for details and full recommendations.\n Whitmill, MS, CCC-SLP\n Pager #\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660631,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped reglan per neuro recs\n - optho c/s done started cipro eye drops and Q1H lacrilube\n administration for significant corneal abrasion without thinning\n - nsurg - OR for sural nerve bx\n - HIT Ab PF4 sent\n - dopof tube placed\n - echo - The left atrium is moderately dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n BRONCHOSCOPY - At 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:00 PM\n Morphine Sulfate - 01:37 AM\n Lorazepam (Ativan) - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 87 (86 - 103) bpm\n BP: 153/103(113) {132/73(87) - 168/114(123)} mmHg\n RR: 18 (14 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,690 mL\n 281 mL\n PO:\n TF:\n 38 mL\n 170 mL\n IVF:\n 1,593 mL\n 11 mL\n Blood products:\n Total out:\n 2,830 mL\n 1,280 mL\n Urine:\n 2,830 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -999 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 212 (212 - 389) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 7.9 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n Not cooperating with neuro exam this morning, moving all 4 extremities\n against gravity but not pushing against resistance, reflexes continue\n to be 3+\n Labs / Radiology\n 118 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.2 mg/dL\n 28 mEq/L\n 3.2 mEq/L\n 4 mg/dL\n 103 mEq/L\n 137 mEq/L\n 31.6 %\n 6.8 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n Plt\n 76\n 80\n 107\n 118\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.4 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities. Working diagnosis is an INF\n related primary myopathy with an underlying secondary neuropathy\n related to cyroglobulemiia. Neuro and neurosurg following\n - cyro levels pending\n - plan to review OSH muscle biopsies with neuro. OSH doctor is Dr. ,\n call for bx results (or can page Dr. )\n - possible plan for nerve biopsy tomorrow, may be pending the muscle\n biopsy results whether or not it is needed; Dr. is following and\n she is scheduled for OR tomorrow\n - appreciate neuro and neurosurg recs\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Nonetheless, she is on a day course abx. Given that her weakness\n preceeded her critical illness, I suspect cryoglobulinemia as primary\n process.\n - complete 10 day of cefepime, \n - doing well on trach mask trial\n - consult neuron/liver for help determining etiology of muscle weakness\n - continue nebs given hx asthma\n .\n # HCV: stable, viral load undetectable\n - appreciate liver recs, abd US done and showed minimal ascites\n - dobhoff placed yesterday, starting nutrition; will have to follow up\n long term nutrition plans\n - holding INF as it may be possible cause of weakness\n - cyro levels pending\n .\n # Corneal abrasion and conjunctivitis\n opthamology following;\n - tx with lacrilube ointment q 1hr, lacrilube drops q2 hr and cipro\n gtts q 6hrs\n - at risk for worsening corneal damage in setting of muscle weakness\n and inability to close eyes; will need close eye care for now and\n follow up with opthomology\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, requiring less and less medicine\n - starting tube feeds now that dobhoff placed\n - transitioned back to nadolol for varicies; can titrate up as needed\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopped ranitidine\n - dobhoff in place\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab - negative\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - nadolol as above for tachycardia\n .\n # FEN:\n - on tube feeds, stopping maintenance fluids\n - replete electrolytes\n - tube feeds started\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n - no HIT\n starting SQ heparin after nerve biopsy, holding for possible\n surgery\n .\n # Access:\n - RIJ from OSH removed, now with PIVs\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 09:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660574,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped reglan per neuro recs\n - optho c/s done started cipro eye drops and Q1H lacrilube\n administration for significant corneal abrasion without thinning\n - nsurg - OR for sural nerve bx\n - HIT Ab PF4 sent\n - dopof tube placed\n - echo - The left atrium is moderately dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n BRONCHOSCOPY - At 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:00 PM\n Morphine Sulfate - 01:37 AM\n Lorazepam (Ativan) - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 87 (86 - 103) bpm\n BP: 153/103(113) {132/73(87) - 168/114(123)} mmHg\n RR: 18 (14 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,690 mL\n 281 mL\n PO:\n TF:\n 38 mL\n 170 mL\n IVF:\n 1,593 mL\n 11 mL\n Blood products:\n Total out:\n 2,830 mL\n 1,280 mL\n Urine:\n 2,830 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -999 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 212 (212 - 389) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 7.9 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 118 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.2 mg/dL\n 28 mEq/L\n 3.2 mEq/L\n 4 mg/dL\n 103 mEq/L\n 137 mEq/L\n 31.6 %\n 6.8 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n Plt\n 76\n 80\n 107\n 118\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.4 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach at OSH. Her difficulty weaning from vent is\n presumptively neuromuscular weakness, although improving. her\n pneumonia appears to have cleared rapidly. ? pneumonitis vs pneumonia.\n Nonetheless, she is on a day course abx. Given that her weakness\n preceeded her critical illness, I suspect cryoglobulinemia as primary\n process.\n - complete 10 day of cefepime, last day today\n - continue PS with goal to wean, daily RSBI and SBT; continuing to\n improve, will do trach collar trial today\n - NIF is still -18 today\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult; plan for EMG and a nerve biopsy with neurosurg (Dr.\n \n - will follow up OSH biopsy, plan is to have specimen sent to after\n it is fixed\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs, abd US done and showed no ascites; question is\n now PEG v. dobhoff\n - holding INF as it may be possible cause of weakness\n - HCV virus and cyro levels pending\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - improved, rates in 90s-100s mostly now\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - on maintenance fluids for now\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI; will switch from IV to PO nadolol when access to gut\n is achieved\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopped ranitidine\n - will discuss with liver if PEG tube can be placed; likely can be\n placed since no ascites\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n results pending\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement per liver recs, likely should\n have PEG to avoid two procedures as likely will need long term feeding\n options\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n - no heparin problems\n .\n # Access:\n - RIJ from OSH removed, now with PIVs\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 09:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660571,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped reglan per neuro recs\n - optho c/s done started cipro eye drops and Q1H lacrilube\n administration for significant corneal abrasion without thinning\n - nsurg - OR for sural nerve bx\n - HIT Ab PF4 sent\n - dopof tube placed\n - echo - The left atrium is moderately dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n BRONCHOSCOPY - At 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:00 PM\n Morphine Sulfate - 01:37 AM\n Lorazepam (Ativan) - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 87 (86 - 103) bpm\n BP: 153/103(113) {132/73(87) - 168/114(123)} mmHg\n RR: 18 (14 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,690 mL\n 281 mL\n PO:\n TF:\n 38 mL\n 170 mL\n IVF:\n 1,593 mL\n 11 mL\n Blood products:\n Total out:\n 2,830 mL\n 1,280 mL\n Urine:\n 2,830 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -999 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 212 (212 - 389) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 7.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 118 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.2 mg/dL\n 28 mEq/L\n 3.2 mEq/L\n 4 mg/dL\n 103 mEq/L\n 137 mEq/L\n 31.6 %\n 6.8 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n Plt\n 76\n 80\n 107\n 118\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.4 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 09:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660572,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - stopped reglan per neuro recs\n - optho c/s done started cipro eye drops and Q1H lacrilube\n administration for significant corneal abrasion without thinning\n - nsurg - OR for sural nerve bx\n - HIT Ab PF4 sent\n - dopof tube placed\n - echo - The left atrium is moderately dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n BRONCHOSCOPY - At 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 06:02 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:00 PM\n Morphine Sulfate - 01:37 AM\n Lorazepam (Ativan) - 04:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 87 (86 - 103) bpm\n BP: 153/103(113) {132/73(87) - 168/114(123)} mmHg\n RR: 18 (14 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,690 mL\n 281 mL\n PO:\n TF:\n 38 mL\n 170 mL\n IVF:\n 1,593 mL\n 11 mL\n Blood products:\n Total out:\n 2,830 mL\n 1,280 mL\n Urine:\n 2,830 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,140 mL\n -999 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 212 (212 - 389) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 7.9 L/min\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 118 K/uL\n 10.5 g/dL\n 101 mg/dL\n 0.2 mg/dL\n 28 mEq/L\n 3.2 mEq/L\n 4 mg/dL\n 103 mEq/L\n 137 mEq/L\n 31.6 %\n 6.8 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n 05:08 PM\n 03:55 AM\n 03:28 AM\n WBC\n 6.4\n 6.7\n 6.0\n 6.8\n Hct\n 29.5\n 29.9\n 30.0\n 31.9\n 31.6\n Plt\n 76\n 80\n 107\n 118\n Cr\n 0.3\n 0.3\n 0.3\n 0.2\n TropT\n 0.18\n 0.14\n TCO2\n 27\n Glucose\n 73\n 84\n 92\n 101\n Other labs: PT / PTT / INR:14.8/30.2/1.3, CK / CKMB /\n Troponin-T:128/15/0.14, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.4\n mg/dL, Mg++:1.4 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n MYOPATHY, OTHER (NOT OF CRITICAL ILLNESS)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 09:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 04:50 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "ICU Attending",
"row_id": 660418,
"text": "CRITICAL CARE STAFF\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. The ICU team\ns note\n from today reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Yesterday, we decreased her ventilatory support, which she has\n tolerated. She was seen by liver and neurology.\n On exam, she is comfortable on CMV. With conversion to PSV 10/5 she\n also remains comfortable. NIF is -18. Sclerae are injected. Heart is\n regular. Lungs are coarse. Abdomen is soft and nontender. Trach site\n is oozing. Neuro exam is limited by ?cooperation and difficulty\n communicating due to trach. In general, she has paresesis of eyelids\n (mid-position), and at best antigravity strength or less. Muscle\n biopsy site intact.\n Labs, imaging, and medications reviewed.\n Assessment and Plan\n 55-year-old woman with\n echo\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n Myopathy and neuropathy\n o Discuss with her neurologist, since substantial workup\n already done\n o Get report and slides of recent muscle biopsy\n o Based on biopsy and neuro, may need further eval (e.g. rheum)\n o Will need eye gtt since can\nt keep lids closed\n Access\n o Will try for PIVs. If unable, pursue PICC.\n o CVL out after alterative access obtained.\n o Will discuss PEG with liver team\n HCV\n o Will discuss role of interferon with hepatology\n o Beta blockers IV for now\n Tachycardia\n o Try sequential diagnostic rx: pain control, fluids, beta\n blocker\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Now back closer to baseline\n Other issues as per ICU team note above.\n She is critically ill. 40 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-27 00:00:00.000",
"description": "ICU Attending",
"row_id": 660525,
"text": "CRITICAL CARE STAFF\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. The ICU team\ns note\n from today reflects my input. I would add/emphasize:\n 56-year-old woman with HCV on interferon, complicated by\n cryoglobulinemia (presumably mixed essential) had been undergoing\n evaluation for progressive weakness as well as dysphagia. During\n admission to OSH, developed pneumonia\n respiratory failure\n trach.\n Also underwent muscle biopsy.\n Yesterday, we decreased her ventilatory support, which she has\n tolerated. She was seen by liver and neurology.\n On exam, she is comfortable on PSV. Eyes are injected. Heart is\n regular. Today there is a holosystolic murmur. Lungs are coarse.\n Abdomen is soft and nontender. Neurologic exam is unchanged c/w\n yesterday, though her affect is brighter today. Muscle biopsy site\n intact.\n Labs, imaging, and medications reviewed in today\ns ICU team note.\n Assessment and Plan\n 55-year-old woman with\n Hypoxemic respiratory failure s/p trach\n o Likely related to PNA/ARDS from aspiration\n o Weakness also very likely contributes\n o Complete 10 days of antibiotics for OSH-cultured organisms\n o Appears to have improved substantially\n try trach mask today\n Myopathy and neuropathy\n o Appreciate neuro\ns help.\n o Awaiting results of recent muscle biopsy\n o Anticipate nerve biopsy this week, per neuro\n Conjunctivitis\n o Ophtho consult\n Access\n o PIVs adequate\n o Liver team feels Dobhoff appropriate course for enteral\n access. Will do under bronchoscopic guidance.\n HCV\n o Hold interferon\n o [image002.jpg] Beta blockers IV for now\n Tachycardia\n o Showing improvement\n NSTEMI (demand)\n o No evidence of unstable plaque\n Thrombocytopenia\n o Improving\n Other issues as per ICU team note above.\n She is critically ill. 45 minutes\n ------ Protected Section ------\n Addendum\n Case reviewed with ophtho, whose help is greatly appreciated.\n Met with patient\ns family at 7pm x 20 minutes, required due to her\n critical illness. Her course at to date reviewed, plans going\n forward discussed, and all questions answered.\n 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 10:44 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 660134,
"text": "Chief Complaint: OSH transfer for further management of vent wean and\n weakness\n HPI:\n Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n .\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n .\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDS:\n artificial tears\n ativan 1-2 mg Q8H PRN\n Moxifloxacin 400 mg IV daily\n Combivent Q4H\n Cymbalta 60 mg daily\n folic acid 1mg daily\n erythromycin OU TID, day 1 = \n morphine PRN\n nexium 40 mg IV BID\n Cefepime 1 gm daily\n reglan 5 mg Q6H PRN\n Vit B1\n chlorhexidine\n .\n HOME MEDS:\n ALBUTEROL 1 -2 puff by mouth twice a day\n DULOXETINE [CYMBALTA] 60 mg once a day\n GABAPENTIN 600 mg TID\n HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN\n MONTELUKAST [SINGULAIR]\n NADOLOL 20 mg daily\n OMEPRAZOLE 20 mg \n PEGINTERFERON ALFA-2B Q week\n RANITIDINE 300 mg QHS\n ZOLPIDEM 12.5 mg qhs prn\n Past medical history:\n Family history:\n Social History:\n 1. Active hepatitis C.\n - diagnosed genotype 1a, \n - treated with PEG interferon and ribavirin x 48 weeks ending in \n - virologic relapse after 4 weeks leading to low dose PEG interferon\n starting in x 4 years, finished in \n - In had a cryocrit of 6% so maintenance PEG interferon restarted\n - known cirrhosis\n - known varices\n 2. Asthma.\n 3. Recent hoarseness which was evaluated by Dr. in ENT\n and was felt to be due to reflux esophagitis.\n 4. s/p choly\n 5. s/p appendectomy\n 6. hx venous thrombophlebitis 25 yrs ago\n Her mother has diabetes with neuropathy. She does not have any muscle\n problems or dysphagia in the family. Her mother had a three-vessel\n CABG. There is no evidence of Parkinson's, MS, strokes, seizures, or\n other neurologic diagnoses in the family.\n Occupation:\n Drugs: none\n Tobacco: 60 pack year\n Alcohol: none\n Other: She is married and has two sons. She does not use any herbal\n medicines or supplements. She denies any drug use.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, Conjunctival edema\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Signs or concerns for abuse : No\n Flowsheet Data as of 10:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 114 (114 - 114) bpm\n BP: 134/84(95) {134/83(95) - 134/84(95)} mmHg\n RR: 22 (21 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL, conjunctival edema\n Head, Ears, Nose, Throat: trach\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, CN: unable to squeeze eyes, EOM minimal upward gaze,\n PERRL 2mm-> 1 mm, tongue midline, sternocleidomastoids , shoulder\n shrug: pt did not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n [image002.jpg]\n Imaging: EMG: Abnormal study. There is electrophysiologic\n evidence for a mild proximally predominant myopathy with some\n denervating features. There is also evidence for a mild to moderate,\n chronic, sensorimotor, generalized polyneuropathy which is axonal in\n nature and appears symmetric. Compared with the prior study of ,\n the polyneuropathy is new and the myopathy is more clearly present.\n Microbiology: : HCV viral load 374 IU/mL\n : HIV neg\n .\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n and peg after intubation for aspiration pneumonia and persistant\n difficulty weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process. She\n does not appear to have had prlongued illness or steroid use.\n - continue PS with goal to wean, daily RSBI and SBT\n - apprec neurology recs\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - d/w neuro re: nerve bx\n - continue nebs given hx asthma\n - repeat CXR tonight\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia.\n - neurology c/s in am\n - I will email Dr. , her outpt neurologist, tonight\n - check cryo levels\n .\n # HCV: stable on peg interferon maintenance; known varices\n - appreciate liver recs\n - continue IFN Q week\n - consider restart nadolol if BP tolerates\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continue ranitidine and PPI\n - c/s IP for peg in AM, if not possible tomorrow, would place NGT for\n tube feeds\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - check EKG and CE's\n - would start ASA\n .\n # FEN:\n - No IVF\n - replete electrolytes\n - tube feeds after NGT\n .\n # Prophylaxis:\n - pneumoboots\n - PPI and H2 blocker\n .\n # Access:\n - RIJ from OSH (placed on )\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: TF, Jevity 40 cc/hr\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI and H2 blocker\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 660135,
"text": "Chief Complaint: OSH transfer for further management of vent wean and\n weakness\n HPI:\n Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n .\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n .\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDS:\n artificial tears\n ativan 1-2 mg Q8H PRN\n Moxifloxacin 400 mg IV daily\n Combivent Q4H\n Cymbalta 60 mg daily\n folic acid 1mg daily\n erythromycin OU TID, day 1 = \n morphine PRN\n nexium 40 mg IV BID\n Cefepime 1 gm daily\n reglan 5 mg Q6H PRN\n Vit B1\n chlorhexidine\n .\n HOME MEDS:\n ALBUTEROL 1 -2 puff by mouth twice a day\n DULOXETINE [CYMBALTA] 60 mg once a day\n GABAPENTIN 600 mg TID\n HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN\n MONTELUKAST [SINGULAIR]\n NADOLOL 20 mg daily\n OMEPRAZOLE 20 mg \n PEGINTERFERON ALFA-2B Q week\n RANITIDINE 300 mg QHS\n ZOLPIDEM 12.5 mg qhs prn\n Past medical history:\n Family history:\n Social History:\n 1. Active hepatitis C.\n - diagnosed genotype 1a, \n - treated with PEG interferon and ribavirin x 48 weeks ending in \n - virologic relapse after 4 weeks leading to low dose PEG interferon\n starting in x 4 years, finished in \n - In had a cryocrit of 6% so maintenance PEG interferon restarted\n - known cirrhosis\n - known varices\n 2. Asthma.\n 3. Recent hoarseness which was evaluated by Dr. in ENT\n and was felt to be due to reflux esophagitis.\n 4. s/p choly\n 5. s/p appendectomy\n 6. hx venous thrombophlebitis 25 yrs ago\n Her mother has diabetes with neuropathy. She does not have any muscle\n problems or dysphagia in the family. Her mother had a three-vessel\n CABG. There is no evidence of Parkinson's, MS, strokes, seizures, or\n other neurologic diagnoses in the family.\n Occupation:\n Drugs: none\n Tobacco: 60 pack year\n Alcohol: none\n Other: She is married and has two sons. She does not use any herbal\n medicines or supplements. She denies any drug use.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, Conjunctival edema\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Signs or concerns for abuse : No\n Flowsheet Data as of 10:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 114 (114 - 114) bpm\n BP: 134/84(95) {134/83(95) - 134/84(95)} mmHg\n RR: 22 (21 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL, conjunctival edema\n Head, Ears, Nose, Throat: trach\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, CN: unable to squeeze eyes, EOM minimal upward gaze,\n PERRL 2mm-> 1 mm, tongue midline, sternocleidomastoids , shoulder\n shrug: pt did not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n [image002.jpg]\n Imaging: EMG: Abnormal study. There is electrophysiologic\n evidence for a mild proximally predominant myopathy with some\n denervating features. There is also evidence for a mild to moderate,\n chronic, sensorimotor, generalized polyneuropathy which is axonal in\n nature and appears symmetric. Compared with the prior study of ,\n the polyneuropathy is new and the myopathy is more clearly present.\n Microbiology: : HCV viral load 374 IU/mL\n : HIV neg\n .\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n and peg after intubation for aspiration pneumonia and persistant\n difficulty weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process. She\n does not appear to have had prlongued illness or steroid use.\n - continue PS with goal to wean, daily RSBI and SBT\n - apprec neurology recs\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - d/w neuro re: nerve bx\n - continue nebs given hx asthma\n - repeat CXR tonight\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia.\n - neurology c/s in am\n - I will email Dr. , her outpt neurologist, tonight\n - check cryo levels\n .\n # HCV: stable on peg interferon maintenance; known varices\n - appreciate liver recs\n - continue IFN Q week\n - consider restart nadolol if BP tolerates\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continue ranitidine and PPI\n - c/s IP for peg in AM, if not possible tomorrow, would place NGT for\n tube feeds\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - check EKG and CE's\n - would start ASA\n .\n # FEN:\n - No IVF\n - replete electrolytes\n - tube feeds after NGT\n .\n # Prophylaxis:\n - pneumoboots\n - PPI and H2 blocker\n .\n # Access:\n - RIJ from OSH (placed on )\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: TF, Jevity 40 cc/hr\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI and H2 blocker\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n REVISED NEURO EXAM:\n CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm-> 1 mm,\n tongue midline, sternocleidomastoids , shoulder shrug: pt did not\n coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: 4+/5\n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil; patellar: 3+ bilt; achilles: unable\n to be elicited\n ------ Protected Section Addendum Entered By: , MD\n on: 22:55 ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-25 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 660136,
"text": "Chief Complaint: OSH transfer for further management of vent wean and\n weakness\n HPI:\n Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n .\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n .\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDS:\n artificial tears\n ativan 1-2 mg Q8H PRN\n Moxifloxacin 400 mg IV daily\n Combivent Q4H\n Cymbalta 60 mg daily\n folic acid 1mg daily\n erythromycin OU TID, day 1 = \n morphine PRN\n nexium 40 mg IV BID\n Cefepime 1 gm daily\n reglan 5 mg Q6H PRN\n Vit B1\n chlorhexidine\n .\n HOME MEDS:\n ALBUTEROL 1 -2 puff by mouth twice a day\n DULOXETINE [CYMBALTA] 60 mg once a day\n GABAPENTIN 600 mg TID\n HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN\n MONTELUKAST [SINGULAIR]\n NADOLOL 20 mg daily\n OMEPRAZOLE 20 mg \n PEGINTERFERON ALFA-2B Q week\n RANITIDINE 300 mg QHS\n ZOLPIDEM 12.5 mg qhs prn\n Past medical history:\n Family history:\n Social History:\n 1. Active hepatitis C.\n - diagnosed genotype 1a, \n - treated with PEG interferon and ribavirin x 48 weeks ending in \n - virologic relapse after 4 weeks leading to low dose PEG interferon\n starting in x 4 years, finished in \n - In had a cryocrit of 6% so maintenance PEG interferon restarted\n - known cirrhosis\n - known varices\n 2. Asthma.\n 3. Recent hoarseness which was evaluated by Dr. in ENT\n and was felt to be due to reflux esophagitis.\n 4. s/p choly\n 5. s/p appendectomy\n 6. hx venous thrombophlebitis 25 yrs ago\n Her mother has diabetes with neuropathy. She does not have any muscle\n problems or dysphagia in the family. Her mother had a three-vessel\n CABG. There is no evidence of Parkinson's, MS, strokes, seizures, or\n other neurologic diagnoses in the family.\n Occupation:\n Drugs: none\n Tobacco: 60 pack year\n Alcohol: none\n Other: She is married and has two sons. She does not use any herbal\n medicines or supplements. She denies any drug use.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, Conjunctival edema\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Signs or concerns for abuse : No\n Flowsheet Data as of 10:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 114 (114 - 114) bpm\n BP: 134/84(95) {134/83(95) - 134/84(95)} mmHg\n RR: 22 (21 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL, conjunctival edema\n Head, Ears, Nose, Throat: trach\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, CN: unable to squeeze eyes, EOM minimal upward gaze,\n PERRL 2mm-> 1 mm, tongue midline, sternocleidomastoids , shoulder\n shrug: pt did not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n [image002.jpg]\n Imaging: EMG: Abnormal study. There is electrophysiologic\n evidence for a mild proximally predominant myopathy with some\n denervating features. There is also evidence for a mild to moderate,\n chronic, sensorimotor, generalized polyneuropathy which is axonal in\n nature and appears symmetric. Compared with the prior study of ,\n the polyneuropathy is new and the myopathy is more clearly present.\n Microbiology: : HCV viral load 374 IU/mL\n : HIV neg\n .\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n and peg after intubation for aspiration pneumonia and persistant\n difficulty weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process. She\n does not appear to have had prlongued illness or steroid use.\n - continue PS with goal to wean, daily RSBI and SBT\n - apprec neurology recs\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - d/w neuro re: nerve bx\n - continue nebs given hx asthma\n - repeat CXR tonight\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia.\n - neurology c/s in am\n - I will email Dr. , her outpt neurologist, tonight\n - check cryo levels\n .\n # HCV: stable on peg interferon maintenance; known varices\n - appreciate liver recs\n - continue IFN Q week\n - consider restart nadolol if BP tolerates\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continue ranitidine and PPI\n - c/s IP for peg in AM, if not possible tomorrow, would place NGT for\n tube feeds\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - check EKG and CE's\n - would start ASA\n .\n # FEN:\n - No IVF\n - replete electrolytes\n - tube feeds after NGT\n .\n # Prophylaxis:\n - pneumoboots\n - PPI and H2 blocker\n .\n # Access:\n - RIJ from OSH (placed on )\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: TF, Jevity 40 cc/hr\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI and H2 blocker\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n REVISED NEURO EXAM:\n CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm-> 1 mm,\n tongue midline, sternocleidomastoids , shoulder shrug: pt did not\n coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: 4+/5\n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil; patellar: 3+ bilt; achilles: unable\n to be elicited\n ------ Protected Section Addendum Entered By: , MD\n on: 22:55 ------\n Attending Addendum\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Corrections: pt has lost 35 lbs over past 3-4 months. Pt has trach but\n no PEG.\n 55 yo woman with HCV, cryoglobulinemia, several month h/o weakness, who\n now is ventilator dependent due to weakness. Intubated , trach ,\n completing treatment for aspiration pneumonia. Her weakness began\n distally (weakness in her feet and numbness in feet and hands) and\n progressed proximally. Exam shows more pronounced weakness in proximal\n muscles. Had DOE prior to admission, but not clear if she had more\n difficulty when supine than sitting/standing.\n Neuro consult\n Rest on high pressure PSV overnight and attempt decrease in\n AM to evaluate, also evaluate in more upright position to elucidate\n diaphragmatic component\n PEG as soon as feasible\n Thrombocytopenia, off heparin, repeating plt count, change\n PPI to sucralfate if plt count is truly profoundly depressed to assess\n response\n Day cefipime for aspiration pna\n Other issues per Dr \ns note.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:14 ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-25 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 660137,
"text": "Chief Complaint: OSH transfer for further management of vent wean and\n weakness\n HPI:\n Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n .\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n .\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDS:\n artificial tears\n ativan 1-2 mg Q8H PRN\n Moxifloxacin 400 mg IV daily\n Combivent Q4H\n Cymbalta 60 mg daily\n folic acid 1mg daily\n erythromycin OU TID, day 1 = \n morphine PRN\n nexium 40 mg IV BID\n Cefepime 1 gm daily\n reglan 5 mg Q6H PRN\n Vit B1\n chlorhexidine\n .\n HOME MEDS:\n ALBUTEROL 1 -2 puff by mouth twice a day\n DULOXETINE [CYMBALTA] 60 mg once a day\n GABAPENTIN 600 mg TID\n HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN\n MONTELUKAST [SINGULAIR]\n NADOLOL 20 mg daily\n OMEPRAZOLE 20 mg \n PEGINTERFERON ALFA-2B Q week\n RANITIDINE 300 mg QHS\n ZOLPIDEM 12.5 mg qhs prn\n Past medical history:\n Family history:\n Social History:\n 1. Active hepatitis C.\n - diagnosed genotype 1a, \n - treated with PEG interferon and ribavirin x 48 weeks ending in \n - virologic relapse after 4 weeks leading to low dose PEG interferon\n starting in x 4 years, finished in \n - In had a cryocrit of 6% so maintenance PEG interferon restarted\n - known cirrhosis\n - known varices\n 2. Asthma.\n 3. Recent hoarseness which was evaluated by Dr. in ENT\n and was felt to be due to reflux esophagitis.\n 4. s/p choly\n 5. s/p appendectomy\n 6. hx venous thrombophlebitis 25 yrs ago\n Her mother has diabetes with neuropathy. She does not have any muscle\n problems or dysphagia in the family. Her mother had a three-vessel\n CABG. There is no evidence of Parkinson's, MS, strokes, seizures, or\n other neurologic diagnoses in the family.\n Occupation:\n Drugs: none\n Tobacco: 60 pack year\n Alcohol: none\n Other: She is married and has two sons. She does not use any herbal\n medicines or supplements. She denies any drug use.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, Conjunctival edema\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Signs or concerns for abuse : No\n Flowsheet Data as of 10:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 114 (114 - 114) bpm\n BP: 134/84(95) {134/83(95) - 134/84(95)} mmHg\n RR: 22 (21 - 22) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n Plateau: 17 cmH2O\n SpO2: 99%\n Ve: 9.3 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL, conjunctival edema\n Head, Ears, Nose, Throat: trach\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, CN: unable to squeeze eyes, EOM minimal upward gaze,\n PERRL 2mm-> 1 mm, tongue midline, sternocleidomastoids , shoulder\n shrug: pt did not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n [image002.jpg]\n Imaging: EMG: Abnormal study. There is electrophysiologic\n evidence for a mild proximally predominant myopathy with some\n denervating features. There is also evidence for a mild to moderate,\n chronic, sensorimotor, generalized polyneuropathy which is axonal in\n nature and appears symmetric. Compared with the prior study of ,\n the polyneuropathy is new and the myopathy is more clearly present.\n Microbiology: : HCV viral load 374 IU/mL\n : HIV neg\n .\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n and peg after intubation for aspiration pneumonia and persistant\n difficulty weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process. She\n does not appear to have had prlongued illness or steroid use.\n - continue PS with goal to wean, daily RSBI and SBT\n - apprec neurology recs\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - d/w neuro re: nerve bx\n - continue nebs given hx asthma\n - repeat CXR tonight\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia.\n - neurology c/s in am\n - I will email Dr. , her outpt neurologist, tonight\n - check cryo levels\n .\n # HCV: stable on peg interferon maintenance; known varices\n - appreciate liver recs\n - continue IFN Q week\n - consider restart nadolol if BP tolerates\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continue ranitidine and PPI\n - c/s IP for peg in AM, if not possible tomorrow, would place NGT for\n tube feeds\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - check EKG and CE's\n - would start ASA\n .\n # FEN:\n - No IVF\n - replete electrolytes\n - tube feeds after NGT\n .\n # Prophylaxis:\n - pneumoboots\n - PPI and H2 blocker\n .\n # Access:\n - RIJ from OSH (placed on )\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition: TF, Jevity 40 cc/hr\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI and H2 blocker\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n REVISED NEURO EXAM:\n CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm-> 1 mm,\n tongue midline, sternocleidomastoids , shoulder shrug: pt did not\n coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: 4+/5\n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil; patellar: 3+ bilt; achilles: unable\n to be elicited\n ------ Protected Section Addendum Entered By: , MD\n on: 22:55 ------\n Attending Addendum\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Corrections: pt has lost 35 lbs over past 3-4 months. Pt has trach but\n no PEG.\n 55 yo woman with HCV, cryoglobulinemia, several month h/o weakness, who\n now is ventilator dependent due to weakness. Intubated , trach ,\n completing treatment for aspiration pneumonia. Her weakness began\n distally (weakness in her feet and numbness in feet and hands) and\n progressed proximally. Exam shows more pronounced weakness in proximal\n muscles. Had DOE prior to admission, but not clear if she had more\n difficulty when supine than sitting/standing.\n Neuro consult\n Rest on high pressure PSV overnight and attempt decrease in\n AM to evaluate, also evaluate in more upright position to elucidate\n diaphragmatic component\n PEG as soon as feasible\n Thrombocytopenia, off heparin, repeating plt count, change\n PPI to sucralfate if plt count is truly profoundly depressed to assess\n response\n Day cefipime for aspiration pna\n Other issues per Dr \ns note.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:14 ------\n Critically ill.\n 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 23:15 ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660138,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660140,
"text": "Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient from OSH vented via trach tube , A/C 400/../5 and 50%.\n Bilateral lung sounds rhonchorus and diminished bases. Copius amount of\n thick blood tinged secreation with suction. From OSH patient has\n difficulty in weaning is may be due to neuromuscular weakness. O2 sats\n 99-100%\n Action:\n Continued vent settings, O2 down to 40%, suctioned thick blood tinged\n secreation, CXR taken. Ativan 1mg q8hrs for agitation and morphine\n 2-4mg PRN for pain.\n Response:\n Blood gas satisfactory, O2 sats 98-100%,\n Plan:\n Daily RSBI and SBT, wean vent as tolerated, MDI\ns as ordered\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n NPO tonight, D51/2 NS 100ml/hr on flow and continued PPI, finger stick\n qid\n Response:\n Plan:\n C/s IP for PEG in Am, if not NGT placement for tube feeds.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change,\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 660141,
"text": "Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with\n progressively worsening peripheral myopathy followed by neurology and\n dysphagia who was recently admitted to OSH for planned peg due to\n dysphagia, poor PO intake and 5 pound weight loss over past 3-4 months.\n During admission, she developed hypoxia, fever and was found to have an\n aspiration pneumonia. Sputum Cx grew serratia, E. coli, and staph. She\n required intubation and was hypotensive requiring pressors X 2 days.\n She is currently on day of cefepime and has been off pressors X 4\n days. Per ICU attd at OSH, she was difficult to wean from vent\n presumably from neuromuscular weakness and is now s/p trach on \n and currently on PS 15/5 30%. She received daily PS trials but was not\n able to maintain sufficient tidal volumes with PS below 10. She also\n received a muscle biopsy on with results pending. She is\n transferred to forfurther neurologic evaluation.\n Upon arrival to , she reports feeling pain around her trach, but no\n other complaints besides fatigue. Prior to her admission, her husband\n denies any sick contacts, cold-like symptoms, no unusual fevers/chills\n beyond those assoc with IFN. NO chest pain, palp, abd pain,\n bladder/bowel incontinence. No Diplopia/blurry vision/headache.\n With review of OMR and OSH records, it appears that for past 6 months,\n she has had progressive weakness and DOE/SOB as well as paresthesias of\n both legs to the knees and fingers. Prior to this, she has no\n probalems. Also, she has had difficulty swallowing X 3-4 months,\n decreased appetite and 30 pound weight loss over last 2 months. He\n husband finally brought her in for evaluation because she was not able\n to keep any foods down. Her dysphagia started with solids and then\n progressed to liquids.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient from OSH vented via trach tube , A/C 400/../5 and 50%.\n Bilateral lung sounds rhonchorus and diminished bases. Copius amount of\n thick blood tinged secreation with suction. From OSH patient has\n difficulty in weaning is may be due to neuromuscular weakness. O2 sats\n 99-100%\n Action:\n Continued vent settings, O2 down to 40%, suctioned thick blood tinged\n secreation, CXR taken. Ativan 1mg q8hrs for agitation and morphine\n 2-4mg PRN for pain.\n Response:\n Blood gas satisfactory, O2 sats 98-100%,\n Plan:\n Daily RSBI and SBT, wean vent as tolerated, MDI\ns as ordered\n Alteration in Nutrition\n Assessment:\n NPO, H/o dysphagia and poor po intake and weight loss\n Action:\n NPO tonight, D51/2 NS 100ml/hr on flow and continued PPI, finger stick\n qid\n Response:\n Plan:\n C/s IP for PEG in Am, if not NGT placement for tube feeds.\n Impaired Skin Integrity\n Assessment:\n Yeast on her coccyx and skin excoriation and redness. Lt eye is very\n red\n Action:\n Frequent position change,\n Response:\n Plan:\n Myopathy, other (not of critical illness)\n Assessment:\n Progressive neuromuscular weakness now s/p with trach, persistent\n difficulty weaning from vent . EMG showed a mild sensory motor\n polyneuropathy as well as a myopathic process in several proximal\n muscles Muscle and nerve biopsy are needed to help evaluate the nature\n of her myopathy and to look for evidence of a vasculitic neuropathy in\n the setting of her cryoglobulinemia.\n Action:\n Check cryo levels\n Response:\n Plan:\n Neurology consult in AM, F/U muscle biopsy result from OSH.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 660218,
"text": "Chief Complaint: OSH transfer for workup of weakness\n 24 Hour Events:\n Events:\n - overnight remained anxious and uncomfortable, received ativan and\n morphine with only mild effect\n - tachycardic to 110s\n - no PO access, consider PEG v. NG tube today\n INVASIVE VENTILATION - START 09:05 PM\n MULTI LUMEN - START 09:42 PM\n EKG - At 10:53 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 01:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 01:00 AM\n Morphine Sulfate - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.6\n HR: 104 (104 - 122) bpm\n BP: 150/87(103) {127/83(95) - 150/89(103)} mmHg\n RR: 15 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8 mL\n 583 mL\n PO:\n TF:\n IVF:\n 8 mL\n 583 mL\n Blood products:\n Total out:\n 145 mL\n 265 mL\n Urine:\n 145 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n -138 mL\n 318 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.37/45/179/29/0\n Ve: 8.2 L/min\n PaO2 / FiO2: 447\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN: unable to squeeze eyes, EOM minimal upward gaze, PERRL 2mm->\n 1 mm, tongue midline, sternocleidomastoids , shoulder shrug: pt did\n not coorperate fully\n delt: unable to move against gravity\n biceps: \n triceps: \n Finger ext: \n hip flex: \n quads: exam difficult as pt not completely cooperating \n hams: \n foot plantar/dorsiflex: \n reflexes: brachoradialis: 3+ bil\n patellar: 3+ bilt\n achilles: unable to be elicited\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 84 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 106 mEq/L\n 139 mEq/L\n 29.9 %\n 6.7 K/uL\n [image002.jpg]\n 10:13 PM\n 11:55 PM\n 03:13 AM\n WBC\n 6.4\n 6.7\n Hct\n 29.5\n 29.9\n Plt\n 76\n 80\n Cr\n 0.3\n 0.3\n TropT\n 0.18\n TCO2\n 27\n Glucose\n 73\n 84\n Other labs: PT / PTT / INR:15.5/31.8/1.4, CK / CKMB /\n Troponin-T:98//0.18, ALT / AST:18/69, Alk Phos / T Bili:104/1.0,\n Amylase / Lipase:113/124, Albumin:2.2 g/dL, LDH:270 IU/L, Ca++:7.5\n mg/dL, Mg++:1.5 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,\n progressive neuromuscular weakness followed by neurology now s/p trach\n after intubation for aspiration pneumonia and persistant difficulty\n weaning from vent.\n .\n .\n # Hypoxic respiratory failure: She now has resolving resp failure from\n PNA/ARDS now s/p trach today at OSH. Her difficulty weaning from vent\n is presumptively neuromuscular weakness. her pneumonia appears to\n have cleared rapidly. ? pneumonitis vs pneumonia. Nonetheless, she is\n on a day course abx. Given that her weakness preceeded her\n critical illness, I suspect cryoglobulinemia as primary process.\n - complete 10 day of cefepime, will get ID approval\n - continue PS with goal to wean, daily RSBI and SBT; did well with\n decrease PS this morning\n - try sitting upright to see if diaphragmatic paralysis\n - consult neuron/liver for help determining etiology of muscle weakness\n - f/u outpt muscle bx results. Per OSH ICU attd, Dr. , call\n for bx results (or can page Dr. )\n - continue nebs given hx asthma\n .\n # Myopathy/Neuropathy: She is followed by neurology.\n Myopathy/neuropathy felt possibly mixed cryoglobulinemia associated\n with HCV. Per recent neurology outpatient visit, EMG showed a mild\n sensorimotor polyneuropathy as well as a myopathic process in several\n proximal muscles (IP, biceps, infraspinatus, and prominently in L3\n paraspinals). Muscle and nerve biopsy are needed to help evaluate the\n nature of her myopathy and to look for evidence of a vasculitic\n neuropathy in the setting of her cryoglobulinemia. Other differential\n includes vitamin deficiencies, rheumatological problems like\n dermatomyositis or other myosities.\n - cyro levels pending\n - neuron consult and will touch base with Dr. ; plan for possible\n nerve biopsy and / or EMG\n .\n # HCV: stable on peg interferon maintenance\n - appreciate liver recs\n - continue IFN Q week, although need to consider IFN as toxic cause of\n her myopathy\n .\n # Tachycardia\n likely from pain as responsive to morphine; could also\n be fluid down.\n - tx with morphine for now, can transition to long acting pain control\n when G tube or NG place\n - IVF boluses PRN\n - IV metoprolol standing for heart rate control and cardioprotection in\n setting of NSTEMI\n .\n # Dysphagia: seen by neuro and ENT as well as S&S eval in . Felt\n to have laryngeal reflux.\n - NPO tonight\n - continuing PPI, stopping ranitidine today\n - will discuss with liver if PEG tube can be placed\n .\n # Thrombocytopenia: baseline in last 6 months 50-70's. At OSH, plts to\n 20's and OSH stopped heparin with concern for HIT. No HIT sent yet.\n - trend and transfuse for plt <20 or bleeding\n - hold all heparin products\n - check HIT Ab\n .\n # NSTEMI: likely demand ischemia at OSH\n - trending troponins, CKs negative; EKGs without signs of ischemia\n - holding aspirin\n - metoprolol as above for tachycardia\n .\n # FEN:\n - maintenance fluids\n - replete electrolytes\n - tube feeds after NGT or PEG placement\n .\n # Prophylaxis:\n - pneumoboots\n - PPI\n .\n # Access:\n - RIJ from OSH (placed on ); plan for PIVs and then d/c of RIJ if\n possible\n .\n # Code: FULL CODE\n .\n # Communication: Patient and husband\n - of note, pt does not wish for extended family to know about HCV\n status\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 660146,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer:\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received as direct admit from OSH() trached and\n placed on mech vent as per Metavision. Lung sounds sl coarse suct sm th\n bld tinged sput. MDI given as per order. ABGs stable; able to wean\n FIO2. Cont mech vent support.\n"
}
] |
95,707 | 160,189 | 75y/o M with a PMH of CAD s/p CABG with AVR in and thrombocytopenia transferred to for management of S. aureus bacteremia and acute on chronic systolic CHF. . # Bacteremia - The patient was found to have 4/4 bottles growing MSSA at an outside hospital. The patient was initially continued on vancomycin but switched to nafcillin once the sensitivities were available. A transthoracic echo initially showed no evidence of a vegetation (albeit poor windows), and a TEE was obtained, which showed a small vegetation on the patient's prosthetic aortic valve. Infectious disease was consulted who agreed with nafcillin and adding gentamicin and rifampin. The nafcillin was switched back to vancomycin when evidence of acute interstitial nephritis was found. . # Hypotension - Presentation of hypotension in setting of bacteremia. His initial wedge pressure was 32 with a CVP of 14-24, which was consistent with a cardiogenic shock. The patient remained dependent on peripheral dopamine and initially improved, but later again became severely hypotensive. A swan was re-floated which showed extremely high wedge pressure in the 60s in the setting of hypotension. Cardiac output numbers however showed somewhat preserved cardiac output with an extremely low systemic vascular resistance which was consistent with septic shock. The patient remained dependent on maximum pressor support, but his blood pressure continued to fall. A family meeting was gathered, and it was determined that the patient was to be made comfort measures only. The patient expired on the evening of when pressors were discontinued. . # Acute on Chronic Systolic CHF - The patient had evidence of volume overload as above, and was diuresed with lasix. However, he developed acute renal failure and became unresponsive to diuresis. . # Acute Renal failure - The patient was found to have evidence of acute renal failure that worsened over the course of his admission. Renal was consulted, and white cell casts were found on urine sediment inspection, which was concerning for acute interstitial nephritis. Nafcillin was discontinued and vancomycin was re-initiated as above. . # Thrombocytopenia - Per OSH reports the patient has a chronic thrombocytopenia of unclear etiology. Pt reported history of easy bleeding & bruising. Hematology was consulted, who thought that this was likely bone marrow suppression in the setting of sepsis. . | Novegetation/mass on pulmonic valve.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Thrombocytopenia: pt. Thrombocytopenia: pt. Pt here with endocarditis, on nafacillian, Afebrile today. Additional comments: endocarditis, renal failure, hypotention ------ Protected Section Addendum Entered By: , MD on: 09:29 ------ The right ventricular cavity is mildly dilated withmild global free wall hypokinesis. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. pt increasingly tachypnic, through am w/ bp dropping requiring ^ in neo. Thickened aortic valve bioprosthesis withhigh-than-normal transvalvular gradients but no significant regurgitation.Mild to moderate regional left ventricular systolic dysfunction, c/wmultivessel CAD. MSSA Bacteremia/ endocarditis Assessment: Stable BPs off Neo. MSSA Bacteremia/ endocarditis Assessment: Stable BPs off Neo. Bacteremia Assessment: Action: Response: Plan: .H/O heart failure (CHF), Systolic, Acute on Chronic Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: pt increasingly tachypnic, through am w/ bp dropping requiring ^ in neo. pt increasingly tachypnic, through am w/ bp dropping requiring ^ in neo. covered with humulog SSRI. covered with humulog SSRI. covered with humulog SSRI. Thrombocytopenia: pt. Thrombocytopenia: pt. Thrombocytopenia: pt. Action: Nafcillin q4hr. Action: Nafcillin q4hr. Action: Nafcillin q4hr. Action: Neo weaned off abx given as ordered Response: Afebrile, WBC 4.5(10.2). Action: Neo weaned off abx given as ordered Response: Afebrile, WBC 4.5(10.2). Neo weaned off. Neo weaned off. BPdropping after dopa d/cd : 89-94/49. BPdropping after dopa d/cd : 89-94/49. Bacteremia Assessment: TM 97po. Bacteremia Assessment: TM 97po. Bacteremia Assessment: TM 97po. Less stool Action: Neo weaned off abx given as ordered Response: Afebrile, WBC 4.5(10.2). Incont small amt brown guiac neg stool Action: Attempted to wean neo abx given as ordered Response: Afebrile, WBC 10.2 (2.9). # Acute on Chronic Systolic CHF - Pt currently with evidence of volume overload as above - Diurese with lasix goal 1L negative but will follow hemodynamics and Cr - Plan for beta blocker and ACE-I once BP allows . # Acute on Chronic Systolic CHF - Pt currently with evidence of volume overload as above - Diurese with lasix goal 1L negative but will follow hemodynamics and Cr - Plan for beta blocker and ACE-I once BP allows . # Acute on Chronic Systolic CHF - Pt currently with evidence of volume overload as above - Diurese with lasix goal 1L negative but will follow hemodynamics and Cr - Plan for beta blocker and ACE-I once BP allows . repeat TEE if worried (no new murmur, pulse pressure widening, EKG QRS prolongation) - appreciate CSurg recs # Hypotension - has a mixed picture. repeat TEE if worried (no new murmur, pulse pressure widening, EKG QRS prolongation) - appreciate CSurg recs # Hypotension - has a mixed picture. Pt here with endocarditis, on nafacillian, Afebrile today. To OSH febrile, hypotensive and tachycardic. To OSH febrile, hypotensive and tachycardic. Found to have + BCx 4/4 bottles Staph and thrombocytopenia. Found to have + BCx 4/4 bottles Staph and thrombocytopenia. repeat TEE if worried (no new murmur, pulse pressure widening, EKG QRS prolongation) - appreciate CSurg recs # Hypotension - has a mixed picture. repeat TEE if worried (no new murmur, pulse pressure widening, EKG QRS prolongation) - appreciate CSurg recs # Hypotension - has a mixed picture. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. DIC less concerning given long history of thrombocytopenia and fibrinogen normal. Intraventricular conduction delay with left axis deviation maybe left anterior fascicular block. Since the previous tracing of same datemultiple atrial waveform morphologies are now present and ventricular responseis irregular.TRACING #4 MSSA Bacteremia/ endocarditis Assessment: Stable BPs off Neo. Intraventricular conduction delay with left axisdeviation may be left anterior fascicular block. Consider vasculitis vs chronic ITP. Consider vasculitis vs chronic ITP. CONTRAINDICATIONS for IV CONTRAST: creatinine elevated. Intraventricular conductiondelay with left axis deviation may be due to left anterior fascicular block.Left ventricular hypertrophy. Delayed R wave progression may be due to intraventricularconduction delay, left ventricular hypertrophy or possible prior anteriormyocardial infarction. Since the previous tracing of atrial fluttermay have been replaced by atrial fibrillation.TRACING #2 Pt with endocarditis Aortic valve veg, good valve fx by echo. ST-T wave abnormalities may be due tointraventricular conduction delay, left ventricular hypertrophy or possiblemyocardial ischemia. any evidence of emboli with hemorrhagic conversion. | 80 | [
{
"category": "Echo",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 91040,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function. Bioprosthetic AVR.\nHeight: (in) 69\nWeight (lb): 190\nBSA (m2): 2.02 m2\nBP (mm Hg): 74/48\nHR (bpm): 119\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV. Normal IVC diameter (<2.1cm) with\n35-50% decrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Moderate-severe regional left\nventricular systolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Increased AVR\ngradient. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Calcified tips of\npapillary muscles. MR present but cannot be quantified.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is elongated. The estimated right atrial pressure is 0-10mmHg.\nThe left ventricular cavity is moderately dilated. There is moderate to severe\nregional (LVEF 25%). Right ventricular chamber size is normal with depressed\nfree wall contractility. A well-seated bioprosthetic aortic valve prosthesis\nis present. The prosthetic aortic valve leaflets are thickened with mildly\nincreased gradient. No discrete vegetation is seen (cannot exclude due to\nsuboptimal image quality). Trace aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mitral regurgitation is present but\ncannot be quantified - ?moderate. The pulmonary artery systolic pressure could\nnot be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Well seated bioprosthetic AVR with\nslightly increased gradient and trace aortic regurgitation. Left ventricular\ncavity enlargement with extensive regional systolic dysfunction c/w\nmultivessel CAD or other diffuse process.\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is slightly worse (was overestimated on the prior study).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Report",
"row_id": 91041,
"text": "PATIENT/TEST INFORMATION:\nIndication: Bacteremia, ?Endocarditis.\nHeight: (in) 69\nWeight (lb): 190\nBSA (m2): 2.02 m2\nBP (mm Hg): 105/45\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 14:02\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA. No\nthrombus/mass in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or thrombus in\nthe body of the RA or RAA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: No atheroma in ascending aorta. Simple atheroma in aortic arch. Complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move\nnormally. Thickened AVR leaflets. Increased AVR gradient. Small vegetation on\naortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. No TEE related complications. Echocardiographic\nresults were reviewed with the houseofficer caring for the patient.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium. No\nthrombus/mass is seen in the body of the left atrium. No spontaneous echo\ncontrast or thrombus is seen in the body of the right atrium or the right\natrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nThere is mild regional left ventricular systolic dysfunction with hypokinesis\nof the mid and distal anteroseptal walls and the basal inferior wall. Right\nventricular chamber size is normal. with mild global free wall hypokinesis.\nThere are simple atheroma in the aortic arch. There are complex (>4mm)\natheroma in the descending thoracic aorta. A bioprosthetic aortic valve\nprosthesis is present. The aortic valve prosthesis leaflets appear to move\nnormally. The prosthetic aortic valve leaflets are thickened. The transaortic\ngradient is higher than expected for this type of prosthesis. There is a small\nvegetation on the aortic valve measuring 0.5 x 0.3 cm associated with the\nnoncoronary cusp (best seen on clips 87, 90, 112, 113, and 115) with no\nassociated abscess. No aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal without vegetations seen. Moderate (2+) mitral\nregurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There\nis a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Small mobile echodensity (0.5 x 0.3 cm) on the aortic\nbioprosthetic valve consistent with a small vegetation. No aortic\nregurgitation, paravalvular leak or parvalvar abcess seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Report",
"row_id": 91042,
"text": "PATIENT/TEST INFORMATION:\nIndication: Bioprosthetic AVR. Staph bacteremia. Coronary artery disease (s/p CABG). Congestive heart failure.\nHeight: (in) 69\nWeight (lb): 190\nBSA (m2): 2.02 m2\nBP (mm Hg): 106/52\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 11:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAortic sinus, arch, and ascending aorta not well visualized. Unable to\ncalculate severity of aortic stenosis given inability to obtain an accurate\nleft ventricular outflow dimension given limited echo windows and patient\ncooperation.\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus. Transmitral Doppler E>A\nand TDI E/e' <8 suggesting normal diastolic function, and normal LV filling\npressure (PCWP<12mmHg). No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; basal inferior - akinetic; mid inferior - akinetic;\nanterior apex - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Thickened AVR\nleaflets. Increased AVR gradient. No masses or vegetations on aortic valve,\nbut cannot be fully excluded due to suboptimal image quality. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nMild mitral annular calcification. Mild thickening of mitral valve chordae.\nCalcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality as the patient was difficult to position. Suboptimal\nimage quality - patient unable to cooperate. The rhythm appears to be atrial\nfibrillation. If clinically indicated, a transesophageal echocardiographic\nexamination is recommended.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. There is mild to moderate regional\nleft ventricular systolic dysfunction with akinesis of the inferior wall and\nhypokinesis of the distal anterior wall, septum and apex (multivessel CAD).\nThe remaining segments contract normally (LVEF = 40%). No masses or thrombi\nare seen in the left ventricle. Transmitral and tissue Doppler imaging\nsuggests normal diastolic function, and a normal left ventricular filling\npressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with\nmild global free wall hypokinesis. A bioprosthetic aortic valve prosthesis is\npresent. The prosthetic aortic valve leaflets are thickened. The transaortic\ngradient is higher than expected for this type of prosthesis. No masses or\nvegetations are seen on the aortic valve, but cannot be fully excluded due to\nsuboptimal image quality. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. No masses or vegetations are seen on the mitral\nvalve, but cannot be fully excluded due to suboptimal image quality. Moderate\n(2+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. No vegetation/mass is seen on the pulmonic valve. There is no\npericardial effusion.\n\nIMPRESSION: No vegetations seen. Thickened aortic valve bioprosthesis with\nhigh-than-normal transvalvular gradients but no significant regurgitation.\nMild to moderate regional left ventricular systolic dysfunction, c/w\nmultivessel CAD. Moderate mitral regurgitation. Mild pulmonary hypertension.\n\nIf clinically indicated, a transesophageal echocardiographic examination is\nrecommended.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724252,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history). Rate 70\ns BP 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Response:\n Remains afeb.\n Plan:\n TEE. Repeat BC (surveillance), vanco q24hr (next dose at 0800). AM\n vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. neg. 400cc by 0300. goal for AM was 1L negative.\n Sats 98% on 3lnc.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change.\n Thrombocytopenia: pt. with hx\n baseline 50,000. admit plts 48.\n multiple areas of bruising on arms, stomach\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x2. incontinent while straining to void.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724254,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history). Rate 70\ns BP 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Dopa d/c\nd at 0300.\n Response:\n Remains afeb.\n BP lower than admit: 94/54, HR 60 aflutter. No VEA.\n Plan:\n TEE. Repeat BC (surveillance)- sent with AM labs. , vanco q24hr\n (next dose at 0800). AM vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. neg. 400cc by 0300. goal for AM was 1L negative.\n Sats 98% on 3lnc.\n Plan:\n Follow PAPs. ? d/c swan since it came from OSH.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n - awake most of the night. Groaning much of the time and when\n asked why he states he is thirsty , not in pain.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change.\n Thrombocytopenia: pt. with hx\n baseline 50,000. Per OSH reports the\n patient has a chronic thrombocytopenia of unclear etiology. Pt reports\n history of easy bleeding & bruising. DDx is broad and includes ITP,\n myelodysplastic syndrome, drug induced admit plts 48. multiple areas\n of bruising on arms, stomach\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x2. incontinent while straining to void. Large brown soft\n stool, guiac neg.\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724588,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n - PA catheter self-DCed by pt this AM , so dopamine and lasix gtt had\n been off and patient's BPs in 80s systolic, restarted once IV placed\n another peripheral ; lasix gtt restarted 12:30pm (~-1200cc since\n midnight by that time)\n - TTE: suboptimal image quality, TEE for further eval recommended,\n IMPRESSION: No vegetations seen. Thickened aortic valve bioprosthesis\n with high-than-normal transvalvular gradients but no significant\n regurgitation. Mild to moderate regional left ventricular systolic\n dysfunction, c/w multivessel CAD. Moderate mitral regurgitation. Mild\n pulmonary hypertension.\n - ID recs - MRI head, agree likely endocarditis, will treat for\n endocarditis. Nafcillin for now. If TEE positive will likely add gent\n for 2 weeks and rifampin for 6 weeks and nafcillin for 6 weeks.\n - call OSH and add rifampin to sensitivities - done\n - no schisto's on smear as per lab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 05:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.8\n HR: 97 (70 - 100) bpm\n BP: 97/54(65) {80/31(31) - 124/69(80)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,208 mL\n 677 mL\n PO:\n 1,500 mL\n 420 mL\n TF:\n IVF:\n 708 mL\n 257 mL\n Blood products:\n Total out:\n 3,780 mL\n 670 mL\n Urine:\n 3,780 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,572 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, confused\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n ejection murmur radiating to carotid\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : laterally, Bronchial:\n laterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed, lesions noted\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, orientated x 2\n Labs / Radiology\n 29 K/uL\n 11.3 g/dL\n 130 mg/dL\n 2.2 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 67 mg/dL\n 108 mEq/L\n 143 mEq/L\n 33.5 %\n 2.9 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n WBC\n 7.7\n 3.5\n 2.9\n Hct\n 34.6\n 33.2\n 33.5\n Plt\n 43\n 41\n 29\n Cr\n 2.0\n 2.1\n 2.2\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - heme consult\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:52 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724745,
"text": "Pt here with endocarditis, on nafacillian, Afebrile today. Pt has some\n baseline dementia, and has been confused since he has been in the\n hospital. He is to get an MRI tomorrow to rule out any septic emboli.\n Altered mental status (not Delirium)\n Assessment:\n Pt was disoriebnted and trying to get OOB frequently last night. Today\n pt sleeping most of the day\n But awake for meals and turning.\n Action:\n Discussed with team plan to calm pt at night and ensure sllep cycle at\n night and awake in days.\n Response:\n Team ordered Zyprexia and HS so pt can get his dose at SIX PM, then\n again at HS if he does not respond\n To that. Gave dose at six pm after pm meal\n Plan:\n Zyprexia as ordered and per plan.\n Bacteremia\n Assessment:\n Pt has positive BC from OSH and veg on aortic valve, no signs of septic\n emboli finger toes, good perfusion.\n Pt does have pettichiae on his back\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724441,
"text": "Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724730,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n TEE performed today, showed small vegetation on aortic valve.\n - ortho consulted concerning red right elbow, they stated unlikely to\n be septic joint, would not tap.\n - consulted renal - for hematuria, low complement, ; unclear\n etiology at this time, recommended sending ANCA/, getting renal\n ultrasound with doplers.\n - consulted CT - no surgical intervention indicated at this time,\n (nurse practitioner).\n - consulted heme/onc - unclear etiology for leukopenia,\n thrombocytopenia - consider SLE, MDS, marrow suppression in setting of\n sepsis. Most likely is sepsis. Can start G-CSF if leukopenia becomes\n <500. Recommend ultrasound of liver/spleen for septic emboli.\n -CT head - Small hyperdensity at the left frontal lobe which may\n reflect an occult vascular malformation. A focus of infarction is\n unlikely.\n -given 500cc NS - patient has been hypotensive and elevation of\n creatinine, likely over-diuresed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:00 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:50 AM\n Fentanyl - 11:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.6\nC (99.6\n HR: 93 (74 - 145) bpm\n BP: 88/47(55) {70/38(46) - 125/71(85)} mmHg\n RR: 25 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 3,123 mL\n 354 mL\n PO:\n 1,980 mL\n TF:\n IVF:\n 1,143 mL\n 354 mL\n Blood products:\n Total out:\n 2,360 mL\n 351 mL\n Urine:\n 2,360 mL\n 351 mL\n NG:\n Stool:\n Drains:\n Balance:\n 763 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 42 K/uL\n 12.3 g/dL\n 107 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 67 mg/dL\n 110 mEq/L\n 144 mEq/L\n 36.5 %\n 10.2 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n Plt\n 43\n 41\n 29\n 42\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n Other labs: PT / PTT / INR:18.1/34.0/1.6, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:46/55, Alk Phos / T Bili:56/5.2,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:415 IU/L, Ca++:7.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.2 mg/dL\n Imaging: CT head: Small hyperdensity at the left frontal lobe which may\n reflect an\n occult vascular malformation. A focus of infarction is unlikel. MRI is\n recommended for better characterization, if clinically indicated.\n TEE: Small mobile echodensity (0.5 x 0.3 cm) on the aortic\n bioprosthetic valve consistent with a small vegetation. No aortic\n regurgitation, paravalvular leak or parvalvar abcess seen.\n Microbiology: C-diff negative\n Blood cultures: NGTD.\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. \n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus . Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Continue nafcillin given aortic vegetation\n - confer with ID concerning gent/rifampin dosing.\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - neo as needed.\n - will try to keep even as patient has possibly distributive shock\n picture from bacteremia.\n - Treat bacteremia as above\n # Acute Kidney injury\n may be pre-renal currently due to poor forward\n flow, although urine WBCs suggest potentially AIN. No red cell casts\n that would be consistent with glomerulonephritis.\n - trend creatinine\n - appreciate renal recs.\n - Follow up anca/\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - lasix if patient has respiratory distress, however keep even for now.\n - Plan for beta blocker and ACE-I once BP allows\n .\n #Hyperbilirubinemia\n will acquire RUQ ultrasound to evaluate for\n cholecystitis, although acalculous cholecystitis possible in setting of\n critical illness. Also look for obstructing mass.\n - fractionate bilis\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - appreciate heme recs.\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n CCU ATTENDING PROGRESS NOTE\n I have reviewed the progress note history and physical examination on\n by Dr. above. I was present during the\n pertinent portions of the physical examination today. I concur with\n the diagnostic evaluation and treatment plan outlined above.\n Approximately 50% allocated time involved coordination of care.\n MEDICAL DECISION MAKING. This 75 year old man s/p CABG and\n bioprosthetic AVR in presented with 4/4 blood cultures positive\n for MS . TTE has shown a small vegetation. He was\n implemented on appropriate antibiotic therapy.\n ASSESSMENT: prosthetic aortic valve endocarditis on\n appropriate antibiotic therapy\n PLAN: Continue antibiotics\n Monitor for evidence of valvular aortic\n insufficiency or hemodynamic compensation\n , MD \n ------ Protected Section Addendum Entered By: , MD\n on: 15:51 ------\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724896,
"text": "spiked fever , All BCx neg x3. Cdiff neg x3 (.\n MSSA Bacteremia/ endocarditis\n Assessment:\n Stable BPs off Neo. ~04:00, c/o dull reproducible CP, worse upon\n inspiration\n hypotensive to 60s\nmentating. Tachypneic to 40s, labored\n Action:\n Supplemental 02 placed, EKG, STAT CXR, cardiac enzymes sent\n Response:\n Afebrile, WBC (5.8) 4.5\n Plan:\n Continue Nafcillin Q4hrs\n ? diurese\n Monitor WBC/fever curve\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. Pain w/ urination, urine slightly\n pink/concentrated\n Plan:\n Renal following\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2-3, Pleasant and Cooperative at times then\n confused/belligerent at times. Unsure of place\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa given at 02:00 for acute agitation.\n Response:\n Slept well until 02:00, turning self in bed independently. OOB to BSC\n x2 assist-weak. Talks in sleep. Very adamant about taking P-boot off\n despite freq reminders of importance from RN.\nI heard that a thousand\n times\n \n !\n Plan:\n Continue present management, safety measures, FALL RISK\n Alteration in Nutrition\n Assessment:\n Albumin 2.2. S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: PLT 34 (42)\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724804,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n - still needs HIV consent but non-consentable\n - Fractionated Bili high ;\n - RUQ and Renal U/S -- No evidence of lesions suggesting emboli in the\n liver, spleen, or kidneys. Limited evaluation of the renal vasculature\n due to poor pt cooperation. Main renal arteries doppler normal. Small\n left pleural effusion.\n - Olanzapine PRN + QHS , likely to be given 6pm and at bedtime --\n helped with agitation\n - fluid challenge 500cc to wean off pressor\n - weaned off pressors but I/Os more positive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:04 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 97 (90 - 103) bpm\n BP: 92/43(49) {74/31(34) - 112/56(66)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 2,978 mL\n 682 mL\n PO:\n 870 mL\n 360 mL\n TF:\n IVF:\n 2,108 mL\n 322 mL\n Blood products:\n Total out:\n 1,143 mL\n 427 mL\n Urine:\n 1,143 mL\n 427 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,835 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 34 K/uL\n 11.2 g/dL\n 116 mg/dL\n 3.6 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 78 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.9 %\n 4.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n Plt\n 43\n 41\n 29\n 42\n 34\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n Other labs: PT / PTT / INR:19.1/38.8/1.7, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:30/39, Alk Phos / T Bili:50/5.1,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:2.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Continue nafcillin given aortic vegetation\n - confer with ID concerning gent/rifampin dosing.\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - neo as needed.\n - will try to keep even as patient has possibly distributive shock\n picture from bacteremia.\n - Treat bacteremia as above\n # Acute Kidney injury\n may be pre-renal currently due to poor forward\n flow, although urine WBCs suggest potentially AIN. No red cell casts\n that would be consistent with glomerulonephritis.\n - trend creatinine\n - appreciate renal recs.\n - Follow up anca/\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - lasix if patient has respiratory distress, however keep even for now.\n - Plan for beta blocker and ACE-I once BP allows\n #Hyperbilirubinemia\n will acquire RUQ ultrasound to evaluate for\n cholecystitis, although acalculous cholecystitis possible in setting of\n critical illness. Also look for obstructing mass.\n - fractionate bilis\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - appreciate heme recs.\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:30 PM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:CCU\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724815,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n - PA catheter self-DCed by pt this AM , so dopamine and lasix gtt had\n been off and patient's BPs in 80s systolic, restarted once IV placed\n another peripheral ; lasix gtt restarted 12:30pm (~-1200cc since\n midnight by that time)\n - TTE: suboptimal image quality, TEE for further eval recommended,\n IMPRESSION: No vegetations seen. Thickened aortic valve bioprosthesis\n with high-than-normal transvalvular gradients but no significant\n regurgitation. Mild to moderate regional left ventricular systolic\n dysfunction, c/w multivessel CAD. Moderate mitral regurgitation. Mild\n pulmonary hypertension.\n - ID recs - MRI head, agree likely endocarditis, will treat for\n endocarditis. Nafcillin for now. If TEE positive will likely add gent\n for 2 weeks and rifampin for 6 weeks and nafcillin for 6 weeks.\n - call OSH and add rifampin to sensitivities - done\n - no schisto's on smear as per lab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 05:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.8\n HR: 97 (70 - 100) bpm\n BP: 97/54(65) {80/31(31) - 124/69(80)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,208 mL\n 677 mL\n PO:\n 1,500 mL\n 420 mL\n TF:\n IVF:\n 708 mL\n 257 mL\n Blood products:\n Total out:\n 3,780 mL\n 670 mL\n Urine:\n 3,780 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,572 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, confused\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n ejection murmur radiating to carotid\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : laterally, Bronchial:\n laterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed, lesions noted\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, orientated x 2\n Labs / Radiology\n 29 K/uL\n 11.3 g/dL\n 130 mg/dL\n 2.2 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 67 mg/dL\n 108 mEq/L\n 143 mEq/L\n 33.5 %\n 2.9 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n WBC\n 7.7\n 3.5\n 2.9\n Hct\n 34.6\n 33.2\n 33.5\n Plt\n 43\n 41\n 29\n Cr\n 2.0\n 2.1\n 2.2\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - heme consult\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:52 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:40 ------\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724819,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n - still needs HIV consent but non-consentable\n - Fractionated Bili high ;\n - RUQ and Renal U/S -- No evidence of lesions suggesting emboli in the\n liver, spleen, or kidneys. Limited evaluation of the renal vasculature\n due to poor pt cooperation. Main renal arteries doppler normal. Small\n left pleural effusion.\n - Olanzapine PRN + QHS , likely to be given 6pm and at bedtime --\n helped with agitation\n - fluid challenge 500cc to wean off pressor\n - weaned off pressors but I/Os more positive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:04 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 97 (90 - 103) bpm\n BP: 92/43(49) {74/31(34) - 112/56(66)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 2,978 mL\n 682 mL\n PO:\n 870 mL\n 360 mL\n TF:\n IVF:\n 2,108 mL\n 322 mL\n Blood products:\n Total out:\n 1,143 mL\n 427 mL\n Urine:\n 1,143 mL\n 427 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,835 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, confused; somnolent but easily\n arousable and responsive; oriented to and not to year\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n ejection murmur radiating to carotid\n Respiratory / Chest: bilateral bibasilar rales\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: trace lower extremity edema\n Skin: more diffuse petechiae on back, nonblanching\n Neurologic: orientated x 2\n Labs / Radiology\n 34 K/uL\n 11.2 g/dL\n 116 mg/dL\n 3.6 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 78 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.9 %\n 4.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n Plt\n 43\n 41\n 29\n 42\n 34\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n Other labs: PT / PTT / INR:19.1/38.8/1.7, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:30/39, Alk Phos / T Bili:50/5.1,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:2.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus. Concern for endovascular source of\n infection given high grade bacteremia. No clear portal of entry as the\n patient denies recent procedures/dental work, no focal symptoms. Given\n his presentation with community acquired bacteremia with symptoms of\n day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve.\n - On nafcillin given aortic vegetation but may need to switch to Vanc\n in setting of possible AIN\n - has not started Gent due to worsening renal function\n - continue surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - appears to be in Distributive shock. Neo weaned off\n with fluid challenge last night but restarted early this AM. AM\n cortisol yesterday normal.\n - will try to keep even as patient has possibly distributive shock\n picture from bacteremia. Holding diuresis\n - Treat bacteremia as above\n - will fluid challenge very slowly and gently today\n - consider Swan tomorrow to help w fluid management if not improving\n - continue phenylephrine and attempting to wean\n # Acute Kidney injury\n Multifactorial, may be pre-renal currently due\n to poor forward flow, in addition to AIN as suggested by urine WBCs.\n Possibly also contribution of immune-mediated complexes.\n - may need to switch Nafcillin to Vancomycin in setting of AIN\n - trend creatinine\n - appreciate renal recs.\n - Follow up anca/\n .\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP\n - Rheumatology consult to consider restarting steroids\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - lasix if patient has respiratory distress, however keep even for now\n or mildly positive with fluid challenges.\n - Plan for beta blocker and ACE-I once BP allows\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs.\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - ..\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds\n - Rheum consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:30 PM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:CCU\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724821,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n - still needs HIV consent but non-consentable\n - Fractionated Bili high ;\n - RUQ and Renal U/S -- No evidence of lesions suggesting emboli in the\n liver, spleen, or kidneys. Limited evaluation of the renal vasculature\n due to poor pt cooperation. Main renal arteries doppler normal. Small\n left pleural effusion.\n - Olanzapine PRN + QHS , likely to be given 6pm and at bedtime --\n helped with agitation\n - fluid challenge 500cc to wean off pressor\n - weaned off pressors but I/Os more positive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:04 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 97 (90 - 103) bpm\n BP: 92/43(49) {74/31(34) - 112/56(66)} mmHg\n RR: 17 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 2,978 mL\n 682 mL\n PO:\n 870 mL\n 360 mL\n TF:\n IVF:\n 2,108 mL\n 322 mL\n Blood products:\n Total out:\n 1,143 mL\n 427 mL\n Urine:\n 1,143 mL\n 427 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,835 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, confused; somnolent but easily\n arousable and responsive; oriented to and not to year\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n ejection murmur radiating to carotid\n Respiratory / Chest: bilateral bibasilar rales\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: trace lower extremity edema\n Skin: more diffuse petechiae on back, nonblanching\n Neurologic: orientated x 2\n Labs / Radiology\n 34 K/uL\n 11.2 g/dL\n 116 mg/dL\n 3.6 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 78 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.9 %\n 4.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n Plt\n 43\n 41\n 29\n 42\n 34\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n Other labs: PT / PTT / INR:19.1/38.8/1.7, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:30/39, Alk Phos / T Bili:50/5.1,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:2.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus. Concern for endovascular source of\n infection given high grade bacteremia. No clear portal of entry as the\n patient denies recent procedures/dental work, no focal symptoms. Given\n his presentation with community acquired bacteremia with symptoms of\n day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve.\n - On nafcillin given aortic vegetation but may need to switch to Vanc\n in setting of possible AIN\n - has not started Gent due to worsening renal function\n - continue surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - appears to be in Distributive shock. Neo weaned off\n with fluid challenge last night but restarted early this AM. AM\n cortisol yesterday normal.\n - will try to keep even as patient has possibly distributive shock\n picture from bacteremia. Holding diuresis\n - Treat bacteremia as above\n - will fluid challenge very slowly and gently today\n - consider Swan tomorrow to help w fluid management if not improving\n - continue phenylephrine and attempting to wean\n # Acute Kidney injury\n Multifactorial, may be pre-renal currently due\n to poor forward flow, in addition to AIN as suggested by urine WBCs.\n Possibly also contribution of immune-mediated complexes.\n - may need to switch Nafcillin to Vancomycin in setting of AIN\n - trend creatinine\n - appreciate renal recs.\n - Follow up anca/\n .\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP\n - Rheumatology consult to consider restarting steroids\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - lasix if patient has respiratory distress, however keep even for now\n or mildly positive with fluid challenges.\n - Plan for beta blocker and ACE-I once BP allows\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs.\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - ..\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds\n - Rheum consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:30 PM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 50 minutes of critical care time.\n Additional comments:\n endocarditis, renal failure, hypotention\n ------ Protected Section Addendum Entered By: , MD\n on: 09:29 ------\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724445,
"text": "Bacteremia\n Assessment:\n Afeb.\n 2 sets of BC pnd from admission. Urine Cx negative. MRSA screening\n pnd.\n Dopa at 3mcq/k/min to maintain SBP 90-100/. MAP >60.\n Action:\n Nafcillin q4hr.\n Response:/Plan\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS diminished bases. No crackles on exam. Pt. refusing to wear O2-\n takes off NC.\n - HR elevated 90\ns-105ST. rare PVC. BP 90\ns/40\ns. MAP\n 60;\n Negative 1.5L for on lasix drip.\n Pt. c/o being thirsty and hungry.\n Action:\n Discussed with team. Decision made to d/d lasix gtt . d/cd at\n Maintained fluid restriction. Ice chips and sips of water only.\n NPO for TEE today\n Response:\n Sats 90-95% on RA. Denies SOB. u/o 80cc/hr.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Ox1\n self only. Unable to state date or place.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724717,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n TEE performed today, showed small vegetation on aortic valve.\n - ortho consulted concerning red right elbow, they stated unlikely to\n be septic joint, would not tap.\n - consulted renal - for hematuria, low complement, ; unclear\n etiology at this time, recommended sending ANCA/, getting renal\n ultrasound with doplers.\n - consulted CT - no surgical intervention indicated at this time,\n (nurse practitioner).\n - consulted heme/onc - unclear etiology for leukopenia,\n thrombocytopenia - consider SLE, MDS, marrow suppression in setting of\n sepsis. Most likely is sepsis. Can start G-CSF if leukopenia becomes\n <500. Recommend ultrasound of liver/spleen for septic emboli.\n -CT head - Small hyperdensity at the left frontal lobe which may\n reflect an occult vascular malformation. A focus of infarction is\n unlikely.\n -given 500cc NS - patient has been hypotensive and elevation of\n creatinine, likely over-diuresed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:00 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:50 AM\n Fentanyl - 11:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.6\nC (99.6\n HR: 93 (74 - 145) bpm\n BP: 88/47(55) {70/38(46) - 125/71(85)} mmHg\n RR: 25 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 3,123 mL\n 354 mL\n PO:\n 1,980 mL\n TF:\n IVF:\n 1,143 mL\n 354 mL\n Blood products:\n Total out:\n 2,360 mL\n 351 mL\n Urine:\n 2,360 mL\n 351 mL\n NG:\n Stool:\n Drains:\n Balance:\n 763 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 42 K/uL\n 12.3 g/dL\n 107 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 67 mg/dL\n 110 mEq/L\n 144 mEq/L\n 36.5 %\n 10.2 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n Plt\n 43\n 41\n 29\n 42\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n Other labs: PT / PTT / INR:18.1/34.0/1.6, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:46/55, Alk Phos / T Bili:56/5.2,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:415 IU/L, Ca++:7.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.2 mg/dL\n Imaging: CT head: Small hyperdensity at the left frontal lobe which may\n reflect an\n occult vascular malformation. A focus of infarction is unlikel. MRI is\n recommended for better characterization, if clinically indicated.\n TEE: Small mobile echodensity (0.5 x 0.3 cm) on the aortic\n bioprosthetic valve consistent with a small vegetation. No aortic\n regurgitation, paravalvular leak or parvalvar abcess seen.\n Microbiology: C-diff negative\n Blood cultures: NGTD.\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Continue nafcillin given aortic vegetation\n - confer with ID concerning gent/rifampin dosing.\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - neo as needed.\n - will try to keep even as patient has possibly distributive shock\n picture from bacteremia.\n - Treat bacteremia as above\n # Acute Kidney injury\n may be pre-renal currently due to poor forward\n flow, although urine WBCs suggest potentially AIN. No red cell casts\n that would be consistent with glomerulonephritis.\n - trend creatinine\n - appreciate renal recs.\n - Follow up anca/\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - lasix if patient has respiratory distress, however keep even for now.\n - Plan for beta blocker and ACE-I once BP allows\n .\n #Hyperbilirubinemia\n will acquire RUQ ultrasound to evaluate for\n cholecystitis, although acalculous cholecystitis possible in setting of\n critical illness. Also look for obstructing mass.\n - fractionate bilis\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - appreciate heme recs.\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724796,
"text": "Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented but confused at\n times, freq picking at PICC/foley/p-boots\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa zydis given at HS and again at 03:15\n Response:\n Very short effect w/ zyprexa, slept in very short naps. Continues to be\n restless\n Plan:\n Continue present management, safety measures, FALL RISK\n MRI today\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo. Incont small amt brown guiac\n neg stool\n Action:\n Attempted to wean neo\n abx given as ordered\n Response:\n Afebrile, WBC 4.5(10.2). SBP down to 80s w/ MAPs 50 off neo\nremains on\n low dose\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n f/u w/ cultures\n Wean neo as tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p 500cc fluid challenge at .\n UOP 30-80cc/hr slightly concentrated, very dry mucous membranes, poor\n dentition\nc/o excessive thirst\n Action:\n Urine lytes sent\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n ? Fluid challenge today\n Renal following\n OTHER: PLT 34 (42) -- Send HIV test when consent signed\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724997,
"text": "Received pt awake, alert, oriented x2. HR 106 afib, bp 107/67 on 1.5\n mcg/kg/min. RR 28, w/ SATs 96% on 3lnp. Making urine ~ 100cc/hr from\n lasix given at 0500.\n At approximately 0900 pt becoming increasingly tachypnic, urine output\n decreased to 20cc/hr. Given lasix 40 mg w/ no reaponse, and 12.5 mg po\n lopressor. pt increasingly tachypnic, through am w/ bp dropping\n requiring ^ in neo. ABG done showing acidosis. Decision made to\n intubate pt. Pt intubated, bp continued to drop requiring invreased\n pressor use. Neo changed to levophed, milrinone added briefly, then\n vasopressin and dopamine. Swan placed showing extremely high folling\n pressures, given additional 100 mg lasix w/ no response. MD met w/\n famil and decision made not to escalatecare but to continue present\n treatment until other family members could come late this afternoon\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724899,
"text": "spiked fever , All BCx neg x3. Cdiff neg x3 (.\n MSSA Bacteremia/ endocarditis\n Assessment:\n Stable BPs off Neo. Transient episodes Atach to 130s. ~04:00, c/o dull\n reproducible CP, worse upon inspiration\n hypotensive to\n 60s\nmentating. Tachypneic to 40s, labored\n Action:\n Supplemental 02 placed, EKG, STAT CXR, cardiac enzymes sent,\n 2mg morphine IVP, 40mg IV lasix\n Response:\n Pain free. CXR wet. Afebrile, WBC (5.8) 4.5\n Plan:\n Continue Nafcillin Q4hrs\n ? diurese\n Monitor WBC/fever curve\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. Pain w/ urination, urine slightly\n pink/concentrated\n lido jelly applied w/ effect\n Plan:\n Renal following\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2-3, Pleasant and Cooperative at times then\n confused/belligerent at times. Unsure of place\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa given at 02:00 for acute agitation.\n Response:\n Slept well until 02:00, turning self in bed independently. OOB to BSC\n x2 assist-weak. Talks in sleep. Very adamant about taking P-boot off\n despite freq reminders of importance from RN.\nI heard that a thousand\n times\n \n !\n Plan:\n Continue present management, safety measures, FALL RISK\n Alteration in Nutrition\n Assessment:\n Albumin 2.2. S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: PLT 34 (42)\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724778,
"text": "Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented but confused at\n times, freq picking at PICC/foley/p-boots\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa zydis given at HS and again at 03:15\n Response:\n Very short effect w/ zyprexia, slept in very short naps. Continues to\n be restless\n Plan:\n Continue present management, safety measures, FALL RISK\n MRI today\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo (wide pulse pressure). Incont\n small amt brown guiac neg stool\n Action:\n Attempted to wean neo\n abx given as ordered\n Response:\n Afebrile, WBC 10.2 (2.9). SBP down to 80s w/ MAPs 50\nremains on low\n dose neo\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n f/u w/ cultures\n Wean neo as tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p 500cc fluid challenge at .\n UOP 30-80cc/hr slightly concentrated, very dry mucous membranes\n excessive thirst\n Action:\n Urine lytes sent\n UOP monitored\n Response:\n BUN/Cr. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n ? Fluid challenge today\n Renal following\n OTHER: PLT -- Send HIV test when consent signed\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724789,
"text": "Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented but confused at\n times, freq picking at PICC/foley/p-boots\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa zydis given at HS and again at 03:15\n Response:\n Very short effect w/ zyprexia, slept in very short naps. Continues to\n be restless\n Plan:\n Continue present management, safety measures, FALL RISK\n MRI today\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo (wide pulse pressure). Incont\n small amt brown guiac neg stool\n Action:\n Attempted to wean neo\n abx given as ordered\n Response:\n Afebrile, WBC 10.2 (2.9). SBP down to 80s w/ MAPs 50\nremains on low\n dose neo\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n f/u w/ cultures\n Wean neo as tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p 500cc fluid challenge at .\n UOP 30-80cc/hr slightly concentrated, very dry mucous membranes, poor\n dentition\nc/o excessive thirst\n Action:\n Urine lytes sent\n UOP monitored\n Response:\n BUN/Cr. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n ? Fluid challenge today\n Renal following\n OTHER: PLT -- Send HIV test when consent signed\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724883,
"text": "MSSA Bacteremia/ ? endocarditis\n Assessment:\n Low grade temps (spiked fever ), SBPs 90-100s w/ MAPs ~60 on Neo.\n Action:\n Neo weaned off\n abx given as ordered\n Response:\n Afebrile, WBC 4.5(10.2). Stable off neo. All BCx neg x3. Cdiff neg x3\n ()\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2-3, Pleasant and Cooperative at times then\n confused/belligerent at times. Unsure of place\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa given at 02:00 for acute agitation.\n Response:\n Slept well, turning self in bed independently. OOB to BSC x2\n assist-weak. Not pulling at PICC, p-boots, ETC. No zyprxa given. Talks\n in sleep\n Plan:\n Continue present management, safety measures, FALL RISK\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n IVF PRN\n Renal following\n Alteration in Nutrition\n Assessment:\n Albumin 2.2. S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: PLT 34 (42)\n"
},
{
"category": "Respiratory ",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725004,
"text": "Day of mechanical ventilation: 1\n Airway Placement Data\n Known difficult intubation: NO\n ETT:\n Position:22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Crackles\n Comments:\n 75yr male is CHF/pulmonary edema intubated for increasing tachypnea.\n Family has decided on no escalation of care and ? CMO. Wean FiO2 as\n appropriate.\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724512,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n - PA catheter self-DCed by pt this AM , so dopamine and lasix gtt had\n been off and patient's BPs in 80s systolic, restarted once IV placed\n another peripheral ; lasix gtt restarted 12:30pm (~-1200cc since\n midnight by that time)\n - TTE: suboptimal image quality, TEE for further eval recommended,\n IMPRESSION: No vegetations seen. Thickened aortic valve bioprosthesis\n with high-than-normal transvalvular gradients but no significant\n regurgitation. Mild to moderate regional left ventricular systolic\n dysfunction, c/w multivessel CAD. Moderate mitral regurgitation. Mild\n pulmonary hypertension.\n - ID recs - MRI head, agree likely endocarditis, will treat for\n endocarditis. Nafcillin for now. If TEE positive will likely add gent\n for 2 weeks and rifampin for 6 weeks and nafcillin for 6 weeks.\n - call OSH and add rifampin to sensitivities - done\n - no schisto's on smear as per lab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 05:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.8\n HR: 97 (70 - 100) bpm\n BP: 97/54(65) {80/31(31) - 124/69(80)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 2,208 mL\n 677 mL\n PO:\n 1,500 mL\n 420 mL\n TF:\n IVF:\n 708 mL\n 257 mL\n Blood products:\n Total out:\n 3,780 mL\n 670 mL\n Urine:\n 3,780 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,572 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, confused\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n ejection murmur radiating to carotid\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : laterally, Bronchial:\n laterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed, lesions noted\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed, orientated x 2\n Labs / Radiology\n 29 K/uL\n 11.3 g/dL\n 130 mg/dL\n 2.2 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 67 mg/dL\n 108 mEq/L\n 143 mEq/L\n 33.5 %\n 2.9 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n WBC\n 7.7\n 3.5\n 2.9\n Hct\n 34.6\n 33.2\n 33.5\n Plt\n 43\n 41\n 29\n Cr\n 2.0\n 2.1\n 2.2\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TTE this AM\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - Check peripheral smear\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - Consider repeat Head CT ; will likely need MRI in future when can\n tolerate to eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:52 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724519,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - encephalopathic all night\n - complaints of thirst all night\n - Had BMx4, soft not diarrhea; checking C diff on next one\n - lasix boluses x2, after which net neg -500cc, started lasix drip ~5am\n ; urinary output didn't change which 20mg IV bolus (already had\n 100cc/hr output), increased w 40mg IV bolus\n - dopamine turned off 3am, but restarted for MAPs in mid 50s\n - patient pulled out Swan and central line this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 75 (68 - 85) bpm\n BP: 115/55(71) {86/48(54) - 119/73(135)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 69 Inch\n CVP: 15 (14 - 24)mmHg\n PAP: (65 mmHg) / (30 mmHg)\n CO/CI (Fick): (5.4 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 60 - 66\n Total In:\n 419 mL\n 435 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 59 mL\n 75 mL\n Blood products:\n Total out:\n 2,055 mL\n 1,380 mL\n Urine:\n 480 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,636 mL\n -945 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./22/-2\n Physical Examination\n GENERAL: elderly male, sleepy but easily arousable and conversational,\n in NAD\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva with multiple\n petechiae\n NECK: Supple with JVP of 10 cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. III/VI systolic murmur loudest at right 2nd intercostal\n space with loud radiation to carotids No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations\n unlabored, no accessory muscle use. bibasilar crackles more clear in\n mid and upper lung fields\n ABDOMEN: Soft, NTND. Spleen not palpable, no hepatomegaly No abdominial\n bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: Multiple areas of bruising, multiple petechiae over palms and\n soles ; painless dark spots in toes and fingers\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Neuro: The patient has poor attention span; cannot always finish train\n of thought when speaking in sentences\n Labs / Radiology\n 41 K/uL\n 10.9 g/dL\n 127 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 75 mg/dL\n 108 mEq/L\n 139 mEq/L\n 33.2 %\n 3.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n WBC\n 7.7\n 3.5\n Hct\n 34.6\n 33.2\n Plt\n 43\n 41\n Cr\n 2.0\n 2.1\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TTE this AM\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - Check peripheral smear\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - Consider repeat Head CT ; will likely need MRI in future when can\n tolerate to eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 07:15 PM\n 20 Gauge - 05:28 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 45 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:29 ------\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724881,
"text": "MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo. Less stool\n Action:\n Neo weaned off\n abx given as ordered\n Response:\n Afebrile, WBC 4.5(10.2). Stable off neo. All BCx neg x3. Cdiff neg x3\n ()\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Altered mental status (not Delirium)\n Assessment:\n Pleasant and Cooperative, confused at times. oriented to self, family,\n time, DOB. Unsure of place at times.\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n Response:\n Slept very well, turning self in bed independently. Not pulling at\n PICC, p-boots, ETC. No zyprxa given\n Plan:\n Continue present management, safety measures, FALL RISK\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n IVF PRN\n Renal following\n Alteration in Nutrition\n Assessment:\n Albumin 2.2. S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: PLT 34 (42)\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724776,
"text": "Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented but confused at\n times, freq picking at PICC/foley/p-boots\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa zydis given at HS and again at 03:15\n Response:\n Very short effect w/ zyprexia, slept in very short naps. Continues to\n be restless\n Plan:\n Continue present management, safety measures, FALL RISK\n MRI today\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo. Incont small amt brown guiac\n neg stool\n Action:\n Attempted to wean neo\n abx given as ordered\n Response:\n Afebrile, WBC 10.2 (2.9). SBP down to 80s w/ MAPs 50\nremains on low\n dose neo\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n f/u w/ cultures\n Wean neo as tol\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p 500cc fluid challenge at .\n UOP 30-80cc/hr slightly concentrated, very dry mucous membranes\n excessive thirst\n Action:\n Urine lytes sent\n UOP monitored\n Response:\n BUN/Cr. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n ? Fluid challenge today\n Renal following\n OTHER: PLT -- Send HIV test when consent signed\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724882,
"text": "MSSA Bacteremia/ ? endocarditis\n Assessment:\n Low grade temps (spiked fever ), SBPs 90-100s w/ MAPs ~60 on Neo.\n Action:\n Neo weaned off\n abx given as ordered\n Response:\n Afebrile, WBC 4.5(10.2). Stable off neo. All BCx neg x3. Cdiff neg x3\n ()\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2-3, Pleasant and Cooperative at times then\n confused/belligerent at times. Unsure of place\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa given at 02:00 for acute agitation.\n Response:\n Slept well, turning self in bed independently. OOB to BSC x2\n assit-weak. Not pulling at PICC, p-boots, ETC. No zyprxa given\n Plan:\n Continue present management, safety measures, FALL RISK\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr rising 78/3.6. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n IVF PRN\n Renal following\n Alteration in Nutrition\n Assessment:\n Albumin 2.2. S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: PLT 34 (42)\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724773,
"text": "Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented but confused at\n times, freq picking at PICC/foley/p-boots\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa zydis given at HS and again at 03:15\n Response:\n Very short effect w/ zyprexia, slept in very short naps. Continues to\n be restless\n Plan:\n Continue present management, safety measures, FALL RISK\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Afebrile, SBPs 90-100s w/ MAPs ~60 on Neo. Incont small amt brown guiac\n neg stool\n Action:\n Attempted to wean neo\n abx given as ordered\n Response:\n Afebrile, WBC 10.2 (2.9). SBP down to 80s w/ MAPs 50\nremains on low\n dose neo\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n f/u w/ cultures\n Wean neo as tol\n Send HIV test when consent signed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p 500cc fluid challenge at .\n UOP 30-80cc/hr slightly concentrated, very dry mucous membranes\n excessive thirst\n Action:\n Urine lytes sent\n UOP monitored\n Response:\n BUN/Cr. Gd UOP. +1800cc at MN, Neg 400cc LOS\n Plan:\n ? Fluid challenge today\n OTHER: PLT\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725028,
"text": "Received pt awake, alert, oriented x2. HR 106 afib, bp 107/67 on 1.5\n mcg/kg/min. RR 28, w/ SATs 96% on 3lnp. Making urine ~ 100cc/hr from\n lasix given at 0500.\n At approximately 0900 pt becoming increasingly tachypnic, urine output\n decreased to 20cc/hr. Given lasix 40 mg w/ no reaponse, and 12.5 mg po\n lopressor. pt increasingly tachypnic, through am w/ bp dropping\n requiring ^ in neo. ABG done showing acidosis. Decision made to\n intubate pt. Pt intubated, bp continued to drop requiring invreased\n pressor use. Neo changed to levophed, milrinone added briefly, then\n vasopressin and dopamine. Swan placed showing extremely high folling\n pressures, given additional 100 mg lasix w/ no response. MD met w/\n famil and decision made not to escalatecare but to continue present\n treatment until other family members could come late this afternoon\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725029,
"text": "Received pt awake, alert, oriented x2. HR 106 afib, bp 107/67 on 1.5\n mcg/kg/min. RR 28, w/ SATs 96% on 3lnp. Making urine ~ 100cc/hr from\n lasix given at 0500.\n At approximately 0900 pt becoming increasingly tachypnic, urine output\n decreased to 20cc/hr. Given lasix 40 mg w/ no reaponse, and 12.5 mg po\n lopressor. pt increasingly tachypnic, through am w/ bp dropping\n requiring ^ in neo. ABG done showing acidosis. Decision made to\n intubate pt. Pt intubated, bp continued to drop requiring invreased\n pressor use. Neo changed to levophed, milrinone added briefly, then\n vasopressin and dopamine. Swan placed showing extremely high folling\n pressures, given additional 100 mg lasix w/ no response. MD met w/\n famil and decision made not to escalate care but to continue present\n treatment until other family members could come late this afternoon.\n All family arrived, agreed they wanted to withdraw care. Morphine gtt\n started, pressors turned off and pt expired at 1834.\n Organ bank notified.\n"
},
{
"category": "General",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Death Note",
"row_id": 725031,
"text": "TITLE: Death Note\n The patient , 75 y.o male with history of aortic valve\n replacement admitted for MSSA endocarditis, acutely decompensated on\n morning of with increased work of breathing, tachypnea,\n tachycardia and decreased blood pressure. Central venous access,\n swan-ganz catheter was placed and the patient was intubated. Family\n meeting was conducted with son (alternate HCP) and\n daughter-in-law present. , daughter and health-care\n proxy notified of patient\ns tenuous status. The patient\ns condition\n continued to deteriorate to blood pressures in low 40s systolic despite\n maximum pressors, and in the afternoon the family decided to initiate\n comfort measures only. Morphine drip was initiated, pressors were\n stopped and asystole was noted on telemetry at 6:34pm. On exam patient\n demonstrated no spontaneous breaths and no heart sounds. Time of death\n was 6:34pm. A postmortem was offered to the family but was declined.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724276,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history and on coumadin). Rate 70\ns BP\n 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Dopa d/c\nd at 0300.\n Response:\n TM 99.8R.\n BPdropping after dopa d/c\nd : 89-94/49. MAP 59-60. , HR 60\n aflutter. No VEA.\n 0400: dopa was restarted at 3mcq/k/min. team aware. MAP 66-72,\n Plan:\n TEE. Repeat BC (surveillance)- sent with AM labs. , vanco q24hr\n (next dose at 0800). AM vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. neg. 400cc by 0300. goal for AM was 1L negative.\n Only 400ccneg at 0500.\n ****0530: lasix 40mg IV x1 followed by lasix drip at 5mg/hr.\n Sats 98% on 3lnc.\n Plan:\n Follow PAPs. ? d/c swan since it came from OSH. Monitor response to\n lasix drip.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n - awake most of the night. Groaning much of the time and when\n asked why he states he is thirsty , not in pain.\n A bit better toward morning. Not moaning as much and appears to\n sleep more peacefully.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change.\n Thrombocytopenia: pt. with hx\n baseline 50,000. Per OSH reports the\n patient has a chronic thrombocytopenia of unclear etiology. Pt reports\n history of easy bleeding & bruising. DDx is broad and includes ITP,\n myelodysplastic syndrome, drug induced admit plts 48. multiple areas\n of bruising on arms, stomach ( sc heparin at OSH).\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x3. incontinent while straining to void. Small- Large\n brown soft stool, guiac neg. pt. cannot say ahead of time that he\n needs bedpan. He is very embarrassed about stooling in bed. Send for\n C.diff next sample.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724277,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history and on coumadin). Rate 70\ns BP\n 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Dopa d/c\nd at 0300.\n Response:\n TM 99.8R.\n BPdropping after dopa d/c\nd : 89-94/49. MAP 59-60. , HR 60\n aflutter. No VEA.\n 0400: dopa was restarted at 3mcq/k/min. team aware. MAP 66-72,\n Plan:\n TEE planned for today. Repeat BC (surveillance)- sent with AM labs.\n , vanco q24hr (next dose at 0800). AM vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. . goal for AM was 1L negative. Only 400ccneg at\n 0500.\n ****0530: lasix 40mg IV x1 followed by lasix drip at 5mg/hr.\n Sats 98% on 3lnc.\n Plan:\n Follow PAPs. ? d/c swan since it came from OSH. Monitor response to\n lasix drip.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n - awake most of the night. Groaning much of the time and when\n asked why he states he is thirsty , not in pain.\n A bit better toward morning. Not moaning as much and appears to\n sleep more peacefully.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change. ?\n need for further eval with MRI.\n Thrombocytopenia: pt. with hx\n baseline 50,000. Per OSH reports the\n patient has a chronic thrombocytopenia of unclear etiology. Pt reports\n history of easy bleeding & bruising. DDx is broad and includes ITP,\n myelodysplastic syndrome, drug induced admit plts 48. multiple areas\n of bruising on arms, stomach ( sc heparin at OSH).\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x3. incontinent while straining to void. Small- Large\n brown soft stool, guiac neg. pt. cannot say ahead of time that he\n needs bedpan. He is very embarrassed about stooling in bed. Send for\n C.diff next sample.\n Social: D-I- called and spoke with RN\n updated on\n condition. Son and have flown in from CA and will be\n coming to hospital today. Daughter is HCP but is currently\n undergoing treatment for Cancer-\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724464,
"text": "Bacteremia\n Assessment:\n Afeb.\n 2 sets of BC pnd from admission. Urine Cx negative. MRSA screening\n pnd.\n Dopa at 3mcq/k/min to maintain SBP 90-100/. MAP >60.\n Action:\n Nafcillin q4hr.\n Dopa stopped at 0400\n Response:/Plan\n BP dropping to 87/48 MAP 57. dopa restarted at 0450 at 3mcq/k/min.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS diminished bases. No crackles on exam. Pt. refusing to wear O2-\n takes off NC.\n - HR elevated 90\ns-105ST. rare PVC. BP 90\ns/40\ns. MAP\n 60;\n Negative 1.5L for on lasix drip.\n Pt. c/o being thirsty and hungry.\n Action:\n Discussed with team. Decision made to d/d lasix gtt . d/cd at\n Maintained fluid restriction. Ice chips and sips of water only.\n NPO for TEE today\n Response:\n Sats 90-95% on RA. Denies SOB. u/o 80cc/hr.\n HR remains elevated. Borderline BP on low dose dopamine\n Plan:\n Follow u/o off lasix. Fluid restriction\n Altered mental status (not Delirium)\n Assessment:\n Ox1\n self only. Unable to state date or place.\n Only sleeping for very short periods. Mostly awake.\n Becoming slightly argumentative at times- frustrated because he is\n hungry.\n Trying to get OOB requiring constant supervision.\n Pulling off O2, BP cuff and compression sleeves from legs.\n Action:\n Seraquel 25mg x1 at .\n Bed alarm on, side rails up. Constant supervision.\n IVs wrapped with kerlix\n Response:\n Slept for ~ 1.5 hours after seraquel then was awake for most of night.\n Ox1 only. Occas. c/o pain with foley while urinating.\n Plan:\n Monitor for change in MS. ? increase dose of seraquel for tonight.\n Safety /fall precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724466,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt remains confused most of the time, oriented mostly only to person\n Action:\n Frequently redirected\n Bed alarm on, family at bedside most of the day\n Bed in low position, call bell accessible\n Response:\n Mental status waxes and wanes\n Plan:\n Monitor, mointain safety\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Pt pulled swan ganz catheter out at 0730\n Remains on lasix gtt at 5 mg/hr\n c/o of feeling very thirst, always wanting water\n Dopamine remains at 3 mcg/kg/min\n Hhr 80\ns af\n Bp 97-115/60\n SATs 96-98% on RA, lungs cta\n Action:\n Attempt to wean dopamine\n ECHO done\n Response:\n Unable to wean dopa\n Good response to lasix\n Plan:\n Wean dopa as possible\n TEE in am\n Bacteremia\n Assessment:\n afebrile\n Action:\n Vanc changed to nafcillin\n Response:\n Plan:\n Monitor temp curve, wbc, cx data\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724475,
"text": "Bacteremia\n Assessment:\n Afeb.\n 2 sets of BC pnd from admission. Urine Cx negative. MRSA screening\n pnd.\n Dopa at 3mcq/k/min to maintain SBP 90-100/. MAP >60.\n Action:\n Nafcillin q4hr.\n ******Dopa stopped at 0400\n Response:/Plan\n BP dropping to 87/48 MAP 57. dopa restarted at 0450 at 3mcq/k/min.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS diminished bases. No crackles on exam. Pt. refusing to wear O2-\n takes off NC.\n - HR elevated 90\ns-105ST. rare PVC. BP 90\ns/40\ns. MAP\n 60;\n Negative 1.5L for on lasix drip.\n Pt. c/o being thirsty and hungry.\n Action:\n Discussed with team. Decision made to d/d lasix gtt . d/cd at\n Maintained fluid restriction. Ice chips and sips of water only.\n NPO for TEE today\n Response:\n Sats 90-95% on RA. Denies SOB. u/o 80cc/hr.\n HR remains elevated. Borderline BP on low dose dopamine. Did not\n tolerate off dopa.\n Plan:\n Follow u/o off lasix. Fluid restriction\n Altered mental status (not Delirium)\n Assessment:\n Ox1\n self only. Unable to state date or place.\n Only sleeping for very short periods. Mostly awake.\n Becoming slightly argumentative at times- frustrated because he is\n hungry.\n Trying to get OOB requiring constant supervision.\n Pulling off O2, BP cuff and compression sleeves from legs.\n Action:\n Seraquel 25mg x1 at .\n Bed alarm on, side rails up. Constant supervision.\n IVs wrapped with kerlix\n Response:\n Slept for ~ 1.5 hours after seraquel then was awake for most of night.\n Ox1 only. Occas. c/o pain with foley while urinating.\n Plan:\n Monitor for change in MS. ? increase dose of seraquel for tonight.\n Safety /fall precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724261,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history). Rate 70\ns BP 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Dopa d/c\nd at 0300.\n Response:\n Remains afeb.\n BP lower than admit: 89-94/49. MAP 59-60. , HR 60 aflutter. No\n VEA.\n 0400: dopa was restarted at 3mcq/k/min.\n Plan:\n TEE. Repeat BC (surveillance)- sent with AM labs. , vanco q24hr\n (next dose at 0800). AM vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. neg. 400cc by 0300. goal for AM was 1L negative.\n Sats 98% on 3lnc.\n Plan:\n Follow PAPs. ? d/c swan since it came from OSH.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n - awake most of the night. Groaning much of the time and when\n asked why he states he is thirsty , not in pain.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change.\n Thrombocytopenia: pt. with hx\n baseline 50,000. Per OSH reports the\n patient has a chronic thrombocytopenia of unclear etiology. Pt reports\n history of easy bleeding & bruising. DDx is broad and includes ITP,\n myelodysplastic syndrome, drug induced admit plts 48. multiple areas\n of bruising on arms, stomach ( sc heparin at OSH).\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x3. incontinent while straining to void. Small- Large\n brown soft stool, guiac neg. pt. cannot say ahead of time that he\n needs bedpan. He is very embarrassed about stooling in bed.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724460,
"text": "Bacteremia\n Assessment:\n Afeb.\n 2 sets of BC pnd from admission. Urine Cx negative. MRSA screening\n pnd.\n Dopa at 3mcq/k/min to maintain SBP 90-100/. MAP >60.\n Action:\n Nafcillin q4hr.\n Dopa stopped at 0400\n Response:/Plan\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS diminished bases. No crackles on exam. Pt. refusing to wear O2-\n takes off NC.\n - HR elevated 90\ns-105ST. rare PVC. BP 90\ns/40\ns. MAP\n 60;\n Negative 1.5L for on lasix drip.\n Pt. c/o being thirsty and hungry.\n Action:\n Discussed with team. Decision made to d/d lasix gtt . d/cd at\n Maintained fluid restriction. Ice chips and sips of water only.\n NPO for TEE today\n Response:\n Sats 90-95% on RA. Denies SOB. u/o 80cc/hr.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Ox1\n self only. Unable to state date or place.\n Only sleeping for very short periods. Mostly awake.\n Becoming slightly argumentative at times- frustrated because he is\n hungry.\n Trying to get OOB requiring constant supervision.\n Pulling off O2, BP cuff and compression sleeves from legs.\n Action:\n Seraquel 25mg x1 at .\n Bed alarm on, side rails up. Constant supervision.\n IVs wrapped with kerlix\n Response:\n Slept for ~ 1.5 hours after seraquel then was awake for most of night.\n Ox1 only. Occas. c/o pain with foley while urinating.\n Plan:\n Monitor for change in MS. ? increase dose of seraquel for tonight.\n Safety /fall precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724241,
"text": "Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Encephalitis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 724242,
"text": "Chief Complaint: Bacteremia\n HPI:\n The patient is a 75y/o M with a PMH of CAD s/p CABG with AVR in \n transferred to for management of suspected endocarditis. On\n arrival to the patient is unable to fully relate his HPI. Limited\n history is taken from OSH DC Summary and admission note. The patientwas\n in his usual state of health, living independently who presented to\n hospital after being found unresponsive by his daughter\n with tachypnea and fever. He had previously complained of days of\n general malaise. He was taken to the ED, where he was found to be\n hypotensive with a BP 85/49 and temp of 102. He was started on\n Vancomycin/Zosyn. CXR per reports was suggestive of CHF with bilateral\n infiltrates. He was also started on stress dose hydrocortisone given\n history of prednisone therapy for RA. He was admitted to the \n ICU and started on pressors after receiving a few small fuid boluses\n per report. Swan-ganz catheter was placed and he was found to have a\n wedge of 26. He was given an unclear amount of diuretics as well as an\n attempt at Bipap. Per report blood cultures grew Staphylococcus aureus\n and zosyn was disontinued. TTE was completed on day of transfer however\n was not read. Per nursing reports he was intermittently requiring\n dopamine and neosynephrine for intermittent hypotension. At the time of\n transfer he was continued on levophed 5mcg/kg/min, dopamine\n 2.5mcg/kg/min. Per report he also briefly required sedation with\n Precedex for agitation however he was never intubated.\n .\n On arrival to the CCU, the patient is sleepy but easily arousable and\n conversant. He is oriented to hospital and name but not to date. He\n currently denies chest pain and shortness of breath. Denies headache,\n vision changes. Denies abdominal pain, hemoptysis, black or red stools.\n He reports a history of bleeding and bruising of unknown etiology,\n states he has had bleeding of his nose and gums previously which\n resolved without intervention.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2.5 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS: Per OSH Admission Note\n - Zocor 40 mg po daily\n - Sildenafil PRN\n - Aricept\n - Hydroxychloroquin - 400mg po daily\n - Prednisone - 5mg daily\n - Lasix 20mg po daily\n - Neurontin 600mg po daily\n - Amaryl 1mg po daily\n .\n MEDICATIONS ON TRANSFER:\n Levophed 5mcg/kg/min\n Dopamine 2.5mcg/kg/min\n Vancomycin 1gm Q12\n Ativan 0.5mg Q 3 PRN agitation\n Azithromycin 500mg IV Q 24\n Hydrocortisone 50mg IV Q 8\n Heparin 5000Units SC TID\n Insulin SS\n Pantoprazole 40 mg IV daily\n Past medical history:\n Family history:\n Social History:\n - CABG in with bioprosthetic AVR for aortic stenosis\n - Gram Positive Cocci bacteremia\n - Thrombocytopenia with baseline 50,000\n - History of transbronchial biopsy with suggestion of bronchiolitis\n obliterans \n - Hypertension\n - Diabetes Mellitus\n - Rheumatoid Arthritis\n - Polymyalgia Rheumatica\n The patient reports that he does not know his past family history.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient has lived alone with assistance of daughter who\n lives near by. Has 9 children. Reports past history of tobacco use\n 10pack/yrs, quit 20 years ago. Denies EtOH, IVDU. He was adopted, he\n joined the army at age 19.\n Review of systems:\n Constitutional: Fatigue, Fever\n Psychiatric / Sleep: Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 75 (72 - 75) bpm\n BP: 118/71(81) {102/58(69) - 118/71(81)} mmHg\n RR: 22 (19 - 22) insp/min\n SpO2: 97%\n Height: 69 Inch\n CVP: 15 (14 - 15)mmHg\n PAP: (66 mmHg) / (29 mmHg)\n Mixed Venous O2% Sat: 60 - 60\n Total In:\n 32 mL\n PO:\n TF:\n IVF:\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 1,875 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,843 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./21/-2\n Physical Examination\n VS: T 97.7 BP 102/58 HR 72 RR 19 O2 97% on 2L NC\n GENERAL: elderly male in NAD\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva with multiple\n petechiae\n NECK: Supple with JVP of cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. III/VI systolic murmur loudest at right 2nd intercostal\n space with radiation to carotids No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. + scattered crackles throughout\n ABDOMEN: Soft, NTND. Spleen not palpable, no hepatomegaly No abdominial\n bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: Multiple areas of bruising, multiple petechiae over palms and\n soles\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Neuro: The patient is able to name months backward from -\n and days of week Sun - Thursday. Oriented to name but not\n month, day, year. CN II-XII intact, PERRLA.\n Labs / Radiology\n 43 K/uL\n 11.6 g/dL\n 156 mg/dL\n 2.0 mg/dL\n 72 mg/dL\n 21 mEq/L\n 110 mEq/L\n 4.5 mEq/L\n 138 mEq/L\n 34.6 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A2/17/ 07:35 PM\n \n 10:20 P2/17/ 07:58 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 34.6\n Plt\n 43\n Cr\n 2.0\n TC02\n 21\n Glucose\n 156\n Other labs: PT / PTT / INR:17.7/35.4/1.6, CK / CKMB / Troponin-T:277//,\n ALT / AST:62/104, Alk Phos / T Bili:42/2.0, Differential-Neuts:84.6 %,\n Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %, Albumin:2.4 g/dL, LDH:428 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: LABORATORY DATA:\n OSH Labs:\n VBG 7.36/38/35/20 Lactate 2.1\n Na 133 K 4.9 Cl 104 HCO3 20 BUN 66 Cr 2.12\n AST 130 ALT 62 Alk Ph 47 TB 2.3 Alb 2.6\n CK 575 Trop I 2.30\n CBC 6.6 Hgb 3.43 HCT 34 Plt 33\n MICRO: Verbally confirmed with OSH micro lab - 4/4 bottles\n Staphylococcus aureus - sensitivities pending.\n ECG\n \n Irreg/irreg vent rate 75bpm, LAD, LVH, QRS 136 with L\n bundle pattern, V5-V6 ST dep with TWI V6\n Assessment and Plan: 75y/o M with a PMH of CAD s/p CABG with AVR in\n and thrombocytopenia transferred to for management of S.\n aureus bacteremia and acute on chronic systolic CHF\n .\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. By Duke Criteria - he has major\n criteria of high gradebacteremia with typical organism, by minor\n criteria he has fever, predisposing heart condition, he also has skin\n findings of petechiae however difficult to interpret in the setting of\n significant thrombocytopenia.\n - Will continue Vancoymcin dosed 1 gm Q 12\n - Contact OSH micro lab - SA is likely MSSA but sensitivities are not\n finalized, will fax results in am - if so, plan to transition to\n nafcillin\n - Would opt for TEE in am given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - ID consult in am given high grade Staph aureus bacteremia\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Current\n CVP 16 with PAP 66/29\n - Continue to taper dopamine/neosynephrine\n - Will diureses with IV lasix\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - Diurese with lasix goal 1L negative but will follow hemodynamics and\n Cr\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia however in setting of\n acute infection, must consider. HIT also unlikely given documented long\n history of thrombocytopenia.\n - Will check LFTs/Bili/LDH\n - Check Fibrinogen\n - Check B12/folate\n - Trend INR\n - Check peripheral smear\n - Consider hematology consult in am\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter however this is in the setting of\n pressors\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection\n - Repeat CK/Trop\n - TTE in am as above\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex\n - Hold sedating medications\n - Treat infection as above\n - Check LFTs, Ca\n - Obatin read of Head CT\n .\n FEN: Low Na, diabetic diet, NPO in am for possible TEE\n .\n ACCESS: R CVL/PA catheter - will need to change in am as placed at OSH\n .\n PROPHYLAXIS:\n -DVT ppx pneumoboots\n -Bowel regimen with colace/senna\n .\n CODE: Full\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 07:15 PM\n 18 Gauge - 07:15 PM\n 20 Gauge - 07:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Agree with above assessment and plan as outlined by CCU housestaff, Dr.\n .\n Briefly, 75M h/o CABG and bioprosthetic AVR (), DM, RA on\n hydroxychloroquin and PMR on low-dose prednisone, chronic\n thrombocytopenia (Plt 50s) presented to OSH with altered mental status,\n fever (102), tachycardia and hypotension (SBP 80s) found to have\n high-grade staph aureus bacteremia (sensitivities pending) of presumed\n endovascular source. Treated with vancomycin and zosyn tailored to\n vancomycin alone once bacterial speciation returned. Given stress-dose\n steroids however required dopamine and norepinephrine for blood\n pressure support. PA catheter placed to guide therapy (PCWP 26 mmHg),\n and received furosemide and BiPAP for CHF although only mild-moderate\n oxygen requirement not requiring intubation. TTE performed prior to\n transfer but no report available presently for review.\n Currently he has been weaned from pressors with BP 110/60, HR 75. He\n denies pain or dyspnea, reports hunger. Exam with holosyt murm at apex\n radiating to axilla. Bibasilar rales without wheeze. No peripheral\n edema. Scattered petechiae but no Osler or . PA line in right IJ\n confirmed position on CXR, which also shows evidence of pulmonary\n edema. Latest PA values with CI 4 and SVG 1200. OSH labs notable for\n Cre 2.1, CK 575, TnI 2.3, WBC 6.6, Hct 34, Plt 33. ECG with atrial\n flutter 70s variable block, LAD, left bundle pattern, probable LVH with\n repolarization changes.\n Plan for vancomycin for high grade staph aureus bacteremia pending\n further sensitivities. TTE/TEE in AM to assess valves including close\n evaluation of bioprosthesis. Would keep patient NPO. Surveillance blood\n cultures. ID consult in AM. Hypotension now resolved off pressors, most\n likely from sepsis physiology. Attempt gentle diuresis as tolerated.\n Elevated troponin most likely due to demand from\n tachycardia/hypotension/sepsis, rather than infective thromboemboli.\n Would recheck cardiac biomarkers and continue statin. Await\n echocardiogram to assess wall motion. Holding aspirin given\n thrombocytopenia, and beta-blocker/ACEi due to hypotension. Aflutter\n rate controlled, no heparin given thrombocytopenia and elevated INR.\n Monitor platelets closely, would send smear and type and screen. Follow\n INR which is slightly elevated however no evidence of active bleeding.\n Above discussed with CCU team.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:09 ------\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724243,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724244,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n Action:\n BC x2 sent, urine Cx and UA sent.\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724245,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n Action:\n BC x2 sent, urine Cx and UA sent.\n Response:\n Remains afeb.\n Plan:\n TEE. Repeat BC (surveillance), vanco q24hr (next dose at 0800). AM\n vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724247,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history). Rate 70\ns BP 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Response:\n Remains afeb.\n Plan:\n TEE. Repeat BC (surveillance), vanco q24hr (next dose at 0800). AM\n vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-06 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 724236,
"text": "Chief Complaint: Bacteremia\n HPI:\n The patient is a 75y/o M with a PMH of CAD s/p CABG with AVR in \n transferred to for management of suspected endocarditis. On\n arrival to the patient is unable to fully relate his HPI. Limited\n history is taken from OSH DC Summary and admission note. The patientwas\n in his usual state of health, living independently who presented to\n hospital after being found unresponsive by his daughter\n with tachypnea and fever. He had previously complained of days of\n general malaise. He was taken to the ED, where he was found to be\n hypotensive with a BP 85/49 and temp of 102. He was started on\n Vancomycin/Zosyn. CXR per reports was suggestive of CHF with bilateral\n infiltrates. He was also started on stress dose hydrocortisone given\n history of prednisone therapy for RA. He was admitted to the \n ICU and started on pressors after receiving a few small fuid boluses\n per report. Swan-ganz catheter was placed and he was found to have a\n wedge of 26. He was given an unclear amount of diuretics as well as an\n attempt at Bipap. Per report blood cultures grew Staphylococcus aureus\n and zosyn was disontinued. TTE was completed on day of transfer however\n was not read. Per nursing reports he was intermittently requiring\n dopamine and neosynephrine for intermittent hypotension. At the time of\n transfer he was continued on levophed 5mcg/kg/min, dopamine\n 2.5mcg/kg/min. Per report he also briefly required sedation with\n Precedex for agitation however he was never intubated.\n .\n On arrival to the CCU, the patient is sleepy but easily arousable and\n conversant. He is oriented to hospital and name but not to date. He\n currently denies chest pain and shortness of breath. Denies headache,\n vision changes. Denies abdominal pain, hemoptysis, black or red stools.\n He reports a history of bleeding and bruising of unknown etiology,\n states he has had bleeding of his nose and gums previously which\n resolved without intervention.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2.5 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS: Per OSH Admission Note\n - Zocor 40 mg po daily\n - Sildenafil PRN\n - Aricept\n - Hydroxychloroquin - 400mg po daily\n - Prednisone - 5mg daily\n - Lasix 20mg po daily\n - Neurontin 600mg po daily\n - Amaryl 1mg po daily\n .\n MEDICATIONS ON TRANSFER:\n Levophed 5mcg/kg/min\n Dopamine 2.5mcg/kg/min\n Vancomycin 1gm Q12\n Ativan 0.5mg Q 3 PRN agitation\n Azithromycin 500mg IV Q 24\n Hydrocortisone 50mg IV Q 8\n Heparin 5000Units SC TID\n Insulin SS\n Pantoprazole 40 mg IV daily\n Past medical history:\n Family history:\n Social History:\n - CABG in with bioprosthetic AVR for aortic stenosis\n - Gram Positive Cocci bacteremia\n - Thrombocytopenia with baseline 50,000\n - History of transbronchial biopsy with suggestion of bronchiolitis\n obliterans \n - Hypertension\n - Diabetes Mellitus\n - Rheumatoid Arthritis\n - Polymyalgia Rheumatica\n The patient reports that he does not know his past family history.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient has lived alone with assistance of daughter who\n lives near by. Has 9 children. Reports past history of tobacco use\n 10pack/yrs, quit 20 years ago. Denies EtOH, IVDU. He was adopted, he\n joined the army at age 19.\n Review of systems:\n Constitutional: Fatigue, Fever\n Psychiatric / Sleep: Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 75 (72 - 75) bpm\n BP: 118/71(81) {102/58(69) - 118/71(81)} mmHg\n RR: 22 (19 - 22) insp/min\n SpO2: 97%\n Height: 69 Inch\n CVP: 15 (14 - 15)mmHg\n PAP: (66 mmHg) / (29 mmHg)\n Mixed Venous O2% Sat: 60 - 60\n Total In:\n 32 mL\n PO:\n TF:\n IVF:\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 1,875 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,843 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./21/-2\n Physical Examination\n VS: T 97.7 BP 102/58 HR 72 RR 19 O2 97% on 2L NC\n GENERAL: elderly male in NAD\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva with multiple\n petechiae\n NECK: Supple with JVP of cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. III/VI systolic murmur loudest at right 2nd intercostal\n space with radiation to carotids No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. + scattered crackles throughout\n ABDOMEN: Soft, NTND. Spleen not palpable, no hepatomegaly No abdominial\n bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: Multiple areas of bruising, multiple petechiae over palms and\n soles\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Neuro: The patient is able to name months backward from -\n and days of week Sun - Thursday. Oriented to name but not\n month, day, year. CN II-XII intact, PERRLA.\n Labs / Radiology\n 43 K/uL\n 11.6 g/dL\n 156 mg/dL\n 2.0 mg/dL\n 72 mg/dL\n 21 mEq/L\n 110 mEq/L\n 4.5 mEq/L\n 138 mEq/L\n 34.6 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A2/17/ 07:35 PM\n \n 10:20 P2/17/ 07:58 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 34.6\n Plt\n 43\n Cr\n 2.0\n TC02\n 21\n Glucose\n 156\n Other labs: PT / PTT / INR:17.7/35.4/1.6, CK / CKMB / Troponin-T:277//,\n ALT / AST:62/104, Alk Phos / T Bili:42/2.0, Differential-Neuts:84.6 %,\n Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %, Albumin:2.4 g/dL, LDH:428 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: LABORATORY DATA:\n OSH Labs:\n VBG 7.36/38/35/20 Lactate 2.1\n Na 133 K 4.9 Cl 104 HCO3 20 BUN 66 Cr 2.12\n AST 130 ALT 62 Alk Ph 47 TB 2.3 Alb 2.6\n CK 575 Trop I 2.30\n CBC 6.6 Hgb 3.43 HCT 34 Plt 33\n MICRO: Verbally confirmed with OSH micro lab - 4/4 bottles\n Staphylococcus aureus - sensitivities pending.\n Assessment and Plan\n ASSESSMENT AND PLAN: 75y/o M with a PMH of CAD s/p CABG with AVR in\n and thrombocytopenia transferred to for management of S.\n aureus bacteremia and hypotension.\n .\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. By Duke Criteria - he has major\n criteria of high gradebacteremia with typical organism, by minor\n criteria he has fever, predisposing heart condition, he also has skin\n findings of petechiae however difficult to interpret in the setting of\n significant thrombocytopenia.\n - Will continue Vancoymcin - dosed 1gm Q 24 based on GFR 32, will check\n trough in am\n - Contact OSH micro lab - SA is likely MSSA but final sensitivities\n are not finalized, will fax results in am - if so, plan to transition\n to nafcillin\n - Will obtain TTE in am, NPO at MN for possible TEE given prosthetic\n aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - ID consult in am given high grade Staph aureus bacteremia\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Current\n CVP 16 with PAP 66/29\n - Continue to taper dopamine/neosynephrine\n - Will diureses with IV lasix\n - Treat bacteremia as above\n - Obtain TTE to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - Diurese with lasix goal 1L negative but will follow hemodynamics and\n Cr\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia however in setting of\n acute infection, must consider. HIT also unlikely given documented long\n history of thrombocytopenia.\n - Will check LFTs/Bili/LDH\n - Check Fibrinogen\n - Check B12/folate\n - Trend INR\n - Check peripheral smear\n - Consider hematology consult in am\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter however this is in the setting of\n pressors\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection\n - Repeat CK/Trop\n - TTE in am as above\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex\n - Hold sedating medications\n - Treat infection as above\n - Check LFTs, Ca\n .\n FEN: Low Na, diabetic diet, NPO in am for possible TEE\n .\n ACCESS: R CVL/PA catheter - will need to change in am as placed at OSH\n .\n PROPHYLAXIS:\n -DVT ppx pneumoboots\n -Bowel regimen with colace/senna\n .\n CODE: Full\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 07:15 PM\n 18 Gauge - 07:15 PM\n 20 Gauge - 07:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-06 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 724237,
"text": "Chief Complaint: Bacteremia\n HPI:\n The patient is a 75y/o M with a PMH of CAD s/p CABG with AVR in \n transferred to for management of suspected endocarditis. On\n arrival to the patient is unable to fully relate his HPI. Limited\n history is taken from OSH DC Summary and admission note. The patientwas\n in his usual state of health, living independently who presented to\n hospital after being found unresponsive by his daughter\n with tachypnea and fever. He had previously complained of days of\n general malaise. He was taken to the ED, where he was found to be\n hypotensive with a BP 85/49 and temp of 102. He was started on\n Vancomycin/Zosyn. CXR per reports was suggestive of CHF with bilateral\n infiltrates. He was also started on stress dose hydrocortisone given\n history of prednisone therapy for RA. He was admitted to the \n ICU and started on pressors after receiving a few small fuid boluses\n per report. Swan-ganz catheter was placed and he was found to have a\n wedge of 26. He was given an unclear amount of diuretics as well as an\n attempt at Bipap. Per report blood cultures grew Staphylococcus aureus\n and zosyn was disontinued. TTE was completed on day of transfer however\n was not read. Per nursing reports he was intermittently requiring\n dopamine and neosynephrine for intermittent hypotension. At the time of\n transfer he was continued on levophed 5mcg/kg/min, dopamine\n 2.5mcg/kg/min. Per report he also briefly required sedation with\n Precedex for agitation however he was never intubated.\n .\n On arrival to the CCU, the patient is sleepy but easily arousable and\n conversant. He is oriented to hospital and name but not to date. He\n currently denies chest pain and shortness of breath. Denies headache,\n vision changes. Denies abdominal pain, hemoptysis, black or red stools.\n He reports a history of bleeding and bruising of unknown etiology,\n states he has had bleeding of his nose and gums previously which\n resolved without intervention.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2.5 mcg/Kg/min\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS: Per OSH Admission Note\n - Zocor 40 mg po daily\n - Sildenafil PRN\n - Aricept\n - Hydroxychloroquin - 400mg po daily\n - Prednisone - 5mg daily\n - Lasix 20mg po daily\n - Neurontin 600mg po daily\n - Amaryl 1mg po daily\n .\n MEDICATIONS ON TRANSFER:\n Levophed 5mcg/kg/min\n Dopamine 2.5mcg/kg/min\n Vancomycin 1gm Q12\n Ativan 0.5mg Q 3 PRN agitation\n Azithromycin 500mg IV Q 24\n Hydrocortisone 50mg IV Q 8\n Heparin 5000Units SC TID\n Insulin SS\n Pantoprazole 40 mg IV daily\n Past medical history:\n Family history:\n Social History:\n - CABG in with bioprosthetic AVR for aortic stenosis\n - Gram Positive Cocci bacteremia\n - Thrombocytopenia with baseline 50,000\n - History of transbronchial biopsy with suggestion of bronchiolitis\n obliterans \n - Hypertension\n - Diabetes Mellitus\n - Rheumatoid Arthritis\n - Polymyalgia Rheumatica\n The patient reports that he does not know his past family history.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient has lived alone with assistance of daughter who\n lives near by. Has 9 children. Reports past history of tobacco use\n 10pack/yrs, quit 20 years ago. Denies EtOH, IVDU. He was adopted, he\n joined the army at age 19.\n Review of systems:\n Constitutional: Fatigue, Fever\n Psychiatric / Sleep: Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 75 (72 - 75) bpm\n BP: 118/71(81) {102/58(69) - 118/71(81)} mmHg\n RR: 22 (19 - 22) insp/min\n SpO2: 97%\n Height: 69 Inch\n CVP: 15 (14 - 15)mmHg\n PAP: (66 mmHg) / (29 mmHg)\n Mixed Venous O2% Sat: 60 - 60\n Total In:\n 32 mL\n PO:\n TF:\n IVF:\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 1,875 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,843 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./21/-2\n Physical Examination\n VS: T 97.7 BP 102/58 HR 72 RR 19 O2 97% on 2L NC\n GENERAL: elderly male in NAD\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva with multiple\n petechiae\n NECK: Supple with JVP of cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. III/VI systolic murmur loudest at right 2nd intercostal\n space with radiation to carotids No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. + scattered crackles throughout\n ABDOMEN: Soft, NTND. Spleen not palpable, no hepatomegaly No abdominial\n bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: Multiple areas of bruising, multiple petechiae over palms and\n soles\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Neuro: The patient is able to name months backward from -\n and days of week Sun - Thursday. Oriented to name but not\n month, day, year. CN II-XII intact, PERRLA.\n Labs / Radiology\n 43 K/uL\n 11.6 g/dL\n 156 mg/dL\n 2.0 mg/dL\n 72 mg/dL\n 21 mEq/L\n 110 mEq/L\n 4.5 mEq/L\n 138 mEq/L\n 34.6 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A2/17/ 07:35 PM\n \n 10:20 P2/17/ 07:58 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 34.6\n Plt\n 43\n Cr\n 2.0\n TC02\n 21\n Glucose\n 156\n Other labs: PT / PTT / INR:17.7/35.4/1.6, CK / CKMB / Troponin-T:277//,\n ALT / AST:62/104, Alk Phos / T Bili:42/2.0, Differential-Neuts:84.6 %,\n Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %, Albumin:2.4 g/dL, LDH:428 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: LABORATORY DATA:\n OSH Labs:\n VBG 7.36/38/35/20 Lactate 2.1\n Na 133 K 4.9 Cl 104 HCO3 20 BUN 66 Cr 2.12\n AST 130 ALT 62 Alk Ph 47 TB 2.3 Alb 2.6\n CK 575 Trop I 2.30\n CBC 6.6 Hgb 3.43 HCT 34 Plt 33\n MICRO: Verbally confirmed with OSH micro lab - 4/4 bottles\n Staphylococcus aureus - sensitivities pending.\n ECG\n \n Irreg/irreg vent rate 75bpm, LAD, LVH, QRS 136 with L\n bundle pattern, V5-V6 ST dep with TWI V6\n Assessment and Plan: 75y/o M with a PMH of CAD s/p CABG with AVR in\n and thrombocytopenia transferred to for management of S.\n aureus bacteremia and acute on chronic systolic CHF\n .\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. By Duke Criteria - he has major\n criteria of high gradebacteremia with typical organism, by minor\n criteria he has fever, predisposing heart condition, he also has skin\n findings of petechiae however difficult to interpret in the setting of\n significant thrombocytopenia.\n - Will continue Vancoymcin dosed 1 gm Q 12\n - Contact OSH micro lab - SA is likely MSSA but sensitivities are not\n finalized, will fax results in am - if so, plan to transition to\n nafcillin\n - Would opt for TEE in am given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - ID consult in am given high grade Staph aureus bacteremia\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Current\n CVP 16 with PAP 66/29\n - Continue to taper dopamine/neosynephrine\n - Will diureses with IV lasix\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - Diurese with lasix goal 1L negative but will follow hemodynamics and\n Cr\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia however in setting of\n acute infection, must consider. HIT also unlikely given documented long\n history of thrombocytopenia.\n - Will check LFTs/Bili/LDH\n - Check Fibrinogen\n - Check B12/folate\n - Trend INR\n - Check peripheral smear\n - Consider hematology consult in am\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter however this is in the setting of\n pressors\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection\n - Repeat CK/Trop\n - TTE in am as above\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex\n - Hold sedating medications\n - Treat infection as above\n - Check LFTs, Ca\n - Obatin read of Head CT\n .\n FEN: Low Na, diabetic diet, NPO in am for possible TEE\n .\n ACCESS: R CVL/PA catheter - will need to change in am as placed at OSH\n .\n PROPHYLAXIS:\n -DVT ppx pneumoboots\n -Bowel regimen with colace/senna\n .\n CODE: Full\n .\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 07:15 PM\n 18 Gauge - 07:15 PM\n 20 Gauge - 07:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724433,
"text": "Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724351,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - encephalopathic all night\n - complaints of thirst all night\n - Had BMx4, soft not diarrhea; checking C diff on next one\n - lasix boluses x2, after which net neg -500cc, started lasix drip ~5am\n ; urinary output didn't change which 20mg IV bolus (already had\n 100cc/hr output), increased w 40mg IV bolus\n - dopamine turned off 3am, but restarted for MAPs in mid 50s\n - patient pulled out Swan and central line this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 75 (68 - 85) bpm\n BP: 115/55(71) {86/48(54) - 119/73(135)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 69 Inch\n CVP: 15 (14 - 24)mmHg\n PAP: (65 mmHg) / (30 mmHg)\n CO/CI (Fick): (5.4 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 60 - 66\n Total In:\n 419 mL\n 435 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 59 mL\n 75 mL\n Blood products:\n Total out:\n 2,055 mL\n 1,380 mL\n Urine:\n 480 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,636 mL\n -945 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./22/-2\n Physical Examination\n GENERAL: elderly male, sleepy but easily arousable and conversational,\n in NAD\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva with multiple\n petechiae\n NECK: Supple with JVP of 10 cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. III/VI systolic murmur loudest at right 2nd intercostal\n space with loud radiation to carotids No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations\n unlabored, no accessory muscle use. bibasilar crackles more clear in\n mid and upper lung fields\n ABDOMEN: Soft, NTND. Spleen not palpable, no hepatomegaly No abdominial\n bruits.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: Multiple areas of bruising, multiple petechiae over palms and\n soles ; painless dark spots in toes and fingers\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Neuro: The patient has poor attention span; cannot always finish train\n of thought when speaking in sentences\n Labs / Radiology\n 41 K/uL\n 10.9 g/dL\n 127 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 75 mg/dL\n 108 mEq/L\n 139 mEq/L\n 33.2 %\n 3.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n WBC\n 7.7\n 3.5\n Hct\n 34.6\n 33.2\n Plt\n 43\n 41\n Cr\n 2.0\n 2.1\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TTE this AM\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - Check peripheral smear\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - Consider repeat Head CT ; will likely need MRI in future when can\n tolerate to eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 07:15 PM\n 20 Gauge - 05:28 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: CCU\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724312,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - encephalopathic all night\n - complaints of thirst all night\n - Had BMx4, soft not diarrhea; checking C diff on next one\n - lasix boluses x2, after which net neg -500cc, started lasix drip ~5am\n ; urinary output didn't change which 20mg IV bolus (already had\n 100cc/hr output), increased w 40mg IV bolus\n - dopamine turned off 3am, but restarted for MAPs in mid 50s\n - patient pulled out Swan and central line this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 05:28 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 75 (68 - 85) bpm\n BP: 115/55(71) {86/48(54) - 119/73(135)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 69 Inch\n CVP: 15 (14 - 24)mmHg\n PAP: (65 mmHg) / (30 mmHg)\n CO/CI (Fick): (5.4 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 60 - 66\n Total In:\n 419 mL\n 435 mL\n PO:\n 360 mL\n 360 mL\n TF:\n IVF:\n 59 mL\n 75 mL\n Blood products:\n Total out:\n 2,055 mL\n 1,380 mL\n Urine:\n 480 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,636 mL\n -945 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.42/32/95./22/-2\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 41 K/uL\n 10.9 g/dL\n 127 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 75 mg/dL\n 108 mEq/L\n 139 mEq/L\n 33.2 %\n 3.5 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n WBC\n 7.7\n 3.5\n Hct\n 34.6\n 33.2\n Plt\n 43\n 41\n Cr\n 2.0\n 2.1\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n Other labs: PT / PTT / INR:16.3/33.5/1.4, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:59/92, Alk Phos / T Bili:39/1.7,\n Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.2 %, Eos:0.1 %,\n Fibrinogen:351 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.4 g/dL, LDH:415\n IU/L, Ca++:7.4 mg/dL, Mg++:2.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. By Duke Criteria - he has major\n criteria of high gradebacteremia with typical organism, by minor\n criteria he has fever, predisposing heart condition, he also has skin\n findings of petechiae however difficult to interpret in the setting of\n significant thrombocytopenia.\n - Will continue Vancoymcin dosed 1 gm Q 12\n - Contact OSH micro lab - SA is likely MSSA but sensitivities are not\n finalized, will fax results in am - if so, plan to transition to\n nafcillin\n - TEE given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - ID consult in am given high grade Staph aureus bacteremia\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated.\n - F/U B12/folate\n - Trend INR\n - Check peripheral smear\n - Consider hematology consult in am\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter however this is in the setting of\n pressors\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex\n - Hold sedating medications\n - Treat infection\n - Consider repeat Head CT\n # Rheumatoid Arthritis\n - holding meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 07:15 PM\n 20 Gauge - 05:28 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724294,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated\n requiring ativan and then precedex. A Swan-ganz catheter was placed\n and he was found to have a wedge of 26. He was given an unclear amount\n of diuretics as well as an attempt at Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions.\n Bacteremia\n Assessment:\n TM 97po. WC 7.7. skin warm and dry. Received one dose of vanco on\n at OSH (~ 1800)\n EKG showing Aflutter (pt. has history and on coumadin). Rate 70\ns BP\n 100-120\ns/50\n Arrived on dopamine 2.5mcq and levophed 0.055mcq/k/min.\n Action:\n BC x2 sent, urine Cx and UA sent.\n Levo weaned to off by 2200.\n Dopa d/c\nd at 0300.\n Response:\n TM 99.8R.\n BPdropping after dopa d/c\nd : 89-94/49. MAP 59-60. , HR 60\n aflutter. No VEA.\n 0400: dopa was restarted at 3mcq/k/min. team aware. MAP 66-72,\n Plan:\n TEE planned for today. Repeat BC (surveillance)- sent with AM labs.\n , vanco q24hr (next dose at 0800). AM vanco level with morning labs.\n Follow temp.\n .H/O heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Hx CHF and on po lasix at home. Foley draining dark yellow urine on\n arrival.\n LS crackles at bases with overall course BS. Sats 97% on 3lnc.\n RIJ swan tracing sharp with good placement by CXR. PAP 60/28-30, CVP\n 15-18. C.O. 4.3/2.1/1200. MVO2 60%.\n Action:\n Lasix 20mg at 2200 followed by 40mg at 0100.\n Response:\n u/o 100-160cc/hr. . goal for AM was 1L negative. Only 400ccneg at\n 0500.\n ****0530: lasix 40mg IV x1 followed by lasix drip at 5mg/hr.\n Sats 98% on 3lnc.\n Plan:\n Follow PAPs. ? d/c swan since it came from OSH. Monitor response to\n lasix drip.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had confusion and agitation at OSH. Dx wth ? toxic/metabolic\n encephalopathy d/t infection.\n Arrived to CCU lethargic but arousable. Oriented to person only.\n Unable to state year. Dozing off and needing to be aroused for\n interview.\n - pt. is very loud in his requests for water\n c/o thirst and\n has constant request for water and appears never satisfied. giving\n mostly icechips.\n - He also c/o foley and difficulty voiding and will yell\n outloud when he has to urinate.\n - he got out of bed once , stating he was looking for water. Helped\n back to bed with bed alarm on and close supervision.\n - restless in bed, only dozing for very short periods. Moving\n all extremeties.\n - awake most of the night. Groaning much of the time and when\n asked why he states he is thirsty , not in pain.\n A bit better toward morning. Not moaning as much and appears to\n sleep more peacefully.\n Action:\n Bed alarm on, side rails up.\n No sedation given.\n Bilat. Wrist restraints were placed at 0400-0600\n pt. was pulling at\n foley and at risk for pulling out central line.\n Response:\n Remains Ox1. unable to state place, year or month. Thought he was at\n hospital. Redirectied easily but continues confused.\n Plan:\n Safety precautions. Bed alarm on. Assess and monitor for change. ?\n need for further eval with MRI.\n Thrombocytopenia: pt. with hx\n baseline 50,000. Per OSH reports the\n patient has a chronic thrombocytopenia of unclear etiology. Pt reports\n history of easy bleeding & bruising. DDx is broad and includes ITP,\n myelodysplastic syndrome, drug induced admit plts 48. multiple areas\n of bruising on arms, stomach ( sc heparin at OSH).\n NIDDM: FS 174 on admit . covered with humulog SSRI.\n GI: had BM x3. incontinent while straining to void. Small- Large\n brown soft stool, guiac neg. pt. cannot say ahead of time that he\n needs bedpan. He is very embarrassed about stooling in bed. Send for\n C.diff next sample.\n Social: D-I- called and spoke with RN\n updated on\n condition. Son and have flown in from CA and will be\n coming to hospital today. Daughter is HCP but is currently\n undergoing treatment for Cancer- she called at 0630 and was updated by\n RN and MD. ICU consent was obtained.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724679,
"text": "75 M w/ h/o CAD s/p CABG w/ AVR in found unresponsive at home \n by dtr. To OSH febrile, hypotensive and tachycardic. Started on\n pressors. A Swan-ganz catheter was placed w/ wedge of 26. Found to have\n + BCx 4/4 bottles Staph and thrombocytopenia. Transferred to \n for management of S. aureus bacteremia and acute on chronic\n systolic CHF.\n Confused and agitated at times.\n TEE : sm vegetation on aortic valve, no absess, valvue functioning\n well\n Head CT done to help r/o septic emboli (pt unable to stay still enough\n to do MRI)\n Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented to self, DOB,\n children and occasionally month\n Action:\n Pt frequently reoriented.\n Safety measures in place\nsoft wrist restraints placed as pt\n freq picking at /foley/p-boots\n 5mg Zyprexa zydis given\n Response:\n Dozed intermittently, Continues to be confused/restless, agitated at\n times\n Plan:\n Continue present management, safety measures, FALL RISK\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Temp spike 100.8 PO\n R elbow red, warm and tender to touch\n Ortho consulted for elbow, ?\n bursitis\n Pinpoint red spots on hands and feet, ? septic emboli\n Action:\n Attempted to wean neo\n abx given as ordered\n BCx x2 sent (venipunctures)\n Response:\n temp 99.8 PO, WBC 10.2 (2.9). SBPs down to 60-70s after 1hr neo off\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Wean neo as tol\n Send HIV test when consent signed\n Thrombocytopenia\n Assessment:\n per OSH reports, pt w/ chronic thrombocytopenia of unclear etiology.\n PLT 29 yesterday, pt has multiple ecchymotic areas on torso and limbs\n Action:\n monitored\n Response:\n AM PLT 42\n Plan:\n continue to monitor\nhematology following\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 100s AF/flutter, lasix gtt DCd \nautodiuresing well. Very dry\n mucous membranes\n Action:\n 12.5mg PO lopressor given\n Response:\n HR down to 80s Af/Flutter when calm. Neg 2.5L LOS. +700cc at MN. UOP\n tapering down, now concentrated. BUN/Cr 67/2.7 (75/2.2)\n Plan:\n CHF management, 1200 fluid restriction, daily wts.\n ? IVF\n ACCESS: Pt has self DCd PA line and mult \nPt to be evaluated\n for PICC line today\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724668,
"text": "75 M w/ h/o CAD s/p CABG w/ AVR in found unresponsive at home \n by dtr. To OSH febrile, hypotensive and tachycardic. Started on\n pressors. A Swan-ganz catheter was placed w/ wedge of 26. Found to have\n + BCx 4/4 bottles Staph and thrombocytopenia. Transferred to \n for management of S. aureus bacteremia and acute on chronic\n systolic CHF.\n Confused and agitated at times.\n TEE : sm vegetation on aortic valve, no absess, valvue functioning\n well\n Head CT done to help r/o septic emboli (pt unable to stay still enough\n to do MRI)\n Altered mental status (not Delirium)\n Assessment:\n restless, agitated, moving constantly in bed. Oriented to self, DOB,\n children and occasionally month\n Action:\n Pt frequently reoriented.\n Safety measures in place\nsoft wrist restraints placed as pt\n freq picking at /foley/p-boots\n 5mg Zyprexa zydis given\n Response:\n Dozed intermittently, Continues to be agitated/confused/restless.\n Plan:\n Continue present management, safety measures, FALL RISK\n MSSA Bacteremia/ ? endocarditis\n Assessment:\n Temp spike 100.8 PO\n R elbow red, warm and tender to touch\n Ortho consulted for elbow, ?\n bursitis\n Pinpoint red spots on hands and feet, ? septic emboli\n Action:\n Attempted to wean neo\n abx given as ordered\n BCx x2 sent (venipunctures)\n Response:\n temp 99.8 PO, WBC 10.2 (2.9)\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Send HIV test when consent signed\n Thrombocytopenia\n Assessment:\n per OSH reports, pt w/ chronic thrombocytopenia of unclear etiology.\n PLT 29 yesterday, pt has multiple ecchymotic areas on torso and limbs\n Action:\n monitored\n Response:\n AM PLT 42\n Plan:\n continue to monitor\nhematology following\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 100s AF/flutter, lasix gtt DCd \nautodiuresing well. Very dry\n mucous membranes\n Action:\n 12.5mg PO lopressor given\n Response:\n HR down to 80s Af/Flutter when calm. Neg 2.5L LOS. +700cc at MN. UOP\n tapering down, now concentrated. BUN/Cr 67/2.7 (75/2.2)\n Plan:\n CHF management, 1200 fluid restriction, daily wts.\n ? IVF\n ACCESS: Pt has self DCd PA line and mult \nPt to be evaluated\n for PICC line today\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724603,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated . A\n Swan-ganz catheter was placed and he was found to have a wedge of 26.\n He was given an unclear amount of diuretics as well as an attempt at\n Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions\n Altered mental status (not Delirium)\n Assessment:\n Pt has continued to be restless, agitated, moving constantly in bed\n Oriented to self, hospital and occasionally month\n Action:\n Head CT done to help r/o septic emboli (pt unable to stay still enough\n to do MRI)\n Pt frequently reoriented.\n Safety measures in place\n Response:\n Continues to be agitated, restless\n Plan:\n Monitor, maintain safety measures\n Bacteremia\n Assessment:\n Remains afebrile,\n Continues on Nafcillin q4 hr\n R elbow red, warm and tender to touch\n Pinpoint red spots on hands and feet, ? septic emboli\n Dopamine d/c d/t episode of tachycardia to 145, changed to neo .5-1.5\n mcg/kg/min to maintain sbp > 100\n Action:\n TEE done\n Ortho consulted for elbow\n Response:\n TEE showed small vegetation on aortic valve, no abcess, valve\n functioning well\n Elbow felt to be bursitis\n Plan:\n Continue abx\n Pt to be evaluated for PICC line\n PLT 29, wbc 2.9, pt has multiple ecchymotic areas on torso and limbs,\n hematology consulted\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724675,
"text": "TITLE:\n Chief Complaint: Endocarditis\n 24 Hour Events:\n TEE performed today, showed small vegetation on aortic valve.\n - ortho consulted concerning red right elbow, they stated unlikely to\n be septic joint, would not tap.\n - consulted renal - for hematuria, low complement, ; unclear\n etiology at this time, recommended sending ANCA/, getting renal\n ultrasound with doplers.\n - consulted CT - no surgical intervention indicated at this time,\n (nurse practitioner).\n - consulted heme/onc - unclear etiology for leukopenia,\n thrombocytopenia - consider SLE, MDS, marrow suppression in setting of\n sepsis. Most likely is sepsis. Can start G-CSF if leukopenia becomes\n <500. Recommend ultrasound of liver/spleen for septic emboli.\n -CT head - Small hyperdensity at the left frontal lobe which may\n reflect an occult vascular malformation. A focus of infarction is\n unlikely.\n -given 500cc NS - patient has been hypotensive and elevation of\n creatinine, likely over-diuresed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:00 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:50 AM\n Fentanyl - 11:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.6\nC (99.6\n HR: 93 (74 - 145) bpm\n BP: 88/47(55) {70/38(46) - 125/71(85)} mmHg\n RR: 25 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 69 Inch\n Total In:\n 3,123 mL\n 354 mL\n PO:\n 1,980 mL\n TF:\n IVF:\n 1,143 mL\n 354 mL\n Blood products:\n Total out:\n 2,360 mL\n 351 mL\n Urine:\n 2,360 mL\n 351 mL\n NG:\n Stool:\n Drains:\n Balance:\n 763 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 42 K/uL\n 12.3 g/dL\n 107 mg/dL\n 2.7 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 67 mg/dL\n 110 mEq/L\n 144 mEq/L\n 36.5 %\n 10.2 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n Plt\n 43\n 41\n 29\n 42\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n TropT\n 0.20\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n Other labs: PT / PTT / INR:18.1/34.0/1.6, CK / CKMB /\n Troponin-T:277/6/0.20, ALT / AST:46/55, Alk Phos / T Bili:56/5.2,\n Differential-Neuts:82.5 %, Band:0.0 %, Lymph:6.6 %, Mono:10.5 %,\n Eos:0.4 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.2\n g/dL, LDH:415 IU/L, Ca++:7.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.2 mg/dL\n Imaging: CT head: Small hyperdensity at the left frontal lobe which may\n reflect an\n occult vascular malformation. A focus of infarction is unlikel. MRI is\n recommended for better characterization, if clinically indicated.\n TEE: Small mobile echodensity (0.5 x 0.3 cm) on the aortic\n bioprosthetic valve consistent with a small vegetation. No aortic\n regurgitation, paravalvular leak or parvalvar abcess seen.\n Microbiology: C-diff negative\n Blood cultures: NGTD.\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n # Bacteremia - The patient was found to have 4/4 bottles growing\n Staphylococcus aureus. Concern for endovascular source of infection\n given high grade bacteremia. No clear portal of entry as the patient\n denies recent procedures/dental work, no focal symptoms. Given his\n presentation with community acquired bacteremia with symptoms of \n day duration prior to presentation pt is at high risk for complicated\n bacteremia, including endocarditis. MSSA bacteremia speciation per new\n outside hospital records this morning.\n - Will switch to Nafcillin for better coverage of MSSA\n - TEE today given bioprosthetic aortic valve\n - If evidence of vegetation or new/worsening valvular dysfunction,\n consider addition of gentamicin/rifamplin for S. aureus prosthetic\n valve endocarditis\n - Will obtain surveillance blood cultures\n - Appreciate ID recs\n .\n # Hypotension - Presentation of hypotension in setting of bacteremia\n could be consistent with sepsis, however the patient has a mixed\n picture given PCWP of 32 and CVP 14-24. Also consider worsening aortic\n valvular function in the setting of endocarditis. Currently, the\n patient appears volume overloaded with elevated JVP. Per reports\n pressor requirements have decreased since beginning diuresis. Neo\n weaned off. Dopamine weaned off overnight but restarted. Patient\n pulled out PA catheter this AM.\n - Continue to taper dopamine\n - Continue lasix gtt\n - Treat bacteremia as above\n - TEE as above to evaluate EF/valvular dysfunction\n .\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above\n - continue lasix gtt\n - Plan for beta blocker and ACE-I once BP allows\n .\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - check HIV\n - F/U B12/folate\n - Trend INR\n - heme consult\n .\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n .\n # Elevated CK/Troponin - No prior ECG for comparison, no clear\n ischemia. Trop bump most likely occurred in the setting of hypotension\n secondary to infection. Likely demand in setting of hypotension. Not\n concerned for ACS.\n - Continue statin\n - Start BB and ACE-I as BP allows\n .\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved.\n - Hold sedating medications\n - Treat infection\n - repeat Head CT ; will likely need MRI in future when can tolerate to\n eval for septic emboli\n # Rheumatoid Arthritis\n - holding meds ; does not likely need further stress dose steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 724858,
"text": "Subjective\n Per discussion w/ son, patient w/ decreased po intake prior to\n admission. Also w/ weight loss, although unable to quantify amount\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 86.6 kg\n 90.2 kg ( 08:00 AM)\n Weight up w/ fluid boluses\n 29\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 123%\n 74 kg\n Son unsure\n Diagnosis: Endocarditis\n PMHx:\n CABG in with bioprosthetic AVR for aortic stenosis\n Gram Positive Cocci bacteremia\n Thrombocytopenia with baseline 50,000\n History of transbronchial biopsy with suggestion of bronchiolitis\n obliterans \n Hypertension\n Diabetes Mellitus\n Rheumatoid Arthritis\n Polymyalgia Rheumatica\n Food allergies and intolerances: soft shell crab\n Pertinent medications: Humalog sliding scale, abx, bowel meds,\n phenylephrine drip, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 04:38 AM\n Glucose Finger Stick\n 152\n 01:00 PM\n BUN\n 78 mg/dL\n 04:38 AM\n Creatinine\n 3.6 mg/dL\n 04:38 AM\n Sodium\n 141 mEq/L\n 04:38 AM\n Potassium\n 3.8 mEq/L\n 04:38 AM\n Chloride\n 109 mEq/L\n 04:38 AM\n TCO2\n 22 mEq/L\n 04:38 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 07:58 PM\n Albumin\n 2.2 g/dL\n 04:34 AM\n Calcium non-ionized\n 6.8 mg/dL\n 04:38 AM\n Corrected Ca\n 8.24\n calculated\n Phosphorus\n 4.1 mg/dL\n 04:38 AM\n Magnesium\n 2.9 mg/dL\n 04:38 AM\n ALT\n 30 IU/L\n 04:38 AM\n Alkaline Phosphate\n 50 IU/L\n 04:38 AM\n AST\n 39 IU/L\n 04:38 AM\n Total Bilirubin\n 5.1 mg/dL\n 04:38 AM\n WBC\n 4.5 K/uL\n 04:38 AM\n Hgb\n 11.2 g/dL\n 04:38 AM\n Hematocrit\n 32.9 %\n 04:38 AM\n Current diet order / nutrition support: Low NA, Heart Healthy/Diabetic\n w/ 1.2L Fluid restriction-Boost Glucose Control w/ meals\n GI: Abd: soft/nbs\n Assessment of Nutritional Status\n Patient at risk due to:\n Estimated Nutritional Needs\n Calories: 1850-2220 (BEE x or / 25-30 cal/kg)\n Protein: 74-96 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate as evidenced by weight loss\n Estimation of current intake: Inadequate\n Specifics:\n 75 year old male admitted w/ MSSA endocarditis- being treated w/ abx-\n complicated by ARF- renal following. Patient w/ decreased po intake\n both PTA and currently. Team added po supplements today and ordered\n calorie counts to better assess intake. If patient unable to meet more\n than 75% estimated nutrition needs, will need to consider supplemental\n nutrition support. Low corrected Ca.\n Medical Nutrition Therapy Plan - Recommend the Following\n Calorie Counts as ordered , , \n Encourage po's and supplements\n Glucose management as oyu are\n Please replete Ca\n Would start multivitamin daily\n Following #\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724845,
"text": "Pt with endocarditis Aortic valve veg, good valve fx by echo. Pt also\n has course complicated by Acute renal failure/septic shock and now\n renal feels kidney failure is complicated picture of nephritis and\n ATN/ARF from shock as well.\n Pt was given fluid today and yesterday in attempt to wean neo. BP is\n improved today and urine output has also improved he is putting out\n 50-80 cc per hour. Although creatinine has continued to rise we are\n checking lytes and renal fx next check tonight at 5 PM. He\n received 250 cc fluid bolus today x 2 and Bp responded to that goal are\n maps 60-65 and good urine output, keep team updated, they wil order\n fluid prn.\n Nutrition wise pt is to start calorie count tomorrow, he ate 50% of\n breakfast and\n for lunch plus team added Boost glucose\n control tid which PT loves. Pt was covered at noon for glucose 150,\n 2 units humalog.\n Neuro wise PT was OOB to chair all morning, sleeping when not eating\n lunch or otherwise stimulated attempting to get pt to stay awake so\n that he can sleep at night. Pt is more cooperative although like\n yesterday he removed his BP cuff every\n hour o more often, he also\n removes his Pneumoboots. Family does assist him as they want him to be\n comfortable, and I did explain to them the importance of Pneumoboots\n to prevent blood clots and that frequent BP checks are required. They\n understand.\n Pt is O x 2, he is more cooperative and although he wants to be\n left\n alone\n and not bothered, he does well with negotiation\n Time left alone and time for procedures .\n He has no adverse reaction to fluid, he is taking po fluids and IV,\n able to lay flat in Bed, is not cooperative with lung exam but\n appears clear and slightly diminished at bases , he is on room air,\n sats 98-100, denies SOB, and occasionally laying flat or prone in bed.\n He has a rash all over his back similar to yesterday, he has a diaper\n rash on his buttocks, he has a spot on his right thumb and on his\n right foot but ders states that it appears to be a heat rash blocking\n of swaet glands and recommended a steroid cream and frequent\n repositioning and a fan.\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724954,
"text": "Chief Complaint: 75y/o M with a PMH of CAD s/p CABG with AVR in \n and thrombocytopenia transferred to for management of MSSA\n bacteremia and acute on chronic systolic CHF\n 24 Hour Events:\n - Derm saw patient - thinks likely heat rash, dont want to do biopsy,\n recommend keeping back dry, clobetazole for rash\n - patient has wide pulse pressure - seems to be getting wider? ? AI -\n no evidence on imaging\n - phenylephrine weaned off today, after fluids\n - chest pain, hypotensive sbp 60s, felt warm, gave some fluids\n initially, sounded wet, gave IV lasix, morphine, phenylephrine back on\n at 2\n - CK 67, tropT elevate but difficult to assess in , follow CE,\n consider anticoagulation if positive, weigh risk with heparin\n STOOL CULTURE - At 07:55 PM\n stool for CDiff \n EKG - At 04:00 AM\n EKG - At 05:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:29 AM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:30 AM\n Furosemide (Lasix) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 109 (83 - 113) bpm\n BP: 91/53(62) {64/22(44) - 125/63(74)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 68 Inch\n Total In:\n 3,500 mL\n 552 mL\n PO:\n 1,860 mL\n 150 mL\n TF:\n IVF:\n 1,640 mL\n 402 mL\n Blood products:\n Total out:\n 1,627 mL\n 725 mL\n Urine:\n 1,627 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: diminished), (S2: diminished), (Murmur:\n holoSystolic II/VI)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffuse, bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 41 K/uL\n 11.3 g/dL\n 129 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 77 mg/dL\n 108 mEq/L\n 138 mEq/L\n 35.5 %\n 5.8 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n 04:04 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n 5.8\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n 35.5\n Plt\n 43\n 41\n 29\n 42\n 34\n 41\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n 3.5\n TropT\n 0.20\n 0.47\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n 129\n Other labs: PT / PTT / INR:18.6/38.8/1.7, CK / CKMB /\n Troponin-T:67/6/0.47, ALT / AST:29/48, Alk Phos / T Bili:59/4.5,\n Differential-Neuts:62.6 %, Band:0.0 %, Lymph:28.1 %, Mono:6.7 %,\n Eos:2.5 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.0\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR - bilateral pulmonary edema\n Microbiology: urine cx NGTD\n blood cx NGTD\n c.diff toxin negative\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of MSSA bacteremia\n and acute on chronic systolic CHF c/b hypotension\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus at OSH. Concern for endovascular source\n of infection given high grade bacteremia. No clear portal of entry as\n the patient denies recent procedures/dental work, no focal symptoms.\n Given his presentation with community acquired bacteremia with symptoms\n of day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve as witness on\n TEE.\n - On nafcillin given aortic vegetation (consider switching to vanc for\n AIN)\n - hold on gent due to renal function, hold on rifampin\n - continue surveillance blood cultures\n - Appreciate ID recs\n - consider further imaging to eval for AI - ? repeat TEE if worried (no\n new murmur, pulse pressure widening, EKG QRS prolongation)\n - appreciate CSurg recs\n # Hypotension - has a mixed picture. Seems to be some component of\n distributive and cardiac shock. Phenylephrine was weaned off after\n successful fluid challenege. However, overnight patient became\n hypotensive requiring phenylephrine. Appears fluid overloaded on exam.\n - consider PA catheter for further hemodynamic monitoring\n - continue to treat endocarditis as above\n - wean pressor as tolerated\n - TTE\n # Acute kidney injury - less likely pre-renal. Likely AIN but may have\n immune-mediated complexes as well.\n - appreciate renal recs\n - urine lytes\n - trend BUN/Cr\n - f/ , ANCA\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above. Required lasix last night for likely pulmonary\n edema.\n - consider PA catheter\n - lasix prn\n - plan for beta blocker, acei once bp allows\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP. Derm thinks likely heat\n rash. No need to biopsy.\n - keep back dry\n - cream for back\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - hold anticoagulation due to thrombocytopenia\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n # other\n - ionized calcium\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n hypotension, respiratory distress\n Physical Examination\n pulmonary edema\n Medical Decision Making\n intubation, cardioversion, diuresis, PA catheter\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 95 minutes of critical care time.\n Additional comments:\n intubation, pressor management, lines, shock, sepsis,...\n ------ Protected Section Addendum Entered By: , MD\n on: 11:47 ------\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724955,
"text": "Chief Complaint: 75y/o M with a PMH of CAD s/p CABG with AVR in \n and thrombocytopenia transferred to for management of MSSA\n bacteremia and acute on chronic systolic CHF\n 24 Hour Events:\n - Derm saw patient - thinks likely heat rash, dont want to do biopsy,\n recommend keeping back dry, clobetazole for rash\n - patient has wide pulse pressure - seems to be getting wider? ? AI -\n no evidence on imaging\n - phenylephrine weaned off today, after fluids\n - chest pain, hypotensive sbp 60s, felt warm, gave some fluids\n initially, sounded wet, gave IV lasix, morphine, phenylephrine back on\n at 2\n - CK 67, tropT elevate but difficult to assess in , follow CE,\n consider anticoagulation if positive, weigh risk with heparin\n STOOL CULTURE - At 07:55 PM\n stool for CDiff \n EKG - At 04:00 AM\n EKG - At 05:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:29 AM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:30 AM\n Furosemide (Lasix) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 109 (83 - 113) bpm\n BP: 91/53(62) {64/22(44) - 125/63(74)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 68 Inch\n Total In:\n 3,500 mL\n 552 mL\n PO:\n 1,860 mL\n 150 mL\n TF:\n IVF:\n 1,640 mL\n 402 mL\n Blood products:\n Total out:\n 1,627 mL\n 725 mL\n Urine:\n 1,627 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: diminished), (S2: diminished), (Murmur:\n holoSystolic II/VI)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffuse, bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 41 K/uL\n 11.3 g/dL\n 129 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 77 mg/dL\n 108 mEq/L\n 138 mEq/L\n 35.5 %\n 5.8 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n 04:04 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n 5.8\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n 35.5\n Plt\n 43\n 41\n 29\n 42\n 34\n 41\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n 3.5\n TropT\n 0.20\n 0.47\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n 129\n Other labs: PT / PTT / INR:18.6/38.8/1.7, CK / CKMB /\n Troponin-T:67/6/0.47, ALT / AST:29/48, Alk Phos / T Bili:59/4.5,\n Differential-Neuts:62.6 %, Band:0.0 %, Lymph:28.1 %, Mono:6.7 %,\n Eos:2.5 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.0\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR - bilateral pulmonary edema\n Microbiology: urine cx NGTD\n blood cx NGTD\n c.diff toxin negative\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of MSSA bacteremia\n and acute on chronic systolic CHF c/b hypotension\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus at OSH. Concern for endovascular source\n of infection given high grade bacteremia. No clear portal of entry as\n the patient denies recent procedures/dental work, no focal symptoms.\n Given his presentation with community acquired bacteremia with symptoms\n of day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve as witness on\n TEE.\n - On nafcillin given aortic vegetation (consider switching to vanc for\n AIN)\n - hold on gent due to renal function, hold on rifampin\n - continue surveillance blood cultures\n - Appreciate ID recs\n - consider further imaging to eval for AI - ? repeat TEE if worried (no\n new murmur, pulse pressure widening, EKG QRS prolongation)\n - appreciate CSurg recs\n # Hypotension - has a mixed picture. Seems to be some component of\n distributive and cardiac shock. Phenylephrine was weaned off after\n successful fluid challenege. However, overnight patient became\n hypotensive requiring phenylephrine. Appears fluid overloaded on exam.\n - consider PA catheter for further hemodynamic monitoring\n - continue to treat endocarditis as above\n - wean pressor as tolerated\n - TTE\n # Acute kidney injury - less likely pre-renal. Likely AIN but may have\n immune-mediated complexes as well.\n - appreciate renal recs\n - urine lytes\n - trend BUN/Cr\n - f/ , ANCA\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above. Required lasix last night for likely pulmonary\n edema.\n - consider PA catheter\n - lasix prn\n - plan for beta blocker, acei once bp allows\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP. Derm thinks likely heat\n rash. No need to biopsy.\n - keep back dry\n - cream for back\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - hold anticoagulation due to thrombocytopenia\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n # other\n - ionized calcium\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n hypotension, respiratory distress\n Physical Examination\n pulmonary edema\n Medical Decision Making\n intubation, cardioversion, diuresis, PA catheter\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 95 minutes of critical care time.\n Additional comments:\n intubation, pressor management, lines, shock, sepsis,...\n ------ Protected Section Addendum Entered By: , MD\n on: 11:47 ------\n A line placed without complications, IJ line placed without\n complications, PA catheter floated without complication\n ------ Protected Section Addendum Entered By: , MD\n on: 11:48 ------\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724748,
"text": "Pt here with endocarditis, on nafacillian, Afebrile today. Pt has some\n baseline dementia, and has been confused since he has been in the\n hospital. He is to get an MRI tomorrow to rule out any septic emboli.\n Altered mental status (not Delirium)\n Assessment:\n Pt was disoriebnted and trying to get OOB frequently last night. Today\n pt sleeping most of the day\n But awake for meals and turning. Pt insisted we remove his o2 sat probe\n and refuses to wea it, he has removed his BP cuff and requested\n Pneumoboots off, but explained to family and pt importance of Pneumo\n boots and we are monitoring his BP frequently.\n Action:\n Discussed with team plan to calm pt at night and ensure sleep cycle at\n night and awake in days.\n Response:\n Team ordered Zyprexia and HS so pt can get his dose at SIX PM, then\n again at HS if he does not respond\n To that. Gave dose at six pm after pm meal\n Plan:\n Zyprexia as ordered and per plan.\n Bacteremia\n Assessment:\n Pt has positive BC from OSH and veg on aortic valve, no signs of septic\n emboli finger toes, good perfusion.\n Pt does have pettichiae on his back . No temp this shift. Continues on\n neo 1MCG/KG. Pt removed his o2 sat probe and his o2, however his sat\n remains 97-100 on room air. Spot check q hour as pt refusesd to wear\n the probe.\n Action:\n pt received fluid bolus in AM and BP was SBP90-100 all day , attempted\n to wean neo later, good urine output.\n Response:\n weaned Neo down by 50 percent BP dropped team ordered fluid challenge.\n Given at 1815\n BP 91/38 ( map 53 ) Similar to where he has been on the\n neo today.\n Plan:\n monitor, wean neo as tolerated, monitor I/o PM lytes sent at five pm.\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724935,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated . A\n Swan-ganz catheter was placed and he was found to have a wedge of 26.\n He was given an unclear amount of diuretics as well as an attempt at\n Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724936,
"text": "Pt with endocarditis Aortic valve veg, good valve fx by echo. Pt also\n has course complicated by Acute renal failure/septic shock and now\n renal feels kidney failure is complicated picture of nephritis and\n ATN/ARF from shock as well.\n Pt was given fluid today and yesterday in attempt to wean neo. BP is\n improved today and urine output has also improved he is putting out\n 50-80 cc per hour. Although creatinine has continued to rise we are\n checking lytes and renal fx next check tonight at 5 PM. He\n received 250 cc fluid bolus today x 2 and Bp responded to that goal are\n maps 60-65 and good urine output, keep team updated, they wil order\n fluid prn.\n Nutrition wise pt is to start calorie count tomorrow, he ate 50% of\n breakfast and\n for lunch plus team added Boost glucose\n control tid which PT loves. Pt was covered at noon for glucose 150,\n 2 units humalog.\n Neuro wise PT was OOB to chair all morning, sleeping when not eating\n lunch or otherwise stimulated attempting to get pt to stay awake so\n that he can sleep at night. Pt is more cooperative although like\n yesterday he removed his BP cuff every\n hour o more often, he also\n removes his Pneumoboots. Family does assist him as they want him to be\n comfortable, and I did explain to them the importance of Pneumoboots\n to prevent blood clots and that frequent BP checks are required. They\n understand.\n Pt is O x 2, he is more cooperative and although he wants to be\n left\n alone\n and not bothered, he does well with negotiation\n Time left alone and time for procedures .\n He has no adverse reaction to fluid, he is taking po fluids and IV,\n able to lay flat in Bed, is not cooperative with lung exam but\n appears clear and slightly diminished at bases , he is on room air,\n sats 98-100, denies SOB, and occasionally laying flat or prone in bed.\n He has a rash all over his back similar to yesterday, he has a diaper\n rash on his buttocks, he has a spot on his right thumb and on his\n right foot but ders states that it appears to be a heat rash blocking\n of swaet glands and recommended a steroid cream and frequent\n repositioning and a fan.\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724939,
"text": "Chief Complaint: 75y/o M with a PMH of CAD s/p CABG with AVR in \n and thrombocytopenia transferred to for management of MSSA\n bacteremia and acute on chronic systolic CHF\n 24 Hour Events:\n - Derm saw patient - thinks likely heat rash, dont want to do biopsy,\n recommend keeping back dry, clobetazole for rash\n - patient has wide pulse pressure - seems to be getting wider? ? AI -\n no evidence on imaging\n - phenylephrine weaned off today, after fluids\n - chest pain, hypotensive sbp 60s, felt warm, gave some fluids\n initially, sounded wet, gave IV lasix, morphine, phenylephrine back on\n at 2\n - CK 67, tropT elevate but difficult to assess in , follow CE,\n consider anticoagulation if positive, weigh risk with heparin\n STOOL CULTURE - At 07:55 PM\n stool for CDiff \n EKG - At 04:00 AM\n EKG - At 05:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:29 AM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:30 AM\n Furosemide (Lasix) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 109 (83 - 113) bpm\n BP: 91/53(62) {64/22(44) - 125/63(74)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 68 Inch\n Total In:\n 3,500 mL\n 552 mL\n PO:\n 1,860 mL\n 150 mL\n TF:\n IVF:\n 1,640 mL\n 402 mL\n Blood products:\n Total out:\n 1,627 mL\n 725 mL\n Urine:\n 1,627 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: diminished), (S2: diminished), (Murmur:\n holoSystolic II/VI)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffuse, bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 41 K/uL\n 11.3 g/dL\n 129 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 77 mg/dL\n 108 mEq/L\n 138 mEq/L\n 35.5 %\n 5.8 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n 04:04 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n 5.8\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n 35.5\n Plt\n 43\n 41\n 29\n 42\n 34\n 41\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n 3.5\n TropT\n 0.20\n 0.47\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n 129\n Other labs: PT / PTT / INR:18.6/38.8/1.7, CK / CKMB /\n Troponin-T:67/6/0.47, ALT / AST:29/48, Alk Phos / T Bili:59/4.5,\n Differential-Neuts:62.6 %, Band:0.0 %, Lymph:28.1 %, Mono:6.7 %,\n Eos:2.5 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.0\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR - bilateral pulmonary edema\n Microbiology: urine cx NGTD\n blood cx NGTD\n c.diff toxin negative\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of MSSA bacteremia\n and acute on chronic systolic CHF c/b hypotension\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus at OSH. Concern for endovascular source\n of infection given high grade bacteremia. No clear portal of entry as\n the patient denies recent procedures/dental work, no focal symptoms.\n Given his presentation with community acquired bacteremia with symptoms\n of day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve as witness on\n TEE.\n - On nafcillin given aortic vegetation (consider switching to vanc for\n AIN)\n - hold on gent due to renal function, hold on rifampin\n - continue surveillance blood cultures\n - Appreciate ID recs\n - consider further imaging to eval for AI - ? repeat TEE if worried (no\n new murmur, pulse pressure widening, EKG QRS prolongation)\n - appreciate CSurg recs\n # Hypotension - has a mixed picture. Seems to be some component of\n distributive and cardiac shock. Phenylephrine was weaned off after\n successful fluid challenege. However, overnight patient became\n hypotensive requiring phenylephrine. Appears fluid overloaded on exam.\n - consider PA catheter for further hemodynamic monitoring\n - continue to treat endocarditis as above\n - wean pressor as tolerated\n - TTE\n # Acute kidney injury - less likely pre-renal. Likely AIN but may have\n immune-mediated complexes as well.\n - appreciate renal recs\n - urine lytes\n - trend BUN/Cr\n - f/ , ANCA\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above. Required lasix last night for likely pulmonary\n edema.\n - consider PA catheter\n - lasix prn\n - plan for beta blocker, acei once bp allows\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP. Derm thinks likely heat\n rash. No need to biopsy.\n - keep back dry\n - cream for back\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - hold anticoagulation due to thrombocytopenia\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n # other\n - ionized calcium\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724912,
"text": "spiked fever , All BCx neg x3. Cdiff neg x3 (.\n MSSA Bacteremia/ endocarditis\n Assessment:\n Stable BPs off Neo. Transient episodes Atach to 130s. ~04:00, c/o dull\n reproducible CP, worse upon inspiration\n hypotensive to\n 60s\nmentating. Tachypneic to 40s, labored\n Action:\n Supplemental 02 placed, EKG, STAT CXR, cardiac enzymes sent,\n 2mg morphine IVP, 40mg IV lasix\n Response:\n Pain free. CXR wet-- Diuresed 250cc in 1 hr. Afebrile, WBC 5.8\n (4.5). Cks flat. WOB improved.\n Plan:\n Continue Nafcillin Q4hrs\n Monitor WBC/fever curve\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr bump yesterday evening 3.2 (2.7). S/p fluid challenges. UOP\n 70-140cc/hr. Very dry mucous membranes, poor dentition\nc/o excessive\n thirst\n Action:\n UOP monitored\n Response:\n BUN/Cr stable 77/3.5 (78/3.6). lytes stable. Gd UOP. Pain w/\n urination, urine slightly pink/concentrated\n lido jelly applied w/\n effect\n Plan:\n Renal following\n Altered mental status (not Delirium)\n Assessment:\n Oriented x2-3, Pleasant and Cooperative at times then\n confused/belligerent at times. Unsure of place\n Action:\n Pt frequently reoriented.\n Safety measures in place\nPICC wrapped in kerlix and netting\n 5mg Zyprexa given at 02:00 for acute agitation.\n Response:\n Slept well until 02:00, turning self in bed independently. OOB to BSC\n x2 assist-weak. Talks in sleep. Very adamant about taking P-boot off\n despite freq reminders of importance from RN.\nI heard that a thousand\n times\n \n !\n Plan:\n Continue present management, safety measures, FALL RISK\n Alteration in Nutrition\n Assessment:\n Low albumin, S/b nutrition yesterday\n Action:\n Boost shakes TID w/ meals\n Response:\n Albumin 2.0 this Am (2.2)\n Plan:\n Start calorie count x3 days starting today\n Monitor FSBG QID\ntreat w/ HISS\n OTHER: CHRONIC THROMBOCYTOPENIA, PLT 41 (34)\n"
},
{
"category": "Physician ",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 724922,
"text": "Chief Complaint: 75y/o M with a PMH of CAD s/p CABG with AVR in \n and thrombocytopenia transferred to for management of MSSA\n bacteremia and acute on chronic systolic CHF\n 24 Hour Events:\n - Derm saw patient - thinks likely heat rash, dont want to do biopsy,\n recommend keeping back dry, clobetazole for rash\n - patient has wide pulse pressure - seems to be getting wider? ? AI -\n no evidence on imaging\n - phenylephrine weaned off today, after fluids\n - chest pain, hypotensive sbp 60s, felt warm, gave some fluids\n initially, sounded wet, gave IV lasix, morphine, phenylephrine back on\n at 2\n - CK 67, tropT elevate but difficult to assess in , follow CE,\n consider anticoagulation if positive, weigh risk with heparin\n STOOL CULTURE - At 07:55 PM\n stool for CDiff \n EKG - At 04:00 AM\n EKG - At 05:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 06:29 AM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:30 AM\n Furosemide (Lasix) - 05:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 109 (83 - 113) bpm\n BP: 91/53(62) {64/22(44) - 125/63(74)} mmHg\n RR: 23 (18 - 40) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 90.2 kg (admission): 86.6 kg\n Height: 68 Inch\n Total In:\n 3,500 mL\n 552 mL\n PO:\n 1,860 mL\n 150 mL\n TF:\n IVF:\n 1,640 mL\n 402 mL\n Blood products:\n Total out:\n 1,627 mL\n 725 mL\n Urine:\n 1,627 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,873 mL\n -173 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffuse, bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 41 K/uL\n 11.3 g/dL\n 129 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 77 mg/dL\n 108 mEq/L\n 138 mEq/L\n 35.5 %\n 5.8 K/uL\n [image002.jpg]\n 07:35 PM\n 07:58 PM\n 04:45 AM\n 05:09 AM\n 04:34 AM\n 04:21 PM\n 04:38 AM\n 04:04 AM\n WBC\n 7.7\n 3.5\n 2.9\n 10.2\n 4.5\n 5.8\n Hct\n 34.6\n 33.2\n 33.5\n 36.5\n 32.9\n 35.5\n Plt\n 43\n 41\n 29\n 42\n 34\n 41\n Cr\n 2.0\n 2.1\n 2.2\n 2.7\n 3.2\n 3.6\n 3.5\n TropT\n 0.20\n 0.47\n TCO2\n 21\n Glucose\n 156\n 127\n 130\n 107\n 295\n 116\n 129\n Other labs: PT / PTT / INR:18.6/38.8/1.7, CK / CKMB /\n Troponin-T:67/6/0.47, ALT / AST:29/48, Alk Phos / T Bili:59/4.5,\n Differential-Neuts:62.6 %, Band:0.0 %, Lymph:28.1 %, Mono:6.7 %,\n Eos:2.5 %, Fibrinogen:314 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:2.0\n g/dL, LDH:405 IU/L, Ca++:6.8 mg/dL, Mg++:3.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR - bilateral pulmonary edema\n Microbiology: urine cx NGTD\n blood cx NGTD\n c.diff toxin negative\n Assessment and Plan\n 75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of MSSA bacteremia\n and acute on chronic systolic CHF c/b hypotension\n # Bacteremia/ Endocarditis - The patient was found to have 4/4 bottles\n growing Staphylococcus aureus at OSH. Concern for endovascular source\n of infection given high grade bacteremia. No clear portal of entry as\n the patient denies recent procedures/dental work, no focal symptoms.\n Given his presentation with community acquired bacteremia with symptoms\n of day duration prior to presentation pt is at high risk for\n complicated bacteremia, including endocarditis. MSSA bacteremia\n speciation. + vegetation on bioprosthetic aortic valve as witness on\n TEE.\n - On nafcillin given aortic vegetation (consider switching to vanc for\n AIN)\n - hold on gent due to renal function, hold on rifampin\n - continue surveillance blood cultures\n - Appreciate ID recs\n - consider further imaging to eval for AI - ? repeat TEE if worried (no\n new murmur, pulse pressure widening, EKG QRS prolongation)\n - appreciate CSurg recs\n # Hypotension - has a mixed picture. Seems to be some component of\n distributive and cardiac shock. Phenylephrine was weaned off after\n successful fluid challenege. However, overnight patient became\n hypotensive requiring phenylephrine. Appears fluid overloaded on exam.\n - consider PA catheter for further hemodynamic monitoring\n - continue to treat endocarditis as above\n - wean pressor as tolerated\n # Acute kidney injury - less likely pre-renal. Likely AIN but may have\n immune-mediated complexes as well.\n - appreciate renal recs\n - urine lytes\n - trend BUN/Cr\n - f/ , ANCA\n # Acute on Chronic Systolic CHF - Pt currently with evidence of volume\n overload as above. Required lasix last night for likely pulmonary\n edema.\n - consider PA catheter\n - lasix prn\n - plan for beta blocker, acei once bp allows\n # Rash- appears to be petechiae, increasing on back, unknown\n etiology. Consider vasculitis vs chronic ITP. Derm thinks likely heat\n rash. No need to biopsy.\n - keep back dry\n - cream for back\n #Hyperbilirubinemia\n RUQ ultrasound did not show evidence of septic\n emboli. Fractionated Bili shows increased Direct. Stable from\n yesterday.\n - continue to monitor\n # Thrombocytopenia - Per OSH reports the patient has a chronic\n thrombocytopenia of unclear etiology. Pt reports history of easy\n bleeding & bruising. DDx is broad and includes ITP, myelodysplastic\n syndrome, drug induced - ex. hydroxychloroquin, unclear when this was\n started, infection with HIV or HCV, nutritional deficiency\n (B12/Folate), EtOH toxicity however no clear history of this. DIC less\n concerning given long history of thrombocytopenia and fibrinogen\n normal. HIT also unlikely given documented long history of\n thrombocytopenia. LFTs and LDH elevated. Peripheral smear showed no\n schistocytes.\n - appreciate heme recs\n # Atrial Fibrillation/Atrial Flutter - the pt reports a history of AF\n however no documented history of this, pt not on anticoagulation.\n Currently ECG shows A. flutter in the setting of pressors. Currently\n Rate controlled.\n - Monitor on telemetry\n - hold anticoagulation due to thrombocytopenia\n # Encephalopathy - Most likely toxic/metabolic in the setting of\n infection. Per report OSH Head CT negative for acute process. Pt also\n had been treated with sedatives at OSH ativan/precedex . Continues to\n be encephalopathic, though appears mildly improved. Getting olanzapine\n here for agitation\n - Hold sedating medications\n - Treat infection\n - MRI in future when can tolerate to eval for septic emboli\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724923,
"text": "75y/o M with a PMH of CAD s/p CABG with AVR in and\n thrombocytopenia transferred to for management of S. aureus\n bacteremia and acute on chronic systolic CHF\n found at home unresponsive by daughter who went to check on him\n when he didn\nt answer the phone. He lives independently alone. He was\n tachycardic and had fever. At OSH ED, BP was 85/40\ns, TM 102. tx\n with IVF boluses , then levo and dopamine. BC (+) staph. And he\n was started on vanco/zosyn. He was confused and at times agitated . A\n Swan-ganz catheter was placed and he was found to have a wedge of 26.\n He was given an unclear amount of diuretics as well as an attempt at\n Bipap.\n Arrived to CCU 1900, lethargic but arousable and responding to\n questions\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "ECG",
"chartdate": "2168-01-07 00:00:00.000",
"description": "Report",
"row_id": 231035,
"text": "Atrial fibrillation. Intraventricular conduction delay with left axis\ndeviation may be left anterior fascicular block. Consider prior inferior\nmyocardial infarction, although it is non-diagnostic. Left ventricular\nhypertrophy. Delayed R wave progression may be due to intraventricular\nconduction delay, left ventricular hypertrophy or possible prior anterior\nmyocardial infarction. ST-T wave abnormalities are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of atrial flutter\nmay have been replaced by atrial fibrillation.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 231030,
"text": "Irregular rhythm of uncertain mechanism but may be multifocal atrial\ntachycardia. Left bundle-branch block. Since the previous tracing of same date\nmultiple atrial waveform morphologies are now present and ventricular response\nis irregular.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 231031,
"text": "Regular tachy-arrhythmia of uncertain mechanism but may be atrial flutter or\natrial tachycardia. Left bundle-branch block. Since the previous tracing of\nsame date atrial waveforms and mechanism are more difficult to assess but\nventricular rate is the same.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 231032,
"text": "Atrial flutter with rapid ventricular response and ventricular premature beat.\nLeft bundle-branch block. Since the previous tracing of further\nintraventricular conduction delay and ST-T wave changes are now present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-10 00:00:00.000",
"description": "Report",
"row_id": 231033,
"text": "Atrial flutter with rapid ventricular response. Intraventricular conduction\ndelay with left axis deviation may be due to left anterior fascicular block.\nLeft ventricular hypertrophy. ST-T wave abnormalities may be due to\nintraventricular conduction delay, left ventricular hypertrophy or possible\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing of the ventricular rate is slower.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-08 00:00:00.000",
"description": "Report",
"row_id": 231034,
"text": "Wide QRS tachycardia. Left bundle-branch block morphology. Compared to the\nprevious tracing of the rate and rhythm have changed.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-06 00:00:00.000",
"description": "Report",
"row_id": 231236,
"text": "Atrial flutter. Intraventricular conduction delay with left axis deviation may\nbe left anterior fascicular block. Consider prior inferior myocardial\ninfarction, although it is non-diagnostic. Left ventricular hypertrophy.\nDelayed R wave progression may be due to intraventricular conduction delay\nand/or left ventricular hypertrophy or possible prior anterior myocardial\ninfarction, although it is non-diagnostic. ST-T wave abnormalities are\nnon-specific. Clinical correlation is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1122525,
"text": " 12:53 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate ETT and line placement. Also evaluate for new infi\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p intubation and Rt IJ line placement with new leukocytosis\n and worsening hypotension.\n REASON FOR THIS EXAMINATION:\n Evaluate ETT and line placement. Also evaluate for new infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man status post intubation, right IJ line placement\n with new leukocytosis. Evaluate ET tube and line placement.\n\n COMPARISON: Chest radiograph from at 5:00 a.m.\n\n SINGLE FRONTAL PORTABLE CHEST RADIOGRAPH:\n\n A right-sided Swan-Ganz catheter is seen terminating in the right ventricular\n outflow tract. An ET tube terminates 8 cm above the carina . Both these\n lines can be advanced. A gastric tube is seen ending below the diaphragm.\n The bilateral lung parenchyma shows worsening pulmonary edema. Cardiac\n silhouette is unremarkable. Sternal wires are in appropriate position.\n\n IMPRESSION:\n\n 1. Swan-Ganz catheter terminating in the right ventricular outflow tract and\n ET tube ending 8 cm above the carina can both be advanced for optimal\n positioning.\n\n 2. Worsening pulmonary edema.\n\n These findings were communicated to MD at the time of\n dictation via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1122288,
"text": " 9:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of 47cm lue basilic picc; call w/\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with new left picc\n REASON FOR THIS EXAMINATION:\n pls assess tip of 47cm lue basilic picc; call w/ wet read thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Line placement.\n\n One portable view. Comparison with . There may be slight interval\n improvement in bilateral interstitial pulmonary infiltrates. The heart and\n mediastinal structures are unchanged. The patient is status post median\n sternotomy as before. A Swan-Ganz catheter has been removed. A PICC line has\n been inserted on the left and terminates in the lower superior vena cava.\n There is no other significant change.\n\n IMPRESSION: Interval improvement in bilateral pulmonary infiltrates that may\n represent edema. Line placement as described.\n\n Result called to , the IV nurse at 10:30 a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122452,
"text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pulm edema\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with endocarditis\n REASON FOR THIS EXAMINATION:\n please evaluate for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Endocarditis, evaluation for pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the severity of the\n pre-existing pulmonary edema is unchanged. Also unchanged is the size of the\n cardiac silhouette and the position of the left PICC line. No interval\n appearance of pleural effusions. No interval appearance of focal parenchymal\n opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1122182,
"text": " 1:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? any evidence of emboli with hemorrhagic conversion.\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with infective endocarditis\n REASON FOR THIS EXAMINATION:\n ? any evidence of emboli with hemorrhagic conversion.\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine elevated.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infective endocarditis, any evidence for emboli with hemorrhagic\n conversion.\n\n COMPARISON: No prior for comparison.\n\n TECHNIQUE: MDCT with contiguous axial images through the head were obtained\n without IV contrast.\n\n There is a small hyperdensity focus at the deep white matter of the left\n frontal lobe, adjacent to the anterior of the lateral ventricle. It is\n unlikely that this represents a hemorrhagic infarction. It may be a small\n occult vascular malformation.\n\n There is no other hyperdensity concerning for intracranial hemorrhage, major\n vascular territorial infarction, mass effect or shift of normally midline\n structures. The ventricles and sulci are prominent in size and configuration,\n compatible with global parenchymal atrophy age-related. The visualized\n paranasal sinuses and mastoid air cells are clear and well aerated.\n\n IMPRESSION: Small hyperdensity at the left frontal lobe which may reflect an\n occult vascular malformation. A focus of infarction is unlikel. MRI is\n recommended for better characterization, if clinically indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1121918,
"text": " 8:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of Swan\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with endocarditis transferred from OSH w Swan-Ganz catheter in\n place\n REASON FOR THIS EXAMINATION:\n placement of Swan\n ______________________________________________________________________________\n WET READ: SHfd WED 11:18 PM\n Slightly rotated. Swan-ganz tip is likely somewhat too distal and\n repositioning is suggested. A repeat radiograph may be helpful. Mild Pulm vasc\n congestion. Cardiomegaly. d/w ccu resident.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of Swan-Ganz placement. The patient\n transferred from outside hospital.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The Swan-Ganz catheter inserted through the right internal jugular approach\n terminates in the right interlobar or right lower lobe pulmonary artery and\n should be repositioned. Cardiomediastinal silhouette is grossly unremarkable\n except for cardiomegaly, mild. Post-sternotomy wires due to prior CABG are\n noted.\n\n The lung volumes are low. There is significant interstitial prominence and\n perihilar vascular engorgement, findings that might be consistent with volume\n overload. The reticulonodular pattern in the lower lobes may be part of the\n pulmonary edema, but infectious process or underlying chronic interstitial\n disease cannot be excluded. Re-imaging after diuresis is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-09 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1122296,
"text": " 11:12 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: PLease assess for evidence of septic embolic to liver/spleen\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with MSSA aortic valve endocarditis, with ARF and rising\n bilirubin\n REASON FOR THIS EXAMINATION:\n PLease assess for evidence of septic embolic to liver/spleen/kidney, please\n assess for evidence of renal dysfunction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SAT 3:26 PM\n No evidence of wedge-shaped lesions in the liver, spleen, or kidneys that\n would suggest emboli. Limited evaluation of the renal vasculature due to\n patient difficulty cooperating with the exam. Doppler signal in the main\n renal arteries bilaterally is normal. Small left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with endocarditis, acute renal failure and\n elevated bilirubin. Evaluate for septic emboli.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: The liver is normal in echotexture. In the central\n right lobe near the porta hepatis, a 1.6 x 2 x 1.5 cm somewhat heterogeneous\n lesion, with peripherally increased echogenicity. However, this does not have\n the appearance of an abscess, fluid collection, or infarct. Flow in the main\n portal vein is hepatopetal. There is no ascites. There is no intra- or\n extra-hepatic biliary ductal dilatation.\n\n The gallbladder contains non-vascularized heterogeneous material consistent\n with sludge. There is no evidence of acute cholecystitis. The common duct\n measures 5 mm.\n\n The right kidney measures 11.5 cm and the left kidney measures 11.4 cm. Both\n are normal without hydronephrosis, stones, or masses. At the interpolar\n region, the left kidney contains a 1 cm simple cyst. The pancreatic head and\n body are unremarkable. The aorta is normal in caliber. The spleen size is\n top normal, measuring 13.4 cm.\n\n RENAL DOPPLER ULTRASOUND: The patient had difficulty cooperating with the\n examination. However, the left and right main renal vein and arteries\n demonstrate normal flow and waveforms. Renal arteries demonstrate sharp\n upstroke and forward flow in diastole. The more distal vessels could not be\n assessed.\n\n Incidentally noted is a small left pleural effusion.\n\n IMPRESSION:\n 1. No suspicious lesions in the liver, spleen, or kidney to suggest infarct\n or emboli.\n (Over)\n\n 11:12 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: PLease assess for evidence of septic embolic to liver/spleen\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Main renal arteries and veins patent with normal waveforms. More\n peripheral vessels could not be evaluated due to patient difficulty\n cooperating with the exam.\n 3. Solitary liver heterogeneity, 1.5 cm, near the porta hepatis, could\n represent atypical hemangioma but is non-specific. Multiphasic CT or MRI,\n preferably MR if the patient can cooperate with breathing maneuvers, is\n recommended for further evaluation.\n 4. Gallbladder sludge without evidence for acute cholecystitis.\n 5. Small left pleural effusion.\n 6. No ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-09 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1122297,
"text": ", V. 11:12 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: PLease assess for evidence of septic embolic to liver/spleen\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with MSSA aortic valve endocarditis, with ARF and rising\n bilirubin\n REASON FOR THIS EXAMINATION:\n PLease assess for evidence of septic embolic to liver/spleen/kidney, please\n assess for evidence of renal dysfunction\n ______________________________________________________________________________\n PFI REPORT\n No evidence of wedge-shaped lesions in the liver, spleen, or kidneys that\n would suggest emboli. Limited evaluation of the renal vasculature due to\n patient difficulty cooperating with the exam. Doppler signal in the main\n renal arteries bilaterally is normal. Small left pleural effusion.\n\n"
}
] |
14,451 | 121,734 | Impression was for an 89 year old woman with a history of coronary artery disease, congestive heart failure and atrial fibrillation on anticoagulation now presenting with a two to three day history of cough, postnasal drip, increased fatigue, shortness of breath. Physical examination was significant for some diffuse wheezing plus right erythematous, edematous lower extremity. In terms of her shortness of breath, she had an interstitial pattern of pulmonary disease on chest x-ray but no overt evidence of pneumonia. The differential diagnosis includes an upper respiratory tract infection versus community acquired pneumonia versus pulmonary embolus versus Amiodarone toxicity versus radiation changes. In terms of possible pulmonary embolism phenomenon, the patient was anticoagulated. Despite that, lower extremity Dopplers were checked and they were both negative for deep vein thrombosis. In terms of her history of radiation exposure and Amiodarone toxicity, we checked a CAT scan of her lungs that showed some new upper zone ground glass opacities of unclear significance but thought possibly to be a superimposed viral infection on top of chronic changes that have previously existed in the lungs. In terms of a possible community acquired pneumonia, we started treating her with Levaquin 250 mg once daily for a ten day course which she tolerated well. We had an incentive spirometer to her bedside. We had the nursing staff perform chest physical therapy with her. Her oxygen saturation remained stable at 94 to 96% on two liters which is unclear, this may possibly be her baseline. In terms of the leg cellulitis, we initially started treating her with Ancef for a ten day course, however, we decided to discontinue the Ancef and just continue the treatment with Levaquin as Levaquin will cover some of the skin flora that may be causing the infection. In terms of her history of coronary artery disease, congestive heart failure, and atrial fibrillation, we continued her Verapamil, Amiodarone and Coumadin. She was also on Lasix 20 mg twice a day which she tolerated well. In terms of her hypothyroidism, we continued her Synthroid. On hospital day two, we had physical therapy staff evaluate the patient and they felt that she was below her baseline in terms of functional mobility and could benefit from a short stay in acute rehabilitation facility. On hospital day three, we had the patient perform a speech and swallow evaluation which showed no evidence of aspiration and normal swallowing physiologic function. | Mild tomoderate (+) mitral regurgitation is seen. Mild (1+) aortic regurgitation is seen. Mild to moderate (+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Mild tomoderate [+] tricuspid regurgitation is seen. There is moderate symmetric leftventricular hypertrophy with somewhat ventricular cavity and excellentsystolic function. Mild aortic regurgitation. There is mildmitral annular calcification. Mild (1+)aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Wean A/c rate as tolerated. Mild-moderatemitral regurgitation.Compared to the report of the prior study (tape reviewed) of , mildaortic regurgitation is now seen. Baseline artifact in lead V6Atrial fibrillation with rapid ventricular response.Right atrial deviationPoor R wave progression - is nonspecific and could be in part ? Mild to moderate (+) mitral regurgitation isseen. Atrial fibrillationRightward axis - is nonspecificDiffuse nonspecific ST-T wave abnormalitiesClinical correlation is suggestedSince previous tracing of , axis less rightward The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Mitral inflow and pulmonaryvein pattern is consistent with a combination of impaired relaxation andelevated left atrial pressure.There is moderate pulmonary artery systolic hypertension. Mild to moderate (+) mitralregurgitation is seen. Bs clear and decreased L base. There is nomitral valve prolapse. Atrial fibrillationLeft ventricular hypertrophy with ST-T wave changesModest nonspecific intraventricular conduction delayST-T abnormalities are diffuseClinical correlation is suggested for in part metabolic/drug effectSince previous tracing of , sinus rhythm absent DRSG D/I. There is moderate pulmonaryartery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: The patient is tachycardic (HR>100bpm).Conclusions:The left atrium is moderately dilated. Left ventricularhypertrophy with ST-T wave changes. Left ventricularhypertrophy with ST-T wave changes. There is an anteriorspace which most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.Compared with the findings of the prior report (tape unavailable for review)of , the estimated pulmonary artery systolic pressure is now lower andthe estimated left ventricular outflow gradient is lower. SERO-SANGUINOUS DRAINAGE NOTED. CXR done. ABLE TO TITRATE FI02 DOWN AND MAINTAIN ABG WNL. Abg's within normal limits. SEROSANGUINOUS DRAINAGE NOTED. Bs clear bilaterally and decreased L base. Suxn'd. PT TOLERATING WELL. TOLERATING WELL.CV: S1 AND S2 AS PER AUSCULTATION. Introducer remains and heparin and neo are infusing though it. CT DRSG AND . Remains in afib with hr low 90s t0 low hundreds. w/o ectopy. DOPPLER PULSES TO BILATERAL DORSALIS, PALPABLE PULSES TO BILATERAL RADIALS. HX OF CATARACT) LOW GRADE TEMP 100.7. RT PUPIL IS 3/BRISK, LEFT PUPIL IS IRREGULARLY SHAPED AND NON-REACTIVE- (? Resp. mae.resp- remains intubated on ac. PT NOTED TO BE IN A FIB WITH HR 90-100'S WITH OCASSIONAL PAC'S NOTED. Continue with Psv and wean as tolerated. CONTINUES ON NEO GTT. SECURE AND PATENT. PROPER PLCMT AS PER AUSCULTATION OF 30CC/AIR. REDRESSED LEFT RADIAL ALINE. Patient was pan cultured. T-max this shift 99.3. Rn Rn AFEBRILE. AFEBRILE. AFEBRILE. SEROSANGUINOUS DRAINAGE.CV: AFIB WITH NO SIGNS OF ECTOPY. pt became tachypneic when sedation was off, now on 1mg/h ativan srr is 4. suctioned for thick secretions.cv- hr afib 80-100 no ectopy noted. GENERALIZED PITTING EDEMA. PROPER PLCMT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. GOAL TO TITRATE NEO OFF. PT HAS BEEN TOLERATING WELL. PASSING FLATUS.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. ATTEMPT TO WEAN FROM VENT AND PRESSERS AS PT WILL TOLERATE. with itching.CV: HR 70's-80's afib. pt needed sedation though and was started on ativan gttat 0.5mg/h and 1mg/h. CONTINUE ON HEPARIN GTT.GI: OGT IS SECURE AND PATENT. Follow ABG's, cont vent support. Pt. Pt. CO=3.42, unable to wedge.Mixed venous sat=70, hgb 6.4. Goal was to have pt. LT RADIAL ALINE IS SECURE AND PATENT AS IS RT IJ CVL. PT NOTED TO HAVE GENERALIZED PITTING EDEMA. micu-b, npn:Neuro: Received pt. SPO2 > OR = TO 94%.CV: AFIB CONTINUES. Bld. Indicated that her R flank itched- no rash noted to site, assisted pt. CXRAY.RESP - PT. C-DIFF SPEC. C-DIFF. TEMP. REMAINS IN A-FIB (ON PROCAINAMIDE; HEP. OGT in place per auscultation. OGT in place per auscultation. ABG's prior to tacypnic episode normal range. Resp. Resp. Resp NOtecorrection abg slight resp. Sxn as needed. Sxn freq. FLAGYL ADDED TO ABX. T/O SHIFT FOR SCANT AMTS. STARTED ON PROPOFOL GTT. WITH DISTENDED ABD. WITH DISTENDED ABD. IN SIZE T/O SHIFT OR INC. Currently on Vasopressin 0.04u/min, and Neosynephrine 0.35mcg/kg/min. Tmax 100.0 po. S/P BRONCH . RECEIVED ON CPAP+PS. GIVEN MSO4 LAST @ 0400 2MG. EXTREM. RREGIME. CX. BS aerating t/o. CT to L to lung to low wall suxn. on 1mg/hr Ativan gtt. CONTINUES ON HEPARIN GTT FOR AFIB. ON HEP. A-line L radial wnl.Plan: Wean Neo as tolerated. State that pt. Dopa. AFEBRILE. AFEBRILE. SX. CONTINUES ON HEPARIN GTT. Pt. Pt. PT. PT. PT. PT. PT. PT. PT. PT. @ START OF SHIFT INDICATING WITH NON-VERBAL GESTURING THAT ABD. SPEC. PROPOFOL GTT. +VOMITUS AROUND ETT (OGT PLACED TO SX. See carevue for abgs. OGT in place and used for po meds. )Access: R scl TLC, wnl. IN NEO.GTT. WITH OGT IN PLACE; PATENT. arouses to voice and tactile stimulous on this dose. )Resp: Changed from A/C to PS. GTT. GTT. U/O wnl, yellow, clear.Endo: Now written for RISSAccess: A-line very positional. DIMIN., BASES. GIVEN X2 PRN MSO4 FOR ? Reshoot numbers. **A-line very positional (however NBP correlating.) Monitor tmax. GIRTH WITH APPARENT INC. MICU-B, NPN:Neuro: Received pt. LACTATE CONT. WITH COMPENSATED MET. w/o ectopy @ start of shift. Able reach up to ETT. RN CT in place, drng serosanguinous fluid, site wnl, no crepitsu noted.? Neo. INITIALLY WITH +BS, NOW HYPOACTIVE. 3.05, C.I. Peripheral pulses palpable. TACHYCARDIC T/O EVE. RR 3-10./PEEP 5. See CareVue for ABG'sand other objective data.NPO for OR. TACHYCARDIA DESPITE FLUID RESUSCITATION AND INC. BILATERAL CHEST EXPANION NOTED. Monitor PTT. CXR done results pending. 1.77, SVR 1258, Wedge 23. IN NEO. SUCTION. Bolus. CXRAY WITH DILATED LOOPS. SPIKE TO 101.6 @ 200 (PAN CX)LACTATE CONT. | 56 | [
{
"category": "Echo",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 101388,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nWeight (lb): 200\nBP (mm Hg): 110/90\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:03\nTest: Portable TTE (Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity is unusually . Regional left ventricular wall\nmotion is normal. Overall left ventricular systolic function is normal\n(LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is no systolic anterior motion of the mitral\nvalve leaflets. Mild to moderate (+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. There is moderate symmetric left\nventricular hypertrophy with somewhat ventricular cavity and excellent\nsystolic function. A left ventricular outflow tract gradient was not examined.\nRegional left ventricular wall motion is normal. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. There is no systolic\nanterior motion of the mitral valve leaflets. Mild to moderate (+) mitral\nregurgitation is seen. There is a prominent anterior space which most likely\nrepresents a fat pad.\n\nIMPRESSION: Prominent symmetric left ventricular hypertrophy with preserved\nbiventricular systolic function. Mild aortic regurgitation. Mild-moderate\nmitral regurgitation.\nCompared to the report of the prior study (tape reviewed) of , mild\naortic regurgitation is now seen. The prominent anterior fat pad is similar.\nThe previously noted LVOT gradient is likely still present, but was not\nexamined on the current study.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2164-12-26 00:00:00.000",
"description": "Report",
"row_id": 101389,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 63\nWeight (lb): 153\nBSA (m2): 1.73 m2\nBP (mm Hg): 122/62\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 09:58\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is severe symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild to moderate (+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild to\nmoderate [+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm).\n\nConclusions:\nThe left atrium is moderately dilated. There is severe symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). There is a moderate\nto severe resting left ventricular outflow tract obstruction. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] The\ntricuspid valve leaflets are mildly thickened. Mitral inflow and pulmonary\nvein pattern is consistent with a combination of impaired relaxation and\nelevated left atrial pressure.\n\nThere is moderate pulmonary artery systolic hypertension. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , the estimated pulmonary artery systolic pressure is now lower and\nthe estimated left ventricular outflow gradient is lower.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 304046,
"text": "Atrial fibrillation\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2165-01-07 00:00:00.000",
"description": "Report",
"row_id": 304047,
"text": "Atrial fibrillation with rapid ventricular response\nRightward axis - is nonspecific\nConsider biventricular hypertrophy\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , ventricular rate has increased and ST-T\nwave changes more prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2165-01-02 00:00:00.000",
"description": "Report",
"row_id": 304048,
"text": "Atrial fibrillation\nRightward axis - is nonspecific\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , axis less rightward\n\n"
},
{
"category": "ECG",
"chartdate": "2165-01-01 00:00:00.000",
"description": "Report",
"row_id": 304049,
"text": "Baseline artifact in lead V6\nAtrial fibrillation with rapid ventricular response.\nRight atrial deviation\nPoor R wave progression - is nonspecific and could be in part ? positional but\nconsider anteroseptal myocardial infarct, age indeterminate\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested for possible chronic pulmonary disease and/or\nright ventricular overload\nSince previous tracing of , right axis deviation and Poor R wave\nprogression seen and precordial QRS voltage less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2164-12-29 00:00:00.000",
"description": "Report",
"row_id": 304050,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy with ST-T wave changes. Compared to the previous tracing\nof atrial fibrillation has reappeared.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2164-12-28 00:00:00.000",
"description": "Report",
"row_id": 304051,
"text": "Sinus rhythm with A-V conduction delay and frequent atrial ectopy. Left\nventricular hypertrophy with ST-T wave changes. Compared to the previous\ntracing of sinus rhythm has appeared.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2164-12-28 00:00:00.000",
"description": "Report",
"row_id": 304052,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy with ST-T wave changes. Compared to the previous tracing\nof the ventricular response has increased and the ST-T wave\nabnormalities are more prominent. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2164-12-21 00:00:00.000",
"description": "Report",
"row_id": 300476,
"text": "Atrial fibrillation\nLeft ventricular hypertrophy with ST-T abnormalities\nConsider septal infarct\nSince previous tracing, R wave progression later may be lead position\n\n"
},
{
"category": "ECG",
"chartdate": "2164-12-19 00:00:00.000",
"description": "Report",
"row_id": 300477,
"text": "Atrial fibrillation\nLeft ventricular hypertrophy with ST-T wave changes\nModest nonspecific intraventricular conduction delay\nST-T abnormalities are diffuse\nClinical correlation is suggested for in part metabolic/drug effect\nSince previous tracing of , sinus rhythm absent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-12-30 00:00:00.000",
"description": "Report",
"row_id": 1450592,
"text": "CCU NPN: Please see flowsheet for objective\n\n89 yo woman transferred from CC7 with worsening resp status.\n\nCardiac: HR 90's afib,BP 93-100/40-50 no CP,on heparin at 1450u/hr. PTT sent at 1830\n\nResp: crackles at rt base,100% NRB,rr 30's,sats 93-95\n\nGU: foley in place\n\nGI: NPO except ice chips\n\nID:99.4 ax,had been on 10 day course of levoquin\n\nSkin: rt leg cellulitis, laceration on rt lower leg,skin very friable.\n\nNeuro: alert and orientedx3. lives independently. does volunteer work.\n\nA/P: will be intubated if needed,plan for bronch tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-12-31 00:00:00.000",
"description": "Report",
"row_id": 1450593,
"text": "CCU NPN 1900-0700\nS/O:\nID TM 101R-100.8R. no tylenol.\nCV: HR 90's Af in eve, down to 70-80's Afib through night after receiving lopressor and verapamil doses.\nBP 98-105/40-50. denies SOB/CP.\nremains on heparin at 1450u/hr. PTT 80.\n\nResp: LS crackles bilat. R>L. RR 23-25. occas. audible wheeze with exertion. pt. states her breathing is much better.\nremains on NRB with sats 95-97% when relaxed or at rest. down to 88-90% with exertion or when mask is off for taking meds, etc.\n\nGU: u/o 30-50cc/hr. given 20 lasix at 0300-> 250cc u/o x2hours. negative 1L for and currently neg. 400cc.\n\nGI: abd soft, NT. no stool. c/o hunger in eve. given jello and juice, Tol. well. NPO after MN\n\nskin: multiple bruises on arms, open area/skin tear on right elbow covered with non adherent dsd. right LE red from cellulites . c/o general itching rx with lotion to affected area.\nturned and repositioned side to side q2-4hours.\n\n\nneuro: pt. A/O x3. pt. verbalizes understanding of plan for bronch today and that she may need to be intubated for short time.\n\nA: pulm. process with increase FIO2 requirements- plan bronch today\nP: remain NPO. bronch today. follow PTT, lytes and HCT. potential for intubation with bronch.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-06 00:00:00.000",
"description": "Report",
"row_id": 1450620,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp. flowsheet. No changes in vent parameters this shift. Pt transported to CT scan of head and chest today. Sxn amount yellow. cont present support, assess Q AM for weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-06 00:00:00.000",
"description": "Report",
"row_id": 1450621,
"text": "micu npn 0700-1900\n\nreview of systems:\nneuro: remains without sedation, nod to yes/no question, moving upper extrem, no spontaneous movement of lower extrem, withdraw to painful stim. head ct done\n\ncv; SBP 70-120/, cont neo 0.8mcg/kg/min, HR 90-100 Af no VEA, cont IV lopressor for rate control. CVP 8-10, cont hep gtt at 1100u/h\n\nresp: remain sintubated with A/C 26/40%/400/5peep, breath sounds coarse upper decreased bases, left ant chest tube with serous drainage, sxn for sm to mod amts thick white secretions. chest CT done bilat infiltrates, right pleural effusion with atelectasis\n\ngi: abd soft +bs +flatus tube feeds probalance at 40cc/hr\n\ngu: foley \n\nid: tmax 100.2 rising WBC, pan cultured including nasal/rectal swabs\n\nskin: bilat upper extrem erythematous oozing large amts serous fluid, right lower leg red warm, left lower leg with skin tear covered with tegaderm oozing serous fluid\n\naccess: RIJ triple lumen, left rad aline\n\nsocial; no contact from today\n\nplan; pulm toilet, follow fever curve, follow cultures, wean neo if able\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450622,
"text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) through the night with no parameter changes made. ABG resukts are compatible with normalized acid-base status with good oxygenation on the current settings (see CareVue).\n\nRSBI = 115 with 0-PEEP and 0-PSV with ATC on 100%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450623,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT HAS NOT HAD ANYTHING FOR SEDATION HOWEVER, WAS GIVEN 2MG OF MORPHINE FOR GENERAL DISCOMFORT AND ANXIETY. PT STILL UNABLE TO OPEN EYES BUT IS ABLE TO OBEY COMMANDS AND NOD YES/NO QUESTIONS APPROPRIATELY. RT PUPIL IS IRREGULAR AND NR. LT PUPIL 3/BRISK. AFEBRILE. NO SEIZURE ACITIVITY NOTED. MAE X 4. AWAITING HEAD CT RESULTS.\n\nRR: INTUBATED. OETT IS SECURE AND PATENT. CURRENT VENT SETTINGS AC/25/400/40%/5. AM ABG WNL. PLEASE SEE CAREVUE AS NEEDED. BILATERAL CHEST EXPANSION. COARSE THROUGHOUT ALL LUNG FIELDS. NOTED TO BE MORE DIMINISHED TO THE BASES. INCREASED SECRETIONS NOTED- SUCTIONING FOR TO MODERATE AMOUNTS OF THICK, WHITE SECRETIONS. SP02 > OR = TO 95%. STRONG COUGH EFFORT. RSBI THIS AM 115. LT CHEST TUBE IS SECURE AND PATENT. DRSG D/I. DRAINING SEROUS LIQUID. NO CREPITUS NOTED. FUNCTIONING PROPERLY.\n\nCV: AFIB- HR 100-120'S. LOPRESSOR FOR RATE CONTROL. TENUOUS BLOOD PRESSURE- UNABLE TO COMPLETELY WEAN OFF NEO GTT. CONTINUES ON HEPARIN GTT FOR AFIB. PTT PENDING. VERY DIFFICULT TO PALPATE DORSALIS OR RADIAL PUSLES DUE TO GROSS PITTING EDEMA. DOPPLERABLE. DENIES ANY CHEST PAIN. PT IS VERY SENSITIVE TO NEO- WILL DROP HER PRESSURE TO THE 70'S IF NEO GTT IS DC'D FOR A SHORT PERIOD OF TIME. AWAITING LABS FOR THIS AM DUE TO INITIALLY HEMOLYZED SPECIMEN.\n\nGI: OGT IS SECURE AND PATENT. PLCMT CONFIRMED WITH AUSCULTATION OF 30CC/AIR. ABD IS OBESE, SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. BROWN BM THIS SHIFT. PASSING LARGE AMOUNTS OF FLATUS.\n\nGU: INDWELLING URETHRAL FOLEY CATHETER IS SECURE AND PATENT. ADEQUATE AMOUNTS OF CLEAR, YELLOW URINE NOTED.\n\nINTEG: PT HAS NO REDNESS OR SKIN BREAKDOWN TO BACK OR BUTTOCKS. PT HAS MULTIPLE WEEPING SKIN TEARS TO BILATERAL UPPER AND LOWER EXT. GROSSLY WEEPING SEROUS DRAINAGE.\n\nSOCIAL: SPOKE WITH NEPHEW ON THE PHONE. AWARE OF PT'S CONDITION. ANSWERED ALL QUESTIONS. NO ISSUES.\n\nPLAN: CONTINUE TO ATTEMPT TO WEAN OFF OF GTT IF ABLE. RESPIRATORY TOILETING. COMFORT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-05 00:00:00.000",
"description": "Report",
"row_id": 1450617,
"text": "MICU NPN 0700-1900\n\nreview of systems:\n\nNEURO: remains off all sedation, grimace, nod yes/no appropriately, +MAE,\nCV: extremely labile BP as low as 68 systolic, HR 110-120 AF, verapamil 5mg IV x1 BP to 60's, lopressor 2.5mg bp unchanged HR to 90-100 range, given second dose of 2.5mg lopressor, cont neo unable to wean to off as low as 0.2mcg/kg/min but labile Bp to 60-70 range with MAP in low 50's, neo titrated back up to 0.8mcg/kg/min. CVP 5 given 500cc NS bolus with no untoward effect/ no immediate hypotension.\n\nRESP: labile breathing rate to 30's, required freq suctioning for thin frothy secretions, vent changed to A/C 26/40%/400/5 peep. breath sounds crackles right base dimminshed left base, cxr with right upper lobe opacity, bilat effusions, left lower lobe collapse. LEft chest tube with 300cc serous fluid for this shift\n\nGI tube feeds probalance at 40cc/hr with min residuals, abd soft +bs no BM\n\nGU: foley with 30-40cc/hr uo\n\nSKIN anasarca, oozing large amounts serous fluid from bilat upper extrem and left lower leg\n\nID; T max 99.8 po wbc 16, 2% bands, cont ceftaz and vanco\nSocial nephew called for update plans to visit this eve\n\n\nPLAN: pulm toilet cpt/sxn, follow cvp goal 10, fluid boluses if need to achieve cvp goal, wean neo to off if able, follow mental status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-06 00:00:00.000",
"description": "Report",
"row_id": 1450618,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Vent settings unchanged. Vt 400, A/c 26, Fio2 40%, and Peep 5. Bs clear and decreased L base. Sx'd for sm amounts of thick white secretions. Increased secretions this shift. Adequate O2 sats. Will repeat RSBI this morning. Plan: Continue with mechanical support. Wean A/c rate as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-06 00:00:00.000",
"description": "Report",
"row_id": 1450619,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS CURRENTLY NOT ON ANY SEDATION. STILL UNABLE TO OPEN EYES BUT WILL ANSWER YES/NO QUESTIONS APPROPRIATELY AND OBEYS COMMANDS. ABLE TO MAE X 4. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY COARSE THROUGHOUT AND DIMINISHED TO BILATERAL LOWER BASES. NO VENT CHANGES MADE THIS SHIFT. PT NOTED TO HAVE INCREASED SECRETIONS THIS SHIFT. AGGRESSIVE PULMONARY TOILETING. BILATERAL CHEST EXPANION. LT CHEST TUBE IS SECURE AND PATENT AND FUNCTIONING. SPO2 > OR = TO 94%.\n\nCV: AFIB CONTINUES. RATE WILL GO UP TO THE 120'S, HOWEVER, IS MORE CONTROLLED SINCE INITIATION OF SCHEDULED LOPRESSOR. PT HAS BEEN TOLERATING WELL. UNABLE TO WEAN OFF OF NEO GTT DUE TO LABILE SBP- OCCASIONAL DROPS TO THE 70-80'S. RECEIVED 1 500 CC NS BOLUS WITH LITTLE EFFECT. CVP 6-8. LT RADIAL ALINE IS SECURE AND PATENT AS IS RT IJ CVL. CONTINUE ON HEPARIN GTT.\n\nGI: OGT IS SECURE AND PATENT. PROPER PLCMT AS VERIFIED WITH AUSCULTATION OF 30CC AIR. TF CONTINUE AT 40CC/HR. PT TOLERATING WELL. NO GASTRIC RESIDUALS. ABD IS SOFT, OBESE, NON-DISTENDED. BS X 4 QUADRANTS. NO BM THIS SHIFT.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: GENERALIZED ANASCARA. PITTING, WEEPING EDEMA. MULTIPLE SKIN TEARS. IMPROVED REDNESS TO COCCYX.\n\nSOCIAL: NO FAMILY CONTACT THIS SHIFT.\n\nPLAN: CONTINUE TO MONITOR NEURO/ RESPIRATORY STATUS. ATTEMPT TO WEAN FROM VENT AND PRESSERS AS PT WILL TOLERATE. PTT AT 1000. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-04 00:00:00.000",
"description": "Report",
"row_id": 1450610,
"text": "Respiratory Care:\nPatient remains on ventilatory support with no changes made through the night (see CareVue).\n\nRSBI = 117.4 on 0-PEEP, 0-PSV, and ATC on 100%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-04 00:00:00.000",
"description": "Report",
"row_id": 1450611,
"text": "NURSING ADDENDUM\nPT IS ON HEPARIN GTT FOR NEXT PTT IS DUE AT 1000. GTT DECREASED FROM 1200 TO 1050 FOR 0400 PTT LEVEL. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-04 00:00:00.000",
"description": "Report",
"row_id": 1450612,
"text": "MICU NPN 0700-1900\n\nREVIEW OF SYSTEMS:\nplease see carevue flow sheet for full details.\n\nNEURO: arouse to voice attempts to open eyes, facial grimace with verbal stim, nod head to yes/no questions, moving all extrem spontaneously upper greater than lower. No sedation.\n\nCV: neo titrate to effect curremtly 0.7mcg/kg/min, HR 80-105 AF no VEA\nBP 90-140's with same dose of neo, attempt wean neo\n\nRESP: am RSBI 117, breath sounds coarse suction for sm to mod amt thick white secretions, vent change to PSV 18 peep 5 fio2 40%\nSRR 18-22 STV 480-500, o2 sat >98%\n\nGI: OGT , tolerating tube feeds advanced to 30cc/hr, abd soft +BS + flatus no stool.\n\nGU: foley with UO 40-100cc/hr\n\nACCESS: cordis d/c, RIJ triple lumen placed, left rad aline \n\nSKIN: bilat upper extrem grossly edematous oozing large amts serous fluid, right foot cold this am, pulses doplerable bilat, legs equal temp as day progressed.\n\nSOCIAL: nephews called for update, no visitors\n\nPLAN: cont to follow mental status, wean and extubate when more awake, wean neo as able, maintain safety.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-05 00:00:00.000",
"description": "Report",
"row_id": 1450613,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT REMAINS WITHOUT SEDATION. WILL NOD YES/NO APPROPRIATELY TO QUESTIONS AND FOLLOWS COMMANDS. HOWEVER, PT DOES NOT OPEN EYES. MAE X 4. NOTED TO BE WEAKER TO BILATERAL LOWER EXT. AFEBRILE. RT IRREGULARLY SHAPED NR PUPIL, LT PUPIL IS 4/BRISK. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY CLEAR TO COARSE TO ALL LUNG FIELDS- DIMINISHED TO BILATERAL LOWER LOBES. OETT IS SECURE AND PATENT. BILATERAL CHEST EXPANSION NOTED. CURRENT VENT SETTINGS ARE CPAP/18PS/40%/5. TV 400-500. RR 20-27. DOES NOT APPEAR UNCOMFORTABLE, DENIES ANY SOB. RISBI THIS AM IS 81. SBT IN PROGRESS. SP02 > OR = TO 93%. LT CHEST TUBE IS SECURE AND PATENT. NO CREPITUS, NO LEAKAGE NOTED. SEROSANGUINOUS DRAINAGE.\n\nCV: AFIB WITH NO SIGNS OF ECTOPY. HR 90-110'S. DENIES ANY CHEST PAIN. S1 AND S2 AS PER AUSCULTATION. CONTINUES ON NEO- HAVE NOT BEEN SUCCESSFUL IN WEANING ATTEMPTS. WILL STILL HAVE TRANSIENT EPISODES OF DROPPING HER MAPS BELOW 60 AND HER SBP TO THE 70'S. DOPPLER PULSES TO BILATERAL DORSALIS, PALPABLE PULSES TO BILATERAL RADIALS. CONTINUES ON HEPARIN GTT- CURRENTLY AT 1050UNITS/HR. NEXT PTT IS DUE AT 1000.\n\nGI: OGT IS SECURE AND PATENT. PROPER PLCMT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. CONTINUES ON PROBALANCE AT 30CC/HR- NO GASTRIC RESIDUALS NOTED. BM THIS SHIFT- LIQUIDY, BROWN. PASSING FLATUS. ABD IS SOFT, NON-DISTENDED, NON-TENDER TO PALPATION. BS X 4 QUADRANTS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS. NO C/O DISCOMFORT FROM THE AREA.\n\nINTEG: PT HAS SEVERAL SKIN TEARS TO ALL EXT. GROSSLY WEEPING SEROUS FLUID. UPPER EXT ARE BRUISED. LOWER EXT ASHY IN APPEARANCE. GENERALIZED PITTING EDEMA. SOME REDNESS NOTED TO COCCYX. NO OTHER SIGNS OF BREAKDOWN NOTED.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS EVENING.\n\nPLAN: THOUGH RISBI IS FAVORABLE AND HAS IMPROVED SINCE YESTERDAY, PT STILL HAS NOT CLEARED NEUROLOGICAL STATUS. IS STILL DEPENDENT ON HER NEO GTT- NEED TO REEVALUATE EXTUBATION. PLEASE SEE FLOW SHEET AS NEEDED FOR INFORMATION AS NEEDED. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-05 00:00:00.000",
"description": "Report",
"row_id": 1450614,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 18, Cpap 5, Fio2 40%. Pt. tolerating Psv well since yesterday. Spont vols 500's with RR mid 20's. Abg's within normal limits. RSBI 83. Bs clear bilaterally and decreased L base. Sx'd for moderate amount of thick white sputum. No further changes made. Continue with Psv and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-05 00:00:00.000",
"description": "Report",
"row_id": 1450615,
"text": "ADDENDUM\n40MEQ OF K IV FOR 3.6 AM LEVEL. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-05 00:00:00.000",
"description": "Report",
"row_id": 1450616,
"text": "Resp. Care Note\nPt received intubated and vented on setting PSV 18 peep 5 and 40%.Pt more tachypneic this morning with RR 28-32 and sats down to lower 90's, also tachycardic to 120's. Pt changed back to AC but took several hours to settle. Currently vented on AC 400x 26x 40% peep 5. Sxn for white secretions. Follow ABG's, cont vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-02 00:00:00.000",
"description": "Report",
"row_id": 1450602,
"text": "Addendum to above:\n\n500cc bolus ns given 1900 after numbers run. CO=3.42, unable to wedge.\nMixed venous sat=70, hgb 6.4. Chest tube drainage=100cc serous fluid. No crepitus,no leak, dressings clean and dry. Second set of numbers to be run.\n Rn\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 1450603,
"text": "Respiratory Care:\nPatient remains on ventilatory support throughout the night. The only change was made early in the shift, and consisted of decreasing the FIO2 from 50% to 40%. ABG results after the change demonstrated nromal acid-base balance with good oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 1450604,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT SEDATED ON 2MG/HR OF ATIVAN. WILL RESPOND TO PAINFUL STIMULI. DOES NOT OPEN EYES SPONTANEOUSLY OR ON COMMAND. DOES NOT FOLLOW ANY COMMANDS. WILL HAVE EPISODES OF AGITATION WHERE SHE WILL ATTEMPT TO REACH FOR OETT- RESTRAINTS APPLIED FOR PATIENT SAFETY. LEFT PUPIL IS 3/BRISK. RT IS IRREGULARLY SHAPED WITH NO REACTION NOTED. NOTED TO MAE X 4 WITH PURPOSE AND WITHOUT DIFFICULTY. STRONG EQUAL GRIPS NOTED. PT HAS HAD LOW GRADE TEMP OF 100. NO SEIZURE ACTIVITY NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. PT NOTED TO BE IN A FIB WITH HR 90-100'S WITH OCASSIONAL PAC'S NOTED. PT CONTINUES ON NEO GTT- GOAL FOR MAPS GREATER THAN 60. NO HYPER OR HYPOTENSIVE CRISIS NOTED WITH NEO MANAGEMENT. UNABLE TO TITRATE OFF DUE TO PT'S DEPENDENCY. PWP 19-22 ALTHOUGH DIFFICULT TO WEDGE\nAT TIMES. PLEASE SEE FLOW SHEET AS NEEDED FOR COMPLETE CARDIAC NUMBERS. CVP 8-10. PT NOTED TO HAVE GENERALIZED PITTING EDEMA. DIFFICULT TO PALPATE PULSES.\n\nRR: INTUBATED. OETT IS SECURE AND PATENT. SUCTIONING Q 2-4 HOURS AS NEEDED FOR SCANT- THICK, WHITE SECRETIONS. BILATERAL CHEST EXPANSION NOTED. LEFT CHEST TUBE IS SECURE AND PATENT. NO CREPITUS NOTED. NO LEAKAGE NOTED. CT DRSG AND . SEROSANGUINOUS DRAINAGE NOTED. COARSE LUNG SOUNDS THROUGHOUT ALL LUNG FIELDS NOTED. CURRENT VENT SETTINGS ARE CMV/20/500/40%/8. ABLE TO TITRATE FI02 DOWN AND MAINTAIN ABG WNL. PLS. SEE CAREVUE AS NEEDED FOR ADDITIONAL INFORMATION.\n\nGI: OGT IS SECURE AND PATENT. PROPER PLCMT AS PER AUSCULTATION OF 30CC/AIR. ABD IS SOFT, NON-DISTENDED, NON-TENDER TO PALPATION. NO BM THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. YELLOW, CLEAR URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: NO SIGNS OF BREAKDOWN NOTED TO BACK AND BUTTUCKS. RT LEG APPEARS TO BE HEALING.\n\nSOCIAL: SPOKE WITH NEPHEW REGARDING STATUS. NO ISSUES.\n\nPLAN: CONTINUE TO MONITOR RESPIRATORY STATUS. MAINTAIN SEDATION. GOAL TO TITRATE NEO OFF. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 1450605,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS VERY PLEASANT. LETHARGIC BUT EASILY AROUSABLE. PT SAT UP IN CHAIR FOR MOST OF SHIFT. ABLE TO MOVE FROM CHAIR BACK TO BED WITH ASSISTANCE. STEADY GAIT. PRIMARILY SPANISH SPEAKING. SPOKE WITH DAUGHTER FROM WHO ATTESTS THAT DESPITE BEING \"SLEEPY\", PT IS LUCID, ALERT AND ORIENTED X 3. OBEYS COMMANDS. WILL OPEN EYES SPONTANEOUSLY. MAE X 4- EQUAL STRENGTH NOTED TO BILATERAL UPPER AND LOWER EXT. AFEBRILE. NO SEIZURE ACTIVITY NOTED. SPEECH IS CLEAR. PERRLA, 3/BRISK. NO SEIZURE ACTIVITY NOTED. ABLE TO SWALLOW PILLS WITHOUT DIFFICULTY- AS LONG AS SUPERVISED.\n\nRR: BBS=, ESSENTIALLY COARSE AND DIMINISHED TO BILATERAL LOWER LOBES. STRONG COUGH EFFORT- NON-PRODUCTIVE. BILATERAL CHEST EXPANSION NOTED. SP02 = TO 88-93%. PA02 HAS BEEN LOW- LAST ABG- PA02 IN THE 50'S- DR. AWARE. DUE TO PT'S STATURE- SOFT CERVICAL COLLAR APPLIED IN AN ATTEMPT TO FURTHER LENGTHEN AIRWAY. PT ALSO PLACED ON BIPAP. TOLERATING WELL.\n\nCV: S1 AND S2 AS PER AUSCULTATION. PT HAS EPISODES OF BRADYCARDIA TO 39-TEAM IS AWARE HOWEVER, WILL NOT INTERVENE UNLESS MENTATION IS DECREASED. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. DENIES ANY CHEST PAIN.\n\nGI: ABD IS SOFT, OBESE, NON-TENDER TO PALPATION. NO BM THIS SHIFT. BS X 4 QUADRANTS. TOLERATING PO MEDS WITH SUPERVISION.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW, URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: NO BREAKDOWN NOTED TO BACK OR BUTTOCKS NOTED.\n\nSOCIAL: DAUGHTER CALLED AND SPOKE WITH PT AT LENGTH.\n\nPLAN: CONTINUE TO MONITOR RESP STATUS AND NEURO STATUS. PLS. SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 1450606,
"text": "ADDENDUM\nPLEASE DISREGARD NOTE ABOVE- WRONG PATIENT. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-03 00:00:00.000",
"description": "Report",
"row_id": 1450607,
"text": "Micu Progress Nursing Note:\n\nNeuro: Patient remains sedated, not opening eyes and with movements of extremities only. Ativan gtt off since 0900. No change with pupils, with right pupil non-reactive, 6mm, and left pupil 3mm, briskly reactive.\n\nCV: Received patient on Neo at .5 mics but she became hypotensive to the 70s systolic with maps in the 50s. Neo increased to 1.5mics. CO done this am by Fick and thermodilution with a 1000cc bolus ns given between numbers. Patient did become hypotensive following the bolus and this phenomenon had been noted yesterday as well. Team is aware. See carevue for swan numbers. Started on Levo titrated to .15 mics but patient became tachy to the 120s. Levo dc'd and Neo restarted at 1.0 mics titrated to 1.4 to keep maps >60. Remains in afib with hr low 90s t0 low hundreds. Swann was dc'd this afternoon. Introducer remains and heparin and neo are infusing though it. Patient received 40meq kcl and is now receiving 15mmol potassium phosphate in 250cc over 6 hours. Heparin at 1350 all shift. PTT sent this afternoon which came back at 103. Heparin decreased per protocol to 1200 units.\n\nResp: No vent changes. Suctioned for to moderate amounts of thick white sputum. Lung sounds coarse. RIsbi this am 237. Tube site changed.\n\nGI/GU: No stool. Urine output this am ~100cc/hr for 4 hours, decreasing to 35-80cc/hr this afternoon. Urine is yellow, clear.\nPositive bowel sounds.\n\nID: Tmax 101.5 rectally. Core temps had been going up during the day and core tmax was 100.8. Patient was pan cultured. CXR done. Tylenol not given as team would like to assess temperature curve.\n\nSkin: Bathed. Skin tears noted right upper and lower arm. Lower right arm tear is a narrow and deeper tear and right upper arm is shallow with no drainage. Tegaderm placed right upper arm. Lower arm tear is weeping copious serous drainage and was cleaned with NS and wrapped in gauze. Compression boots left off this afternoon as patient's legs looked too moist. Wound right lower leg cleaned with soap and water and antibiotic ointment and dsd applied.\n\nSocial: nephew in with wife. Dr. did speak with them and they are realistic about patient's prognosis. Further discussions re: code status to be done although the family would like to give things a little more time.\n\nPlan: Continue to monitor sedation status and hypotension. Patient has been difficult to wean from drips. Cardiac status will make weaning from vent difficult. Continue on heparin gtt; monitor coags.\n\n Rn\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-04 00:00:00.000",
"description": "Report",
"row_id": 1450608,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS AN 89 Y/O FEMALE THAT INITIALLY PRESENTED TO THE ON AFTER SLIPPING ON THE ICE WHILE ATTEMPTING TO GET INTO A CAB. EMS ALERTED WHEN PASSERBYS WITNESSED HER STRUGGLING TO BREATHE. PT ADMITTED TO FLOOR BUT WAS TX TO ICU ON AFTER HER RESPIRATORY STATUS BEGAN TO DECOMPENSATE. CXR AT THAT TIME WAS SIGNIFICANT FOR IRREGULAR OPACITIES BILATERALLY WITH UPPER LOBE SCARRING. PT HAD LUNG BIOPSY AND SUBSEQUENT LT CHEST TUBE INSERTION. QUESTIONABLE CARDIAC FUNCTION. ECHO DONE ON - EF LESS THAN 65%. CHRONIC AFIB.\n\nNEURO: ATIVAN DC'D SINCE 0900 . INITIALLY, AT BEGINNING OF EVENING SHIFT AND FOR MOST OF DAY SHIFT PT WAS UNRESPONSIVE. DURING MY 2400 AND 0400 PT WOULD FOLLOW COMMANDS- UNABLE TO OPEN EYES BUT ABLE TO MAE X 4. LOWER EXT APPEAR TO BE WEAKER THAN UPPER EXT. RT PUPIL IS 3/BRISK, LEFT PUPIL IS IRREGULARLY SHAPED AND NON-REACTIVE- (? HX OF CATARACT) LOW GRADE TEMP 100.7. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. LT CHEST TUBE IS SECURE AND PATENT. NEGATIVE FOR CREPITUS OR LEAK. SERO-SANGUINOUS DRAINAGE NOTED. CURRENT VENT SETTINGS ARE CMV/20/500/40%/5. ABG WNL. PLS. SEE CAREVUE AS NEEDED FOR OBJECTIVE DATA. SP02 > OR = TO 95%. SUCTIONING FOR TO MODERATE WHITE SECRETIONS Q 2-4 HOURS.\n\nCV: S1 AND S2 AS PER AUSCULTATION. AFIB WITH NO SIGNS OF ECTOPY. HR 90-100'S. CONTINUES ON NEO GTT. UNABLE TO WEAN. PT WILL DROP SYSTOLICS TO THE 70'S. VERY SENSITIVE TO GTT TITRATIONS. RECEIVED A 500CC BOLUS OF NS, HOWEVER, PT HAS A TREND OF DROPPING HER SBP TO THE 70'S AFTER BEING ADMINISTERED BOLUS. THIS HAS HAPPENED A TOTAL OF THREE TIMES- MICU TEAM IS AWARE OF THIS PARADOXICAL EFFECT. QUESTIONABLE TAMPONADE- HOWEVER ECHO DOES NOT APPEAR TO BE SIGNIFICANT FOR THAT. GOAL IS FOR MAPS ABOVE 60. REDRESSED LEFT RADIAL ALINE. SECURE AND PATENT. REZEROED AND RECALIBRATED DURING THE SHIFT. SWAN DC'S YESTERDAY- CORDUS STILL - NEED TO CONSIDER SWITCHING THIS TO A TLC IN ORDER TO HAVE MORE ACCESS. GENERALIZED, WEEPING, PITTING EDEMA. PT IS NOTED TO HAVE LARGE AMOUNTS OF SEROUS DRAINAGE FROM BILATERAL UPPER EXTREMITIES. BATHED PT TWICE THIS SHIFT DUE TO COPIUS AMOUNTS BEING SECRETED IN AN ATTEMPT TO PREVENT ANY FURTHER SKIN BREAKDOWN TO ALREADY DELICATE NATURE OF SKIN.\n\nGI: OGT IS SECURE AND PATENT. PROBALANCE INITIATED AT 10CC/HR- NO RESIDUALS NOTED. WILL ADVANCE AS ORDERED AND TOLERATED. TUBE IS IN CORRECT PLCMT AS VERIFIED WITH 30CC AIR BOLUS AND GASTRIC ASPIRATE. ABD IS SOFT, DISTENDED, BS X 4 QUADS. NO BM THIS SHIFT. PASSING FLATUS WITHOUT DIFFICULTY.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT NOTED TO HAVE ASHY LOWER EXTREMITIE\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-04 00:00:00.000",
"description": "Report",
"row_id": 1450609,
"text": "NURSING PROGRESS NOTE 1900-0700\n(Continued)\nS AND COPIOUS SEROUS DRAINAGE FROM BILATERAL UPPER EXTREMITIES. PT HAS MULTIPLE SKIN TEARS TO BILATERAL UPPER EXT- BE WORSENED BY PT'S STEROID THERAPY. GENERALIZED PITTING EDEMA.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE TO MONITOR NEURO STATUS, WEAN FROM VENTILATOR AS PT WILL TOLERATE. ATTEMPT NEO GTT WEAN. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-01 00:00:00.000",
"description": "Report",
"row_id": 1450596,
"text": "micu-b, npn:\nNeuro: Received pt. on 20mcg/kg/min Propofol but pt. very hypotensive to low 80's so reduced Prop. gtt to 15mcg/kg/min. R pupil is surgical, not round and not reactive. L pupil is 2mm and reactive. MAE independently. Answers questions with head nods- nodded when asked if she knew where she was. Indicated that her R flank itched- no rash noted to site, assisted pt. with itching.\n\nCV: HR 70's-80's afib. w/o ectopy. SBP low 80's-low 100's with MAP's 50's-60's. Peripheral pulses weak. Pt. responded well to NS boluses, has received total 4L NS boluses, SBP up to low 100's- peripherals easily palpable. Goal was to have pt. 1L negative, BP did not allow this. ? cardiac consult.\n\nResp: A/C 70%, TV 500, RR 12, PEEP 5, O2Sats mid 90's. Lungs are coarse throughout. CT to L drained 75cc serosanguinous drainage. Last CXR showed worsening irregular interstitial opacities. Suxn'd. q 3 hrs for thick yellow sputum. Lung bx results pending.\n\nHeme/lytes/micro: Heparin gtt for afib. Restarted gtt @ 1:00 @ 1450U/hr. PTT @ this a.m. 53.1, bolused 1300U and increased gtt to 1600U/hr as per protocol. T-max this shift 99.3. Bld. cx's X 2 sent d/t team questioning sepsis as source of hypotension. Cortisol level checked as team also questioned renal insufficiency as source of hypotension.\n\nGI: NPO. + BS, no BM.\n\nGU: Foley to gravity draining clear yellow urine.\n\nDerm: Drsng. to CT site D&I.\n\nSocial: FULL CODE. Nephew and his wife called last night with many questions about procedure. They would like to get in touch with the attng. today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-01 00:00:00.000",
"description": "Report",
"row_id": 1450597,
"text": "attempt to wean Fio2 was made without success, minimal secretions throughout pm\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-01 00:00:00.000",
"description": "Report",
"row_id": 1450598,
"text": "nursing note: 7a-7p\nneuro- received on propofol which needed to be shut off hypotension. pt needed sedation though and was started on ativan gttat 0.5mg/h and 1mg/h. pt is very sensitive to sedatives and drops sbp to 70's. follows commands most of the time. mae.\n\nresp- remains intubated on ac. fio2 weaned to 70% with sats 93-96%. ls coarse with faint crackles at bases. pt became tachypneic when sedation was off, now on 1mg/h ativan srr is 4. suctioned for thick secretions.\n\ncv- hr afib 80-100 no ectopy noted. bp remains very labile and sensitive to sedatives. pt bolused frequently throughout day for sbp less than 80. pa line placed today with initial readings very low likely due to sbp of 67 at the time. last swan numbers show c.o approx 4 and cvp 12 with wedge of 16-18.\n\ngi- abd soft nt nd + bs no stool. ogt placed this evening, awaiting results of xray for placement.\n\ngu- foley patent for 20-30cc/h of yellow urine.\n\naccess- lsc pa line placed today. 2 piv's in place and r left rad aline intact.\n\nsocial- pt's nephew called for update, dr spoke with him and received consent for pa line.\n\ndispo- remains in micu, full code. needs stim test this evening, awaiting dose from pharmacy. team aware of labile bp's and plan to continue to watch and readdress use of pressor vs more fluid.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-02 00:00:00.000",
"description": "Report",
"row_id": 1450599,
"text": "MICU-B, NPN:\nNeuro: Received pt. on 1mg/hr Ativan gtt. Pt. very easily aroused on this dose- agitated @ times. Able reach up to ETT. Following decision to add pressor therpay for BP support, Ativan increased to 3mg /hr, then back down to 2mg/hr. Pt. arouses to voice and tactile stimulous on this dose. PERRLA @ 3mm to L eye, R pupil is surgical, not round and non-reactive. MAE independently.\n\nCV: HR 80's-90's afib. w/o ectopy @ start of shift. SBP 70's-80's. Discussed hypotension with team- decision made to bolus 500cc NS in addition to adding Dopamine @ 5mcg/kg/min. Dopa. hung @ 20:00. HR up to 130's/140's within minutes of initiating Dopa- gtt taken of by 20:30. SBP began dropping from 90's back down to low 80's- began Neo gtt. Neo @ 0.7 mcg/kg/min for rest of shift. HR 80's-low 100's. Neo. stopped briefly while labs drawn from cordis- SBP begin dropping to 70's suggesting very pressor dependent state. Swan #'s @ 24:00 were C.O. 3.05, C.I. 1.77, SVR 1258, Wedge 23. CVP throughout shift , PAP 29. Will shoot next set #'s this a.m. Peripheral pulses palpable. 2+-3+ edema to q 4 extremities. IVF D51/2 @ 50cc/hr.\n\nResp: Received pt. on A/C 70%, TV 400, RR 20, PEEP 8, O2Sats ranging from 90%-100%, usually requiring suxn'ing when low. Suxn'd q 3 hrs for amnts. thick tan sputum. CT to L to lung to low wall suxn. draining straw colored fluid. Lungs sound coarse throughout.\n\nHeme/lytes/micro: Awaiting a.m. labs. . stim test done @ 22:00-22:30. Not written for RISS but have checked FSBG this shift d/t new steroid therapy. T-max this shift 100. PTT @ 20:00 therapuetic per protocol- next PTT due @ 20:00 today.\n\nGI: NPO. OGT placement confirmed by CXR and easily auscultated. +BS, no BM.\n\nGU: Foley to gravity draining clear yellow urine.\n\nDerm: Drsng. to L CT D&I.\n\nSocial: Nephew is proxy- was visiting today with family. Very interested in details re: lung bx results. State that pt. would likely want a chance to beat poor prognosis but end of life wishes include donating her remains to scientific cause. FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-02 00:00:00.000",
"description": "Report",
"row_id": 1450600,
"text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with a high FIO2 (70%). No RSBI performed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-02 00:00:00.000",
"description": "Report",
"row_id": 1450601,
"text": "Micu progress Nursing Note:\n\nNeuro: Patient remains on 2mg Ativan gtt. Has not opened eyes spontaneously this shift. She does respond to local stimulation (moves feet slightly in response to plantar rub). Right pupil non-responsive, irregular shaped, 6mm. Left pupil 2-3mm, brisk. Some spontaneous movement lower extremities noted; no upper extremity movement noted.\n\nCV: Remains on Neo now at .85 mics with sbps in one-teens, maps 60s. Received patient on .7 mics. BP 90s over 50s to 140s over 60s this shift. Attempt to wean Neo when sbp in 140s but sbps dropped to mid-90s on .5 of Neo. Team asked to write order to keep maps >60 in order to attempt to wean neo. CVPs 9-16. Paps 40s/20s, wedge 22 at 10 am. Thermodilution CO at 1000 =2.45 with Fick Co =6.0. Resp Therapy attempted to set up Oxygen consumption measurement device to resolve disparity but the machine did not work. Another set of numbers is to be done after this note, with a 500cc NS bolus given after first set of numbers, followed by a second set of numbers. Patient remains on Heparin gtt, stopped for one and one-half hours this am for PTT>150. Restarted at 1350 units, down from 1600 units. PTT at 1600 =65 with heparin gtt left as is. Next PTT due at 2200. Patient has plus pitting edema both feet. Pedal pulses difficult to detect but weakly palpable. Compression boots on. Feet cool to touch.\n\nResp: Remains on AC, FIO2 decreased to 50% from 70%. See carevue for abgs. Rate 20 with occasional breaths, up to 4 spontaneous. Lung sounds coarse throughout. Peep 8. Suctioned q 2 -3 hours for to moderate amounts thick white sputum.\n\nGI/GU: Abdomen softly distended, hypoactive bowel sounds. OGT in place and used for po meds. Foley draining between 30-50cc yellow urine/hr. No stool.\n\nSkin: Coccyx and buttocks intact. cut right leg appears to be almost closed.\n\nPlan: Attempt neo wean. Reshoot numbers. Bolus. Monitor PTT. Maintain sedation.\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450624,
"text": "NPN 07:00-19:00 MICU\n*Please refer to Carevue for additional patient information.\n*Full Code\n\nROS:\nNeuro: Opening eyes to voice, following commands appropriately, no apparent pain present. Impaired gag, weak cough. R pupil cataract, L pupil 4mm, brisk. Bilateral wrist restraints on for pt safety.\n\nCV: HR 92-155 A-fib, EKG done. Given Diltiazem 5mg w/ ?'able effect. Also given Procanimide loading dose of 1250mg, now written to receive 750 mg q 6hr for A-fib conversion (since Diltiazem and Procanimide have been given, no episodes of tachy/140's has occurred.)*Heparin gtt turned off for Thoracentesis, now on per Dr. to be started at 950u/hr, next PTT due at 21:00. BP very labile, started on Vasopressin 0.04u/min, in hopes of weaning off Neo, however still requring to be on Neo gtt d/t SBP 70's. Currently on Vasopressin 0.04u/min, and Neosynephrine 0.35mcg/kg/min. **A-line very positional (however NBP correlating.) CVP at begining of shift=8, now . Tmax 102.0 po, bld cx x1 sent, urine cx sent.\n\nResp: No vent changes made, remains on A/C 400x26/peep 5/40%, O2 sat's high 90's. LS coarse throughout, and at times, dimished at bases. Thoracentesis done, ~1L serous fluid removed, sent to lab. CT , +fluctuation, - leak, draining serosanguinous fluid ~200cc out (at 16:00.) Sxn'd q 4hr scant amounts of thick white sputum.\n\nGI/GU: +BS, no bm this shift, tolerating TF's (probalance at 30cc/hr, ?goal rate-will check.) OGT in place per auscultation. U/O wnl, yellow, clear.\n\nEndo: Now written for RISS\n\nAccess: A-line very positional. R scl TLC wnl.\n\nSkin: please see carevue.\n\nSocial: Nephew called this afternoon, spoke to Dr. regarding pt's condition; Dr. to speak to nephew at some time this afternoon.\n\nPlan: Wean Neo as tolerated, goal SBP >90. *PTT due at 21:00. Sxn as needed. Monitor tmax. Offer family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-12-31 00:00:00.000",
"description": "Report",
"row_id": 1450594,
"text": "See CareVue for objective data.\n\nThis is an 89 year old female with CAD,HTN,CHF and PAF who presented after slipping on ice while getting into a cab. -LOC -hit head.\nPt reports increased DOE,-CP. EMS was called as passerbys saw her struggling to breathe.\nAdmitted to floor where her respiratory status worsened and admitted to ICU on the night of for gentle diuresis and monitoring. Placed on 100% NRB with sats 96%. CXR demonstrates irregular opacities bilaterally with upper lobe scarring. ?CHF/?infiltrate/?cancer\nAmiodarone was dc'd as differential diagnosis. Heparin was dc'd at noon for preparation video assisted lung biopsy.\nHeart rate controlled with po lopressor and verapamil. Art line placed today in left radial artery without incident. Tolerated well. (Cuff pressure with 10-14 point difference.)\nShe is a very pleasant and coopertive alert and oriented female who requires her HOB elevated to facilitate easier respiratory mechanics.\nTrachae midline. Speaks in full sentences. See CareVue for ABG's\nand other objective data.\nNPO for OR. Pt well informed of possibility of prolonged intubation and consents to the procedure in despite of this.\nShe has a nephew who is her contatct and is aware of her impending surgery.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-12-31 00:00:00.000",
"description": "Report",
"row_id": 1450595,
"text": "Nursing Note 1745-1900 Review of Systems:\nNEURO: Remains unresponsive paralysing given in OR for re-intubation. Med X1 with MSO4 2mg for pain. Propofol drip started at 20mcg/kg/min.\nC/V: Continues in Afib with rate 75-90. SBP 90-130/60's.\nRESP: Vent setting unchanged Lung sounds coarse with crackles bibasilar. Chest tube intact to suction 15cm, draining serous fluid 95cc out. CXR done results pending. Pnewmatic boots on.\nGI/GU: Foley patent clear yellow urine out no Stools. OGT D/cd in OR.\nIVF: D5 infusing at 50cc/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 1450630,
"text": "micu npn 0700-1900\n\nreview of systems:\n\nneuro: alert arouse to voice nodding appropriately, mouthing words, gesturing with hands, +mae. no sedation\n\ncv: HR 90-100 Af, 5pm rapid af to 150's, given IV lopressor 2.5mg x2, 5mg x1, with HR to 120-130 AF, BP 100-110/with rapid rate neo turned off maintaining BP\n\nresp; CPAP 10 peep5 throughout the day with RR 20's, 5pm rate to 30's TV 400, PSV increased to 15 with TV increase to 450-500 rate cont 28-32, breath sounds coarse upper dim bases, sxn for amt white to plae yellow secetions.\n\nid: afebrile, pan cultured, needs stool for cdiff, wbc 29 up from 20\ncont ceftaz and vanco\n\ngi: abd soft +bs no bm, cont tube feeds at goal probalance at 50cc/hr,\nlactulose x1 today\n\ngu; foley with amber urine, 40-50cc/hr uo\n\nskin: +anasarca, weeping serous fluid from bilat upper extrem and right lower leg, right lateral lower leg with raise purple fluid filled lumped team examined on rounds this am.\n\nsocial: nephew visited this am\n\naccess: RIJ triple lumen, left rad aline \n\nplan: ? etiology of new rapid af, follow wbc/fever curve/culture results, pulmonary toilet.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 1450631,
"text": "Resp. Care\nPatient intubated, alert, vented tolerating PS mode t/o most of shift. Around 5pm HR >150 rr >35 NO hypoxia, DR\"S aware, held current mdi dose at this time. No sxing. needed at this time. BS aerating t/o. ABG's prior to tacypnic episode normal range. cxr done, abg repeated, patient to be sedated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 1450632,
"text": "Resp NOte\ncorrection abg slight resp. alkalosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-10 00:00:00.000",
"description": "Report",
"row_id": 1450633,
"text": "Resp Care Note:\n\nPt cont sedated intub on mech vent as per Carevue. Lung sounds coarse suct sm th white sput. Pt initially on PSV @ 15 with notable increase WOB/RR ~36. Increased PSV[25] with good affect brought RR down to 20 and appeared more comfortable. Despite the improvement MD requested to switch to A/C and sedate to rest overnoc. On current vent setting she cont to breath 34. ABGs compensated metabolic acidosis. Would recommend sedating with A/C or return to PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-10 00:00:00.000",
"description": "Report",
"row_id": 1450634,
"text": "MICU-B NPN 1900-0700\nOVER/NOC EVENTS. PT. TACHYCARDIC T/O EVE. REMAINS IN A-FIB (ON PROCAINAMIDE; HEP. GTT (GIVEN X2 ONE TIME DOSES LOPRESSOR FOR ATTEMPTED RATE CONTROL WITH NO EFFECT.) PT. WITH WORSENING HYPOTENSION REQUIRING INC. IN NEO. GTT. PRESENTLY @ 3MCG/KG/MIN WITH TEAM TO ADD SECOND . PT. GIVEN TOTAL OF 2.5L IN FLUID BOLUSES WITH TRANSIENT EFFECT (CVP INITIAL 7 ; LAST 12) WBC @ 0000 39.5. TEMP. SPIKE TO 101.6 @ 200 (PAN CX)LACTATE CONT. TO CLIMB FROM 2.4 @ 0000 TO 4.8 WITH AM LABS. ABD. CXRAY WITH DILATED LOOPS. ? ILEUS VS. ISCHEMIC BOWEL. SURGERY NOT CONSULTED. PT. WITH DISTENDED ABD. (GIRTH HAS NOT INC.) NO STOOL, +BS EARLIER, NOW HYPOACTIVE. +VOMITUS AROUND ETT (OGT PLACED TO SX. WITH >600CC ?FECAL MATTER (THOUGH DOES NOT SMELL LIKE STOOL). C-DIFF. SPEC. SENT FROM OGT; PENDING.\n\nNEURO - PT. RECEIVED ON NO SEDATION. STARTED ON PROPOFOL GTT. @ 2200 PER TEAM TO REST ON VENT. OVER/NOC ON A/C AND SEDATE IN ATTEMPT TO CORRECT ALKALOSIS. PROPOFOL GTT. PRESENTLY @ 20MCG/KG/MIN WITH PT. WELL SEDATED. WITHDRAWING TO PAINFUL STIMULI. ? CHANGING SEDATION HOWEVER SECONDARY TO CONT. HYPOTENSION WITH SECOND PRESSOR TO BE ADDED DESPITE NUMEROUS FLUID BOLUSES AND INC. IN NEO.GTT. (-)MAE. GIVEN X2 PRN MSO4 FOR ? ABD. PAIN. PT. @ START OF SHIFT INDICATING WITH NON-VERBAL GESTURING THAT ABD. PAIN WAS PRESENT. GIVEN MSO4 LAST @ 0400 2MG. AND ANOTHER 2MG. @ 0500 FOR CONT. TACHYCARDIA DESPITE FLUID RESUSCITATION AND INC. IN PRESSOR FOR ? ABD. PAIN IN LIEU OF ?ILEUS IN SETTING OF NO STOOL, INC. WBC TO 39.5, AND CLIMBING LACTATE, WITH DILATED LOOPS ON ABD. CXRAY.\n\nRESP - PT. RECEIVED ON CPAP+PS. CHANGED @ 2200 TO A/C .40/450 X26 WITH SPONT. RR 3-10./PEEP 5. PLEASE SEE CAREVUE FOR ABG RESULTS. PT. WITH COMPENSATED MET. ACIDOSIS MOST OF SHIFT, BUT LAST ABG 7.38/24/116/- WITH LACTATE 4.8. TEAM AWARE. BS COARSE UPPER WITH BILAT. DIMIN., BASES. SX. T/O SHIFT FOR SCANT AMTS. THICK, WHITE SECRETIONS. RR 20'S-30'S. O2SATS 100%. (L) CTUBE IN PLACE; NO LEAK, NO CREPITUS NOTED) SEAL @ 15CM H20, WITH 200CC SEROSANGUINOUS DRAINAGE OUT.\n\nC/V - HR ONE-TEENS >160'S OVER/NOC, REMAINS IN A-FIB. ON HEP. GTT. @ 800U/HR WITH LAST PTT 80.4; AM VALUE PENDING. RECEIVING PROCAINAMIDE FOR RATE CONTROL, AND AS ABOVE GIVEN X2 ONE TIME DOSES IV LOPRESSOR WITH NO EFFECT. ABP AND NBP NOT CORRELATING. ABP 60'S-90'S/40'S-50'S (MAP 50'S-60'S) NBP 70'S-ONE-TEENS/40'S-50'S (MAP 50'S-70'S). CVP INITIALLY 7; NOW 12. PERIPHERAL PULSES WEAK PALPABLE. EXTREM. COOL. + GENERALIZED ANASARCA WITH SEEPING SKIN TEARS. K+ @ 0000 5.7; GIVEN KAYEXALATE AND 2GM CALCIUM GLUCONATE. AM VALUE PENDING.\n\nID - WBC INC. TO 39.5. TEMP SPIKE TO 101.6 @ . PAN. CX. FLAGYL ADDED TO ABX. RREGIME. LACTATE CONT. TO CLIMB FROM 2.4 @ 0000 TO 4.8 THIS AM.\n\nGI/GU - PT. WITH OGT IN PLACE; PATENT. TF RUNNINH @ START OF SHIFT. HIGH RESIDUAL NOTED @ 0000 (140 CC) TF. HELD. PT. WITH DISTENDED ABD. GIRTH WITH APPARENT INC. IN SIZE T/O SHIFT OR INC. IN FIRMNESS. VOMITUS NOTED AROUND OGT EARLY AM; OGT PLACED TO LCWS WITH >600 GOLDEN >\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-10 00:00:00.000",
"description": "Report",
"row_id": 1450635,
"text": "MICU-B NPN 1900-0700\n(Continued)\nWN WITH SEDIMENT (FECAL APPEARING, THOUGH NOT SMELLING LIKE STOOL). C-DIFF SPEC. SENT OF OGT CONTENTS IN CASE. ABD. CXRAY WITH NOTABLE DILATED LOOPS ?ILEUS VS. ISHCEMIC BOWEL. PT. INITIALLY WITH +BS, NOW HYPOACTIVE. NO STOOL THIS SHIFT. ? LAST STOOL. INDWELLING FOLEY IN PLACE; PATENT WITH U/O TAPERING OFF NEAR MID/NOC, NOW EXTREMELY MARGINAL.\n\nSKIN - SKIN TEARS T/O WITH TEGADERM IN PLACE; SEEPING SEROUS FLUID.\n\nACCESS - RIJ MULTI-LUMEN IN PLACE; PATENT, SITE WNL. (L)RADIAL A-LINE IN PLACE; PATENT WITH DAMPENED WAVE FORM AT TIMES; SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-10 00:00:00.000",
"description": "Report",
"row_id": 1450636,
"text": "micu npn 0700-1300\n\nPatient remained hypotensive depite max dose of levo and neo and continued fluid boluses, nephew called to be made aware of acute change in pt status, pt made a dnr/dni but continue current medicines,\npt cont to be hypotensive to 60'systolic, team aware cont as is without additional pressors or fluid boluses.\n\nPatient expired at 13:05, family called aware of death, they will not be coming in to view body, they will be in to collect her belongings tomorrow.\n\nBody transferred to morgue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-08 00:00:00.000",
"description": "Report",
"row_id": 1450626,
"text": "NPN 07:00-19:00 MICU\n*Please refer to Carevue for additional patient information\n*Full Code\n\nROS:\nNeuro: Much more alert today. Attempting to communicate through writing, and mouthing words. No c/o pain, or discomfort. MAE's in bed, restraints remain on for patient safety. Pupils: R w/ cataract, L 4mm brisk.\n\nCV: Remains on Neo now at .25mcg/kg/min, attempted to titrate down however unable to do so. HR 80's-90's, A-fib, continues on Heparin 800u/hr. CVP 4-6. Tmax 100.0 po. Kphos repleted. (Less edema noted in upper extremities in comparison to yesterday, however continues to have weak pedal pulses w/ ^edema.)\n\nResp: Changed from A/C to PS. Trialed on PS 5/5/40% for ~2.5 hrs, tolerating it well, RR mid-20's, O2 sat's 99%, MV ~12L, ABG on this setting= 7.46/33/109/24. Pt becoming tired, now on PS 15/5, RR~20, o2 sat's high 90's. LS coarse upper, slightly diminished LLL. Sxn q2 hr for -moderate amounts of thick, white secretions. Bronchoscopy done today, sputum specimen sent. CT in place, drng serosanguinous fluid, site wnl, no crepitsu noted.\n? Extubation tomorrow. (*Pt nodding \"yes\" to Dr. in regards to wanting to be re-intubated if needed to be.)\n\nGI/GU: Hypoactive bs, no bm, TF's at 40cc/hr, goal 50cc/hr. OGT in place per auscultation. U/O wnl at begining of shift, by 16:00, down to ~20cc for two consecutive hrs, bolused w/ NS 500cc, pndg results.\n\nEndo: RISS; continues on Steroids for ideopathic BOOP, is written to be changed to PO Prednisone tomorrow (please see med sheets.)\n\nAccess: R scl TLC, wnl. A-line L radial wnl.\n\nPlan: Wean Neo as tolerated. Pulmonary toilet, ?extubation tomorrow. Start on PO steroids tomorrow afternoon.\n\nSocial: No contact w/ family today.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-08 00:00:00.000",
"description": "Report",
"row_id": 1450627,
"text": "Resp. Care Note\nPt remains intubated and vented on settings PSV 15 peep 5 and 40%. Pt much more awake and alert today, communicating. Changed from AC to PSV. Was weaned to and 40% and tolerated this well for almost 3 hrs. and then became tachypneic to rate in 30's. Placed on PSV 15 to rest overnight and plan to reassess for wean and possible extubation in AM. Sxn freq. for loose white secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 1450628,
"text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV), and is responding appropriately to questions and interacting with people when they enter the room.\n\nRSBI = 94.1 on 0-PEEP, 0-PSV, and ATC on 100%. SBT to be attempted at 6:00 am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-09 00:00:00.000",
"description": "Report",
"row_id": 1450629,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS ALERT AND ORIENTED. NODDING YES/NO APPROPIATELY TO QUESTIONS, OBEYS COMMANDS, OPENS EYES SPONTANEOUSLY. ATTEMPT TO COMMUNICATE BY MOUTHING WORDS ALTHOUGH IS VERY DIFFICULT TO UNDERSTAND AND HAS ATTEMPTED TO WRITE NEEDS DOWN. AFEBRILE. LT PUPIL IS 3/BRISK. MAE X 4- WITHOUT DIFFICULTY. WILL GET ANXIOUS AT TIMES AND ATTEMPT TO EXTUBATE SELF- BILATERAL WRIST RESTRAINTS FOR SAFETY. NO SEIZURE ACTIVITY NOTED.\n\nRR: INTUBATED. CURRENTLY ON CPAP/15PS/40%/5 WITH TV 500-600'S. RR 20-30. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. DIMINISHED TO BILATERAL BASES. SP02 > OR = TO 95%. CONTINUING TO SUCTION FREQUENTLY FOR THICK, TAN SECRETIONS. S/P BRONCH . BILATERAL CHEST EXPANSION NOTED. LT CT IS SECURE AND PATENT. SUCTION. NEGATIVE FOR LEAK OR CREPITUS. SEROUS DRAININAGE TOTALING 200CC FOR THE SHIFT.\n\nCV: AFIB. HR 90-110' PT TOLERATING AND METOPROLOL FOR RATE CONTROL. PALPABLE PULSES TO BILATERAL DORSALIS AND RADIALS. CONTINUES ON HEPARIN GTT FOR AFIB. NEXT PTT IS DUE AT 1000. UNABLE TO WEAN NEO GTT OFF. WILL DROP SBP TO THE 60'S. CVP 7-8. DENIES ANY CHEST PAIN.\n\nGI: OGT IS SECURE AND PATENT. CONTINUES ON PROBALANCE AT 50CC/HR GOAL RATE. TOLERATING WELL WITH NO GASTRIC RESIDUALS NOTED. ABD IS SOFT, OBESE AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NO BM THIS SHIFT. LARGE AMOUNTS OF FLATUS PASSED.\n\nGU: INDWELLING URETHRAL FOLEY CATHETER IS SECURE AND PATENT. ADEQUATE AMOUNTS OF CLEAR, YELLOW URINE NOTED.\n\nINTEG: NO SIGNS OF REDNESS OR BREAKDOWN NOTED TO BACK OR BUTTOCKS. SKIN TEARS TO ALL EXTREMITIES. OOZING AND ANASARCA HAS IMPROVED BUT REMAINS GENERALLY EDEMATOUS.\n\nSOCIAL: NEPHEW IN TO VISIT.\n\nPLAN: EXTUBATE WHEN POSSIBLE- RSBI IMPROVING BUT PT DOES NOT TOLERATE BREATHING TRIALS WITHOUT GETTING FATIGUED. WEAN NEO AS PT WILL TOLERATE. PTT AT 1000. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-01-08 00:00:00.000",
"description": "Report",
"row_id": 1450625,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: NO SEDATION. WILL OPEN EYES TO VERBAL STIMULUS. OBEYS COMMANDS- ATTEMPTS TO MOUTH WORDS ALTHOUGH DIFFICULT TO UNDERSTAND. CALM, COOPERATIVE. LT PUPIL 3/BRISK. MAE X 4 WITHOUT DIFFICULTY. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: INTUBATED. OETT RETAPED AND SECURED AT 22CM TO THE LIP. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS AND DIMINISHED TO BILATERAL BASES. CURRENT VENT SETTINGS ARE AC/26/400/40%/5. SP02 > OR = TO 99%. BILATERAL CHEST EXPANION NOTED. PT STILL NOTED TO HAVE INCREASED TAN, THICK SECRETIONS. UNABLE TO OBTAIN RSBI THIS MORNING DUE TO PT'S LACK OF SPONTANEOUS BREATHING.\n\nCV: CONTINUES TO BE IN AFIB WITH HR 80-110'S. NO EPISODES OF RAPID AFIB. S1 AND S2 AS PER AUSCULTATION. CONTINUES ON HEPARIN GTT. UNABLE TO WEAN OFF NEO GTT DESPITE NUMEROUS ATTEMPTS. PT WILL DROP SBP TO THE 50-60'S AND IS QUITE SENSITIVE TO NEO. PT DID RECEIVE 500CC NS BOLUS AND 25% ALBUMIN. PT HAS LARGE AMOUNTS OF PITTING EDEMA TO ENTIRE BODY- ESPECIALLY EXTREMITIES, DIFFICULT TO PALPATE DORSALIS AND RADIAL PULSES ALTHOUGH THEY ARE PRESENT.\n\nGI: CONTINUES ON TUBE FEEDS. OGT IS SECURE AND PATENT- PROPER PLCMT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. ABD IS OBESE, SOFT. BS X 4 QUADRANTS. NO BM THIS SHIFT. PASSING LARGE AMOUNTS OF FLATUS.\n\nGU: INDWELLING URETHRAL FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. SEVERAL SEROUS DRAINING SKIN TEARS TO BILATERAL UPPER AND LOWER EXTREMITIES. GENERALIZED PITTING EDEMA.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nPLAN: CONTINUE TO MONITOR NEURO STATUS, WEAN OFF OF NEO GTT IF POSSIBLE, PTT AT 1200. AM LAB RESULTS STILL PENDING. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU\n"
}
] |
51,724 | 127,904 | The patient was brought into the Emergency Deptarment after having coffee grounds from his PEG tube on . The PEG had been placed on for swallow failure and need for enteral feeding. The patient had been discharged to on . On presentation he was admitted to the SICU for monitoring and endoscopy. The upper endoscopy peformed by GI revealed grade 3 esophagitis and - tear. There did not appear to be any bleeding related to the recent PEG tube placement. The patient was kept NPO and recieved tube feeds which he tolerated. Serial hematocrits were checked and remained stable. He had intermittant chest pain, which his wife described as chronic, although he felt it was different than his typical pain. He had an EKG which was unchanged from prior and he had a CTA Chest which showed no PE, but did reveal moderate pneumoperitoneum and portal venous gas likely related to recent gastric insufflation for PEG placement. He became less tolerant of his tube feeds and had an increasing WBC#, as well as persistent orhtostatic hypotension on hospital day 4. At this point a medicine consult was requested to help address these ongoing medical issues. . # LEUKOCYTOSIS: Concern for infectious etiology in setting of orthostatics and tender abdomen. Had been on Dexamethasone since the frontal cranial resection but leukocytosis was new. No diarrhea but possibility of CDiff given high white count and recent hospitalizations/rehab placement. Aspiration pneumonia and microperforation given persistent pneumoperitoneum also on the differential. Increased lethargy since transfer out of the SICU also concerning for encephalitis/meningitis and abscess in setting of recent instrumentation of the central nervous system. Blood and urine cultures did not grow anything. Serial KUBs showed slow resolving of pneumoperitoneum. Lumbar puncture was not done in setting of improved mental status with intravenous fluid rehydration. Of note, patient's liver function tests were noted to be elevated to the 800s (ALT/AST) and total bilirubin ~2. CTA torso did not show any pathology in the liver parenchymal or biliary tree. RUQ ultrasound with dopplers were also negative for any acute processes. It was felt that the patient likely had transient liver damage in setting of hypotension from hypovolemia. Patient LFTs were trended to normal but started rising again to the 100s by day of discharge. Leukocytosis and general physical status improved with starting Zosyn. Patient was eventually transitioned to Unasyn and then Augmentin. - Continue Augmentin 500mg three times daily X10 more days (last day: Saturday, ) - Redraw patient's blood on Monday, and fax to patient's primary care doctor (Dr. ) . # ORTHOSTATICS: Concerning for sepsis (infectious etiology) vs. hypovolemia. More likely the latter given poor Gtube absorption and response to intravenous fluids. Physical therapy worked closely with patient who was no longer orthostatic by day of discharge. . # ABDOMINAL PAIN: Concerning for infection/abscess vs. microperforation given recent instrumentation. Also had been on narcotics without bowel regimen, however, with possibility of ileus given recent surgery and high-residuals from G-tube. Patient was started on metoclopramide, antibiotics and a bowel regimen with resolution of his symptoms. Serial KUBs showed gradual improvement in his pneumoperitoneum. Patient's G-tube site remained clean, dry and intact. Speech and swallow re-evaluated him during this admission and cleared him for PO diet. - Continue PO diet of soft dyphagia solids, thin liquids and medications whole in applesauce. Supplement with Carnation Instant (sugar free) and maintain aspiration precuations. . # NSCLC with brain metastasis: Radiation oncology (Dr. ) saw patient in-house and felt he would benefit from some adjuvant radiation therapy to be started early next week. Per patient's wife, they plan to transfer his oncology care to the . - Radiation Oncology will coordinate with patient and rehab facility regarding outpatient radiation therapy sessions - Continue Decadron taper. Currently Decadron 2mg daily X13 more days. Taper after 13 days to: 1mg daily X 14 days, 0.5mg daily X 14 days. Then STOP. . # DM: Made NPO due to high residuals from Gtube flushes upon transfer to the Medicine Service. Once cleared by Speech and Swallow, patient was resumed on home insulin regimen - Lantus 30 units before bed - Regular insulin sliding scale qACHS . # Anoxic brain injury/dementia: Mildly confused at times, requiring orientation. Otherwise close to baseline. - Resumed home Clonazepam 1mg three times daily - Resumed home Ambien 10mg before bed as needed for insomnia - Also continued patient on home Oxycodone 5-10mg every 4 hours as needed for chronic back pain . # Elevated LFTs: Patient had elevated ALT. Liver ultrasound and CT A/P without obvious metastatic lesions. He should have further outpatient workup and repeat LFTs in days to assess trend. . # ? aspiration: Patient ultimately passed speech and swallow testing and was tolerating food. PEG tube left in place per nutrition in case not tolerating enough POs. He should have ongoing nutritional assessment. he should have repeat CXR in days () to assess for any evidence of recurrent aspiration in which case may need to modify diet or make patient NPO with re-initiation of tube feeds. | Received fluid bolus AM for hypotension SBP 80s with transient improvement. Dexamethasone 4. Dexamethasone 4. Dexamethasone 4. Neurologic: --AAOx3; mental slowing. Hematology: n Hct slowly trending down (nadir of 24), 1 unit PRBC given, will f/u AM HCT Endocrine: n RISS for glycemic control. Hematology: n Hct slowly trending down (nadir of 24), 1 unit PRBC given, will f/u AM HCT n Start heparin SQ Endocrine: n RISS for glycemic control. n Pre-existing - Dexamethasone 2 mgBID unclear reason Infectious Disease: --Afebrile, wbc 21.3->14.2 Lines / Tubes / Drains: Foley, PIV : Consults: Trauma surgery, GI Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 04:55 AM 18 Gauge - 01:37 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Disposition: Total time spent: 31 minutes n Pre-existing - Dexamethasone 2 mgBID unclear reason Infectious Disease: --Afebrile, wbc 21.3->14.2 Lines / Tubes / Drains: Foley, PIV : Consults: Trauma surgery, GI Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 04:55 AM 18 Gauge - 01:37 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Disposition: Total time spent: 31 minutes Metoprolol Tartrate 11. Metoprolol Tartrate 11. Metoprolol Tartrate 11. AUOP Hematology: --HCT slowly trending down (nadir of 24), 1 unit PRBC given, will f/u AM HCT Endocrine: -- RISS for glycemic control --cont Dexamethasone 2 mgBID Infectious Disease: --Afebrile, wbc 21.3->14.2 Lines / Tubes / Drains: Foley, PIV Wounds: Imaging: Fluids: Consults: Trauma surgery, GI Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 04:55 AM 18 Gauge - 01:37 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Disposition: Total time spent: 31 minutes Received fluid bolus AM for hypotension SBP 80s with transient improvement. Hematology: n Hct slowly trending down (nadir of 24), 1 unit PRBC given, will f/u AM HCT n Start heparin SQ Endocrine: n RISS for glycemic control. Possible left atrial abnormality.Compared to the previous tracing of the ST-T wave changes haveresolved. Pulmonary: IS, --Stable Gastrointestinal / Abdomen: --UGIB --GI to scope patient --PPI gtt Nutrition: NPO Renal: -- Creatinine 1.1 baseline. VSS throughout - Repeat crit at 1200 - Protonix gtt Response: - Endoscopy showed resolving esophagitis and resolving gastric ulcer unrelated to his PEG. VSS throughout - Repeat crit at 1200 - Protonix gtt Response: - Endoscopy showed resolving esophagitis and resolving gastric ulcer unrelated to his PEG. Dexamethasone 4. n Pre-existing - Dexamethasone 2 mgBID unclear reason Infectious Disease: --Afebrile, wbc 21.3->14.2 Lines / Tubes / Drains: Foley, PIV : Consults: Trauma surgery, GI Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 04:55 AM 18 Gauge - 01:37 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: Comments: Communication: Comments: Code status: Disposition: Total time spent: 34 minutes S/P frontal craniotomy for mass resection most likely metastatic. Gastrointestinal bleed, other (GI Bleed, GIB) Assessment: - Pt admitted to SICU for scope and serial crits. Gastrointestinal bleed, other (GI Bleed, GIB) Assessment: - Pt admitted to SICU for scope and serial crits. PT/OT Demographics Attending MD: J. Admit diagnosis: UPPER GI BLEED Code status: Full code Height: Admission weight: 87.7 kg Daily weight: Allergies/Reactions: Tramadol "Severe GI Prob Hydrocodone Bitartrate/Apap (Oral) "Severe GI prob Precautions: PMH: CV-PMH: Additional history: .NSCLCA s/p radiation and chemo .vocal cord paralysis .Diabetes Mellitus .Dementia .Brain injury s/p drug overdose .NPH .RUE DVT .right subclavian AVF PSH: s/p Right frontal craniotomy s/p PEG s/p LULectomy Surgery / Procedure and date: s/p Right frontal craniotomy s/p PEG s/p LULectomy Latest Vital Signs and I/O Non-invasive BP: S:94 D:43 Temperature: 98.8 Arterial BP: S: D: Respiratory rate: 14 insp/min Heart Rate: 80 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 100% % O2 flow: 2 L/min FiO2 set: 24h total in: 1,095 mL 24h total out: 450 mL Pertinent Lab Results: Hematocrit: 27.3 % 11:31 AM Finger Stick Glucose: 172 10:00 AM Valuables / Signature Patient valuables: None Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: SICU A Transferred to: CC6 Date & time of Transfer: 1500 | 22 | [
{
"category": "Physician ",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727173,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output at this time. returns with increased\n coffee ground emesis, tachycardia. He is being admitted to the SICU for\n monitoring and serial Hct.\n Chief complaint:\n GIB\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT 4/.\n Current medications:\n 1000 mL LR 2. Acetaminophen 3. HYDROmorphone (Dilaudid) 4. Lorazepam 5.\n Metoprolol Tartrate 6. Ondansetron\n 7. Pantoprazole 8. Tiotropium Bromide\n 24 Hour Events:\n Admitted\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 91 (88 - 96) bpm\n BP: 98/58(66) {98/58(66) - 112/68(77)} mmHg\n RR: 14 (7 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 99 mL\n PO:\n Tube feeding:\n IV Fluid:\n 99 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, somewhat\n lethargic but answers all questions, nonfocal neuro exam\n HEENT: PERRL, EOMI, CNII_XII intact\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: around G tube, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n --AAOx3; mental slowing. Status at baseline.\n --Pain well controlled.\n Cardiovascular:\n - HD stable now\n -- SP R sub clavian portcath placement c/b infection removed\n 1 week later. Now Arteriovenous fistula between the peripheral R\n subclavian artery and vein.\n Pulmonary:\n -IS, stable\n Gastrointestinal / Abdomen:\n - UGIB. On PPI. Hct stable. GI is on the consult for possible scoping\n the patient.\n Nutrition:\n - NPO\n Renal:\n - Creatine elevated but that\ns baseline. Unclear etiology.\n Hematology:\n - Hct stable at 35.3 (reportedly from 31 @ )\n Endocrine:\n - RISS\n --cont Dexamethasone 2 mg''\n Infectious Disease:\n - Afebrile, wbc 21.3 (stable from pre-op in )\n Lines / Tubes / Drains: Foley, PIV\n Wounds: healing Crani\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, GI\n Billing Diagnosis: Other: UGIB\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:54 AM\n 22 Gauge - 04:55 AM\n 18 Gauge - 04:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 727410,
"text": "56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, RUE DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later that evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain. Admitted to SICU\n for close monitoring. Diagnostic endoscopy at bedside with no\n intervention. Received fluid bolus AM for hypotension SBP 80s with\n transient improvement. Hct 26.3-> 24.1 received 1 unit PRBC with Hct\n now 27.5. SBP maintainted 90-100s today. No futher coffee ground\n output from PEG, or stool output noted.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Abd soft, non-tender, + bowel sounds, + flatus.\n PEG tube in place, clear green output. NPO. Reports he is\n hungry.\n Pt c/o generalized pain, HA, abd pain today, dull .\n HR 50s-70s regular with short, self\nterminating wide\n complex run in AM, MDs aware on rounds.\n SBP 90-100s, when asleep occ dips to 85+ with rebound to 90s\n when awoken\n Action:\n Tube feed initiated- boost glucose control.\n Dilaudid for pain\n Repeat Hct at 1200= 27.5\n Response:\n Tolerating TF- advancing toward goal of 85mL/hr.\n Good pain relief with PRN dilaudid\n IVF D/C\n Attempted to D/C back to , unable to return\n today.\n Plan:\n Continue to monitor HCT\n Advance TF to goal\n Maintain NPO ? swallow eval, family requesting barium\n swallow\n Transfer to floor.\n Return to .\n Impaired Skin Integrity\n Assessment:\n Pt with multiple wounds: Unstageable blister to R heel,\n abrasion to L lateral hand, abrasion/full thickness wound to L ear,\n scattered eccymotic areas to BUE and behind ears.\n Surgical incision to scalp from craniectomy with\n staples, well approximated, some staples appear to be removed or have\n fallen out.\n PEG to abd.\n Action:\n Wound care RN to bedside to evaluate pt\n boot to R foot\n Frequent turning and reposistioning\n Barrier cream with turns\n TF initiated for nutrition\n Response:\n Per pt and spouse, ear wound has been present for several\n weeks. Pt reports it is from a telephone, spouse reports it is from\n laying in bed.\n Family previously unaware of heel wound, documented on\n admission.\n PEG care done\n Plan:\n Continue turning, skin care\n Advance diet to optimize nutritional status\n use foam padding for ear if desired wound RN.\n ? PT/OT\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727116,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt is A+OX2-3, MAE, follows commands. Speech at times is\n slurred/garbled. PEG to gravity with small amounts of coffee ground\n material.\n Action:\n HCT 35, VSS.\n Response:\n Pt denies pain.\n Plan:\n Pt to have endoscopy this morning. Continue protonix drip. OOB to\n chiar after endoscopy and transfer to floor. Continue to closely\n monitor HCT.\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727117,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output at this time. returns with increased\n coffee ground emesis, tachycardia. He is being admitted to the SICU for\n monitoring and serial Hct.\n Chief complaint:\n GIB\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT 4/.\n Current medications:\n 1000 mL LR 2. Acetaminophen 3. HYDROmorphone (Dilaudid) 4. Lorazepam 5.\n Metoprolol Tartrate 6. Ondansetron\n 7. Pantoprazole 8. Tiotropium Bromide\n 24 Hour Events:\n Admitted\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 91 (88 - 96) bpm\n BP: 98/58(66) {98/58(66) - 112/68(77)} mmHg\n RR: 14 (7 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 99 mL\n PO:\n Tube feeding:\n IV Fluid:\n 99 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, somewhat\n lethargic but answers all questions, nonfocal neuro exam\n HEENT: PERRL, EOMI, CNII_XII intact\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: around G tube, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic: --s/p frontal craniotomy for mass resection most likely\n metastatic\n --Q4H neurocheck\n --Keppra for seizure Prophylaxy\n --Pain controlled w/ dilaudid\n -Ativan PRN\n Cardiovascular: --Tachycardic in ED, fluid resuscitation as needed,\n currently VSS\n --S/P R sub clavian portcath placement c/b infection removed\n 1 week later. Now Arteriovenous fistula between the peripheral R\n subclavian artery and vein.\n Pulmonary: IS, --Stable\n Gastrointestinal / Abdomen: --UGIB\n --GI to scope patient\n --PPI gtt\n Nutrition: NPO\n Renal: -- Creatinine 1.1 baseline.\n --will monitor uop\n Hematology: --Hct stable at 35.3 (reportedly from 31 @ )\n Endocrine: --RISS\n --cont Dexamethasone 2 mg''\n Infectious Disease: --Afebrile, wbc 21.3 (stable from pre-op in )\n Lines / Tubes / Drains: Foley, PIV\n Wounds: healing Crani\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, GI\n Billing Diagnosis: Other: UGIB\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:54 AM\n 22 Gauge - 04:55 AM\n 18 Gauge - 04:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727232,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n - Pt admitted to SICU for scope and serial crits. PEG placed\n to gravity with only 10 cc of coffee ground mixed drainage. Abd soft,\n positive bowel sounds in all 4 quads. ED crit 35, repeat crit at 0745\n 29. Denies abd pain.\n - Pt alert, oriented X 2, poor historian\n this is baseline\n per primary team. Follows commands, largely pleasant but at times uses\n profanity. Lung sounds clear, diminished in bases.\n Action:\n - Endoscopy at 0900. Received 2 mg versed, 100 of fentanyl.\n VSS throughout\n - Repeat crit at 1200\n - Protonix gtt\n Response:\n - Endoscopy showed resolving esophagitis and resolving gastric\n ulcer unrelated to his PEG.\n - Repeat crit 27.3\n Plan:\n - Continue to monitor hemodynamics, crits as ordered\n - Plan to return to tomorrow\n needs a rescreen\n ------ Protected Section ------\n Above note signed right before patient was to be transferred to CC6\n surgical floor. BP then cycled and noted to be in 80s\n sustained.\n Decision made to hold patient. Crit re-sent, down to 26. 500 cc LR\n bolus given. Pressure came back up into 90s. Currently back into 80s\n will rebolus patient and crit due at .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:07 ------\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727320,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n Chief complaint:\n coffee ground emesis\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT \n Current medications:\n 1000 mL LR 2. Acetaminophen 3. Dexamethasone 4. Dextrose 50% 5.\n Glucagon 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. LeVETiracetam 9. Lorazepam 10. Metoprolol Tartrate 11.\n Midazolam 12. Ondansetron\n 13. Pantoprazole 14. Quetiapine Fumarate 15. Tiotropium Bromide\n 24 Hour Events:\n ENDOSCOPY - At 09:00 AM\n CALLED OUT\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:00 AM\n Pantoprazole (Protonix) - 08:34 PM\n Hydromorphone (Dilaudid) - 01:05 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.2\n HR: 72 (60 - 91) bpm\n BP: 106/57(69) {81/32(45) - 117/72(75)} mmHg\n RR: 13 (7 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,591 mL\n 550 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,591 mL\n 200 mL\n Blood products:\n 350 mL\n Total out:\n 1,045 mL\n 560 mL\n Urine:\n 1,045 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,546 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 24.1 %\n [image002.jpg]\n 07:45 AM\n 11:31 AM\n 03:26 PM\n 08:43 PM\n Hct\n 29.0\n 27.3\n 26.3\n 24.1\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n Mental status as the baseline. S/P frontal craniotomy for\n mass resection most likely metastatic. Keppra for seizure prophylaxis.\n Overnight agitation overnight - ativan prn, started seroquel 50mg PO\n BID PRN\n Pain controlled w/ dilaudid\n Cardiovascular:\n n intermittendly hypotensive overnight, but never tachycardic,\n received fluid bolus (totally 1500ml), then got 1 unit of blood. and BP\n improved\n n S/P R sub clavian portcath placement c/b infection\n removed 1 week later. Now Arteriovenous fistula between the peripheral\n R subclavian artery and vein.\n Pulmonary:\n n Stable\n Gastrointestinal / Abdomen:\n n UGIB -> EGD showed stress ulcer, no other site of\n bleeding, no action necessary. PPI IV BID. Re-assess source of of\n bleeding.\n Nutrition: NPO\n Renal:\n n No issue.\n Hematology:\n n Hct slowly trending down (nadir of 24), 1 unit PRBC given,\n will f/u AM HCT\n n Start heparin SQ\n Endocrine:\n n RISS for glycemic control.\n n Pre-existing - Dexamethasone 2 mgBID\n unclear reason\n Infectious Disease: --Afebrile, wbc 21.3->14.2\n Lines / Tubes / Drains: Foley, PIV\n :\n Consults: Trauma surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:55 AM\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727292,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n Chief complaint:\n coffee ground emesis\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT \n Current medications:\n 1000 mL LR 2. Acetaminophen 3. Dexamethasone 4. Dextrose 50% 5.\n Glucagon 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. LeVETiracetam 9. Lorazepam 10. Metoprolol Tartrate 11.\n Midazolam 12. Ondansetron\n 13. Pantoprazole 14. Quetiapine Fumarate 15. Tiotropium Bromide\n 24 Hour Events:\n ENDOSCOPY - At 09:00 AM\n CALLED OUT\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:00 AM\n Pantoprazole (Protonix) - 08:34 PM\n Hydromorphone (Dilaudid) - 01:05 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.2\n HR: 72 (60 - 91) bpm\n BP: 106/57(69) {81/32(45) - 117/72(75)} mmHg\n RR: 13 (7 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,591 mL\n 550 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,591 mL\n 200 mL\n Blood products:\n 350 mL\n Total out:\n 1,045 mL\n 560 mL\n Urine:\n 1,045 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,546 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 24.1 %\n [image002.jpg]\n 07:45 AM\n 11:31 AM\n 03:26 PM\n 08:43 PM\n Hct\n 29.0\n 27.3\n 26.3\n 24.1\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n Mental status as the baseline. S/P frontal craniotomy for\n mass resection most likely metastatic. Keppra for seizure prophylaxis.\n Overnight agitation overnight - ativan prn, started seroquel 50mg PO\n BID PRN\n Pain controlled w/ dilaudid\n Cardiovascular:\n n intermittendly hypotensive overnight, but never tachycardic,\n received fluid bolus (totally 1500ml), then got 1 unit of blood. and BP\n improved\n n S/P R sub clavian portcath placement c/b infection\n removed 1 week later. Now Arteriovenous fistula between the peripheral\n R subclavian artery and vein.\n Pulmonary:\n n Stable\n Gastrointestinal / Abdomen:\n n UGIB -> EGD showed stress ulcer, no other site of\n bleeding, no action necessary. PPI IV BID. Re-assess source of of\n bleeding.\n Nutrition: NPO\n Renal:\n n No issue.\n Hematology:\n n Hct slowly trending down (nadir of 24), 1 unit PRBC given,\n will f/u AM HCT\n Endocrine:\n n RISS for glycemic control.\n n Pre-existing - Dexamethasone 2 mgBID\n unclear reason\n Infectious Disease: --Afebrile, wbc 21.3->14.2\n Lines / Tubes / Drains: Foley, PIV\n :\n Consults: Trauma surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:55 AM\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 727201,
"text": "56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n - Pt admitted to SICU for scope and serial crits. PEG placed\n to gravity with only 10 cc of coffee ground mixed drainage. Abd soft,\n positive bowel sounds in all 4 quads. ED crit 35, repeat crit at 0745\n 29. Denies abd pain.\n - Pt alert, oriented X 2, poor historian\n this is baseline\n per primary team. Follows commands, largely pleasant but at times uses\n profanity. Lung sounds clear, diminished in bases.\n Action:\n - Endoscopy at 0900. Received 2 mg versed, 100 of fentanyl.\n VSS throughout\n - Repeat crit at 1200\n - Protonix gtt\n Response:\n - Endoscopy showed resolving esophagitis and resolving gastric\n ulcer unrelated to his PEG.\n - Repeat crit 27.3\n Plan:\n - Continue to monitor hemodynamics, crits as ordered\n - Plan to return to tomorrow\n needs a rescreen\n Impaired Skin Integrity\n Assessment:\n - L ear with St II/abrasion scabbed over. Left open to air. Pt\n appeared to hospital with it\n - R heel with large area of eshcar/unstageable pressure ulcer.\n - Back/buttocks skin WNL\n Action:\n - Kept pressure off L ear\n - Kept pressure off R heel by ordering multipodus boot\n Response:\n - Skin unchanged\n Plan:\n - Continue to monitor, ? wound care consult before patient returns to\n tomorrow. Heel ulcer may need debridement.\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727263,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n Chief complaint:\n coffee ground emesis\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT \n Current medications:\n 1000 mL LR 2. Acetaminophen 3. Dexamethasone 4. Dextrose 50% 5.\n Glucagon 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. LeVETiracetam 9. Lorazepam 10. Metoprolol Tartrate 11.\n Midazolam 12. Ondansetron\n 13. Pantoprazole 14. Quetiapine Fumarate 15. Tiotropium Bromide\n 24 Hour Events:\n ENDOSCOPY - At 09:00 AM\n CALLED OUT\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:00 AM\n Pantoprazole (Protonix) - 08:34 PM\n Hydromorphone (Dilaudid) - 01:05 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.2\n HR: 72 (60 - 91) bpm\n BP: 106/57(69) {81/32(45) - 117/72(75)} mmHg\n RR: 13 (7 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,591 mL\n 550 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,591 mL\n 200 mL\n Blood products:\n 350 mL\n Total out:\n 1,045 mL\n 560 mL\n Urine:\n 1,045 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,546 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 24.1 %\n [image002.jpg]\n 07:45 AM\n 11:31 AM\n 03:26 PM\n 08:43 PM\n Hct\n 29.0\n 27.3\n 26.3\n 24.1\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n --s/p frontal craniotomy for mass resection most likely metastatic\n --Q4H neurocheck\n --Keppra for seizure Prophylaxy\n --Pain controlled w/ dilaudid\n --agitation overnight: ativan prn, started seroquel 50mg PO BID PRN\n Neurologic: --s/p frontal craniotomy for mass resection most likely\n metastatic\n --Q4H neurocheck\n --Keppra for seizure Prophylaxysis\n --Pain controlled w/ dilaudid\n --agitation overnight: ativan prn, started seroquel 50mg PO BID PRN\n Cardiovascular: -- intermittendly hypotensive overnight, but never\n tachycardic, received fluid bolus (totally 1500ml), then got 1 unit of\n blood. and BP improved\n --S/P R sub clavian portcath placement c/b infection removed\n 1 week later. Now Arteriovenous fistula between the peripheral R\n subclavian artery and vein.\n Pulmonary: --Stable\n Gastrointestinal / Abdomen: --UGIB -> EGD showed stress ulcer, no\n other site of bleeding, no action necessary\n --PPI IV BID\n Nutrition: NPO\n Renal: -- Creatinine 1.1 baseline. AUOP\n Hematology: --HCT slowly trending down (nadir of 24), 1 unit PRBC\n given, will f/u AM HCT\n Endocrine: -- RISS for glycemic control\n --cont Dexamethasone 2 mgBID\n Infectious Disease: --Afebrile, wbc 21.3->14.2\n Lines / Tubes / Drains: Foley, PIV\n Wounds:\n Imaging:\n Fluids:\n Consults: Trauma surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:55 AM\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 727187,
"text": "56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n - Pt admitted to SICU for scope and serial crits. PEG placed\n to gravity with only 10 cc of coffee ground mixed drainage. Abd soft,\n positive bowel sounds in all 4 quads. ED crit 35, repeat crit at 0745\n 29. Denies abd pain.\n - Pt alert, oriented X 2, poor historian\n this is baseline\n per primary team. Follows commands, largely pleasant but at times uses\n profanity. Lung sounds clear, diminished in bases.\n Action:\n - Endoscopy at 0900. Received 2 mg versed, 100 of fentanyl.\n VSS throughout\n - Repeat crit at 1200\n - Protonix gtt\n Response:\n - Endoscopy showed resolving esophagitis and resolving gastric\n ulcer unrelated to his PEG.\n - Repeat crit _____\n Plan:\n - Continue to monitor hemodynamics, crits as ordered\n - Advance diet when able\n - Continue to monitor\n - Plan to return to tomorrow\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727154,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output at this time. returns with increased\n coffee ground emesis, tachycardia. He is being admitted to the SICU for\n monitoring and serial Hct.\n Chief complaint:\n GIB\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT 4/.\n Current medications:\n 1000 mL LR 2. Acetaminophen 3. HYDROmorphone (Dilaudid) 4. Lorazepam 5.\n Metoprolol Tartrate 6. Ondansetron\n 7. Pantoprazole 8. Tiotropium Bromide\n 24 Hour Events:\n Admitted\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 91 (88 - 96) bpm\n BP: 98/58(66) {98/58(66) - 112/68(77)} mmHg\n RR: 14 (7 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 99 mL\n PO:\n Tube feeding:\n IV Fluid:\n 99 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, somewhat\n lethargic but answers all questions, nonfocal neuro exam\n HEENT: PERRL, EOMI, CNII_XII intact\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: around G tube, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n --s/p frontal craniotomy for mass resection most likely metastatic\n --Q4H neurocheck\n --Keppra for seizure Prophylaxy\n --Pain controlled w/ dilaudid\n -Ativan PRN\n Cardiovascular: --Tachycardic in ED, fluid resuscitation as needed,\n currently VSS\n --S/P R sub clavian portcath placement c/b infection removed\n 1 week later. Now Arteriovenous fistula between the peripheral R\n subclavian artery and vein.\n Pulmonary: IS, --Stable\n Gastrointestinal / Abdomen: --UGIB\n --GI to scope patient\n --PPI gtt\n Nutrition: NPO\n Renal: -- Creatinine 1.1 baseline.\n --will monitor uop\n Hematology: --Hct stable at 35.3 (reportedly from 31 @ )\n Endocrine: --RISS\n --cont Dexamethasone 2 mg''\n Infectious Disease: --Afebrile, wbc 21.3 (stable from pre-op in )\n Lines / Tubes / Drains: Foley, PIV\n Wounds: healing Crani\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, GI\n Billing Diagnosis: Other: UGIB\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:54 AM\n 22 Gauge - 04:55 AM\n 18 Gauge - 04:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727172,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output at this time. returns with increased\n coffee ground emesis, tachycardia. He is being admitted to the SICU for\n monitoring and serial Hct.\n Chief complaint:\n GIB\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT 4/.\n Current medications:\n 1000 mL LR 2. Acetaminophen 3. HYDROmorphone (Dilaudid) 4. Lorazepam 5.\n Metoprolol Tartrate 6. Ondansetron\n 7. Pantoprazole 8. Tiotropium Bromide\n 24 Hour Events:\n Admitted\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.3\nC (99.2\n HR: 91 (88 - 96) bpm\n BP: 98/58(66) {98/58(66) - 112/68(77)} mmHg\n RR: 14 (7 - 19) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 99 mL\n PO:\n Tube feeding:\n IV Fluid:\n 99 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, somewhat\n lethargic but answers all questions, nonfocal neuro exam\n HEENT: PERRL, EOMI, CNII_XII intact\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: around G tube, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n --s/p frontal craniotomy for mass resection most likely metastatic\n --Q4H neurocheck\n --Keppra for seizure Prophylaxy\n --Pain controlled w/ dilaudid\n -Ativan PRN\n Cardiovascular: --Tachycardic in ED, fluid resuscitation as needed,\n currently VSS\n --S/P R sub clavian portcath placement c/b infection removed\n 1 week later. Now Arteriovenous fistula between the peripheral R\n subclavian artery and vein.\n Pulmonary: IS, --Stable\n Gastrointestinal / Abdomen: --UGIB\n --GI to scope patient\n --PPI gtt\n Nutrition: NPO\n Renal: -- Creatinine 1.1 baseline.\n --will monitor uop\n Hematology: --Hct stable at 35.3 (reportedly from 31 @ )\n Endocrine: --RISS\n --cont Dexamethasone 2 mg''\n Infectious Disease: --Afebrile, wbc 21.3 (stable from pre-op in )\n Lines / Tubes / Drains: Foley, PIV\n Wounds: healing Crani\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, GI\n Billing Diagnosis: Other: UGIB\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:54 AM\n 22 Gauge - 04:55 AM\n 18 Gauge - 04:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727259,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt alert and oriented X \n SBP 82-92\n 2100 HCT 24\n Very agitated beginning of shift\n Stating\n I am having bad pain\n In my head, back , side and arms\n Attempting to climb OOB\n Stating he was going leave AMA\n Pulling at IV\n Removing multipodus boot and BP cuff\n Action:\n No further fluid bolus\n Received 1u PRBC\n Reoriented pt\n Pt called wife\n Med with hydromorphone for generalized pain\n Med with ativan for anxiety\n Med with seroquil for agitation\n Response:\n 0400 pt states to be pain free\n Sleeping for rest of shift\n Plan:\n Cont to monitor for S&S of GI bleed\n Serial HCT\n"
},
{
"category": "Physician ",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Intensivist Note",
"row_id": 727416,
"text": "SICU\n HPI:\n 56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n Chief complaint:\n coffee ground emesis\n PMHx:\n 1. Non small cell lung CA s/p radiation, 1 week chemo?,\n right lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT \n Current medications:\n 1000 mL LR 2. Acetaminophen 3. Dexamethasone 4. Dextrose 50% 5.\n Glucagon 6. HYDROmorphone (Dilaudid)\n 7. Insulin 8. LeVETiracetam 9. Lorazepam 10. Metoprolol Tartrate 11.\n Midazolam 12. Ondansetron\n 13. Pantoprazole 14. Quetiapine Fumarate 15. Tiotropium Bromide\n 24 Hour Events:\n ENDOSCOPY - At 09:00 AM\n CALLED OUT\n Allergies:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 09:00 AM\n Midazolam (Versed) - 09:00 AM\n Pantoprazole (Protonix) - 08:34 PM\n Hydromorphone (Dilaudid) - 01:05 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 04:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.2\n HR: 72 (60 - 91) bpm\n BP: 106/57(69) {81/32(45) - 117/72(75)} mmHg\n RR: 13 (7 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,591 mL\n 550 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,591 mL\n 200 mL\n Blood products:\n 350 mL\n Total out:\n 1,045 mL\n 560 mL\n Urine:\n 1,045 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,546 mL\n -10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), +s1/s2\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 24.1 %\n [image002.jpg]\n 07:45 AM\n 11:31 AM\n 03:26 PM\n 08:43 PM\n Hct\n 29.0\n 27.3\n 26.3\n 24.1\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 56M w/PMH of NSCLCA (dx , s/p chemo/rad/rxn)\n s/p Rt frontal craniotomy for mass rxn and PEG by Dr. at\n end of , returns with UGIB.\n Neurologic:\n Mental status as the baseline. S/P frontal craniotomy for\n mass resection most likely metastatic. Keppra for seizure prophylaxis.\n Overnight agitation overnight - ativan prn, started seroquel 50mg PO\n BID PRN\n Pain controlled w/ dilaudid\n Cardiovascular:\n n intermittendly hypotensive overnight, but never tachycardic,\n received fluid bolus (totally 1500ml), then got 1 unit of blood. and BP\n improved\n n S/P R sub clavian portcath placement c/b infection\n removed 1 week later. Now Arteriovenous fistula between the peripheral\n R subclavian artery and vein.\n Pulmonary:\n n Stable\n Gastrointestinal / Abdomen:\n n UGIB -> EGD showed stress ulcer, no other site of\n bleeding, no action necessary. PPI IV BID. Re-assess source of of\n bleeding.\n Nutrition: NPO\n Renal:\n n No issue.\n Hematology:\n n Hct slowly trending down (nadir of 24), 1 unit PRBC given,\n will f/u AM HCT\n n Start heparin SQ\n Endocrine:\n n RISS for glycemic control.\n n Pre-existing - Dexamethasone 2 mgBID\n unclear reason\n Infectious Disease: --Afebrile, wbc 21.3->14.2\n Lines / Tubes / Drains: Foley, PIV\n :\n Consults: Trauma surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:55 AM\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 34 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 727362,
"text": "Subjective: Unable to speak with patient.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 87.7 kg\n 27.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 116%\n 85.5kg ()\n 136kg ()\n 103% (recent usual body wt)\n Diagnosis: Upper GI Bleed\n PMHx: 1. Non small cell lung CA s/p radiation, 1 week chemo?, right\n lung lobectomy. Current status unclear.\n 2. Vocal cord paralysis after post lung surgery\n 3. DM\n 4. Dementia for last 2 yrs\n 5. Residual brain damage from drug overdose \n 6. Possible NPH seen on MRI ?\n 7. RUE DVT \n Food allergies and intolerances: none per family\n Pertinent medications: lactated ringers @ 10mL/hr, RISS, PRotonix,\n dexamethasone, others noted\n Labs:\n Value\n Date\n Glucose\n 150 mg/dL\n 02:13 AM\n Glucose Finger Stick\n 143\n 10:00 AM\n BUN\n 11 mg/dL\n 02:13 AM\n Creatinine\n 0.8 mg/dL\n 02:13 AM\n Sodium\n 135 mEq/L\n 02:13 AM\n Potassium\n 4.5 mEq/L\n 02:13 AM\n Chloride\n 102 mEq/L\n 02:13 AM\n TCO2\n 29 mEq/L\n 02:13 AM\n pH (urine)\n 7.0 units\n 03:00 AM\n Calcium non-ionized\n 8.5 mg/dL\n 02:13 AM\n Phosphorus\n 3.6 mg/dL\n 02:13 AM\n Magnesium\n 1.7 mg/dL\n 02:13 AM\n WBC\n 14.2 K/uL\n 02:13 AM\n Hgb\n 9.3 g/dL\n 02:13 AM\n Hematocrit\n 27.5 %\n 11:23 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Replete with Fiber @ 60mL/hr (ordered, not running) =\n 1440kcals, 89g protein\n GI: PEG in place, abd soft, bowel sounds present\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Patient at risk due to: h/o wt loss, GIB, tube feed dependence\n Estimated Nutritional Needs\n Calories: 2100-2455 ( 24-28 cal/kg)\n Protein: 105-131 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 56 y.o. Male, recently admitted with brain mass and had a craniotomy\n with tumor resection , along with a PEG placed . Patient was\n discharged to rehab , and returned with large amounts of bloody\n output from PEG. EGD done showed esophagitis with evidence of\n recent bleeding at GE junction. Patient is tube feeding dependent due\n to dysphagia found on swallow evaluations and . Current tube\n feeding order underfeeds calories and protein. Recommend changing tube\n feed formula back to goal used at previous admit.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feeding goal of Boost Glucose Control @\n 85mL/hr (2162kcals /118g protein).\n Monitor tolerance with abd exam and residual checks q4hrs;\n hold if greater than 200mL.\n Monitor lytes and hydration.\n Following - #\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 727422,
"text": "56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in . Dementia, brain injury, DM, RUE DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later that evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain. Admitted to SICU\n for close monitoring. Diagnostic endoscopy at bedside with no\n intervention. Received fluid bolus AM for hypotension SBP 80s with\n transient improvement. Hct 26.3-> 24.1 received 1 unit PRBC with Hct\n now 27.5. SBP maintainted 90-100s today. No futher coffee ground\n output from PEG, or stool output noted.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Abd soft, non-tender, + bowel sounds, + flatus.\n PEG tube in place, clear green output. NPO. Reports he is\n hungry.\n Pt c/o generalized pain, HA, abd pain today, dull .\n HR 50s-70s regular with short, self\nterminating wide\n complex run in AM, MDs aware on rounds.\n SBP 90-100s, when asleep occ dips to 85+ with rebound to 90s\n when awoken\n Action:\n Tube feed initiated- boost glucose control.\n Dilaudid for pain\n Repeat Hct at 1200= 27.5\n Response:\n Tolerating TF- advancing toward goal of 85mL/hr.\n Good pain relief with PRN dilaudid\n IVF D/C\n Attempted to D/C back to , unable to return\n today.\n Plan:\n Continue to monitor HCT\n Advance TF to goal\n Maintain NPO ? swallow eval, family requesting barium\n swallow\n Transfer to floor.\n Return to .\n Impaired Skin Integrity\n Assessment:\n Pt with multiple wounds: Unstageable blister to R heel,\n abrasion to L lateral hand, abrasion/full thickness wound to L ear,\n scattered eccymotic areas to BUE and behind ears.\n Surgical incision to scalp from craniectomy with\n staples, well approximated, some staples appear to be removed or have\n fallen out.\n PEG to abd.\n Action:\n Wound care RN to bedside to evaluate pt\n boot to R foot\n Frequent turning and reposistioning\n Barrier cream with turns\n TF initiated for nutrition\n Response:\n Per pt and spouse, ear wound has been present for several\n weeks. Pt reports it is from a telephone, spouse reports it is from\n laying in bed.\n Family previously unaware of heel wound, documented on\n admission.\n PEG care done\n Plan:\n Continue turning, skin care\n Advance diet to optimize nutritional status\n use foam padding for ear if desired wound RN.\n ? PT/OT\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 87.7 kg\n Daily weight:\n Allergies/Reactions:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Precautions:\n PMH:\n CV-PMH:\n Additional history: .NSCLCA s/p radiation and chemo\n .vocal cord paralysis\n .Diabetes Mellitus\n .Dementia\n .Brain injury s/p drug overdose \n .NPH\n .RUE DVT \n .right subclavian AVF\n PSH:\n s/p Right frontal craniotomy \n s/p PEG \n s/p LULectomy\n Surgery / Procedure and date: s/p Right frontal craniotomy \n s/p PEG \n s/p LULectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:93\n D:64\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 67 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,388 mL\n 24h total out:\n 2,820 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:13 AM\n Potassium:\n 4.5 mEq/L\n 02:13 AM\n Chloride:\n 102 mEq/L\n 02:13 AM\n CO2:\n 29 mEq/L\n 02:13 AM\n BUN:\n 11 mg/dL\n 02:13 AM\n Creatinine:\n 0.8 mg/dL\n 02:13 AM\n Glucose:\n 150 mg/dL\n 02:13 AM\n Hematocrit:\n 27.5 %\n 11:23 AM\n Finger Stick Glucose:\n 173\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727285,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt alert and oriented X \n SBP 82-92\n 2100 HCT 24\n Very agitated beginning of shift\n Stating\n I am having bad pain\n In my head, back , side and arms\n Attempting to climb OOB\n Stating he was going leave AMA\n Pulling at IV\n Removing multipodus boot and BP cuff\n Action:\n No further fluid bolus\n Received 1u PRBC\n Reoriented pt\n Pt called wife\n Med with hydromorphone for generalized pain\n Med with ativan for anxiety\n Med with seroquil for agitation\n Response:\n Post transfusion HCT=27\n 0400 pt states to be pain free\n Sleeping for rest of shift\n Plan:\n Cont to monitor for S&S of GI bleed\n Serial HCT\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727203,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n - Pt admitted to SICU for scope and serial crits. PEG placed\n to gravity with only 10 cc of coffee ground mixed drainage. Abd soft,\n positive bowel sounds in all 4 quads. ED crit 35, repeat crit at 0745\n 29. Denies abd pain.\n - Pt alert, oriented X 2, poor historian\n this is baseline\n per primary team. Follows commands, largely pleasant but at times uses\n profanity. Lung sounds clear, diminished in bases.\n Action:\n - Endoscopy at 0900. Received 2 mg versed, 100 of fentanyl.\n VSS throughout\n - Repeat crit at 1200\n - Protonix gtt\n Response:\n - Endoscopy showed resolving esophagitis and resolving gastric\n ulcer unrelated to his PEG.\n - Repeat crit 27.3\n Plan:\n - Continue to monitor hemodynamics, crits as ordered\n - Plan to return to tomorrow\n needs a rescreen\n"
},
{
"category": "Nursing",
"chartdate": "2144-03-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 727204,
"text": "56M with PMH of Non small cell lung CA s/p right lung lobectomy,\n chemo,radiation all in ., dementia, brain injury, DM, DVT\n Recently s/p Rt frontal craniotomy for mass resection, transferred from\n . Per report, at he had some nausea this AM --\n and 450cc of coffee ground liquid was drained from his NGT -- he was\n closely monitored, and tube feeds were held -- later this evening,\n however, another 300cc of bloody output was drawn back. The patient\n had some complaints of nausea but no abdominal pain.\n He currently feels well and has minimal complaints, although is a poor\n historian. His Gtube was placed to suction in the ED with at least\n 200cc of dark, bloody output.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n - Pt admitted to SICU for scope and serial crits. PEG placed\n to gravity with only 10 cc of coffee ground mixed drainage. Abd soft,\n positive bowel sounds in all 4 quads. ED crit 35, repeat crit at 0745\n 29. Denies abd pain.\n - Pt alert, oriented X 2, poor historian\n this is baseline\n per primary team. Follows commands, largely pleasant but at times uses\n profanity. Lung sounds clear, diminished in bases.\n Action:\n - Endoscopy at 0900. Received 2 mg versed, 100 of fentanyl.\n VSS throughout\n - Repeat crit at 1200\n - Protonix gtt\n Response:\n - Endoscopy showed resolving esophagitis and resolving gastric\n ulcer unrelated to his PEG.\n - Repeat crit 27.3\n Plan:\n - Continue to monitor hemodynamics, crits as ordered\n - Plan to return to tomorrow\n needs a rescreen\n Impaired Skin Integrity\n Assessment:\n - L ear with St II/abrasion scabbed over. Left open to air. Pt\n appeared to hospital with it\n - R heel with large area of eshcar/unstageable pressure ulcer.\n - Back/buttocks skin WNL\n Action:\n - Kept pressure off L ear\n - Kept pressure off R heel by ordering multipodus boot\n Response:\n - Skin unchanged\n Plan:\n - Continue to monitor, ? wound care consult before patient returns to\n tomorrow. Heel ulcer may need debridement.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 87.7 kg\n Daily weight:\n Allergies/Reactions:\n Tramadol\n \"Severe GI Prob\n Hydrocodone Bitartrate/Apap (Oral)\n \"Severe GI prob\n Precautions:\n PMH:\n CV-PMH:\n Additional history: .NSCLCA s/p radiation and chemo\n .vocal cord paralysis\n .Diabetes Mellitus\n .Dementia\n .Brain injury s/p drug overdose \n .NPH\n .RUE DVT \n .right subclavian AVF\n PSH:\n s/p Right frontal craniotomy \n s/p PEG \n s/p LULectomy\n Surgery / Procedure and date: s/p Right frontal craniotomy \n s/p PEG \n s/p LULectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:43\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,095 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Hematocrit:\n 27.3 %\n 11:31 AM\n Finger Stick Glucose:\n 172\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: CC6\n Date & time of Transfer: 1500\n"
},
{
"category": "ECG",
"chartdate": "2144-03-17 00:00:00.000",
"description": "Report",
"row_id": 299399,
"text": "Sinus rhythm with baseline artifact. Possible left atrial abnormality.\nCompared to the previous tracing of the ST-T wave changes have\nresolved.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-03-11 00:00:00.000",
"description": "Report",
"row_id": 299400,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-03-10 00:00:00.000",
"description": "Report",
"row_id": 299401,
"text": "Sinus rhythm. RSR' pattern in leads V1-V2 may be normal variant. Modest low\namplitude T wave changes are non-specific. Since the previous tracing\nof sinus tachycardia is absent, delayed R wave progression pattern\nis less prominent and ST-T wave changes have decreased.\n\n"
}
] |
29,347 | 146,160 | Patient is an 84 year old female with history of hypertension, atrial fibrillation, tachy-brady syndrome status post pace-maker placement, who presented with chest pain and EKG findings concerning for a ST elevation myocardial infarction. | Bilat LE edema R>L. ekg-chgs consistant w presvious ekgs. There istrivial mitral regurgitation. Moderate mitral annularcalcification. Palp DP/PT.RESP- LS clear thoughout. breath sounds=deminished through- out. 0530 THIS A.M.->C/O CHEST PRESSURE . ?rx of af after tee. Moderate regionalLV systolic dysfunction. RR even and reg.GI- Decreased PO intake, needs encouragement. rxed w increased po dose & iv lopressor-remains in rate controlled af. Cr 1.7 (no change).ID: WBC flat, afebrile, Contact for VRE urine.SKIN: See careviewSOCIAL: Dtr called last noc--updated. The pacemaker leads terminate in expected location of the right atrium and right ventricle. Pt with some c/o abd discomfort-> relieved with maalox, belching and BM x1. Tx'd w/ 1unit PRBC. "O: Please see careview for VS and additional data.CV: Pt HR 90-124 afib with rare pacing beat noted, NBP 92-120/55-72. updated re pt status.a:large anterior mi rx w ptca & bms to lad. s/p l hip fx.allergies: zantac. ranitidine. There is a trivial/physiologic pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolicdysfunction c/w CAD (LAD distribution). Left ventricular function.Height: (in) 60Weight (lb): 114BSA (m2): 1.47 m2BP (mm Hg): 96/41HR (bpm): 105Status: InpatientDate/Time: at 12:09Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes. METOPROLOL 5MG VP X2 WITH GRADUAL RELIEF OF PRESSURE & HR 90-110 AF. Pt given robitussin x1 after c/o cough earlier this am, otherwise no c/o cough/cough noted. code stemi called. INR 2.2, restarting low-dose coumadin today. htn. Follow renal fxn. IVF bolus for low u/o, pt at . renal=foley. Pt with occ c/o DOE, resolves with rest.Neuro: Pt A&Ox3, MAE, cooperative with care. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Right pleural effusion.Conclusions:The left atrium and right atrium are normal in cavity size. gerd. dp pulses >+1 bilaterally. admitted to ccu w continued cp over 10-?thought to be related to embolization of thrombus.o:pulm=o2 2l nc w sats upper 90's. creat 2.0 up from adm creat of 1.4. heme=am hct stable 33.7 (tx w 1urbc in past-hx chronic anemia). HCT stable 34.5. levaquin. HCT 33.3.GI: ABD. Comparison is made to the prior chest radiographs of . Mild [1+] TR. Medium stool today guaiac negative. id=afebrile. TDI E/e' >15, suggestingPCWP>18mmHg.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; anterior apex - akinetic; septal apex- akinetic; inferior apex -akinetic; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). vancomycin. Check post transfusion HCT. RR 12-17.CARDIAC: HR 70-100 AF WITH OCC. "O: Please see carevue for objective data.Neuro- A&Ox3. Thereis mild symmetric left ventricular hypertrophy with normal cavity size. ck/md-4759/238 w ldh-1703. NBP stable 100-120s/60-70s. BS+. Bilat pedal pulses palp, R groin site CDI.Resp: Pt LS CTA, RR 12-21, O2 sats 98-100%. Given lasix as above. Probable atrial fibrillation with ventricular responseAnterior myocardial infarction with ST-T wave configuration consistent withacute/recent/in evolution processSince previous tracing of the same date, ventricular rate slower Normal sinus rhythm with slight ST segment elevations in the anteriorleads with Q waves in lead V4 and delayed R wave transition consistent withanterior myocardial infarction. Onceagain, this is consistent with evolving anterior myocardial infarction comparedto tracing #2.TRACING #3 Probable atrial fibrillation with rapid ventricular responseAnterior myocardial infarction with ST-T wave configuration consistent withacute/recent/in evolution processSince previous tracing of the same date, ventricular ectopy absent Occasional ventricularpremature beats. Compared to the previous tracing of there has been evolution of anterior myocardial infarction.TRACING #3 ST segmentelevations in leads V1-V6 and, to a lesser degree, in leads I and aVLconsistent with acute anterior myocardial injury. Loss of R waves in theanterior leads with ST segment elevations in leads V3-V4 suggests ongoinganterior wall myocardial infarction. Compared to the previous tracing of atrialfibrillation persists. Acute anteroseptal myocardialinjury. Atrial fibrillation with moderate ventricular response. Atrial fibrillation with moderate ventricular response. Otherwise, findings consistent with ongoing anterior wall myocardialinfarction persist. Compared to the previous tracingof ST segment elevations in the anterior leads persist. Biphasic T waves in leads I and aVL. Sinus rhythm.ST segment elevations in leads I, aVL, V1-V5. Compared tothe previous tracing of atrial fibrillation is new. Compared to tracing #1 occasional ventricular premature beatsare new. ST segment elevations in leads V2-V5 with biphasic T waves inlead V4 and T wave inversions in leads I and aVL all consistent with evolutionof acute anterior myocardial infarction. Atrial fibrillation with rapid ventricular response and a single ventricularpremature beat. ST segments are more prominently elevated in theanterior precordial leads which may be secondary to rate or recurrentischemia. Probable atrial fibrillation with rapid ventricular responseAnterior myocardial infarction with ST-T wave configuration consistent withacute/recent/in evolution processSince previous tracing of , probably no significant change Normal sinus rhythm with atrial pacing and T wave inversions in leads V1-V2with ST segment elevations in leads V2-V5. Compared to tracing #1 theST segment elevations are less prominent suggestive of evolving anteriormyocardial infarction.TRACING #2 Slight ST segmentelevation in leads V2-V5. ST segment elevations in leads V2-V5 with T wave inversionsin leads I and aVL. Clinicalcorrelation is suggested.TRACING #1 Clinicalcorrelation is suggested.TRACING #1 Atrial fibrillation with rapid ventricular response. Compared to the previous tracing ST segment elevations are new.TRACING #1 Sinus rhythm. Sinus rhythm. However,ST segments are less elevated in the anterior precordial leads.TRACING #4 Compared to prior tracingST segments are more elevated in the lateral leads but are decreasing in heightin the anteroseptal leads.TRACING #2 There is intermittent atrial pacing. Clinical correlation is suggested.TRACING #2 TRACING SUBMITTED LATE AND OUT OF SEQUENCE. TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Baseline artifact. Clinical correlation is suggested.TRACING #5 | 27 | [
{
"category": "Radiology",
"chartdate": "2198-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017647,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for evidence of edema, other acute pathology\n Admitting Diagnosis: MYOCARDIAL INFARCTION/CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p large anterior STEMI, AF, pacemaker for tachybrady\n syndrome.\n REASON FOR THIS EXAMINATION:\n please assess for evidence of edema, other acute pathology\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Myocardial infarct, pacemaker placed. Evaluate for\n failure.\n\n Cardiac size is somewhat enlarged. Dual-chamber pacemaker is present with the\n leads in satisfactory position. No failure is present. The costophrenic\n angles are sharp. There has been no significant change since the prior chest\n x-ray of .\n\n IMPRESSION: No failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017568,
"text": " 1:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, volume overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with Hx angina, now CP\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with history of angina. Please evaluate for\n infiltrate or volume overload.\n\n Comparison is made to the prior chest radiographs of .\n\n The heart size is in the upper limit of normal. The aorta is mildly tortuous.\n The hilar contours are normal. No focal consolidation, pleural effusion or\n pneumothorax is noted. The pacemaker leads terminate in expected location of\n the right atrium and right ventricle. The overlying osseous structures appear\n unremarkable.\n\n IMPRESSION: No acute intrathoracic pathology including no pneumonia or heart\n failure.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-01 00:00:00.000",
"description": "Report",
"row_id": 1642664,
"text": "ccu nsg admit note.\n84 yo female admitted from cardiac cath lab s/p intervention.\n\npmh:extensive-afib. tachy-brady syndrome-ddi pacer . htn. cri(baseline creat 1.5-1.6). mastocytosis rx w chemo therapy. osteoporosis. gerd. cataracts. chronic back pain. s/p l hip fx.\n\nallergies: zantac. ranitidine. pcn. asa. vancomycin. levaquin. lisinopril.\n\nsocial:widowed. lives in housing. non smoker/drinker. daughter lives nearby.\n\npresent hx: developed sever squeezing chest pain w radiation to jaw & back. wo nausea, diaphoresis, or sob. called 911. transported to ew. ekg-ste v2-6. code stemi called. rxed in ew w heparin, integrillin bolus-180mg, plavix 600mg, & asa 325mg. taken to cath lab=to occuled lad @ origin-ptca to lad resulted in increased cp & ste >5mm in v2-5 & subsequently had bms x1 placed in lad w gradual improvement in severity of cp. admitted to ccu w continued cp over 10-?thought to be related to embolization of thrombus.\n\no:pulm=o2 2l nc w sats upper 90's. breath sounds=deminished through- out. wo c/o dyspnea/sob.\n cv=continued chest pressure. ekg-chgs consistant w presvious ekgs. chest pressure rxed w increased ntg gtt & prn morphine iv w limited effect. medical team aware. rhythm-nsr wo ectopy w rate 60's. maps >60. iv ntg @ 1.54mcg/kg/min. ck/md-4759/238 w ldh-1703. inr-2.4 -2.8.\nr fem site-sl ooze wo hematoma. dp pulses >+1 bilaterally.\n gi=tolerating clear liquids. wo stool.\n renal=foley. adeq uo. acetylcysteine po given-1st of 2 ordered doses. d5w w sodium bicarb completed @ 0000. bun/crea stable @ 36/1.4.\n heme=hct-25.5 (normally recieves tx every other week).\n id=afebrile. wbc-6.6.\n skin=l glut w contusion & r heel reddened-see care view for details.\n social=daughter & son-in-law initially in to visit. updated re pt status.\n\na:large anterior mi rx w ptca & bms to lad. contin chest pressure post procedure being rxed w iv ntg & iv morphine.\n\np:contin presetn management. close monitoring. support pt/family as indicated.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-01 00:00:00.000",
"description": "Report",
"row_id": 1642665,
"text": "CCU Nursing Progress Note 0700-1900\nS: \"I feel exhausted.\"\n\nO: Please see carevue for objective data.\n\nNeuro- A&Ox3. Pleasant and cooperative with care. Moving all extremities. OOB to commode x 2, gait steady.\n\nPain- c/o Left chronic lower back pain, present at 8/10 with movement, 0/10 rest. Pain usually not this bad at home but pt suspects worse r/t bedrest. Hot pack applied w/ some relief. Has taken tramadol in past, so CCU team notified and pt given 50mg tramadol @ 1830- monitor effects.\n\nCV- HR 60s-70s NSR with occasional PVCs. NIBP 95-130s/40s-50s. No futher residual chest pressure post cath. IV nitro weaned to off by 1200. Tolerating lopressor and new med cozaar (unclear if pt has allergy to , so started on ). HCT 25.5 from 33 on admission. Tx'd w/ 1unit PRBC. Repeat HCT @ 1830 PND. R groin cardiac cath site- dsg removed, CDI, no ooze/hematoma. Palp DP/PT bilat. Bilat LE edema R>L. Given 20mg IV lasix @ 1715 for decreased urine output w/ good response in first hour (220ml out)- continue to monitor.\n\nRESP- LS diminished bilat. SPO2 100% RA. Dry cough. +SOB with exertion.\n\nGI- Prefers pills crushed in ice cream or applesauce. +BS x 4 quad. Abd soft, NT/ND. Medium stool today guaiac negative. Tolerating heart healthy diet. Elevated LFTs.\n\nGU- Foley cath w/ 0-20ml/hour x several hours. CCU team notified. Little improvement after unit of blood. Given lasix as above. Currently 900ml+ for today. Cr 1.4, BUN 36 (baseline)\n\nSKIN- Multiple areas of bruising presumably from ACT 500 yesterday. R groin as above. R heel s/p prior stage 2, now pink. Elevated on pillow throughout day, barrier cream PRN.\n\nID- VRE Precautions. Afebrile. WBC 6.6.\n\nAccess- PIV x 2 #18 RFA- both flushed and patent\n\nSocial- dtr and granddaughter in to visit. Updated on plan of care by RN. RN copy of pt's HCP, living will, and power of attorney-> placed in front of chart.\n\nA/P: 84 yo female w/ large anterior STEMI s/p BMS to 100% Occluded LAD. Presently hemodynamically stable. Chest pain/pressure free. Continue to monitor hemodynamics. Follow urine output s/p lasix. Monitor response to pain meds on lower back pain. Skin care PRN. Check post transfusion HCT. ECHO and PT consult tomorrow. Follow renal fxn. Emotional support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 1642666,
"text": "ccu nsg progress note.\n84 yo female s/p large anterior stemi rxed w ptca & bms to lad.\n\no:cv=nsr to af @ 0100 (past hx of af). af rate from 90-120. stable bp. wo c/o chest pain. rxed w increased po dose & iv lopressor-remains in rate controlled af. not on heparin-inr 3.4.\n gi=npo for tee in am.\n gu=lasix 20mg ivp @ 0000-gd response. creat 2.0 up from adm creat of 1.4.\n heme=am hct stable 33.7 (tx w 1urbc in past-hx chronic anemia).\n misc=intermittently co low back pain-repositioned, heat applied, & med w effect.\n skin=see care view for documentation.\n\na:new onset af-awaiting tee-?amiodarone.\n\np:contin present management. tee in am. ?rx of af after tee. support pt/ family as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 1642667,
"text": "CCU NPN 1000-1900\nS: \" Its just a pressure that comes and goes...I'm not a headache person.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt with c/o CP x2-once at 0930 with HR afib 120's-> resolved without intervention as HR decreased, done, MD's aware, second episode this afternoon, pt again with \"chest pressure\" HR noted to be 120 NSR-> EKG done, CCU intern, resident and fellow aware, 5 mg IV metoprolol given x2 with no effect in HR, chest pressure resolved without intervention and HR continued 110-120's. Esmolol gtt started without bolus up to 150 mcg/kg/min with no effect. RN spoke with Dr. and Dr. > V.O for 500 mcg/kg/min bolus over one minute and esmolol gtt titrated up to 100 mcg/kg/min with effect in HR, HR 80's-90's afib. Metoprolol PO dose increased this afternoon, increased dose to continue when esmolol gtt is OFF as per orders. Bilat pedal pulses palp, R groin site CDI.\n\nResp: Pt LS CTA, RR 12-21, O2 sats 98-100%. Pt given robitussin x1 after c/o cough earlier this am, otherwise no c/o cough/cough noted. Pt denies SOB, mild DOE noted with pt OOB to chair this afternoon.\n\nNeuro: Pt A&Ox3, cooperative with care, MAE. Pt OOB to chair with 1 assist this afternoon, pt steady on feet. Pt asking appropriate questions re. POC.\n\nGI/GU: Foley cath draining clear (at times pink tinged) amber colored u/o-> CCU intern aware, u/o 10-45 cc's/hr. Pt -1345 cc's at 1700. Creatinine decreased to 1.8 this afternoon (from 2.0). Pt abd soft, +BS x4, pt NPO this am for anticipated TEE-> Changed to ECHO, pt tol 2 crackers and tea in afternoon, 100% of dinner (eggs and 1 slics toast)this eve.\n\nID: Afebrile.\n\nSkin: Pt noted for Sm purple bruise like area on left buttock, also, pink area with fluid filled appearing blister noted. Pt also with pink heel-pt turned and barrier cream applied as pt tol. Pt enc to frequently turn and reposition.\n\nSocial: Pt dtr, grandson in this afternoon, son-in-law in this eve, spoke with RN re. pt condition and POC.\n\nA/P: 84 y/o female s/p anterior STEMI with PTCA and BMS to LAD, pt with \"chest pressure\" x2 in setting of tachycardia, HR controlled with esmolol gtt. As discussed with CCU MD's, cont to monitor pt hemodynamics, titrate esmolol gtt to goal HR <90. Cont to monitor resp status, u/o, enc diet and activity as tol. Cont to monitor skin, enc to turn. Cont to provide emotional support to pt and family, awaiting further POC per CCU Team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-03 00:00:00.000",
"description": "Report",
"row_id": 1642668,
"text": "84 YR. OLD WOMAN S/P LG ANTERIOR STEMI. CATH LAB->PTCA & BMS TO LAD.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE WITH CARE.\n\nRESP: O2->2L NP WITH O2 SAT 97-100%. BS CLEAR. RR 12-17.\n\nCARDIAC: HR 70-100 AF WITH OCC. PACED BEATS. SBP 70-80'S ON ESMOLOL 100MCG/KG. DOSE TITRATED DOWN & OFF WITH PERSISTENT HYPOTENSION. NS BOLUS 250CC X2 GIVEN WITH EVENTUAL INCREASE IN BP 90-102/40-50'S. 0530 THIS A.M.->C/O CHEST PRESSURE . HR 100-140'S RAF. BP 90-113/40-50. EKG DONE->NO CHANGES. NTG SL X3. METOPROLOL 5MG VP X2 WITH GRADUAL RELIEF OF PRESSURE & HR 90-110 AF. R. GROIN SITE C&D. HCT 33.3.\n\nGI: ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING TEA COLOR URINE WITH SEDIMENT. U/O 8-15CC/HR. HO AWARE. CREAT 1.8.\n\nID: AFEBRILE.\n\nAM LABS PENDING.\n\nPLAN: ? RESTART DIG VS OTHER RATE CONTROLLING .\n INCREASE ACTIVITY AS TOL.--?? PT CONSULT.\n ADDRESS LOW URINE OUTPUT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-03 00:00:00.000",
"description": "Report",
"row_id": 1642669,
"text": "CCU NPN 0700-1900\nS: \"It's just so hard to take these pills.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 90-124 afib with rare pacing beat noted, NBP 92-120/55-72. Pt started on PO amiodarone and restarted on Po lasartan for afib/remodeling post MI, pt tol thus far, pt metoprolol dose increased to 37.5 mg TID. Bilat pedal pulses palp, no c/o chest pain/pressure. Pt given 5 mg IV lopressor x1 with HR from 130 to 90's-110's.\n\nResp: Pt LS CTA, RR 13-23, O2 sats 98-100% on room air. Pt with occ c/o DOE, resolves with rest.\n\nNeuro: Pt A&Ox3, MAE, cooperative with care. Pt OOB to commode with 1 assist, pt steady on feet. Ambulated in hallway with PT, see note in chart. Pt asking appropriate questions re. POC. Pt with some c/o abd discomfort-> relieved with maalox, belching and BM x1. Pt with some c/o L hip discomfort ( pt baseline), lidocaine patch applied with relief.\n\nGI/GU: Pt abd soft, +BSx4, 1 med brown stool this afternoon. Pt eating approx 50% of meals, some c/o nausea-resolved with sitting upright, belching and BM. Pt taking in MINIMAL PO fluids, pt enc to drink throughout day-pt continues with minimal intake, CCU intern aware, will possibly get IVF bolus this eve MD if u/o does not improve/increase in PO. Pt likes pills crushed with applesauce or ice cream. Foley dc'd at 1200, pt at . CCU intern notified that pt had not voided as of 1700, will cont to monitor MD.\n\nID: Pt afebrile.\n\nSkin: Pt with areas of skin impairment, see flowsheet.\n\nSocial: Pt dtr in at bedside this afternoon, spoke with RN re. pt condition and POC.\n\nA/P: 84 y/o female s/p anterior STEMI with BMS TO LAD, continues with poor rate control-> amiodarone, losartan added and metoprolol to be increased. As discussed CCU MD's, cont to monitor pt hemodynamics-titrate meds as tol, rate control. COnt to monitor fluid status-? IVF bolus for low u/o, pt at . Cont to monitor skin, provide emotional support to pt and family. Awaiting further POC per CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-04 00:00:00.000",
"description": "Report",
"row_id": 1642670,
"text": "CCU NPN 1900-0700\nS: \"Maybe I'm imagining all of this pain\"\nO: Pls see careview for further details\n\nNEURO/PAIN: Did not sleep much most of noc-took sm naps. Declined sleep aid. Lidocaine patch L hip for chronic L hip pain s/p replacement--off @ MN, to be placed at noon.\n\nCV: AF rate 90-one teens, down to 70-90s after cardiac meds. NBP stable 100-120s/60-70s. Tol new dosage 37.5mg Po lopressor and 400mg Amio. No further runs RAF. Rare paced beats--see strips in chart. HCT stable 34.5. INR 2.2.\n\nRESP: C/o intermittent SOB @ rest % w/ exertion--\"not getting air\". No apparent resp distress. Sats >96% on RA, LCTAB, resp unlabored & WNL. CCU team aware.\n\nGI/GU: Poor PO intake, enc to drink. Pills crushed in applesauce. +belching. LBM--yesterday. Foley DCd yesterday afternoon at 1400. No uop, rec'd 250cc IVF--w/ no response. States she has to void. Tiny dribbles on sanitary napkin. No c/o burning. Bladder scanned--489cc urine. Straight cath--330cc clr urine w. sediment. UA/UCx sent. Cr 1.7 (no change).\n\nID: WBC flat, afebrile, Contact for VRE urine.\n\nSKIN: See careview\n\nSOCIAL: Dtr called last noc--updated. Spoke to pt on phone in room.\n\nACCESS: 2 PIVS due to be changed today. 1 placed today. See careview.\n\nA: Tol new adjustments in cardiac meds, better rate ctl. Little to no uop s/p foley DC. ?c/o this afternoon.\n-fluid challenge, bladder scan, ?re-insert foley\n-restart coumadin for AF today\n-^ activity as tol\n-pain management\n-freq reassurance, emotional support, update fam on POC PRN.\nAwaiting further plan from CCU team\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2198-07-04 00:00:00.000",
"description": "Report",
"row_id": 1642671,
"text": "CCU Nursing Progress Note 0700-\nS: \"I just don't feel well!\"\n\nO: Please see carevue for all objective data.\n\nNeuro/Pain- A&Ox3. Pleasant and cooperative with care. Moving all extremities. OOB to chair/commode w/ min one assist. Expressing frustration r/t hospitalization and illness. Emotional support provided. Cont to complain of general malaise- unable to pinpoint location or describe discomfort. CCU team aware. Sleeping in naps throughout day.\n\nCV- HR 90s-110s, AFib this AM and pt c/o SOB. Given 5mg IV lopressor with no effect on HR (pt unable to take po meds r/t nausea). After one hour, pt able to take pos and given AM dose of amiodarone plus increased dose of lopressor 50mg PO TID with HR down to 70s-90s Afib. Occasional A-V pacing noted as well as rare failure to A-sense. EP notified, interrogated device and changed parameters. ECHO - EF 25-35% w/ akinetic apex. INR 2.2, restarting low-dose coumadin today. Lasix started PO today. Palp DP/PT.\n\nRESP- LS clear thoughout. SPO2>95% RA. No cough. RR even and reg.\n\nGI- Decreased PO intake, needs encouragement. Likes meds crushed in ice cream (can't swallow pills). +BS x 4 quad. Abd soft, NT/ND.\n\n Pt w/ no urine out until 1500 when voided 150ml clear, yellow urine. Bladder scan post-void= 570ml. Team notified and reinserted foley cath- drained 280ml immediately. Continue to monitor.\n\nSKIN- R groin cath site CDI, +ecchymosis, no ooze. Coccyx w/ pink area per carevue. Buttocks w/ small bruise per carevue.\n\nAccess- PIV x one, .\n\nActivity- OOB to chair x few hours. PT involved.\n\nID- VRE urine-precautions. Afebrile.\n\nPLAN: Call out to 3. Pt and family aware of plan. Continue to monitor urine output, hemodynamics, labs, R groin. Continue post-MI and discharge teaching.\n"
},
{
"category": "Echo",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 95584,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 114\nBSA (m2): 1.47 m2\nBP (mm Hg): 96/41\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 12:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No LA mass/thrombus (best excluded\nby TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional\nLV systolic dysfunction. No LV mass/thrombus. TDI E/e' >15, suggesting\nPCWP>18mmHg.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; anterior apex - akinetic; septal apex- akinetic; inferior apex -\nakinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No left atrial\nmass/thrombus seen (best excluded by transesophageal echocardiography). There\nis mild symmetric left ventricular hypertrophy with normal cavity size. There\nis moderate regional left ventricular systolic dysfunction with near akinesis\nof the distal half of the anterior septum and anterior walls, distal inferior\nwall and apex. The remaining segments contract normally (LVEF = 25-30 %).\nTissue Doppler indicates an increased E/e' suggesting an increased LVEDP\n(>18mmHg). No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are mildly thickened. There is\ntrivial mitral regurgitation. The estimated pulmonary artery systolic pressure\nis high normal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic\ndysfunction c/w CAD (LAD distribution). Increased LVEDP.\nCompared with the prior study (images reviewed) of , regional left\nventricular systolic function is new.\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-06 00:00:00.000",
"description": "Report",
"row_id": 252083,
"text": "Atrial fibrillation with controlled ventricular response. Delayed R wave\nprogression across the anterior precordial leads with associated ST segment\nelevation up to two millimeters in leads V4 and one millimeter in leads V2-V3\nconsistent with recent anterior ST segment elevation myocardial infarction.\nCompared to the previous tracing of ST segment elevation is decreased.\nOtherwise, the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-05 00:00:00.000",
"description": "Report",
"row_id": 252084,
"text": "Atrial fibrillation with controlled ventricular response. ST segment\nelevations in leads V3-V5 consistent with anterior myocardial infarction.\nCompared to the previous tracing of there has been no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-04 00:00:00.000",
"description": "Report",
"row_id": 252085,
"text": "Baseline artifact. Atrial fibrillation with a single wide complex beat which\nis ventricular paced at a rate of 60. Low limb lead voltage. Prominent\nRS complex with ST segment elevation in the early precordial leads with\nR wave reversal in leads V3-V4. Consider left ventricular hypertrophy and/or\nanterior myocardial infarction. Since the previous tracing of the rate\nis more variable.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-03 00:00:00.000",
"description": "Report",
"row_id": 252086,
"text": "Probable atrial fibrillation with ventricular response\nAnterior myocardial infarction with ST-T wave configuration consistent with\nacute/recent/in evolution process\nSince previous tracing of the same date, ventricular rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-03 00:00:00.000",
"description": "Report",
"row_id": 252087,
"text": "Probable atrial fibrillation with rapid ventricular response\nAnterior myocardial infarction with ST-T wave configuration consistent with\nacute/recent/in evolution process\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 252088,
"text": "Probable atrial fibrillation with rapid ventricular response\nAnterior myocardial infarction with ST-T wave configuration consistent with\nacute/recent/in evolution process\nSince previous tracing of the same date, ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 252089,
"text": "Atrial fibrillation with rapid ventricular response and a single ventricular\npremature beat. ST segment elevations in leads V2-V5 with T wave inversions\nin leads I and aVL. Compared to the previous tracing of atrial\nfibrillation persists. ST segments are more prominently elevated in the\nanterior precordial leads which may be secondary to rate or recurrent\nischemia. Clinical correlation is suggested.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2198-06-30 00:00:00.000",
"description": "Report",
"row_id": 252092,
"text": "TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Sinus rhythm. ST segment\nelevations in leads V1-V6 and, to a lesser degree, in leads I and aVL\nconsistent with acute anterior myocardial injury. Compared to prior tracing\nST segments are more elevated in the lateral leads but are decreasing in height\nin the anteroseptal leads.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-06-30 00:00:00.000",
"description": "Report",
"row_id": 252093,
"text": "TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Baseline artifact. Sinus rhythm.\nST segment elevations in leads I, aVL, V1-V5. Acute anteroseptal myocardial\ninjury. Compared to the previous tracing ST segment elevations are new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2198-06-30 00:00:00.000",
"description": "Report",
"row_id": 252315,
"text": "Normal sinus rhythm with slight ST segment elevations in the anterior\nleads with Q waves in lead V4 and delayed R wave transition consistent with\nanterior myocardial infarction. There is intermittent atrial pacing. Once\nagain, this is consistent with evolving anterior myocardial infarction compared\nto tracing #2.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2198-06-30 00:00:00.000",
"description": "Report",
"row_id": 252316,
"text": "Normal sinus rhythm with atrial pacing and T wave inversions in leads V1-V2\nwith ST segment elevations in leads V2-V5. Compared to tracing #1 the\nST segment elevations are less prominent suggestive of evolving anterior\nmyocardial infarction.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-06-30 00:00:00.000",
"description": "Report",
"row_id": 252317,
"text": "Atrial paced rhythm at 60 beats per minute with prominent ST segment elevations\nin leads V1-V5 consistent with acute anterior myocardial infarction. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-07 00:00:00.000",
"description": "Report",
"row_id": 251869,
"text": "Atrial fibrillation with moderate ventricular response. Occasional ventricular\npremature beats. Compared to tracing #1 occasional ventricular premature beats\nare new. Otherwise, findings consistent with ongoing anterior wall myocardial\ninfarction persist. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-06 00:00:00.000",
"description": "Report",
"row_id": 251870,
"text": "Atrial fibrillation with moderate ventricular response. Loss of R waves in the\nanterior leads with ST segment elevations in leads V3-V4 suggests ongoing\nanterior wall myocardial infarction. Compared to the previous tracing\nof ST segment elevations in the anterior leads persist. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-02 00:00:00.000",
"description": "Report",
"row_id": 252090,
"text": "Atrial fibrillation with rapid ventricular response. Slight ST segment\nelevation in leads V2-V5. Biphasic T waves in leads I and aVL. Compared to\nthe previous tracing of atrial fibrillation is new. However,\nST segments are less elevated in the anterior precordial leads.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-01 00:00:00.000",
"description": "Report",
"row_id": 252091,
"text": "Sinus rhythm. ST segment elevations in leads V2-V5 with biphasic T waves in\nlead V4 and T wave inversions in leads I and aVL all consistent with evolution\nof acute anterior myocardial infarction. Compared to the previous tracing of\n there has been evolution of anterior myocardial infarction.\nTRACING #3\n\n"
}
] |
14,436 | 195,581 | 73 y/o female with PMH significant for CAD s/p CABG in and relook cath in ; GERD; and hypercholesterolemia admitted with abdominal pain. Pt was hypotensive following taking several SL NTG at home for "chest pain" and did not respond initially to fluid resucitation. Pt's right lower quadrant pain was associated with rebound and gaurding since admission. Pt initially declined surgical intervention, so she was managed expectantly (NPO, IVF, antibiotics, serial abdominal exams). CT scans on admission and repeated indicated cecal colitis of unclear etiology (infectious v. ischemic); colonoscopy on confirmed ischemic colitis, and pt was scheduled for R colectomy on . The procedure itself was uncomplicated, and is further detailed in the operative note dated dictated by Dr. . Of note, the pt was ruled out for MI on admission. During her admission she continued to complain of intermittent L arm heaviness not associated with CP; serial EKGs were unchanged and cardiac enzymes were negative. Cardiology was consulted and recommended transfusing to maintain Hct above 30; pt received several units of blood and was noted on to have converted to antibody positive, indicating that she would be very likely to have a hemolytic transfusion reaction; thus no further transfusions were administered. She was advised to have a postop echo and continue ASA and statin. Postoperatively the pt's course was complicated by the following: 1. Ileus: resolved by POD#7 2. Sepsis/Intra-abdominal abscess: MRSA+, treated with Vanco. Two abscesses located on CT, the more superficial andn larger of which was addressed with placement of a perc drain, and remains in place at time of discharge. The smaller, deeper collection is not amenable to perc drainage, and will be addressed with linezolid. 3. C. difficile infection: treated with flagyl x16 days, resolved at time of discharge 4. Wound abscess: Erythema noted at superior aspect of wound on POD#6. Staples removed and small seroma evacuated. Similar erythema noted at inferior aspect of wound on POD#9; staples were removed and another seroma evacuated. Wounds cultured, revealing MRSA. Wound has been packed open with dressing changes, now shows healthy granulation tissue in both areas. 5. Renal failure with Cr rising from baseline of 0.8 to a peak of 2.0 in the setting of administration of IV contrast. Urine output fell precipitously when she became septic, and she developed bilateral pleural effusions and anasarca. Her urine output increased to a normal level after antibiotics were instituted, and has remained normal since then; her Cr is trending downwards, and is 1.5 at the time of discharge. On , she was deemed stable and suitable for discharge. She was discharged with pigtail catheter and instructed to have it flushed . PICC line and foley were removed on day of discharge. Code- DNR/DNI, confirmed with PCP. | Serosang, purulent drainage noted. Using I/S well w/encouragement.CV: Afebrile. Mild [1+] TR. Pt using PCA w/ good effect. Trace aortic regurgitation is seen. Borderline resting sinus tachycardia. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. The aortic root is mildly dilated. +pulses.GI: Abdomen soft, distended, diffusely tender. There is mild regional left ventricular systolicdysfunction with focal hypokinesis of the distal septum and apex. Nausea, Anzemet x1 w/minimal effect. Sinus rhythm. Sinus rhythm. Sinus rhythm. Slightly hypotensive, SBP 88-100. +BS, hypoactive. Baseline artifact.Incomplete right bundle-branch block. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Metoprolol IV held for SBP<110. CT. PERRLA. Pt denies dizziness/ lightheadedness. DP/PT pulses palpable. Sinus rhythm versus an ectopic atrial rhythm. Right bundle-branch block. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: septal apex -hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic root. Sinus rhythmIncomplete right bundle branch blockReverse poor R wave progressionSince previous tracing, reverse R wave - ? The tracing is marred by baselineartifact. Cont. Limb lead reversal. Mild pulmonary artery systolic hypertension. current plan of care. Bilateral pleural effusions.Conclusions:The left atrium is mildly dilated. Mildpulmonary artery systolic hypertension.Compared with the prior report (tape unavailable for review) of ,regional left ventricular dysfunction is now identified c/w interim ischemiaand mild pulmonary artery hypertension and a dilated ascending aorta are nowapparent.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). THANKS. Dilaudid PCA controlling abd. There is mild pulmonary arterysystolic hypertension. There is no pericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD.Dilated ascending aorta. Nursing note:NEURO: A/Ox3, pleasant and appropriate. lead placement Per Dr. , notify HO if uo<20cc/hr.Endo: FS q6hr w/ RISS. Now bilateral pleural effusions and pedal edema. Edema to BUE and BLE noted (extremities elevated on pillows). Compared to the previous tracing thelimb leads are correctly attached. Scant amount serous drainage noted to lower pole when dsg changed. Moderately dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Incompleteright bundle-branch block. SR-ST to 90s, no ectopy. Left ventricular function.Height: (in) 63Weight (lb): 153BSA (m2): 1.73 m2BP (mm Hg): 110/52HR (bpm): 85Status: InpatientDate/Time: at 09:44Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (tape not available)of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a low risk (prophylaxis not recommended). The ascending aorta ismoderately dilated. The P-R interval is 0.14. MAE. Lower pole of incision open; packed w/ 2x2 gauze (soaked in NS) and covered w/ 4x4 gauze. No c/o SOB; no apparent distress.GI: Abdomen softly distended w/ + bowel sounds. Continue to follow I/O's, bolus PRN, pain control. Continue ICU care and treatments. ? The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. UO>/= 30cc/hr. The mitralvalve leaflets are structurally normal. LR @ 200cc/hr continued.Pulm: Lungs sound diminished. RR 13-24. Asks appropriate questions. Theremaining segments contract well. Mid-abdominal incision w/ staples; erythema noted around staples; OTA and C/D/I. There is no mitral valve prolapse.Mild (1+) mitral regurgitation is seen. Left ventricular wall thicknesses andcavity size are normal. NGT to LWS w/ small amount liquid, green drainage. No AS. Right ventricular chamber size and free wallmotion are normal. Maintain skin integrity. Incontinent of frequent liquid stools, +cdiff. pain well.RESP: Lung sounds clear, sats 100% on 2-3L NC. NBP 90-110s/40-50s. Monitor uo and pigtail drainage. MAE and follows commands. Pleasant and cooperative w/ care. Stool sample sent for C.diff.GU: Foley intact w/ clear, dark-yellow urine. Compared to the previous tracing no significantchange. Update family and pt w/ plan of care. Some response to fluid challenge.SKIN: Intact.ENDO: Glucose stable.SOCIAL: Sister in to visit, updated.A/P: Stable, mild hypotension, low HUO. Compared to the previous tracingof no diagnostic change. Continuing to attempt PO contrast for abd. Compared to the previous tracing of no diagnostic interimchange. Skin pale, warm and dry. start lasix in AM. Staples intact to abdomen, small amount packing to distal end of incision, no drainage.GU: Foley patent minimal amount concentrated amber urine, 10-25cc/hr. Peritoneal fluid sent for culture and Gram stain. O2 sat WNL on 2LNC. Non- productive cough at times. CVP 7-10 (per Dr. , monitor CVP via PICC line). Speech is clear. Addendum: PICC line placed, awaiting CXR for placement. HR 70-80s. Nursing Progress Note:Please refer to CareVue for details.Neuro: Pt easily arousable by voice when asleep. NGT in place, vomited contrast around tube x2 so to sxn for afternoon. No SOB. No MVP. Ox3. Rectal tube placed for large amount of liquid golden/green stool. H/O CABG, multiple PCI. Clinical decisionsregarding the need for prophylaxis should be based on clinical andechocardiographic data. Clinicaldecisions regarding the need for prophylaxis should be based on clinical andechocardiographic data. Pt c/o nausea while in CT scan, but no emesis. Sister will visit in AM. No changes in PCA settings; no boluses given.CV: Afebrile. Dr. notified that pt's 24hr net body balance: +6040cc (lg amount of stool not quantified; several IVB during day shift). +Response to 250cc LR bolus x2. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. BS stable overnoc.Integ: CT-guided pigtail drain placed on RLQ abdomen to drain abscess. NURSING PROGRESS NOTE 0700-1500FOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN "NURSING TRANSFER NOTE "SECTION OF CAREVIEW. The rate has increased. Pt spoke to sister via telephone.Plan: Continue to monitor VS (esp temp and BP), I's and O's. Buttocks reddened d/t freq stool; lotion applied.Social: RN called pt's sister per pt's request; sister updated w/ plan of care, CT, and drain placement. Pigtail drain flushed w/ 10cc NS x1 d/t no drainage in bag. | 10 | [
{
"category": "Echo",
"chartdate": "2190-04-05 00:00:00.000",
"description": "Report",
"row_id": 96240,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O CABG, multiple PCI. Now bilateral pleural effusions and pedal edema. Left ventricular function.\nHeight: (in) 63\nWeight (lb): 153\nBSA (m2): 1.73 m2\nBP (mm Hg): 110/52\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 09:44\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: septal apex -\nhypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. Bilateral pleural effusions.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with focal hypokinesis of the distal septum and apex. The\nremaining segments contract well. Right ventricular chamber size and free wall\nmotion are normal. The aortic root is mildly dilated. The ascending aorta is\nmoderately dilated. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Trace aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD.\nDilated ascending aorta. Mild pulmonary artery systolic hypertension. Mild\npulmonary artery systolic hypertension.\nCompared with the prior report (tape unavailable for review) of ,\nregional left ventricular dysfunction is now identified c/w interim ischemia\nand mild pulmonary artery hypertension and a dilated ascending aorta are now\napparent.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-20 00:00:00.000",
"description": "Report",
"row_id": 264456,
"text": "Sinus rhythm. The P-R interval is 0.14. The tracing is marred by baseline\nartifact. Compared to the previous tracing of no diagnostic interim\nchange. The rate has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-16 00:00:00.000",
"description": "Report",
"row_id": 264457,
"text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing the\nlimb leads are correctly attached.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-13 00:00:00.000",
"description": "Report",
"row_id": 264458,
"text": "Limb lead reversal. Sinus rhythm versus an ectopic atrial rhythm. Incomplete\nright bundle-branch block. Compared to the previous tracing no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-11 00:00:00.000",
"description": "Report",
"row_id": 264459,
"text": "Sinus rhythm\nIncomplete right bundle branch block\nReverse poor R wave progression\nSince previous tracing, reverse R wave - ? lead placement\n\n"
},
{
"category": "ECG",
"chartdate": "2190-02-22 00:00:00.000",
"description": "Report",
"row_id": 264460,
"text": "Sinus rhythm. Borderline resting sinus tachycardia. Baseline artifact.\nIncomplete right bundle-branch block. Compared to the previous tracing\nof no diagnostic change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-25 00:00:00.000",
"description": "Report",
"row_id": 1450462,
"text": "NURSING PROGRESS NOTE 0700-1500\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE \"SECTION OF CAREVIEW. THANKS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-24 00:00:00.000",
"description": "Report",
"row_id": 1450459,
"text": "Nursing note:\nNEURO: A/Ox3, pleasant and appropriate. MAE. Dilaudid PCA controlling abd. pain well.\nRESP: Lung sounds clear, sats 100% on 2-3L NC. No SOB. Using I/S well w/encouragement.\nCV: Afebrile. SR-ST to 90s, no ectopy. Skin pale, warm and dry. Slightly hypotensive, SBP 88-100. +Response to 250cc LR bolus x2. +pulses.\nGI: Abdomen soft, distended, diffusely tender. +BS, hypoactive. Incontinent of frequent liquid stools, +cdiff. Nausea, Anzemet x1 w/minimal effect. NGT in place, vomited contrast around tube x2 so to sxn for afternoon. Continuing to attempt PO contrast for abd. CT. Staples intact to abdomen, small amount packing to distal end of incision, no drainage.\nGU: Foley patent minimal amount concentrated amber urine, 10-25cc/hr. Some response to fluid challenge.\nSKIN: Intact.\nENDO: Glucose stable.\nSOCIAL: Sister in to visit, updated.\n\nA/P: Stable, mild hypotension, low HUO. Continue to follow I/O's, bolus PRN, pain control. Cont. current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-24 00:00:00.000",
"description": "Report",
"row_id": 1450460,
"text": "Addendum: PICC line placed, awaiting CXR for placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-25 00:00:00.000",
"description": "Report",
"row_id": 1450461,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n\nNeuro: Pt easily arousable by voice when asleep. Ox3. MAE and follows commands. Speech is clear. PERRLA. Asks appropriate questions. Pleasant and cooperative w/ care. Pt using PCA w/ good effect. No changes in PCA settings; no boluses given.\n\nCV: Afebrile. HR 70-80s. NBP 90-110s/40-50s. Pt denies dizziness/ lightheadedness. CVP 7-10 (per Dr. , monitor CVP via PICC line). Metoprolol IV held for SBP<110. Edema to BUE and BLE noted (extremities elevated on pillows). DP/PT pulses palpable. Dr. notified that pt's 24hr net body balance: +6040cc (lg amount of stool not quantified; several IVB during day shift). Per pt, she takes 20mg Lasix qdaily at home, but Dr. stated that Lasix will not be started tonight d/t ?sepsis and low BP. LR @ 200cc/hr continued.\n\nPulm: Lungs sound diminished. RR 13-24. O2 sat WNL on 2LNC. Non- productive cough at times. No c/o SOB; no apparent distress.\n\nGI: Abdomen softly distended w/ + bowel sounds. NGT to LWS w/ small amount liquid, green drainage. Pt c/o nausea while in CT scan, but no emesis. Rectal tube placed for large amount of liquid golden/green stool. Stool sample sent for C.diff.\n\nGU: Foley intact w/ clear, dark-yellow urine. UO>/= 30cc/hr. Per Dr. , notify HO if uo<20cc/hr.\n\nEndo: FS q6hr w/ RISS. BS stable overnoc.\n\nInteg: CT-guided pigtail drain placed on RLQ abdomen to drain abscess. Pigtail drain flushed w/ 10cc NS x1 d/t no drainage in bag. Serosang, purulent drainage noted. Peritoneal fluid sent for culture and Gram stain. Mid-abdominal incision w/ staples; erythema noted around staples; OTA and C/D/I. Lower pole of incision open; packed w/ 2x2 gauze (soaked in NS) and covered w/ 4x4 gauze. Scant amount serous drainage noted to lower pole when dsg changed. Buttocks reddened d/t freq stool; lotion applied.\n\nSocial: RN called pt's sister per pt's request; sister updated w/ plan of care, CT, and drain placement. Sister will visit in AM. Pt spoke to sister via telephone.\n\nPlan: Continue to monitor VS (esp temp and BP), I's and O's. ? start lasix in AM. Monitor uo and pigtail drainage. Update family and pt w/ plan of care. Maintain skin integrity. Continue ICU care and treatments.\n"
}
] |
10,751 | 190,485 | IMPRESSION: 28 year old brittle diabetic admitted in DKA and with dental abscess. . 1. DKA: Patient was started on insulin gtt and IV fluids and monitored in the ICU until her DKA had resolved. A central line was placed in the MICU due to poor peripheral access, and the central line was discontinued 4 days later after an IR-guided PICC line was placed. At that point, she was transferred to the medical floor on her home regimen of NPH insulin and humalog SS. The Diabetes Center followed her closely during her stay. Her glucose levels were very difficult to manage initially, likely her ongoing infection, and were complicated by the patient's inability to tolerate po intake. The patient was unable to eat very much, and was also refusing to have an NG tube placed or parenteral nutrition. Her insulin regimen was continuously adjusted to avoid large fluctuations in her sugars. Her diabetic control was also complicated by the patient's inability to sense episodes of hypoglycemia. On discharge, the patient's sugars were maintained in the 100's-200's on 45 units of NPH qAM and 50 units of NPH qPM, with a Humalog sliding scale. The patient was discharged on this regimen, and will followup with the Diabetes Center on Tuesday, , for further management. . 2. Mandibular Dental abscess: Her R mandibular dental abscess was debrided on by Dr. from Oral Maxillofacial Surgery. Micro data from bone and tooth granulation tissue cultures were suggestive of osteomyelitis, with multiple gram-positives and gram-negative rods, as well as MSSA and albicans. The patient was treated with IV antibiotics during her admission, and the ID service was consulted. The patient continued to have significant jaw pain unrelieved by high doses of morphine and tramadol, and the pain clinic was also consulted for her management. CT imaging of her jaw showed no evidence of osteomyelitis, and her bone pathology was also negative for signs of acute osteomyelitis. A panoramic X-ray of her teeth indicated possible involvement of tooth #28, and this tooth was extracted on by Dr. . On discharge, the patient's pain was relatively controlled, although still requiring high dose narcotics. The patient was discharged with a PICC line in place for IV clindamycin at home, as well as po levafloxacin and fluconazole, for 5 weeks for presumptive osteomyelitis. Although ID felt that po clindamycin would likely be sufficient, the patient was extremely anxious about going home without IV treatent, as she had had poor response to oral antibiotic therapy in the past. The patient was also discharged on MSContin and morphine sulfate IR as needed, along with neurontin for neuropathic pain, per the pain clinic evaluation. The patient was instructed to follow up with her PCP 2 weeks, and she will also followup with the post-op Trauma Clinic in 1 week. In addition, the efficacy of her antibiotic treatment will be evaluated by ID in 3 weeks. ID will also check her LFTs at that time. . 3. Urinary Retention: During her admission, the patient also was complaining of very low urine output despite adequate fluid intake, and difficulty voiding. Bedside bladder scans indicated bladder retention of volumes ranging from 500-900 cc of urine. However, the patient refused any catheter intervention, and preferred to continue to attempt to void on her own. Her renal function was monitored closely, and she never showed signs of renal failure or urinary tract infection. Her urine output remained low at several hundred cc/day throughout her admission. She was encouraged to followup with her PCP regarding this issue. . 4. Asthma: The patient also demonstrated increased wheezing from her baseline asthma during her admission. She attributed it initially to being put on amoxacillin-sulbactam, as she claims to have had this reaction to ampicillin in the past. However, her symptoms did not resolve upon discontinuing the ampacillin. Her wheezing was relieved by albuterol nebs. The patient was discharged on low-dose Advair diskus in addition to her albuterol, and was encouraged to followup with her PCP should her symptoms continue. . 5. Lower extremity edema: The patient began to complain of lower extremity swelling and tenderness 2 days prior to discharge. The patient had refused all subcutaneous heparin DVT prophylaxis. Bilateral lower extremity ultrasound was performed and showed no evidence of DVT. Urinalysis had all been negative. On discharge, her edema had improved somewhat, but the etiology of her mild edema remained unclear. . 6. Chronic sinusitis: The patient was concerned about her chronic problems with sinusitis. A head CT was evaluated by from ENT. It was deemed to be significant only for a benign mucus retention cyst. No acute issues. ENT recommended follow-up for long-term management as outpatient after resolution of current infection. . 7. Psychosocial: The patient throughout her admission demonstrated an inability to cope with many issues surrounding her illness. She was at times refusing interventions that were deemed to be necessary for preventing life-threatening complications. Psychiatry and social work closely followed the patient. Her medical team focused on being non confrontational, bargaining with the patient and trying to present options for her management. Clear and consistent communication with the patient was encouraged. The patient eventually complied with most issues surrounding her treatment, although she remained resistant to certain interventions as well as attempts to increase her po nutrition intake. Her nortryptiline was increased to 75mg qhs during admission, and benzodiazepines were used as needed for anxiety. The patient was transitioned back to her home dose of nortryptiline prior to discharge. . 8. Anemia: The patient also developed a mild iron-deficiency anemia that was stable for most of her hospital stay, likely poor nutrition. She was maintained on po iron supplementation, and discharged on daily ferrous sulfate. . 9. GI: Patient refused bowel regimen despite ongoing constipation. She did have one episode of watery diarrhea, and her stool was negative for C. Diff. Protonix was continued prophylactically throughout admission. | IMPRESSION: No PTX after right CVL placement. FINDINGS: Grayscale and Doppler son of the right common femoral, superficial femoral, and popliteal veins were performed. PER ORAL SURGEON HAD AN OGT PLACED AT END OF CASE. There is stable discontinuity of the medial walls of the maxillary sinuses, possibly post surgical in nature. DR AWARE PATIENT VOIDED PREOP.ENDO- ON INUSLIN DRIP AT 6-5U/HR. Note is made of discontinuity of the medial wall of the maxillary sinuses which may represent patent secondary ostia or, less likely, be postsurgical. DID RECEIVE ANZIMET AND REGALN AT END OF OR CASE. FINDINGS: Right CVL has been placed with the tip in the SVC and no PTX. PAIN RELATED, TEAM AWARE...REMAINED TACHY 90-100BPM ALSO ? Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY FINAL REPORT (Cont) SHE WAS GIVEN FLUID BOLUS AND DID VOID 200CC PREOP. consistently denies c/o nausea and abd pain. (Over) 12:21 PM CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # Reason: ? FINDINGS: -scale and Doppler son of the left common femoral, superficial femoral, and popliteal veins were performed. The right upper extremity was prepped and draped in a usual sterile fashion. she required kcl and magnesium repletion overnoc.review of systemsrespiratory-> lung sounds diminished at bases w/a poor respiratory effort. BS DIMINISHED.CARDIAC- HR 90- WITHOUT ECTOPI. A single fluoroscopic spot image was obtained to confirm placement. NOTHING IN STOMACH SO OGT DC'D.GU- HNV THIS AM. 12:21 PM CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # Reason: ? Partially visualized TM joints are symmetric and WNL. LIMITED BLADDER ULTRASOUND: A single transverse image of the bladder was obtained, which demonstrates a transverse measurement of 4.9 cm. continues to be hypertensive w/sbp's 140-160's, ?d/t anxiety and pain.neuro-> pt was generally compliant w/care, particularly after a moderate degree of pain relief was obtained. Stable right maxillary mucous retention cyst versus polyp. MOUTH CARE DONE X1. BLOOD FINALLY OBTAINED VIA RIGHT WHILE PT OOB TO CHAIR- CBC, LYTES, BLD CX X2 PENDING. VS AS PER PREOP SHEET. BS SINCE HAVE COME UP. Coronal and sagittal reformations were provided. A right-sided PICC terminates at the cavoatrial junction. XRAY DONE WHEN RETURNED TO MICU. an ekg was obtained and the micu team was made aware. The right common femoral vein remains patent. DR MADE AWARE. DR MADE AWARE. RN ATTEMPTED STICK X2 IN ARM AND ASSESSED FEET W/O SUCCESS. Sinus rhythmLead(s) unsuitable for analysis: V1 V2 V4 V5Septal T wave changes are nonspecificNo change from previous COMMENCE ABS' IN AM FOR ? PT DENIES SOB. PATIENT REFUSING FOLEY CATH PLACEMENT IN OR. 6:25 PM UNILAT LOWER EXT VEINS LEFT Clip # Reason: ? Under fluoroscopic guidance, a 0.018 guidewire was advanced with its tip placed at the level of the atriocaval junction. HAD BEEN NPO FOR OR THIS AM. she is currently receiving kphos as well.neuro-> pt is alert but continues to intermittently refuse necessary aspects of her care. PT VOIDED ONLY 5CC, SENT FOR KETONES, PH, AND HCG- RESULTS PENDING. TAKEN TO THE OR TODAY FOR EXTRACTION OF TOOTH # 29 AND 30 AND DEBRIDEMENT OF TOOTH 30 AND 31. Note is made of a right molar root which may transgress the right maxillary floor. CONTINUE ICU SUPPORTIVE CARE. The visualized lower maxillary sinuses are normally aerated. PLEMBOTOMY ATTEMPTED BLOOD DRAW- UNABLE. As no suitable visible vein was identifiable, ultrasound was used to identify an appropriate right brachial vein. PT CALMED DOWN AFTER DISCUSSION W/ PSYCH MD. The thyroid gland appears within normal limits. FOCUS; ADDENDUMPAIN- MED X2 WITH 2MG IV MSO4 WITH GOOD EFFECT PER PATIENT.ACCESS- PER DR OK TO USE CL. The right lateral costophrenic angle has been cut off from view. AWAITING CONFIRMATION OF LINE PALCEMENT.PLAN- NEEDS CHLORHEXIDE MOUTH RINSES X2 TONIGHT. BOTH OR AND ANESTHESIA. AS THEY FEEL NPH HAS PEAKED. DR MICU ATTENDING MADE AWARE. 10:43 AM PICC LINE PLACMENT SCH Clip # Reason: placement of PICC Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. CONT TO MONITOR BS. ?last bm. Right maxillary mucus retention cyst, with possible adjacent small fluid level. WENT TO THE OR FOR 2 TEETH EXTRACTION AND DEBRIDEMENT.REVEIW OF SYSTEMS-NEURO- ALERT AND ORIENTED X2. PT FINALLY AGREED. DR AND REST OF MICU TAM AWARE. NURSING UPDATE 0500HRSNEURO...CONTINUED CALM/CO-OPERTAIVE NO SEDATION REQUIRED..FEELS TIRED AND HAS SLEPT, DOES AWAKE EASILY WHEN GENTLY STIMULATED..RECEIVED X1 DOSE OF PERCOCETS FOR TOOTHE ACHE WITH SOME EEFECT [ APPARENTLY TAKIN PERCOCETS FOR PAIN CONTROL AT HOME ]DENIES NAUSEARESP...CONTINUES CLEAR/SATS >95% ON ROOM AIRCVS...B/P 120-145 SYSTOLIC ? NURSING NOTE 00.30HRS... PER ORAL SURGEON CAN START CLEAR LIQUID DIET AND ADVANCE TO SOFT DIET AS TOL ONCE MORE AWAKE. 1 AMP D50 GIVEN. LS= CLEAR/DIM. LATEST BS 150 ON 5U INSULIN.ACCESS- HAD RIJ PLACED IN OR. PATIENT REFUSED FOLEY CATHETER PRIOR TO OR. IMPRESSION: Successful placement of 37 cm single lumen PICC via the right brachial vein with its tip at the atriocaval junction; line is ready for use. PT ALERT AND ORIENTED X3, MAE, PERLA. NSR TO ST @ 82-101, OCCAS PVC. | 20 | [
{
"category": "ECG",
"chartdate": "2111-01-23 00:00:00.000",
"description": "Report",
"row_id": 147140,
"text": "Sinus rhythm\nLead(s) unsuitable for analysis: V1 V2 V4 V5\nSeptal T wave changes are nonspecific\nNo change from previous\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-25 00:00:00.000",
"description": "Report",
"row_id": 1404257,
"text": "pmicu npn 7p-7a\n\n pt c/o severe mouth pain for much of the evening, eventually receiving a total of 10mg iv morphine and 1mg iv ativan. she slept for much of the noc. the insulin qtt was weaned off @0530 with the plan to transition the pt to sq nph/humalog in the am. she required kcl and magnesium repletion overnoc.\n\nreview of systems\n\nrespiratory-> lung sounds diminished at bases w/a poor respiratory effort. she is maintaining sats >97% on room air with no c/o sob.\n\ncardiac-> hr 90-100's, sr with no noted ectopy. continues to be hypertensive w/sbp's 140-160's, ?d/t anxiety and pain.\n\nneuro-> pt was generally compliant w/care, particularly after a moderate degree of pain relief was obtained. initially refusing to use the toilet located in her room when she needed to void, the pt later agreed to use the toilet after much encouragement.\n\ngi-> abd is obese, soft, w/+bs. consistently denies c/o nausea and abd pain. ?last bm. to start a soft diet as tolerated this morning.\n\ngu-> pt voided only 25cc overnoc. she has recieved 16 liters of fluid and has voided only 280cc in approx 2 days. it seems likely that the pt is retaining urine, but she adamently refuses catherization.\n\nendocrine-> fingerstick goal 150-200 so the insulin qtt was titrated off @0530 based on those parameters. plan to give scheduled nph/humalog this morning in anticipation of the pt eating breakfast.\n\naccess-> right ij tlcl patent and intact.\n\nsocial-> pt's husband stayed at a hotel overnoc. he will be back this morning. ?transfer to medicine once the pt has transitioned to a sq insulin regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-23 00:00:00.000",
"description": "Report",
"row_id": 1404250,
"text": "NURSING NOTE 00.30HRS...\n\n RECENT ADMISSION WITH DKA AND TREATMENT WITH AB'S FOR TOOTHE ABCESS [ DISCHARGE ]..RE-PRESENTS WITH 1 WEEK HISTORY OF NAUSEA AND HIGH B/S WITH CONTINUING LEFT MANDIBULAR PAIN IN REGION OF DENTAL ABCESS....B/S >600 ON ADMISSION TO ED BUT UNABLE TO CALCULATE GAP AT THAT TIME DUE TO NO ACCESS PH 7.14 [ VENOUS]LARGE AMOUNTS KETONES IN URINE, COMMENCED ON FLUIDS [ 4L GIVEN] AND INSULIN DRIP IN ED VIA X1 PERIPHERAL LINE, MULTIPLE ATTEMTS AT GAINING ACCESS UNSUCCESSFUL AND REFUSED CENTRAL LINE PLACEMENT.. ABG OBTAINED AT 2000HRS VIA FEMORAL STICK PH IMPROVED TO 7.33 GAP CALCULATED AT 14\n\n\nNEURO....CALM CO-OPERTAIVE APPROPRIATE ON ADMISSION, PARTAKING WITH CARE...APPARENTLY REFUSED LINES IN ED AND THREATENED DISCHARGE, PSYCH EVALUATED NOT SECTIONED AT THAT TIME BUT THEY DO WANT TO BE INFORMED IF PATIENT ATTEMPTS SELF-DISCHARGE ..PATIENT ADMITS TO FEELING OVERWHELMED IN ED ESPECILLY WITH RECENT ADMIT/DISCHAGE AND APPEARS AWARE OF THE IMPLICATIONS OF REFUSING TREATMENT AND SELF DISCHARGE..C/O LEFT MANDIBULAR DISCOMFORT [ CT PERFORMED AWAIT RESULTS] TO RECEIVE P/O ANALGESIA\n\n\nRESP..CLEAR SATS 98% ON ROOM AIR\n\nCVS..B/P STABLE 110-120 SYSYTOLIC..TACHY 95-105BPM..AFEBRILE ? COMMENCE ABS' IN AM FOR ? ONGOING TOOTH ABCESS\n\nENDO...DECISION TAKEN BY ATTENDING, AFTER DISCUSSING WITH PATIENT, NOT FOR ANY FURTHER ATTMPTS AT LAB DRAWS TONIGHT... TO CHECK Q1HR FINGERSTICKS AND WHEN URINATES TO SEND TO LAB TO CHECK PH AND KETONE LEVEL..LAST PH/GAP AS ABOVE...COMMENCED ON D10 @ 100CC/HR AND INSULIN @ 5U/HR TO TITRATE TO B/S 80-120\n\n\nGI...BOWEL SOUNDS PRESENT DENIES PAIN, FEELS SLIGHTLY NAUSEATED, HAS TAKEN SMALL AMOUNTS OF FLUIDS WITHOUT COMPLAINT\n\nGU..NOT PASSED URINE SO FAR..PREVIUOUSLY IN ED\n\nSKIN..INTACT\n\nLINES..UNABLE TO OBTAIN FURTHER LINES AND OR BLOOD DRAWS, TEAM FULLY AWARE AND WILL RE-REVIEW CENTRAL LINE PLACEMENT IN AM\n\n\nSOCIAL..HUSBAND WITH HER AND FATHER HAS \n\n\n\nPLAN..Q1HRLY FINGERSTICKS...MEDS FOR PAIN CONTROL/NAUSEA..CHECK PH/KETONES WHEN URINATES..DENTAL REVIEW/?AB'S ? LINE PLACEMENT IN THE AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-23 00:00:00.000",
"description": "Report",
"row_id": 1404251,
"text": "NURSING UPDATE 0500HRS\n\n\nNEURO...CONTINUED CALM/CO-OPERTAIVE NO SEDATION REQUIRED..FEELS TIRED AND HAS SLEPT, DOES AWAKE EASILY WHEN GENTLY STIMULATED..RECEIVED X1 DOSE OF PERCOCETS FOR TOOTHE ACHE WITH SOME EEFECT [ APPARENTLY TAKIN PERCOCETS FOR PAIN CONTROL AT HOME ]DENIES NAUSEA\n\n\nRESP...CONTINUES CLEAR/SATS >95% ON ROOM AIR\n\n\nCVS...B/P 120-145 SYSTOLIC ? HIGH B/P FOR PATIENT ? PAIN RELATED, TEAM AWARE...REMAINED TACHY 90-100BPM ALSO ? PAIN RELATED OR ? DRY..TEAM AWARE...FLUIDS RE-REVIWED AT 0400HRS AND IN VIEW OF ONGOING TACHCARDIA AND LOW U/O [ SEE BELOW] IV FLUIDS SWITCHED TO D5 .45N/S AT 250CC [ FOR 1L] TO OBSERVE FOR RESPONSE\nREMAINED AFEBRILE\nGIVEN 20MCQS OF K LAST PM FOR LEVEL @ 3.9..NO FURTHER LABS DRAWN DUE TO ACCESS ISSUE\n\n\nENDO...TEAM RE-SET PARAMETERS FOR B/S RANGE..AIM 150-200..HAS BEEN MAINTAINED 164 -234 OVERNIGHT WITH INSULIN DRIP TITRATED ACCORDINGLY..PRESENTLY ON 7U/HR..NOT ABLE TO CHECK FOR PH/KETONES AS HAS NOT PASSED URINE AND GAP NOT CHECKED AS NO LINE AVAILABLE FOR BLOOD DRAWS, TEAM AWARE\n\n\nGI...NO NAUSEA OVERNIGHT..HAS TAKEN FLUIDS AND TOLLERTED..NO BOWEL MOTION\n\nGU...PASSED URINE X2 IN ED BUT NIL SINCE ADMISSION TO THE UNIT..TEAM INFORMED AT 0400HRS AND AFTER REVIEW FLUIDS INCRESAED TO 250CC/HR..TO OBSERVE FOR A RESPONSE\n\n\nLINES...PHLEBOTOMY CALLED AND WILL ATTEMPT TO OBTAIN AM LABS..? TEAM TO PLACE LINE TODAY\n\n\nPLAN...Q1HRLY FINGERSTICKS/TITRATE INSULIN DRIP ACCORDINGLY.. OBSERVE U/O AND THEN CHECK URINE FOR KETONES/PH..? LINE PLACEMENT TODAY\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-23 00:00:00.000",
"description": "Report",
"row_id": 1404252,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. DR PAGER# ON CALL FOR MICU TEAM TONIGHT. PT ALERT AND ORIENTED X3, MAE, PERLA. PT REFUSING CARE AT TIMES. EXTREMELY DIFFICULT STICK, IV TEAM PLACED PIV BUT UNABLE TO DRAW BLOOD OFF. PLEMBOTOMY ATTEMPTED BLOOD DRAW- UNABLE. RN ATTEMPTED STICK X2 IN ARM AND ASSESSED FEET W/O SUCCESS. TRIED TO CONVINCE PT ALL SHIFT TO HAVE TLC PLACED, IMPORTANCE OF IV ACCESS AND BLOOD DRAWS TO TREAT DKA EFFECTIVELY EXPLAINED SEVERAL TIMES TO PT, SPOUSE, AND PT'S MOTHER BY THIS RN, MICU TEAM RESIDENT, INTERN, AND ATTENDING MD, TEAM, AND PSYCH MD. REFUSED TLC ALL SHIFT. AT APPROX 1630, PT REPORTED THAT SHE WOULD RATHER GO HOME AND DIE THAN HAVE THE TLC PLACED, AND BEGAN TO GET DRESSED TO LEAVE HOSPITAL. PT TOLD THIS RN THAT SHE WOULD REMOVE IVL HER SELF IF NRSG DID NOT REMOVE THEM AND THAT SHE WOULD SIGN OUT AMA. AT THIS TIME, PSYCH CALLED FOR ?SECTION 12 AND SECURITY ON FLOOR FOR POSSIBLE ATTEMPT TO LEAVE FACILITY. PT CALMED DOWN AFTER DISCUSSION W/ PSYCH MD. PT REFUSING TO USE BSC AND REPORTED ALL SHIFT NO URGE TO VOID. HNV SINCE ER LAST HS, MICU TEAM FULLY AWARE. PT STATES LAST TIME ADMIT W/ DKA SHE DID NOT VOID UNTIL APPROX 10L GIVEN. MICU TEAM CONTINUES TO ORDER IVF, NS W/ 20MEQ @ 200CC/HR AT THIS TIME. PT AMBULATED TO HALLWAY BR FOR PRIVACY R/T PT'S REQUEST PER MICU TEAM VERBAL ORDER OKAY, MONITORED BY THIS RN. PT VOIDED ONLY 5CC, SENT FOR KETONES, PH, AND HCG- RESULTS PENDING. MENSES PRESENT. BLOOD FINALLY OBTAINED VIA RIGHT WHILE PT OOB TO CHAIR- CBC, LYTES, BLD CX X2 PENDING. TEAM DISCUSSED W/ PT AGAIN REASONS FOR TLC, PT'S SPOUSE AND MOTHER AT BEDSIDE. PT FINALLY AGREED. MICU FELLOW TO PLACE TLC THIS EVENING, PT WILL REQUIRE SEDATION AND TLC FROM NRSG. LS= CLEAR/DIM. RR=16-23. 02 SAT 100%B ON RA. PT DENIES SOB. C/O HEADACHE, TYLENOL GIVEN W/ GOOD EFFECTS. NSR TO ST @ 82-101, OCCAS PVC. AFEBRILE. NBP= 113-150/57-75. INSULIN GTT @ 2-6U/HR PROTOCOL W/ FS=88-301, OFF SINCE 1800. D51/2NS INFUISNG ON AND OFF DURING DAY, OFF AT THIS TIME. ABD OBESE/ SOFT. PRESENT BS. TOL CLEAR LIQUIDS, REFUSING SOLIDS. SKIN INTACT. FULL CODE. FAMILY SUPPORTIVE.\n\nPLAN- TLC PLACEMENT THIS EVENING BY FELLOW. FOLLOW UP LABS SENT AT 1830. TITRATE INSULIN GTT FOR FS 150-200. ENC PO FLUIDS AND FOOD AS TOLERATED. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-24 00:00:00.000",
"description": "Report",
"row_id": 1404253,
"text": "pmicu npn 7p-7a\n\n at approx mn, the pt again threatened to leave ama and required intervention from the psych resident to diffuse the situation. security was called and on hand in case the pt required physical restraint. this was avoided when the pt agreed to stay if her blood pressure was checked less frequently and she was allowed to use the restroom when necessary to void. she has been amenable to vs checks, fingersticks, and blood draws since this event. her husband has stayed w/her overnoc. also of note, earlier in the evening, the pt spoke at length with the oral surgeon and agreed to a debridement and tooth extraction. the pt signed consents for surgery and anesthesia. she is aware that a central line and foley catheter will be placed preopertively in the or and is amenable to this as well.\n\nreview of systems\n\nrespiratory-> pt continues on room air, maintaining sats >97%. at one point last evening, the pt did c/o sob but denied chest pain. an ekg was obtained and the micu team was made aware. she stated that the discomfort felt most like her usual indigestion and felt better when assisted to a sitting position in bed.\n\ncardiac-> no complaints other than the above. hr 80-90's, sr with no noted ectopy. she continues to be hypertensive w/sbp ranging 140-160's but consistently refuses ativan although admits to feeling \"stressed out\" by her circumstances. she was repleted with oral potassium and mag, and phosphorous overnoc. she is currently receiving kphos as well.\n\nneuro-> pt is alert but continues to intermittently refuse necessary aspects of her care. she is getting oob to the chair and ambulated to the restroom with a steady gait.\n\ngi-> abd is obese w/+bs. pt c/o n/v last evening and received anzimet x1 with good effect. she is npo after mn, anticipating an early or time.\n\ngu-> pt voided x1 last evening but only 50cc of concentrated urine. she denies any further urge to void. foley to be placed in the or.\n\nendocrine-> fs varying widely last evening while attempting to titrate the insulin qtt to maintain fs in a 150-200 range. several changes to ivf made as well.\n\naccess-> 2 #20g angios in either arm. unable to draw blood from peripheral line but did obtain blood by venipuncture once. will attempt another blood draw this morning if the pt will allow.\n\nsocial-> the pt's husband slept in the pt's room overnoc. he is aware that we want to avoid confrontation, but that his wife is unable to make reasonable decisions re: her care and, at last resort, may require physical restraint in order to deliver care. he appears to understand and is amenable to this.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-24 00:00:00.000",
"description": "Report",
"row_id": 1404254,
"text": "FOCUS; PREOP NOTE\nO.CONSENTS SIGNED FOR SURGERY LAST PM. BOTH OR AND ANESTHESIA. PATIENT UNABLE TO HAVE BLOODS DRAWN THIS AM. EXPERT PHLEBOTOMIST ATTEMPTED WITHOUT SUCESS. DR MADE AWARE. PATIENT REFUSING FOLEY CATH PLACEMENT IN OR. DR MICU ATTENDING MADE AWARE. SPOKE TO PATIENT ABOUT THIS ON ROUNDS. SHE WAS GIVEN FLUID BOLUS AND DID VOID 200CC PREOP. VS AS PER PREOP SHEET. PATIENT REFUSES TO REMOVE PANTS. HOSPITAL GOWN ON. JEWELRY REMOVED WHICH HUSBAND HAS.\nA. READY FOR OR\nP. READY FOR OR\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-25 00:00:00.000",
"description": "Report",
"row_id": 1404258,
"text": "FOCUS; NURSING PROGRESS NOTE\n28 YEAR OLD WITH IDDM ADMITTED WITH DKA. BS>600. TX WITH IV AND INSULIN DRIP. FELT DKA DUE TO ABSCESS TOOTH. WENT TO THE OR FOR 2 TEETH EXTRACTION AND DEBRIDEMENT.\nREVEIW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X2. COOPERATIVE WITH CARE TODAY. C/O OF MOUTH PAIN AND MED WITH 2MG MSO4 X3 TODAY WITH GOOD EFFECT PER PATIENT.\nRESP- ON RA WITH RESP 16-27. SATS 94-99%. BS DIMINISHED.\nCARDIAC- HR 90- WITHOUT ECTOPI. SBP 140-150. K 3.6 TODAY TX WITH 40MEQ KCL. MG 1.8 TX WITH 2GMS MG.\nGI- ABD SOFT OBESE WITH POS BS. TOLERATING ONLY SMALL AMOUNTS OF CLEAR LIQ. POPSICLES ARE THE BEST FOR PATIENT DUE TO MOUTH PAIN.\nGU- VOIDED 200CC THIS AM AND 150 LATER THIS AM.\nENDO- GIVEN NORMAL DOSE OF INSULIN THIS AM 50U HUMOLOGUE AND 50U NPH. INSULIN DRIP SHE WAS ON SHUT OFF 1 HOUR LATER. ONLY TOOK SIPS OF JUICE FOR BREAKFAST. BS DOWN TO 48. 1 AMP D50 GIVEN. BS SINCE HAVE COME UP. PRESENTLY STABALIZED AND COMING UP. LATEST BS 83. OK WITH CALL OUT TEAM FOR PATIENT TO GO TO FLOOR. AS THEY FEEL NPH HAS PEAKED. INSULIN FOR BED TIME DECREASED TO 40U NPH WITH A NEW SS.\nID- AFEBRILE. WBC 5. ORAL SURGEON CALLED SHE WOULD LIKE ID CONSULT AS SPEC FOR OR GROWING GP AND GM NEG RODS. DR MADE AWARE. SHE WOULD ALSO LIKE PERIDEX MOUTH RINSES DONE X A DAY. ONE DONE THIS AFTERNOON PRIOR TO PATIENT'S TRANSFER.\n HUSBAND WITH PATIENT. VERY SUPPORTIVE.\nPLAN- ? NEED FOR PICC AS NEED LONG TERM ANTIIODICS.\n CONT TO MONITOR BS.\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-02 00:00:00.000",
"description": "TEETH (PANOREX FOR DENTAL)",
"row_id": 901549,
"text": " 5:10 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: ? tooth abnormality in R mandible, requested by oral surgeon\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with refractory R mandibular pain s/p surgical debridement of\n mandibular abscess\n REASON FOR THIS EXAMINATION:\n ? tooth abnormality in R mandible, requested by oral surgeon\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right mandibular pain post-surgical debridement of abscess.\n\n Single Panorex view of the mandible shows complete removal of all mandibular\n teeth lateral to the right mandibular canine tooth. No associated bone\n destruction in this area or elsewhere. Partially visualized TM joints are\n symmetric and WNL. The visualized lower maxillary sinuses are normally\n aerated. Third molar teeth are removed in both the maxilla and mandible.\n\n IMPRESSION: No radiographic evidence of osseous abscess or osteomyelitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-05 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 901950,
"text": " 6:25 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: ? DVT, please ensure that exam is done completely despite pa\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with significant R lower extremity edema, also mild LLE\n edema, now with calf tenderness\n REASON FOR THIS EXAMINATION:\n ? DVT, please ensure that exam is done completely despite patient discomfort\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old woman with significant right lower extremity edema and\n mild left lower extremity edema, now with calf tenderness.\n\n FINDINGS: -scale and Doppler son of the left common femoral,\n superficial femoral, and popliteal veins were performed. Normal flow,\n augmentation, compressibility, and waveforms are demonstrated. Intraluminal\n thrombus is not identified.\n\n Evaluation over the right superficial femoral vein at the location which was\n not previously compressible on prior exam demonstrates normal compressibility\n and waveforms. The right common femoral vein remains patent.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-26 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 900598,
"text": " 10:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: placement of PICC\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with mandibular abscess\n REASON FOR THIS EXAMINATION:\n placement of PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mandibular abscess, requiring PICC line for antibiotics.\n\n PROCEDURE: This procedure was performed by Dr. , with Dr. \n , the Attending Radiologist, being present and supervising throughout.\n The right upper extremity was prepped and draped in a usual sterile fashion.\n As no suitable visible vein was identifiable, ultrasound was used to identify\n an appropriate right brachial vein. Under ultrasound guidance, a 21-gauge\n micropuncture needle was used to access the right brachial vein. Hard\n copy ultrasound images were obtained before and after venous access\n documenting vessel patency. Under fluoroscopic guidance, a 0.018 guidewire was\n advanced with its tip placed at the level of the atriocaval junction. Via\n introducer sheath, a PICC line, trimmed to 37 cm was advanced with its tip\n placed at the atriocaval junction. A single fluoroscopic spot image was\n obtained to confirm placement. The line was StatLock, heplocked, flushed, and\n dress to the skin. Line is ready for use.\n\n IMPRESSION: Successful placement of 37 cm single lumen PICC via the right\n brachial vein with its tip at the atriocaval junction; line is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900956,
"text": " 5:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluation for placement of PICC\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with likely DKA, fever, cough\n\n REASON FOR THIS EXAMINATION:\n Evaluation for placement of PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old woman with mandibular abscess requiring PICC.\n Evaluate line placement.\n\n PORTABLE AP CHEST: Comparison with . There is a right IJ\n line terminating in the proximal right atrium. A right-sided PICC terminates\n at the cavoatrial junction. There are low lung volumes, but the lungs appear\n clear. Cardiac, mediastinal, and hilar contours are unremarkable. Bony\n structures are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900176,
"text": " 2:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with DKA\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old woman with diabetic ketoacidosis.\n\n COMPARISON: .\n\n PORTABLE CHEST: Accounting for the low lung volumes on the exam, the cardiac,\n mediastinal, and hilar contours are within normal limits. Pulmonary\n vasculature is unremarkable. There is mild left basilar atelectasis. The\n lungs are otherwise clear. There are no pleural effusions. Osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 900452,
"text": " 4:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line placement\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with DKA s/p Central line placed (R-IJ)\n\n REASON FOR THIS EXAMINATION:\n assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 16:39.\n\n INDICATION: Central line placement.\n\n FINDINGS:\n\n Right CVL has been placed with the tip in the SVC and no PTX. Shallow level\n of inspiration markedly underpenetrated technique limits the assessment of the\n lung parenchyma and comparison with the prior study. Accounting for the\n technical differences, I believe it is unlikely that there is a significant\n interval change. The right lateral costophrenic angle has been cut off from\n view.\n\n IMPRESSION:\n\n No PTX after right CVL placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-28 00:00:00.000",
"description": "P BLADDER VOLUMETRIC US PORT",
"row_id": 900918,
"text": " 2:21 PM\n BLADDER VOLUMETRIC US PORT Clip # \n Reason: ? urinary retention\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with Type I DM, low urine output, asymptomatic\n REASON FOR THIS EXAMINATION:\n ? urinary retention\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old woman with type 1 diabetes and no urine output,\n evaluate for urinary retention.\n\n LIMITED BLADDER ULTRASOUND: A single transverse image of the bladder was\n obtained, which demonstrates a transverse measurement of 4.9 cm. The patient\n refused any further imaging.\n\n IMPRESSION: Limited ultrasound of the bladder, as the patient refused further\n images.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-22 00:00:00.000",
"description": "CT ORBITS, SELLA & IAC W/ CONTRAST",
"row_id": 900184,
"text": " 4:01 PM\n CT ORBITS, SELLA & IAC W/ CONTRAST Clip # \n Reason: eval for abscess\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with known dental abscess, DKA\n REASON FOR THIS EXAMINATION:\n eval for abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old with known dental abscess and DKA.\n\n COMPARISON: .\n\n TECHNIQUE: Axial images of the facial bones were obtained before and after\n the administration of Optiray contrast. Coronal reformatted images were\n then obtained\n\n FINDINGS: There is no evidence of abscess or acute sinusitis. There is a\n large right maxillary antral retention mucus cyst, with possible small\n adjacent air- fluid level in the right maxilla. Note is made of a right molar\n root which may transgress the right maxillary floor. There is no\n evidence of periapical abscess. Note is made of discontinuity of the medial\n wall of the maxillary sinuses which may represent patent secondary ostia or,\n less likely, be postsurgical. The anterior clinoid processes are not\n pneumatized. The cribriform plates are equal in height. The lamina papyracea\n is intact. Nasal septum is midline.\n\n IMPRESSION:\n\n 1. No evidence of abscess or acute sinusitis.\n\n 2. Right maxillary mucus retention cyst, with possible adjacent small fluid\n level.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-03 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 901687,
"text": " 6:21 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG DISCOMFORT, EVAL FOR DVT\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with significant R lower extremity edema\n REASON FOR THIS EXAMINATION:\n Evaluation for DVT\n ______________________________________________________________________________\n WET READ: JCT TUE 6:43 PM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old woman with significant right lower extremity edema.\n\n FINDINGS: Grayscale and Doppler son of the right common femoral,\n superficial femoral, and popliteal veins were performed. The patient was\n unable to tolerate compression of the distal superficial femoral vein.\n Otherwise, normal flow, augmentation, compressibility, and waveforms are\n demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-01 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 901373,
"text": " 12:21 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? abscess/fluid collection/osteomyelitis of mandible.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with diabetes s/p dental abscess now with increasing pain in\n neck and with swallowing.\n REASON FOR THIS EXAMINATION:\n ? abscess/fluid collection/osteomyelitis of mandible.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes, status post dental abscess with increasing pain in neck\n and with swallowing, evaluate for abscess or fluid collections or\n osteomyelitis of mandible.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained through the neck following the\n administration of 100 mL of intravenous Optiray. Coronal and sagittal\n reformations were provided.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE NECK WITH INTRAVENOUS CONTRAST: Since the examination of\n , there has been extraction of three right-sided molars with sockets\n visualized within the right mandible. Visualization of the surrounding soft\n tissues is somewhat limited by streak artifact, however, no definite focal\n fluid collection is identified about this region to suggest abscess. The\n parapharyngeal fat planes appear intact. The airway is patent. There are\n numerous nonpathologically enlarged lymph nodes within the submental,\n submandibular, anterior and posterior cervical triangles.\n\n Within the right maxillary sinus, a rounded soft tissue density consistent\n with mucous retention cyst versus polyp is noted. There is stable\n discontinuity of the medial walls of the maxillary sinuses, possibly post\n surgical in nature.\n\n The internal carotid arteries and internal jugular veins appear patent\n bilaterally. The visualized portion of the lung apices appear unremarkable.\n The thyroid gland appears within normal limits.\n\n IMPRESSION:\n 1. No definite evidence of abscess within the soft tissues of the neck or\n within the region of the mandible. Interval extraction of three molars since\n .\n 2. Stable right maxillary mucous retention cyst versus polyp.\n\n (Over)\n\n 12:21 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? abscess/fluid collection/osteomyelitis of mandible.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-24 00:00:00.000",
"description": "Report",
"row_id": 1404255,
"text": "FOCUS; NURSING PROGRESS NOTE\n28 YEAR OLD WITH IDDM ADMITTED WITH DKA, WITH KNOWN TOOTH ABSCESS. TAKEN TO THE OR TODAY FOR EXTRACTION OF TOOTH # 29 AND 30 AND DEBRIDEMENT OF TOOTH 30 AND 31. SHE WAS DOPNE UNDER GE AND RECEIVED 125MCGS OF FENTANYL AND 2MG VERSED. SHE WAS PARALYZED AND REVERSED. WENT TO THE OR JUST AT 1345 AND RETURNED AT 1600.\nREVEIW OF SYSTEMS-\nNEURO- SHE WAS ALERT AND ORIENTED X3 THIS AM. WAS COOPERATIVE WITH CARE. REFUSED HAVING A FOLEY PLACED GOING TO THE OR. DR WAS AWARE. SHE DID VOID 200CC PRIOR TO THE OR. ON RETURN FROM THE OR SHE IS LETHARGIC BUT AROUSABLE. FOLLOWS COMMANDS. HAS GAUZE IN MOUTH SO DIFFICULT TO DETERMINE ORIENTATION. MAE. DOES C/O OF MOUTH PAIN WHEN AWAKE BUT QUICKLY FALLS BACK TO SLEEP.\nRESP- ON RA THIS AM WITH SATS 94-100%. ON REUTRN FROM THE OR ON 5L VIA FM OF O2 WITH SATS 100%. RESP 19-20. BS DIMINISHED . NO C/O OF SOB.\nCARDIAC- HR 90'S THIS AM DOWN TO 80'S NSR THIS AFTERNOON. SBP 130'S TP 150'S. AM LABS DRAWN AT 1700.\nGI- ABD OBESE WITH POS BS. HAD BEEN NPO FOR OR THIS AM. PER ORAL SURGEON CAN START CLEAR LIQUID DIET AND ADVANCE TO SOFT DIET AS TOL ONCE MORE AWAKE. NO STOOL TODAY. DID RECEIVE ANZIMET AND REGALN AT END OF OR CASE. PER ORAL SURGEON HAD AN OGT PLACED AT END OF CASE. NOTHING IN STOMACH SO OGT DC'D.\nGU- HNV THIS AM. RECIEVED TOTAL OF 1L NS BOLUS AND PASSED 200CC CLEAR YELLOW URIEN PRIOR TO OR. URINE SENT FOR U/A. DTV AT MN POST OR. PATIENT REFUSED FOLEY CATHETER PRIOR TO OR. DR AND REST OF MICU TAM AWARE. DR AWARE PATIENT VOIDED PREOP.\nENDO- ON INUSLIN DRIP AT 6-5U/HR. LATEST BS 150 ON 5U INSULIN.\nACCESS- HAD RIJ PLACED IN OR. XRAY DONE WHEN RETURNED TO MICU. AWAITING CONFIRMATION OF LINE PALCEMENT.\nPLAN- NEEDS CHLORHEXIDE MOUTH RINSES X2 TONIGHT.\n MONITOR BS ON INSULIN DRIP.\n LABS AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-01-24 00:00:00.000",
"description": "Report",
"row_id": 1404256,
"text": "FOCUS; ADDENDUM\nPAIN- MED X2 WITH 2MG IV MSO4 WITH GOOD EFFECT PER PATIENT.\nACCESS- PER DR OK TO USE CL. BOTH PERIPHERALS BOTHERING PATIENT AND DC'D BY THIS NURSE. AND INSULIN DRIP VIA CL.\nPOSTOP- GAUZE REMOVED FROM MOUTH. TEETH EXTRACTION SITES WITHOUT EVIDENCE OF ACTIVE BLLEDING. MOUTH CARE DONE X1.\n"
}
] |
27,293 | 121,941 | A/P: This is a 76 yo man with a 2 day h/o of fever, hypotension, malaise and abdominal pain admitted to ICU for cholangitis and sepsis with plan for ERCP in am. . # Cholangitis/Sepsis: The patient presented with cholangitis, fever, transient abdominal pain , hypotension and mild jaundice on presentation. Radiographic evidence of 1.3 cm obstructing stone in CBD. He then underwent ERCP with stent placement but no stone removal or sphincterotomy given elevated INR. He tolerated the procedure well and remained afebrile, pain free and stable. He was continued on Levofloxacin and Flagyl during his hospital stay and was discharged on these antibiotics for a 14 day course. On HD 1, - notified us that his blood cultures grew gram negative rods in bottles but no further speciation was available by the time of discharge. These blood cultures need to be followed up and his antibiotics changed accordingly; however, given his clinical improvment and lack of fever, the current antibiotics appear to be effective. Per the ERCP team, he will need follow up with gasteroenterology and repeat ERCP with stone removal and sphincerotomy in weeks. He was discharged home ambulating well and tolerating PO's. . # Afib: The patient has a long history of afib. At the OSH he was noted to have afib with RVR but his beta blockers had been held in the setting of possible sepsis. During his hospital stay he was occaisonally tachycardic but with improved rate controlled. He was restarted on his home doses of digoxin and metoprolol. His coumadin was initially held for ERCP and given FFP and his IRN came down to 1.2. He was restarted on coumadin 5mg - reduced from home dose of 7mg given Flagyl. He will need to be off of coumadin for a week prior to his next ERCP. | Had ERCP w/stent placement . Had ERCP w/stent placement. Had hematuria w/clots since. Restarted on metoprolol.Afebrile. Right IJ central venous catheter overlies the mid SVC. for ERCP. MAE.CV: HR:80's-101 Afib w/rare PVC. Denies pain.ERCP done this a.m. Tol well. Started on levoquin and flagyl for presumed cholangitis. Currently off sepsis protocol MD as he is stable. Recieved 20mg IV lasix x2 in ERCP suite with >2.5L diuresis. His WBC was found 11.2, RUQ US showed gall large blasser, CBD dilatation with stone visualization in the duct. Plan for follow-up ERCP and removal of gallblader in 1 mos per GI attending.Placed on nasal bipap post procedure per anasthesia request. Stent placed. BP:120's-130's/60's-80. Drsg . FINDINGS: AP chest radiograph. BC from OSH grew GN bacilli. Gallstone partially obsructing lower portion of common bile duct was seen, as well as dilated CBD. CVP:14-15.Resp: RR21-30. Received 5L IV fluid resusitation for BP. Repleted w/20mEq of 60 mEq total. Serum K 3.3. Soft distended abdomen w/+ bowel sounds. In ED given 10 mg Vit K, blood and urine cxs drawn, sepsis line RIJ was inserted and started on sepsis protocol, admitted to ICU for further sepsis treatment and possible ERCP.ROS:Neuro: alert, oriented x3, denied any pain or disconfort, calm, cooperative and pleasant.Resp: breathing regularly on O2 NC 2 LPM, sat 92-96%, RR 22, LS CTA bilaterally.CV: A fib HR 70s-90s, BP 103-109/61-66, with sepsis line RIJ bleeding at the site, dressing changed, also with PIV lines, to be started on D5 1/2NS and to receive 2 units of FFP, weak peripheral pulses, CVP 18-19, SVO2 92-93, lactate 1.3, Hct 36.2, WBCs 9, INR 2.1.GI/GU: NPO, abdomen obese, BS present, with Foley adequate color U/O.Integ: intact warm dry skin, T 96.4.Social: Full code, HCP is the wife, no calls/visits by family since admission to ICU.Plan: To be given the Influenza Virus, to be started on IV fluids (Dextrose NS), to be transfused with 2 units FFP, to continue sepsis protocol, continue antibiotics, to be evaluated by surgical team and ? Gd wt bearing. The pulmonary vasuclarity is within normal limits. +flatus. Cont antibiotics. The right costophrenic angle is clear, the left has been excluded. Needs to be observed X24 hrs.GU: Foley draining 100cc+/hr pink bloody urine w/occasional clot in it.A/P: Patient will be called out soon.Monitor O2 sat & need for O2.Monitor u/o. Some bleeding noted @ L IJ exit site. C/O nausea as well which he attributes to not having BM in a few days. The portion of the pancreatic duct which is opacified appears normal in appearance. Needs help with lines and cables.NPO changed to cl liqs. Right IJ sepsis catheter placed REASON FOR THIS EXAMINATION: Central line placement FINAL REPORT CLINICAL HISTORY: 76-year-old status post central line placement. 1:33 AM CHEST PORT. Patient comfortable on bipap, used it X 20 yrs.GI: LBM . Follow O2sats and VSs. Also developed rapid A fib 130s improved to lopressor and hypotension to 70s systolic improved with IV fluid about 5 Liters. Tol RA when bipap off.No episodes of hyppotention. According to the endoscopy report two round stones ranging in size from 6 mm to 8 mm were visualized at the lower third of the common bile duct. To be observed X24 hrs after procedure in ICU.Neuro: A&OX3. INR 1.2. O2 sat 92-97% on bipap w/6-8L O2. Six fluoroscopic images were provided which show partial filling of the distal common bile duct. MICU EAST NPN 0700-1900Please see flowsheet for further details...A&O. Tol well. Tol well. Increased interstitial lung markings are likely chronic. Stone not removed d/t INR 1.6. Moderate cardiac enlargement is appreciated. For further details regarding this procedure please see the endoscopy note available on CareWeb. Evaluate line placement. Respiratory Care:Patient wore nasal CPAP of +5 with O2 bled in starting at 8lpm and weaned to 6 with sPO2>95%. No antibiotic changes at this time.OOB-chair x2 hrs. C/O constipation which he says he never has. There are multiple filling defects seen in the opacified distal common bile duct. NPN 1900-0700This 76 yr old man was admitted w/abdominal pain, fever, low BP. There is a plastic stent in place. IMPRESSION: Multiple stones in the distal common bile duct causing distal common bile duct dilation. Given colace and senna.Family in to visit for short while.Plan to monitor overnight. A biliary stent was placed and recommendations were made to repeat the ERCP in weeks for stent pull and stone extraction. Currently napping on bipap. Intern & resident aware. 2:53 PM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: ERCP films for review MEDICAL CONDITION: 76 year old gentleman with probable cholangitis and CBD stones on imaging.ERCP done REASON FOR THIS EXAMINATION: ERCP films for review FINAL REPORT INDICATION 76-year-old gentleman with probable cholangitis and common bile duct stones on imaging. Tolerated clear liqs well. Admission and NPN 0500-0700:This is a 76 yo male pt with hx of A fib on coumadim who presented to ED from hospital with abdominal pain primarily started 3 days ago, then pain resolved and pt developed malaise and fever up to 103. NPN Addendum 0655Patient admitted to waking up last night, forgetting that he had foley & pulling hard on it. LINE PLACEMENT Clip # Reason: Central line placement MEDICAL CONDITION: 76 year old man with Central line placement. | 7 | [
{
"category": "Radiology",
"chartdate": "2131-11-08 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 988255,
"text": " 2:53 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP films for review\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old gentleman with probable cholangitis and CBD stones on imaging.ERCP\n done \n REASON FOR THIS EXAMINATION:\n ERCP films for review\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION 76-year-old gentleman with probable cholangitis and common bile\n duct stones on imaging.\n\n COMPARISON: None available.\n\n FINDINGS: Radiologist was not present during this procedure. Six\n fluoroscopic images were provided which show partial filling of the distal\n common bile duct. There are multiple filling defects seen in the opacified\n distal common bile duct. The rest of the biliary tree is not visualized.\n The portion of the pancreatic duct which is opacified appears normal in\n appearance. There is a plastic stent in place. According to the endoscopy\n report two round stones ranging in size from 6 mm to 8 mm were visualized at\n the lower third of the common bile duct. A biliary stent was placed and\n recommendations were made to repeat the ERCP in weeks for stent pull and\n stone extraction.\n\n IMPRESSION: Multiple stones in the distal common bile duct causing distal\n common bile duct dilation.\n\n For further details regarding this procedure please see the endoscopy note\n available on CareWeb.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-11-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 987729,
"text": " 1:33 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with Central line placement. Right IJ sepsis catheter placed\n REASON FOR THIS EXAMINATION:\n Central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old status post central line placement. Evaluate\n line placement.\n\n COMPARISON: None.\n\n FINDINGS: AP chest radiograph. Right IJ central venous catheter overlies the\n mid SVC. No pneumothorax is identified. Increased interstitial lung markings\n are likely chronic. Moderate cardiac enlargement is appreciated. The\n pulmonary vasuclarity is within normal limits. The right costophrenic angle is\n clear, the left has been excluded.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-11-08 00:00:00.000",
"description": "Report",
"row_id": 1619523,
"text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details...\n\nA&O. Denies pain.\n\nERCP done this a.m. Tol well. Stent placed. Stone not removed d/t INR 1.6. Plan for follow-up ERCP and removal of gallblader in 1 mos per GI attending.\n\nPlaced on nasal bipap post procedure per anasthesia request. Pt also wanted to sleep and he is on C-PAP at home. Currently napping on bipap. Tol RA when bipap off.\n\nNo episodes of hyppotention. Recieved 20mg IV lasix x2 in ERCP suite with >2.5L diuresis. Restarted on metoprolol.\n\nAfebrile. BC from OSH grew GN bacilli. No antibiotic changes at this time.\n\nOOB-chair x2 hrs. Tol well. Gd wt bearing. Needs help with lines and cables.\n\nNPO changed to cl liqs. Tol well. C/O constipation which he says he never has. +flatus. C/O nausea as well which he attributes to not having BM in a few days. Did not want anything for his nausea. Given colace and senna.\n\nFamily in to visit for short while.\n\nPlan to monitor overnight. Follow O2sats and VSs. Cont antibiotics. Currently off sepsis protocol MD as he is stable.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-11-09 00:00:00.000",
"description": "Report",
"row_id": 1619524,
"text": "NPN 1900-0700\n\nThis 76 yr old man was admitted w/abdominal pain, fever, low BP. Received 5L IV fluid resusitation for BP. Gallstone partially obsructing lower portion of common bile duct was seen, as well as dilated CBD. Had ERCP w/stent placement. To be observed X24 hrs after procedure in ICU.\n\nNeuro: A&OX3. MAE.\n\nCV: HR:80's-101 Afib w/rare PVC. BP:120's-130's/60's-80. CVP:14-15.\n\nResp: RR21-30. O2 sat 92-97% on bipap w/6-8L O2. Patient comfortable on bipap, used it X 20 yrs.\n\nGI: LBM . Soft distended abdomen w/+ bowel sounds. Tolerated clear liqs well. Had ERCP w/stent placement . Needs to be observed X24 hrs.\n\nGU: Foley draining 100cc+/hr pink bloody urine w/occasional clot in it.\n\nA/P: Patient will be called out soon.\nMonitor O2 sat & need for O2.\nMonitor u/o.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-11-09 00:00:00.000",
"description": "Report",
"row_id": 1619525,
"text": "NPN Addendum 0655\n\nPatient admitted to waking up last night, forgetting that he had foley & pulling hard on it. Had hematuria w/clots since. Intern & resident aware. INR 1.2. Some bleeding noted @ L IJ exit site. Drsg . Serum K 3.3. Repleted w/20mEq of 60 mEq total.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-11-09 00:00:00.000",
"description": "Report",
"row_id": 1619526,
"text": "Respiratory Care:\nPatient wore nasal CPAP of +5 with O2 bled in starting at 8lpm and weaned to 6 with sPO2>95%. Patient wore t/o the night and offered no complaints about mask.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-11-08 00:00:00.000",
"description": "Report",
"row_id": 1619522,
"text": "Admission and NPN 0500-0700:\nThis is a 76 yo male pt with hx of A fib on coumadim who presented to ED from hospital with abdominal pain primarily started 3 days ago, then pain resolved and pt developed malaise and fever up to 103. His WBC was found 11.2, RUQ US showed gall large blasser, CBD dilatation with stone visualization in the duct. Started on levoquin and flagyl for presumed cholangitis. Also developed rapid A fib 130s improved to lopressor and hypotension to 70s systolic improved with IV fluid about 5 Liters. In ED given 10 mg Vit K, blood and urine cxs drawn, sepsis line RIJ was inserted and started on sepsis protocol, admitted to ICU for further sepsis treatment and possible ERCP.\n\nROS:\n\nNeuro: alert, oriented x3, denied any pain or disconfort, calm, cooperative and pleasant.\n\nResp: breathing regularly on O2 NC 2 LPM, sat 92-96%, RR 22, LS CTA bilaterally.\n\nCV: A fib HR 70s-90s, BP 103-109/61-66, with sepsis line RIJ bleeding at the site, dressing changed, also with PIV lines, to be started on D5 1/2NS and to receive 2 units of FFP, weak peripheral pulses, CVP 18-19, SVO2 92-93, lactate 1.3, Hct 36.2, WBCs 9, INR 2.1.\n\nGI/GU: NPO, abdomen obese, BS present, with Foley adequate color U/O.\n\nInteg: intact warm dry skin, T 96.4.\n\nSocial: Full code, HCP is the wife, no calls/visits by family since admission to ICU.\n\nPlan: To be given the Influenza Virus, to be started on IV fluids (Dextrose NS), to be transfused with 2 units FFP, to continue sepsis protocol, continue antibiotics, to be evaluated by surgical team and ? for ERCP.\n"
}
] |
9,002 | 120,994 | Briefly, Mr. was readmitted to the SICU for signs of sepsis with increased WBC and hypotension. He is a 72M who is s/p (4th portion) for adenocarcinoid tumor (duodenal primary w Lung Mets) and CCY . He was previously admitted for tumor recurrence in mediastinal nodes , and biliary obstruction. During this last admission, to treat this obstruction, he received a PTC, EGD with failed duodenal stent placement , PTC internalization , 2 duodenal stents by GI , and failed metallic stents by GI . He was discharged after his diet was advanced and he tolerated PO without any difficulty. However on the day following his discharge he felt lightheaded and had an experienced a fall due to weakness, without loosing consciousness. He was brought to ED, and was found to be hypotensive. He was transferred to SICU, where he temporally required pressors ( no intubation) and was treated with multiple antibiotics for sepsis, presuming his biliary system as the source of infection. After patient was weaned off pressors, with stable VS, he was transferred to OMED service for further management. On the floor patient was intermittently hypotensive with poor | Normalregional LV systolic function. The cardiomediastinal silhouette is obscured by a moderate- sized and unchanged left pleural effusion with associated atelectasis. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Moderately dilated aortic sinus. Noaortic regurgitation is seen. Indeterminate PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is moderately dilated. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Normal interatrial septum. Noted edema in bilat hands. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line placement via the left brachial venous approach. PROCEDURE/FINDINGS: Initial scout film of the abdomen demonstrates the tube to be in unchanged position in the right upper quadrant as well as a duodenal stent overlying the mid abdomen. AP PORTABLE UPRIGHT CHEST RADIOGRAPH: There are moderate aortic arch calcifications. FINDINGS: -scale and Doppler son of the right IJ, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is moderate symmetric left ventricular hypertrophy.The left ventricular cavity is moderately dilated. Initial fluoroscopic image of the abdomen demonstrates the presence of the previously placed internal/external biliary drain and the duodenal stent. The catheter was advanced slightly internally (2 cm) and resutured. IMPRESSION: Thrombotic clot formation in the right cephalic vein with lack of flow consistent with superficial phlebitis. A right internal jugular catheter has been placed with tip overlying the lower SVC. SINGLE SUPINE CHEST RADIOGRAPH: The endotracheal tube is unchanged. A left-sided pacemaker with proximal lead overlying the mid to lower right atrium and distal lead within the right ventricle is stable. The aortic root is moderately dilated atthe sinus level. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 67Weight (lb): 290BSA (m2): 2.37 m2BP (mm Hg): 117/57HR (bpm): 70Status: InpatientDate/Time: at 10:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. There is linear atelectasis within the right lung base. See Carevue for details.Neuro/Resp: Pt remains A&O x3. IMPRESSION: Very limited bedside study demonstrating patent main portal vein with antegrade flow. Moderate mitral annularcalcification. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Status post placement of internal-external biliary drain as well as duodenal stent. The catheter was advanced slightly (2 cm) internally. Rule out cholangitis. There was drainage of the contrast material through the catheter into the proximal jejunum. A new right subclavian central venous catheter is noted with tip overlying the expected region of the cavoatrial junction. The left lung shows some atelectasis but is otherwise clear. COMPARISON: and chest radiographs. IMPRESSION: Stable moderate-sized left pleural effusion with associated atelectasis, no evidence of CHF. There is a similar left lung base atelectasis, similar bilateral small pleural effusion and associated stable left lower lobe atelectasis. Standard positioning of new right subclavian catheter. The tricuspid valve leaflets are mildlythickened. results.Gu: foley placed w/o difficulty,urine icteric w sediment.Bdline urine at times improved w fld boluses.Creat 2.0 Bun 75 team aware.Heme/Id: hct27 wbc 28. afebrile on vanco,flagyl,zosynPsych/Soc/Family: no calls overnight. IVF initiated as stated above.-Pt incontinent of lg liquid stool. ls clear/dim, prod cough-uses suction to clear.cv: on levophed up to 0.05mcg, sbp down to 70s while off levo. Response: PT BY DR AT 0140 Plan: Respiratory failure, acute (not ARDS/) Assessment: PT RESP APPEAR AGONAL AND DICOORDINATE. Recent hx includes placemnt of biliary stent for obstructive jaundice on last adm .Signif pmhx-duodenal ca w resection and incidental ccy on 3/. Transitioning to levophed in attempt to achieve sbp90 mbp>60 once triple lumen line placed.Still req neo and levophed to keep sys bp > 90 mbp>60.cvp-initial 10 w fld bolus running, range 3-5.Distal pulses by doppler only post tibials audible.Skin cool and mottled. Hypotension (not Shock) Assessment: Sbp continued to be hypotensive in 70s and below, mottled from lower abdomen to toes, lactate =9.1, venous ph = 6.94. multiple attemps by team to place aline including attempts in right brachial, pt initially responding to verbal stimuli but progressively less responsive.bowel sounds absent. given marked CXR abnormalities and lobar collapse will pursue this first - bronch - U/S left chest to eval for diagnostic/therapeutic thoracentesis - cultures off bronch - AC 700 x14, PEEP 10, FIO2 as needed - fent gtt, bolus versed for sedation 2) Hypotension: likely mutlifactorial combination of poor vascular tone due to underlying liver and kidney disease, positive pressure ventilation, and potential relapse infection. COOL, PT PULSES BY DOPPLERRESP: BS DIMINISHED ON LEFT SIDE, CLEAR ON RIGHT. - blood, urine, sputum, biliary cultures - check Hct in PM - zosyn, add empiric vanc for now - decrease PEEP to 10 - continue midodrine - dopamine gtt if needed - 3) hyperbilirubinemia: s/p PTC tube replacement, draining partially thick fluid, also with signif skin irritation around the site. Flexi seal placed and continues to stool.Integumentary: Pt has stage II decub in gluteal fold. RUQ US: limited bedside study demonstrating patent main portal vein with antegrade flow. - cont regular diabetic diet 6) renal failure: secodary due to hypotension/ATN+/-HRS: now slowly recoverring. h/o loose stool,had large BM.C-diff neg,no need of precautions now,s/p chemotherapy,last done ,need chemo precautions. h/o loose stool,had large BM.C-diff neg,no need of precautions now,s/p chemotherapy,last done ,need chemo precautions. given his liver failure and his prerenal state will treat for HRS as per renal rec. 4) Metastatic adenocarcinoid s/p second cycle of cisplatinum yesterday. | 35 | [
{
"category": "Radiology",
"chartdate": "2177-04-24 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1009567,
"text": " 2:49 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: pls eval for DVT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72M s/p duodenectomy (4th portion) for adenocarcinoid tumor, s/p duod stents,\n with R subclavian, now with R arm swelling\n REASON FOR THIS EXAMINATION:\n pls eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man status post duodenectomy for adenocarcinoid tumor\n status post duodenal stents with right subclavian, now with right arm\n swelling.\n\n COMPARISON: None.\n\n FINDINGS: -scale and Doppler son of the right IJ, subclavian,\n axillary, brachial, basilic and cephalic veins were performed. There is\n normal compressibility, flow and augmentation in the IJ, subclavian, axillary,\n brachial, and basilic veins. There is mixed echogenicity within the lumen of\n the cephalic vein with lack of flow consistent with thrombotic clot formation\n along the entire cephalic vein. There is no evidence of intraluminal thrombus\n in the other vessels analyzed.\n\n IMPRESSION: Thrombotic clot formation in the right cephalic vein with lack of\n flow consistent with superficial phlebitis.\n\n These results were given to Dr. today, , the day of\n the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1008981,
"text": " 3:52 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest portable line placement.\n\n INDICATION: Evaluate line placement.\n\n COMPARISON: and chest radiographs.\n\n FINDINGS: Study is limited by leftward rotation of the patient. A new right\n subclavian central venous catheter is noted with tip overlying the expected\n region of the cavoatrial junction. A left-sided pacemaker with proximal lead\n overlying the mid to lower right atrium and distal lead within the right\n ventricle is stable. There is dense calcified atherosclerotic plaque within\n the aortic arch. No significant change is present to a dense opacity at the\n left mid and lower lung completely obscuring the hemidiaphragm consistent with\n effusion and associated atelectasis. There appears to be a new slight\n interstitial abnormality within the right lung however there is decreased lung\n volume which may account for this difference.\n\n IMPRESSION:\n 1. Left pleural effusion and basal atelectasis, unchanged.\n 2. Standard positioning of new right subclavian catheter.\n 3. Possible mild pulmonary edema. Repeat radiograph at larger lung volume\n would help with the interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1010822,
"text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evalaute for infiltrates, consolidations\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with intermittent cough, mild dyspnea\n REASON FOR THIS EXAMINATION:\n Evalaute for infiltrates, consolidations\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Intermittent cough, mild dyspnea.\n\n CHEST:\n\n There is complete whiteout of the left chest. Most of this is probably due to\n an enlarging left pleural effusion but underlying collapse/consolidation is\n not excluded.\n\n The right lung is clear. Some atelectasis in the mid zone is again noted.\n\n IMPRESSION: Whiteout of left chest, majority of which is due to an increasing\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-30 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1010304,
"text": " 9:02 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc into left arm, as dvt in R PT HAS HEPARIN\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with duodenal ca and s/p sepsis, now an abx\n REASON FOR THIS EXAMINATION:\n please place picc into left arm, as dvt in R PT HAS HEPARIN ALLERGY (HIT) needs\n !\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Dr. and performed the procedure. Dr. , the\n Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double-lumen PICC line measuring 45 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen\n PICC line placement via the left brachial venous approach. Final internal\n length is 45 cm, with the tip positioned in SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-30 00:00:00.000",
"description": "BILIARY STRICTURE DILATION NO STENT",
"row_id": 1010305,
"text": " 9:02 AM\n BILIARY CATH CHECK Clip # \n Reason: please eval percutaneous tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * BILIARY STRICTURE DILATION NO -58 SERVIC BY SAME MD DURING POST OP *\n * CHANGE PERC BILIARY DRAINAGE C 78 RELATED PROCEDURE DURING POSTOPER *\n * -51 MULTI-PROCEDURE SAME DAY CHALNAGIOGRAPHY VIA EXISTING C *\n * 78 RELATED PROCEDURE DURING POSTOPER -51 MULTI-PROCEDURE SAME DAY *\n * BILIARY STRICTURE DILATION NO CHANGE PERC TUBE OR CATH W/CON *\n * TUBE CHOLANGIOGRAM MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with duodenal ca, s/p percutaneous cholecystostomy tube - tube\n draining into bag but also significant amount (>500) of drainage around the\n tube\n REASON FOR THIS EXAMINATION:\n please eval percutaneous tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with duodenal carcinoma status post percutaneous\n biliary drain placement, presenting with leakage around the catheter.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table, and the abdomen was prepped and draped in the\n standard sterile fashion. A preprocedure timeout was performed.\n\n Initial fluoroscopic image of the abdomen demonstrates the presence of the\n previously placed internal/external biliary drain and the duodenal stent.\n Injection of contrast material through the biliary drain was performed\n demonstrating moderate dilation of the common bile duct and mild dilation of\n the intrahepatic ducts. There was drainage of the contrast material through\n the catheter into the proximal jejunum. There were no signs of leakage of the\n contrast material through the cutaneous tract.\n\n The catheter was cut and a 0.035 Amplatz wire was advanced through the biliary\n drain, and the drain was removed over the wire. A 5 French -Tip sheath\n was advanced over the wire into the common bile duct, and the inner dilator\n was removed. A 0.035 Glidewire was advanced through the sheath into the CBD,\n and the sheath was removed over both wires. The sheath was readvanced over\n the Glidewire, and the Amplatz wire was coiled, clamped and keeped as a\n safety wire. A Kumpe catheter was advanced over the Glidewire through the\n sheath and access was gained into the small bowel. Using a combination of the\n Kumpe catheter and the Glidewire, access was gained into the duodenal stent. A\n 4-mm balloon was advanced over the wire partially inside the stent and balloon\n dilatation was performed attempting to maintain an open access through the\n (Over)\n\n 9:02 AM\n BILIARY CATH CHECK Clip # \n Reason: please eval percutaneous tube\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n duodenal stent. Attempts to cross the stent with the Kumpe catheter were\n unsuccessful. At this point, decision was made to replace the internal-\n external biliary drain without crossing into the duodenal stent.\n\n The sheath, the Kumpe catheter and the Glidewire were removed. An 8 French\n nephroureteral drain was advanced over the Amplatz wire under fluoroscopic\n guidance, and the tip of the catheter was positioned within the proximal\n jejunum. The wire was removed and injection of a small amount of contrast\n material through the drain confirmed its position. The biliary drain was\n secured to the skin with 0 silk suture, and the catheter was connected to a\n bag for external drainage.\n\n The patient tolerated the procedure well without immediate complications.\n\n Moderate sedation was provided by administering divided dose of 75 mcg of\n fentanyl and 1.5 mg of Versed throughout the total intraservice time of 65\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n IMPRESSION: Cholangiogram demonstrating moderate dilatation of the common\n bile duct and mild dilatation of the intrahepatic biliary ducts. There was no\n sign of extravasation of the contrast material through the entry site on the\n skin.\n\n Uncomplicated exchange of the internal/external biliary drain. The tip of the\n catheter is located within the proximal jejunum. The catheter was connected\n to a bag for external drainage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-05-04 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1010888,
"text": " 9:06 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for free air or any signs of perforation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with recurrent small bowel CA with large pleural effusion c/b\n hypoxic respiratory failure s/p intubation on pressors with elevated lactate\n REASON FOR THIS EXAMINATION:\n please eval for free air or any signs of perforation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with recurrent small bowel cancer, in respiratory\n failure, with elevated lactate.\n\n COMPARISON: CT abdomen of and chest radiograph of at \n hours.\n\n TWO SUPINE VIEWS OF THE ABDOMEN: This is a technically very limited study.\n However, air and fecal matter is present in the rectum, and there are no\n obviously dilated loops of bowel. No obvious free air is identified on the\n supine radiograph. Again noted is opacification of the lower left hemithorax\n with ipsilateral shift of the mediastinum, consistent with lower lung\n collapse.\n\n IMPRESSION: Technically limited study reveals no evidence of obstruction and\n no obvious intraperitoneal free air. Again noted is left lower lung collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1010843,
"text": " 12:24 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval lines, tubes, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with recurrent small bowel CA with large pleural effusion c/b\n hypoxic respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n eval lines, tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recurrent small bowel carcinoma with pleural effusion\n status post drainage.\n\n The large left effusion is now considerably smaller consistent with\n thoracentesis. There is no pneumothorax. The left lung shows some\n atelectasis but is otherwise clear.\n\n IMPRESSION: No pneumothorax following thoracentesis, reduction in size of\n left effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-05-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1010884,
"text": " 7:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval for RIJ placement and OG tube.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with recurrent small bowel CA with large pleural effusion c/b\n hypoxic respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n Please eval for RIJ placement and OG tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with recurrent small bowel carcinoma and large\n effusion. Status post intubation. Evaluate for right IJ and orogastric tube\n placement.\n\n COMPARISON: .\n\n SINGLE SUPINE CHEST RADIOGRAPH: The endotracheal tube is unchanged. An\n orogastric tube extends below the field of view below the left hemidiaphragm.\n A right internal jugular catheter has been placed with tip overlying the lower\n SVC.\n\n There is mild bilateral increased interstitial opacity and congested\n pulmonary vasculature consistent with mild overload. There is a similar left\n lung base atelectasis, similar bilateral small pleural effusion and associated\n stable left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-21 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1008969,
"text": " 12:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: EVAL BILIARY TREE,DUODENAL CA, HYPOTENSION\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with duodenal ca, with ptc drains, with leukocytosis and\n hypotension, r/o cholengitis\n REASON FOR THIS EXAMINATION:\n evaluate billiary tree,\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Duodenal CA with PTC drains, leukocytosis, and hypotension. Rule\n out cholangitis.\n\n COMPARISON: CT dated .\n\n FINDINGS: Very limited bedside study due to patient's clinical condition and\n surgical drains. The liver is partially visualized. There is no free fluid.\n No intrahepatic biliary ductal dilatation. The common bile duct is not\n reliably identified. There is no free fluid.\n\n IMPRESSION: Very limited bedside study demonstrating patent main portal vein\n with antegrade flow. The common bile duct is not identified.\n\n The findings were discussed with Dr. at the time of the interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-29 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1010206,
"text": " 3:55 PM\n RENAL U.S. Clip # \n Reason: please eval for metastatic masses leading to obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with metastatic duodenal carcinoma and renal failure\n REASON FOR THIS EXAMINATION:\n please eval for metastatic masses leading to obstruction\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND\n\n INDICATION: 72-year-old man with metastatic duodenal carcinoma and renal\n failure, please evaluate for metastatic masses leading to obstruction.\n\n RENAL ULTRASOUND: The examination is limited by the patient's body habitus.\n The right kidney measures 12.4 cm. A small cortical cyst measuring 1.2 cm is\n seen at mid pole. There is no hydronephrosis. The left kidney is difficult\n to visualize, however, measures 11.1 cm and there is no evidence for\n hydronephrosis. Two cysts are seen in the upper pole. There is free fluid in\n the left flank.\n\n IMPRESSION:\n 1. No evidence for hydronephrosis.\n\n 2. Bilateral renal cysts.\n\n 3. Free fluid in the left flank.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2177-04-30 00:00:00.000",
"description": "Report",
"row_id": 70393,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 290\nBSA (m2): 2.37 m2\nBP (mm Hg): 117/57\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Moderately dilated LV cavity. Normal\nregional LV systolic function. Overall normal LVEF (>55%). No resting LVOT\ngradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect is seen by 2D\nor color Doppler. There is moderate symmetric left ventricular hypertrophy.\nThe left ventricular cavity is moderately dilated. Regional left ventricular\nwall motion is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is moderately dilated at\nthe sinus level. The ascending aorta is moderately dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. The pulmonary artery systolic pressure could not be determined.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no definite\nchange.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1008955,
"text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with\n REASON FOR THIS EXAMINATION:\n pna, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with pneumonia vs. CHF.\n\n COMPARISON: .\n\n AP PORTABLE UPRIGHT CHEST RADIOGRAPH: There are moderate aortic arch\n calcifications. The cardiomediastinal silhouette is obscured by a moderate-\n sized and unchanged left pleural effusion with associated atelectasis. There\n is linear atelectasis within the right lung base. The lungs are otherwise\n stable. A cardiac pacer overlies the left hemithorax with leads terminating\n overlying the right atrium and right ventricle.\n\n IMPRESSION: Stable moderate-sized left pleural effusion with associated\n atelectasis, no evidence of CHF. Cannot entirely exclude underlying\n infiltrate within the left lung base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-21 00:00:00.000",
"description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER",
"row_id": 1009004,
"text": " 8:44 AM\n BILIARY CATH CHECK Clip # \n Reason: eval drain\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER *\n * TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72M s/p duodenectomy (4th portion) for adenocarcinoid tumor (duodenal primary\n w Lung Mets) and CCY , now w/recurrence in mediastinal nodes , and\n biliary obstruction; s/p ptc drain, EGD with failed duodenal stent placement\n ; s/p internalization of ptc , s/p 2 duodenal stents/GI , s/p failed\n GI metallic stents . Now with N/V x2, hypotension, WBC 17.5\n REASON FOR THIS EXAMINATION:\n eval drain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old status post duodenectomy for adenocarcinoid tumor,\n now with recurrence and biliary and duodenal obstruction. Status post\n placement of internal-external biliary drain as well as duodenal stent. Now\n representing with nausea, vomiting, leukocytosis and hypotension. Please\n evaluate for obstruction.\n\n COMPARISON: .\n\n RADIOLOGISTS: Drs. and , the Attending Radiologist who was\n present and supervising throughout, performed the procedure.\n\n PROCEDURE/FINDINGS: Initial scout film of the abdomen demonstrates the tube\n to be in unchanged position in the right upper quadrant as well as a duodenal\n stent overlying the mid abdomen. There is also an aortic stent seen in the\n mid lower abdomen. Injection of 20 cc of IV Optiray via the percutaneous\n biliary stent demonstrates opacification of a moderately dilated biliary tree,\n slightly decreased compared to the prior exam, as well as opacification of the\n cystic duct remnant. There was no evidence of obstruction or extravasation.\n Contrast is also seen opacifying the proximal jejunum via the distal pigtail.\n Contrast also tracks along the course of the intrahepatic portion of the\n biliary catheter with a small amount of contrast extravasating external to the\n patient's skin, likely due to a patulous tract. The catheter was advanced\n slightly internally (2 cm) and resutured. Bacitracin was applied to the\n catheter entry site and a DuoDERM dressing was placed to minimize skin\n irritation secondary to the dressing tape. The patient tolerated the\n procedure well with no immediate complications.\n\n IMPRESSION: Cholangiogram demonstrating internal/external drain in place with\n no evidence of obstruction or extravasation. Contrast passes through the\n catheter into the jejunum. The catheter was advanced slightly (2 cm)\n internally.\n\n (Over)\n\n 8:44 AM\n BILIARY CATH CHECK Clip # \n Reason: eval drain\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1009128,
"text": " 2:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p duodenectomy (4th portion) for adenocarcinoid tumor\n (duodenal primary w Lung Mets) and CCY , now w/recurrence in mediastinal\n nodes , and biliary obstruction; s/p ptc drain, EGD with failed duodenal\n stent placement ; s/p internalization of ptc , s/p 2 duodenal stents/GI\n , s/p failed GI metallic stents . Now in SICU for hypotension with\n leukocytosis\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative appearance, to assess for acute cardiopulmonary\n disease.\n\n FINDINGS: In comparison with the study of , there is again marked\n rotation of the patient. The dense opacification in the left mid and lower\n lung obscuring the hemidiaphragm is again consistent with effusion and\n associated atelectasis. Pacer leads and catheter remain in place.\n\n IMPRESSION: Little overall change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Report",
"row_id": 157546,
"text": "Ventricular paced rhythm. Possible underlying atrial fibrillation. Compared\nto the previous tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-04-20 00:00:00.000",
"description": "Report",
"row_id": 157547,
"text": "Underlying atrial flutter/fibrillation with a ventricular paced rhythm at\n70 beats per minute. Compared to the previous tracing of the atrial\nrhythm appears somewhat more orgaqnized and ventricular pacing is no longer\nintermittent.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-22 00:00:00.000",
"description": "Report",
"row_id": 1381411,
"text": "See Carevue for details.\n\nNeuro/Resp: Pt remains A&O x3. MAE. Strengths intact. Remains on 4L o2 via NC. LS diminished in bases. Productive cough with clear secretions, yankuer used by pt. Pt's family to bring CPAP from home. IS at bedside with pt demonstrating proper use.\n\nCardio: Pt now off Levo since 1230. SBP remains in the 110-120's HR 60-70's. Afebrile. Continue with antibiotics as ordered. MAP greater than 60 as ordered, continue to use Levo prn to obtain goal. Continue to follow ABP and CVP.\n\nGI/GU: Pt urine output approx 100-200 cc/hr. Billary drain patent with brown drainage. Pt tolerating liquid diet. Covering BS with standing and sliding scale as ordered. Small, gelatinous stool sent for C-Diff culture. +BS. +Flatulance.\n\nIntegumentary/Activity: PT consult ordered to assist with OOB order. Pt states \"feeling weak\" Pt turned and repositioned thru out shift. Integumentary intact. Noted edema in bilat hands. No edema in LE's. +pulses thruout.\n\nPlan: Cont to moniter and assess BP, HR, temp, labs. Cont IS treatment. OOB as soon as tolerated with assistance from PT. Cont to encourage clear liquid diet and moniter and tx BG levels. SICU team aware of all above, call with updates and changes.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381412,
"text": "addendum: 10 nph given at bedtime. glucose at 2200 195 tx wigu: urine yellow . drainign via foley in good amounts. creatinine decreased to 1.8 this am from 2.7.\n\nlabsK = 2.7 to be th 4 regular. bs 148 at 0400 no coverage.treat3ed with 60 meq kcl iv.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381413,
"text": "addendum: 10 nph given at bedtime. glucose at 2200 195 tx wigu: urine yellow . drainign via foley in good amounts. creatinine decreased to 1.8 this am from 2.7.\n\nlabsK = 2.7 to be th 4 regular. bs 148 at 0400 no coverage.treat3ed with 60 meq kcl iv.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381414,
"text": "addendum: 10 nph given at bedtime. glucose at 2200 195 tx wigu: urine yellow . drainign via foley in good amounts. creatinine decreased to 1.8 this am from 2.7.\n\nlabsK = 2.7 to be th 4 regular. bs 148 at 0400 no coverage.treat3ed with 60 meq kcl iv.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381415,
"text": "addendum: 10 nph given at bedtime. glucose at 2200 195 tx wigu: urine yellow . drainign via foley in good amounts. creatinine decreased to 1.8 this am from 2.7.\n\nlabsK = 2.7 to be th 4 regular. bs 148 at 0400 no coverage.treat3ed with 60 meq kcl iv.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381416,
"text": "cv:hr 70 vpaced. sbp 95-113/ map 57-67, levo on at .o3o to .041 mics/kg/min with goal to maintain map> 60. bp decreased whne sleeping and levo requirements increased during sleep, currnetly weaning and levo is at .030 mic/kg/min.\n\nresp: o2 at 4 l nc. resp came uip to set up pt biipap machine but humidifier not in bag. pt did well on 4 l overnoc and no epesode of apnea noted.\n\nintegumentary: biliary tube on r side oozes some bilious around tube, there is a duoderm in place to protect skin. Area cleansed with ns and skin protectant applied. pt has many small tape burns around the area so minimal amount of tape used. there is a very small pink skin abrasion between his buttocks at his sacrum base.cleansed and left open to air. turned side to side with minimal time on back.\n\ngi: tolerating liquid diet. taking lots of water, sorbet this am. biliary drain draining cloudy yellow-brown. small geatinous drainage per rectum. positive bowel sounds. c/o discomfort when turning onto right side with position changes.. no need for apin medication.\n\nmental status: alert and oriented calm and cooperative\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-23 00:00:00.000",
"description": "Report",
"row_id": 1381417,
"text": "Nursing Progress Note\nSee Carevue for specifics\n\nPt remains afebrile. Continues on Cipro IV. Maintaining BP 90's-100's/50's with MAP 60 off pressors. V-paced. No ectopy noted. K repleted this am. Repeat pending. OOB to chair with PT. LS clear, diminished at bases. Using IS with encouragement. Productive cough for thick white secretions. Sats 100% on 4L NC. Requires BiPap overnoc. Right abdominal drain site leaking bilious fluid-DSD intact. Biliary drain draining lge amts cloudy bilious drainage. Tolerating full lix-advance as tolerated. Small mucous stoolx1. C. Diff pending.\nFoley draining lge amts clear amber-almost icteric urine.\n\nPlan: Continue closely monitor hemodyamics, antibiotics as ordered, drain output, labs. Continue provide support to pt and family. ?transfer to floor tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-24 00:00:00.000",
"description": "Report",
"row_id": 1381418,
"text": "assessment as noted\n\ngi: poor appetite, denies nausea, tol sips water well, t-tube drains bile, +bs, obese/soft, +flatus and several BM overnight\n\nres: on nc 4l, maintains sat>95, was on BIpap for 1 hour last night and stopped using it and switched back to NC 4l. ls clear/dim, prod cough-uses suction to clear.\n\ncv: on levophed up to 0.05mcg, sbp down to 70s while off levo. in v paced rtm with underlying a/fib. +pulses, slight puffinedd both hands.\n\nneuro: complient and cooperative, no gross deficit,incontinent of stool tryin to help with turns\n\nskin: see carevue, small pink area on coccyx with dsd on covered, blister on l.abd wall,\n\n labs: k was repleted\n\nplan: emotional support, consult podaetrist \"to cut toe nails\", minitor cv, wean off levophed, pt/ot oob to chair if stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-21 00:00:00.000",
"description": "Report",
"row_id": 1381408,
"text": "adm note\nO: Pt adm from e.d. r/o biliary sepsis. Tranferred from hosp after near syncopal episode at home w sbp 77/30-> from to . Recent hx includes placemnt of biliary stent for obstructive jaundice on last adm .Signif pmhx-duodenal ca w resection and incidental ccy on 3/. Pt well-known to oncology dept.See fhp for additional pshx & pmhx.\n\nNeuro: a&ox3 pserl(lt cataract ).Follows commands and mae. Early am more lethargic, restless at times,vague disoriented at times.\n\nCv: vpaced(has dual lead ppm).Adm from e.d. on no gtts(altho had been on low dose neo on arrival to e.d) sbp initially 120-130 dropping to 70-80 syst req neo gtt, fld boluses x 3(2liters total here)Ivflds ^ to 200ccx/hr, album 12.5 gm q6h. Transitioning to levophed in attempt to achieve sbp90 mbp>60 once triple lumen line placed.Still req neo and levophed to keep sys bp > 90 mbp>60.cvp-initial 10 w fld bolus running, range 3-5.Distal pulses by doppler only post tibials audible.Skin cool and mottled. cvl line placemnt confirmed by pcxr per Dr .\n\nResp: np at 3lpm w adeq sats. Strong non prod cough. Bbs clear w crackles bibas. Pcxr -lll collapse ? pna-rec'd levaquin and gent in osh and empiric vanco, zosyn,flagyl here.\n\nGi: npo, abd obese,+ bowel snds.Percutaneous biliary drain w mod amts of foul odored drng-> cult sent and came back + for gm -rods. Site at perc drain indurated and w foul drng around tube as well as through it.Glucoses wnl.Abd ultrasound at bedside,? results.\n\nGu: foley placed w/o difficulty,urine icteric w sediment.Bdline urine at times improved w fld boluses.Creat 2.0 Bun 75 team aware.\n\nHeme/Id: hct27 wbc 28. afebrile on vanco,flagyl,zosyn\n\nPsych/Soc/Family: no calls overnight. Pt states lives w family.Wife went home prior to pt adm to icu.Contact numbers and icu visiting policy will need to be reviewed w family when they phone or visit.\n\nA/P: biliary sepsis cont w fld volume resusc as ordered, monitor for s/s of fld overload, continue antibx as ordered. Cont to support bp titrate pressors as ordered, attempt wean neo to off,utilize levophed primarily to achieve goal mbp >60.? results of abd u/s.Provide emot support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-21 00:00:00.000",
"description": "Report",
"row_id": 1381409,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS. PT TAKEN TO IR THIS MORNING- BILIARY STENT MANIPULATED. RECIEVED 50MG FENTANYL FOR PAIN.\nNEURO: LETHARGIC BUT EASILY AROUSABLE, ORIENTED X3, DENIES PAIN\nCV: AFEBRILE, V-PACED AT 70. SBP 90-140= NEO WEANED TO OFF, LEVO WEANED FROM 0.2 TO 0.1. COOL, PT PULSES BY DOPPLER\nRESP: BS DIMINISHED ON LEFT SIDE, CLEAR ON RIGHT. NC AT 4 LITERS WITH SAT>94%\nGI: ABD SOFTLY DISTENDED, + BS, SM LOOSE COLORED STOOL THIS AM, REMAINS NPO, IVF DECREASED FROM 200CC/HR TO 100CC/HR\nGU: ICTERIC COLORED URINE IN GOOD AMTS, SM AMT SEDIMENT IN URINE NOTED\nENDO: NPH INSULIN HELD SECONDARY TO NPO STATUS, BS 193 AT 10 AND 1600= TX'D WITH 4 UNITS REGULAR INSULIN\nA/P: CONT TO MONITOR HEMODYNAMICS, WEAN LEVO KEEPING MAP>60, MEDICATE FOR PAIN AS NEEDED, ENCOURAGE PULM TOILET- REASSESS BREATH SOUNDS Q4HRS, REPLETE LABS AS NEEDED. WEDDING RING SENT HOME WITH DAUGHTER .\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-22 00:00:00.000",
"description": "Report",
"row_id": 1381410,
"text": "NPN (NOC):\n\nCV: PT REMAINS ON 0.08 OF LEVO. ATEMMPT TO WEAN TO 0.06 DONE X 1 WHICH WAS OKAY UNTIL PT FELL ASLEEP AND SBP WENT TO 89 W/ MAP BELOW 60. LEVO INCREASED BACK TO .0.08 W/ ACCEPTABLE MAPS SINCE.\n\nRESP: RR 20'S, REG AND UNLABORED. SATS MID TO HIGH 90'S ON 4 LITERS. BS'S DIMINSHED ON L. PT COUGHED UP THICK TAN PLUG X1. AFEBRILE.\n\nF/E: UO 200 PER HR. IVF DECREASED TO KVO. AM LYTES PND.\n\nGI: REMAINS NPO. BILE DRAIN PUT OUT 200 CC'S COULDY MATERIAL OVERNOC. BILE IS CLEAR NOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-24 00:00:00.000",
"description": "Report",
"row_id": 1381419,
"text": "Please see carevue for details.\n\nNeuro/Resp: Pt remains A&O x3, no neuro deficits detected. Pt remains on 4L O2 via NC during the day and mantaining Sat of 95%. Presenting with a productive cough with white, thick sputum. Self mouth suctioning via yankuer. Cont to enc. deep breathing and coughing. LS diminished in bases.\n\nCardio: Pt continued on .025mcg of Levo thruout most of shift until 1500. Pt dropped SBP into 80's and MAP of 50. Map goal issued by SICU team is 55. Pt has received x3 boluses of 500 cc NS. Now on LR 40cc/hr. Midorine started TID. Afebrile.\n\nGI/GU: Pt's po appetite remains poor, but improving. SICU team aware and discussing alternative routes of nutrition. Pt able to eat sm amount of cream of wheat and tolerates moderate amounts of H2O.\n-Pt.s urine output decreased to approx 10 cc-30cc/hr tjis past shift. SICU aware. IVF initiated as stated above.\n-Pt incontinent of lg liquid stool. Flexi seal placed and continues to stool.\n\nIntegumentary: Pt has stage II decub in gluteal fold. Cleaned and dsd applied. Pt turned and repositioned several times during shift. OOB to chair with 3-4 assist. Stand and pivot with walker. Pt OOB to chair for approx 3 hrs.\n-Pt to US for study of RUE r/t increased swelling. Awaiting radiology report. RUE elevated.\n\nPlan: Cont to moniter BP and urine output. Cont to turn and reposition freg. OOB during day. Enc. deep breathing and coughing. Moniter labs. ? Tx to medical/oncology floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-04-25 00:00:00.000",
"description": "Report",
"row_id": 1381420,
"text": "pt alert and oriented. no c/o pain. slept in short naps.\nvss, b/p stable 100/50-115/57\nurine output 50-25cc dk amber urine.\nsmall amt loose stool via flexi-seal.\nrt arm edematous-elevated^^on pillow.\nplan is to transfer to today if pt remain stable.\n"
},
{
"category": "Nursing",
"chartdate": "2177-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 324035,
"text": "Hypotension (not Shock)\n Assessment:\n Sbp continued to be hypotensive in 70\ns and below, mottled from lower\n abdomen to toes, lactate =9.1, venous ph = 6.94. multiple attemps by\n team to place aline including attempts in right brachial, pt initially\n responding to verbal stimuli but progressively less responsive.bowel\n sounds absent. KUB done but difficult to visualize anything . pt had to\n remain flat secondary to hypotension and pt is very obese abdomen.\n Action:\n Fluids wide open. 3 liters LR abd 1 liter NS given. Dopamine running at\n 21 mics/kg/min, phenylephrine infusion increased to 9 mics/kg/min and\n vasopressin started and increased to 2.4 units/hr. pt also received\n hydrocortisone 50 mg iv and antibiotic coverage of gentamycin in\n addition to his zosyn and vanco for even broader coverage. He was given\n ca gluconate 2 grams and magnesium sulfate 2 grams and 1 amp bicarb as\n well as bicarb drip 3 amps bicarb in 1 liter d5w at 150 /hr. Family\n updated by Doctor several times and bp continueud to decrease to 60/\n family again notified of the patients continued lack of improvement and\n pt code status was changed to CMO . ALL DRIPS AND FLUIDS STOPPED AND\n FENTANYL DRIP LEFT INFUSING AT 100 MICS /HR FOR PT COMFORT.\n Response:\n PT BY DR AT 0140\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PT RESP APPEAR AGONAL AND DICOORDINATE. Breath sounds diminished agonal\n r side and left base initially. Mottled lower extremities. Vbg drawn\n and venous ph = 6.94. o2 sats difficult to pick up.. sometimes sats\n 80-74 %. Pt made cmo after dr discussion with family.\n Action:\n Response:\n Pt without spontaneous respiration noted` 1;38 AND DR PT DEAD\n AT 0140\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 324010,
"text": "TITLE: PGY 2 Admission Note\n Chief Complaint: hypoxia\n HPI:\n 72 year old man with hx of metastatic duodenal adenoCA (lung mets),\n biliary obstruction c/p stenting transferred to the ICU for hypoxia and\n hypotension. He was initially admitted to the SICU for signs of sepsis\n likely biliary source and treated with cipro. His recent major events\n (including his prior admission) are summarized below.\n : biliary cannulation not possible as D2 was infiltrated with\n tumor. His ERCP was otherwise normal to D3.\n PTC report: External compression of the common hepatic duct and\n distal CBD obstruction by duodenal mass. 8 Fr internal and external\n drainage tube with its distal tip were positioned at duodenal third\n portion.\n : UGI: irregular narrowing of 2nd part duodenum c/w recurrent tumor\n : Biliary stent: internalized successfully with pigtail passed and\n remaining through duodenal obstruction into the jejunum\n : Cholangiogram: dilated hepatic ducts and patent biliary drain with\n terminal pigtail distal to the area of obstruction\n IR metallic stents unsuccessful, still has PTC to gravity drain\n Bile: GS=GNR\n Cdiff: neg, MRSA neg, VRE neg\n IR repositioned PTC - catheter advanced, contrast to jejunum\n RUQ US: limited bedside study demonstrating patent main portal\n vein with antegrade flow. CBD not identified.\n He developed acute renal failure which was felt likely to be related to\n ATN +/- hepatorenal syndrome. He was started on\n octreotide/midodrine/albumin. His Cr peaked at 2.7 but has trended down\n since.\n Transferred to OMED on . He remained on zosyn/vanco then weaned\n to cipro alone.\n He received his second cycle of single cisplatinum on \n with 500cc NS pre-hydration. He continued to drain copious amounts from\n his PTC bilary drain.\n On the day of transfer he was noted to be somnolent but arousable\n to sternal rub with progressive somnolence. He dropped his O2sats to\n 80% on 2L with improvement to 93% on NRB. ABG 7.28/30/52 (on 6L).\n Portable chest xray notable for complete whiteout of left hemithorax.\n I/O for the preceeding 24hrs: 2.7/3.2L, since midnight: 4.2/3.8L. One\n empiric dose of narcan given without improvement in mental status. His\n blood pressure dropped to 80s/20s and dopamine was started as well as a\n NS fluid bolus. Anesthesia called to intubate patient, this was done\n with 8-0 ETT tube with etomidate and succinylcholine. Bilateral\n breathsounds were confirmed.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Heparin Agents\n positive hepari\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Meds On transfer:\n zosyn 2.5 mg IV q6 ( resumed)\n albumin 25% 25gms \n famotidine 20 mg daily\n fondaparinux 7.5 mg daily\n insulin fixed and sliding scale\n loperamide 2-4 mg QID:prn\n midodrine 10 mg TID\n octreotide 100 mcg SQ q8\n ondansetron 8 mg IV q8:prn\n prochlorperazine 10 mg IV q6:prn\n simethicone 40-80 mg QID:prn\n trazodone 25 mg qhs:prn\n Past medical history:\n Family history:\n Social History:\n --a fib w/ tachy-brady syndrome s/p pacemaker placement on by\n Dr. @ \n --AAA s/p endovascular repair by Dr. with known\n endoleak per records.\n --Type II diabetes, insulin-dependent\n --Bilateral LE fx s/p fixation 20 yrs ago\n --Morbid obesity\n --Sleep apnea\n --HTN\n --diabetic retinopathy\n --CHF most likely diastolic as has preserved EF 55%\n --Pulmonary artery hypertension\n --Hyperlipidemia\n --Chronic venous stasis\n --Prior syncope\n --Arthritis\n -- Cardiac Cath to abnormal stress which showed no\n significanty blockage. One vessel coronary artery disease. Normal LV\n systolic function. Mild LV diastolic dysfunction.\n No significant subclavian stenosis on the right or left.\n Angioseal of right femoral artery.\n - Restrictive pattern on PFT's \n - metastatic duodenal cancer with lung mets, complicated by recurrent\n small bowel obstruction s/p duodenal stenting (presented in EGD\n was notable for a small ulcer at the GE junction but also a\n circumferential mass in the third portion of the duodenum. This was a\n fungating mass with malignant appearance. A biopsy demonstrated a\n neuroendocrine carcinoma with surface ulceration. He had an elective\n laparotomy and duodenal resection on . The resected specimen\n demonstrated malignant adenocarcinoid tumor (neuroendocrine\n carcinoma) of the duodenum, which measured 4.8 cm but was a\n pathological T4 lesion as it was perforating a viscus)\n non-contributory\n Occupation: retired realtor/salesman\n Drugs: none\n Tobacco: quit 25yrs ago. (>100pack-years)\n Alcohol: social drinker. former heavy use\n Other: 2 daughters and mother are spokespersons\n Review of systems:\n Constitutional: Fatigue\n Eyes: Conjunctival edema\n Respiratory: Dyspnea, Tachypnea\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Integumentary (skin): Jaundice\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Psychiatric / Sleep: Daytime somnolence\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 70 (69 - 77) bpm\n BP: 91/45(54) {68/24(39) - 98/52(54)} mmHg\n RR: 23 (14 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,445 mL\n PO:\n TF:\n IVF:\n 2,445 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,345 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 680 (680 - 680) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 100%\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n Compliance: 61.8 cmH2O/mL\n SpO2: 99%\n Ve: 16.1 L/min\n Physical Examination\n General Appearance: Overweight / Obese, jaundiced\n Eyes / Conjunctiva: PERRL, Conjunctiva pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ,\n Dullness : at left base), (Breath Sounds: Clear : on right, Bronchial:\n at left anterior, Diminished: at left base)\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Sedated, Tone: Not\n assessed\n Labs / Radiology\n 252 K/uL\n 10.3 g/dL\n 111 mg/dL\n 1.6 mg/dL\n 32 mg/dL\n 11\n 118 mEq/L\n 4.3 mEq/L\n 142 mEq/L\n 33.6 %\n 3.2 K/uL\n [image002.jpg] AG 12\n \n 2:33 A4/27/ 01:35 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 3.2\n Hct\n 33.6\n Plt\n 252\n Cr\n 1.6\n Glucose\n 111\n Other labs: ALT / AST:32/48, Alk Phos / T Bili:170/13.1\n Fluid analysis / Other labs:\n Na 138 Cl 112 BUN 23 Gluc 188 AGap=9\n K 4.4 CO2 17 Cr 0.8\n Ca: 7.7 Mg: 1.8 P: 3.4\n ALT: 34 AP: 220 Tbili: 15.7 Alb: 2.6\n AST: 48 Lip: 28\n WBC 3.0 Hb 9.2 Hct 28.3 Plt 114 MCV 101\n Source: \n PT: 16.4 PTT: 53.0 INR: 1.5\n Imaging: CXR complete white out of left hemithorax with mediastinal\n shift to left in notablly rotated film.\n Microbiology: BCx - negative\n C-dif negative\n ECG: V-paced.\n Assessment and Plan\n 72 yo male with metastatic duodenal ca complicated by lung mets and\n biliary obstruction s/p PTC and intestinal stening with new hypoxia and\n hypotension.\n 1) Hypoxic respiratory failure: likely etiology left lung collapse\n likely with surrounding effusion now markedly re-expansion following\n addition of positive pressure. unclear if there may be a focal airway\n abnormality within the airway. also left pleural effusion potentially\n contributing as well. given marked CXR abnormalities and lobar collapse\n will pursue this first\n - bronch\n - U/S left chest to eval for diagnostic/therapeutic thoracentesis\n - cultures off bronch\n - AC 700 x14, PEEP 10, FIO2 as needed\n - fent gtt, bolus versed for sedation\n 2) Hypotension: likely mutlifactorial combination of poor vascular tone\n due to underlying liver and kidney disease, positive pressure\n ventilation, and potential relapse infection. however no fevers or\n dramatic change in WBC count (although chemo confounds this).\n - blood, urine, sputum, biliary cultures\n - check Hct in PM\n - zosyn, add empiric vanc for now\n - decrease PEEP to 10\n - continue midodrine\n - dopamine gtt if needed\n -\n 3) hyperbilirubinemia: s/p PTC tube replacement, draining partially\n thick fluid, also with signif skin irritation around the site.\n - wound care consult and cont to follow instruction\n - s/p tube exchange on (for excessive leakage)\n - cont zosyn (14 days)\n - trend bili and LFT.\n 4) Metastatic adenocarcinoid\n s/p second cycle of cisplatinum\n yesterday.\n - will discuss with Onc future steps for tumor control\n 5) FEN/GI: underwent IR tube study where tube was repositioned and\n contrast was visualized in the jejunum. He tolerated this procedure\n well without complication. RUQ US: limited bedside study\n demonstrating patent main portal vein with antegrade flow. CBD not\n identified. He remains jaundiced with scleral icterus and dark urine as\n expected.\n - cont regular diabetic diet\n 6) renal failure: secodary due to hypotension/ATN+/-HRS: now slowly\n recoverring. given his liver failure and his prerenal state will treat\n for HRS as per renal rec.\n - appreciate renal recs\n - midodrine/octrotide/albumin 25g \n 7) HIT: Given his heparin allergy, pt has been on fondaparinux for\n treatment of UE dvt and venodyne boots for DVT prophylaxis.\n - continue fondaparinux\n 8) DM: ISS, seen by during his last hospitalization.\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 01:30 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Generic Note",
"row_id": 324011,
"text": "TITLE:\n PT IS A 72 YO MALE FROM 7 W/ DUODENAL CA INTUBATED\n AND VENTILATED FOR INCREASING SOMNOLENCE AND HYPOXEMIA. PT SENT TO\n 4. PT W/ A LEFT LUNG COLLAPSE BY CXRDUE TO MUCOUS PLUGGING AND A\n LARGE LEFT PLEURAL EFFUSION. BRONCHOSCOPY PERFORMED AT BEDSIDE FOR LGE\n AMTS OF THICK YELLOW SPUTUM. ETT 3 CM ABOVE CARINA MD. WILL C/W AC\n MODE AS PER METAVISION W/ PEEP 12. ABG PENDING/ A-LINE PENDING.\n"
},
{
"category": "Nursing",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 324027,
"text": "72 YO male pt with PMH metastatic duodenal Ca, biliary obstruction with\n biliary tree drain, ,urosepsis,discharged from the hospital on \n and had fall at home on , admitted to 7S, c/o abd pain today\n morning ,received dilaudid, after that pt become somnolent,not\n responding, received 0.3mg narcan, desats to 80\ns on NC 2lit/min,sats\n improved to 90\ns with NRBM,CXR showed white out, Lt pleural effusion,\n poor response even after narcan,electively intubated and transffered to\n for further management. BP remained sys 70-80\ns ,started with N/s\n fluid bolus, and dopamine 10mcg/kg/min .\n In , BP remained low throughout,received 2lit LR and 1 litre N/s\n ,dopamine upto 20mcg/kg/min and then started with neo 0.05mcg/kg/min\n and now upto 2mcg/kg/min,bronchoscopy done ,premedicated with fentanyl\n 50mics and versed 4mg, and bronch sample sent to labs. Tried for Aline\n ,unsuccessful. Having double lumen PICC line on Lt upper arm,patent and\n infusing ,but difficult to draw labs,planning to insert central\n line.h/o ? AAA repaired in the past ,lower extremity cold to touch,\n pulse difficult to palpate, skin dark in colour. No urine output after\n admission,foley catheter flushed,patent,no obstruction noted,team\n aware.biliary drain intact,colostomy bag for leakage around the\n biliary drain.no drainage this shift. h/o loose stool,had large\n BM.C-diff neg,no need of precautions now,s/p chemotherapy,last done\n ,need chemo precautions.\n Hypotension (not Shock)\n Assessment:\n BP sys remained 70-100\ns, fluctuating fast.\n Action:\n Fluid bolus N/S 1litr,LR 2litre in and 1lit N/S in the floor. On\n dopamine 20mcg/kg/min and neo 2mcg/kg/min.\n Response:\n BP ranging from 80-105 sys most of the time.\n Plan:\n At present sys 102, may need to go up with the neo if BP drops further.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated and vented, sedated.\n Action:\n AC/ 16/680/12 peep/100%/\n Response:\n Peep down from initial setup 14 to 12.\n Plan:\n Continue with ventillation.\n NG/OGT inserted if needed,at present pt not on any PO meds.\n"
},
{
"category": "Nursing",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 324026,
"text": "72 YO male pt with PMH metastatic duodenal Ca, biliary obstruction with\n biliary tree drain, ,urosepsis,discharged from the hospital on \n and had fall at home on , admitted to 7S, c/o abd pain today\n morning ,received dilaudid, after that pt become somnolent,not\n responding, received 0.3mg narcan, desats to 80\ns on NC 2lit/min,sats\n improved to 90\ns with NRBM,CXR showed white out, Lt pleural effusion,\n poor response even after narcan,electively intubated and transffered to\n for further management. BP remained sys 70-80\ns ,started with N/s\n fluid bolus, and dopamine 10mcg/kg/min .\n In , BP remained low throughout,received 2lit LR and 1 litre N/s\n ,dopamine upto 20mcg/kg/min and then started with neo 0.05mcg/kg/min\n and now upto 2mcg/kg/min,bronchoscopy done ,premedicated with fentanyl\n 50mics and versed 4mg, and bronch sample sent to labs. Tried for Aline\n ,unsuccessful. Having double lumen PICC line on Lt upper arm,patent and\n infusing ,but difficult to draw labs,planning to insert central\n line.h/o ? AAA repaired in the past ,lower extremity cold to touch,\n pulse difficult to palpate, skin dark in colour. No urine output after\n admission,foley catheter flushed,patent,no obstruction noted,team\n aware.biliary drain intact,colostomy bag for leakage around the\n biliary drain.no drainage this shift. h/o loose stool,had large\n BM.C-diff neg,no need of precautions now,s/p chemotherapy,last done\n ,need chemo precautions.\n"
},
{
"category": "Physician ",
"chartdate": "2177-05-04 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 324022,
"text": "Chief Complaint: Hypoxemic Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with recent prolonged hospital course notable for-->\n 1)ERCP--biliary stricture limiting evaluation, percutaneous tube placed\n for drainage of biliary tree\n 2)UGI Evalaution-small bowel obstruction noted as increased and\n worsening\n 3)Acute Renal Failure--ATN vs. Hepato-Renal Syndrome suspected and\n improved creatinine with treatment for HRS.\n On O-Med service patient with-->\n Cisplatin undertaken given evolution of tumor burden\n Biliary drainage continuing\n Today-->\n Patient with hypoxemia leading to need for 100% of 7.28/30/52 on ABG on\n 6 lpm and subsequent intubation with opacification of left hemithorax\n seen leading to patient with emergent intubation for hypoxemic\n respiratory failure.\n Patient then to ICU for further care.\n Allergies:\n Heparin Agents\n positive hepari\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 PM\n Vancomycin - 04:23 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Phenylephrine - 2 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 02:15 PM\n Midazolam (Versed) - 02:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Duodeal CA--Lung Mets and biliary and small bowel obstruction\n A-Fib\n AAA--Repair with endovascular procedure\n DM\n OSA\n HTN\n Non-contributory\n Occupation: Unemployed\n Drugs: None\n Tobacco: 100 py history\n Alcohol: None now\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Nutritional Support: NPO\n Respiratory: Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Endocrine: Hyperglycemia\n Flowsheet Data as of 05:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 70 (68 - 77) bpm\n BP: 104/43(58) {68/24(38) - 104/52(58)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,372 mL\n PO:\n TF:\n IVF:\n 4,372 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,272 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 680 (680 - 680) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 100%\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n Compliance: 61.8 cmH2O/mL\n SpO2: 100%\n ABG: ///11/\n Ve: 16.1 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: Left side througout)\n Abdominal: Soft\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 252 K/uL\n 33.6 %\n 10.3 g/dL\n 111 mg/dL\n 1.6 mg/dL\n 32 mg/dL\n 11 mEq/L\n 118 mEq/L\n 4.3 mEq/L\n 142 mEq/L\n 3.2 K/uL\n [image002.jpg]\n 01:35 PM\n WBC\n 3.2\n Hct\n 33.6\n Plt\n 252\n Cr\n 1.6\n Glucose\n 111\n Other labs: ALT / AST:32/48, Alk Phos / T Bili:170/13.1\n Imaging: CXR--Some improvement in left sided aeration following\n intubation. ETT in good position wtih no evidence of PTX. Film\n quality if limited given significant rotation.\n ECG: V-Paced and in that setting no acute changes appreciated\n Assessment and Plan\n 72 yo male with history of metastatic duodenal CA to lung complicated\n by biliary and small bowel obstruction. He is now admit with hypoxemic\n respiratory failure with prominent left sided collapse on film. He did\n have subsequent bronchoscopy following intubation with substantial\n secretions cleared from the airway. They did appear to be quite thick\n and tenacious given difficulty with clearance. Progressive compromise\n of left lung function with primarily mucus plugging and collapse with\n possible co-contribution from pleural effusion certainly provides\n enough insult to lead to hypoxemic respiratory failure with some\n significant increase in Qs/Qt. Alternative diagnoses such as PE,\n Pneumonia, Aspiration all need to be considered as well.\n 1)Hypoxemic Respiratory Failure-\n -Follow up evaluation with CXR post bronchoscopy\n -Will eval for effusion with ultrasound and utilize thoracentesis if\n needed for significant effusion and to consider possible malignant\n effusion\n -Will continue with A/C support and look to wean FIO2 and will maintain\n PEEP at 10cm H2O\n -PE remains unlikely given alternative explanations but will have to\n evaluate if response limited\n -No new transmural ischemia on paced ECG\n -ABX to continue with Vanco/Zosyn\n 2)Hypotension--Patient with hypotension, SIRS and possible impaired SVR\n with compromised vascular tone. He is clearly at high risk for\n infection. Hypovolemia not clearly seen by exam and no evidence of new\n cardiac insult-->\n -Will continue with Vanco/Zosyn\n -WIll place CVL and check for adequate volume status\n -Dopamine/Neo in place for support and will need to titrate volume\n status to assure adequate perfusion\n -Currently are using Sepsis as working diagnosis\n -Will check stim if response not seen and pressor requirement\n continues\n 3)Acidosis--\n Will check lactate and treat as likely assoiated with hypoperfusion.\n What is provocative is that it is largely non-AG and may well be\n primary contribution from saline and impaired renal function.\n 4)Acute Renal Failure-This has previously been considered most likely\n hepato-renal syndrome however in this setting he has had severe\n worsening of renal function. What is not clear at this time is the\n source of sudden worsening renal function. This may well be a\n consequence of current septic physiology and will need CVL to allow\n optimal titration of volume status and pressor choices.\n gg\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n PICC Line - 01:30 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments: CVL to be placed\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
}
] |
82,279 | 161,415 | 65 y.o. M with history of DM and ETOH abuse transferred from an outside hospital with biliary sepsis, ascites (neutrophilic culture negative), and decompensated cirrhosis. . # Pancreatitis and Biliary Sepsis: The patient was felt to likely have had gallstone pancreatitis and ascending cholangitis in the setting of a retained CBD stone (not removed during his CCY on ). He was noted to have enterobacter bacteremia in his blood cultures from at the OSH. He was treated at the OSH with imipenem and zosyn from on. It was later confirmed that the 2 strains of enterobacter that had been growing were sensitive to both imipenem and zosyn. Lipase on admission to the OSH had been . He also had a large amount of ascites on presentation, that was felt to be due to pancreatitis vs. SBP. He had already received several days of antibiotics prior to initial paracentesis. The patient was initially hypotensive requring pressors. Pt continued zosyn & flagyl in our ICU for likely biliary sepsis. We continued fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr and monitored SVO2 from central venous catheter and goal of 70. On paracentesis w/less than 1L taken off; transudative, cultures no growth. Abdominal ultrasound to evaluate liver, CBD, hepatic and portal flow showed no portal vein thrombosis. On therapeutic paracentesis, removed 4L of fluids and given 50gm albumin. The ascitic fluid showed poly 863. Pt without abdominal pain. Continued on zosyn on which he finished a 14 day course just prior to discharge. He was started on cipro daily for SBP prophylaxis. Pt remained afebrile on the floors. He started on clear liquids and advances as tolerated. He was eating regular, low-sodium meals at time of discharge. . # Respiratory Failure/Pleural Effusions: Likely due to fluid overload and pleural effusions tracking up from ascites. Patient was intubated on transfer. On patient extubated. He was started on lasix/aldactone in . CXR on noted a large R pleural effusion, again felt to be due to his ascites. Pt continued to have O2 sat in mid to high 90's off oxygen on the floor. He was continued on Advair, albuterol and ipratropium. He continued to diurese on the floor losing 20lbs prior to discharge with stable Cr. He was discharged on Lasix 40 QDay and Spironolactone 50 QDay. He was encouraged to continue a low sodium diet. . # Neutrophilic Culture Negative Ascites: He had a negative HIDA scan at OSH, checked to r/o biliary leak. The ascites was felt to be due to massive third spacing in the setting of liver decompensation and severe illness. The neutrophilic predominance is thought to be due to his pancreatitis, although cannot r/o infection given that he had 4 days of antibiotics prior to his initial paracentesis. Para at OSH showed 8000 WBC. Para on (4L off) showed 1150 WBC with 75% polys, up from the 5 WBC seen on . Repeat para on took off 2.5 liters and showed 235 WBC with 72% PMN. Cytology was negative for malignant cells. He was started on aldactone and lasix on . Rpt HIDA was negative for bile leak. . # Cirrhosis: Thought to be due to ETOH. was 1:160, but unclear if this is just in setting of infection. MELD is 12. AFP 2.6. Hep B and C titers are negative. Coagulopathy resolved with INR 1.2 down from 2.4 at OSH. He will need outpatient EGD to assess for varices and possible liver biopsy. Pt to follow up with Dr. (GI) and his PCP on discharge. | Keep depended extremities elevated Response: Improving Plan: Cont to follow Respiratory failure, acute (not ARDS/) Assessment: Remains extub with stable sats on 4l nc. # Renal Failure: Creatinine improving; today 1.7. Chief Complaint: Biliary sepsis, resolving. Chief Complaint: Biliary sepsis, resolving. Chief Complaint: Biliary sepsis, resolving. ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:21 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition : Total time spent: ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:21 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition : Total time spent: - Contnue Zosyn for enterobacter and Vancomycin for possible cellulites (day 3) - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr - . # Renal Failure: Creatinine stable; today 1.3. Chief Complaint: Biliary sepsis, resolving. (Versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol. # Dispo: ICU until extubated . # Dispo: ICU until extubated . # Renal Failure: Creatinine improving; today 1.3. - Contnue Zosyn for enterobacter and Vancomycin for possible cellulites (day 3) - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr - . Ascites (taped at the OSH for 2.4L output), NPO, NGT to low cont suction scant amnt. # PPx: sc heparin tid, pneumoboots, PPI . # Renal Failure: Creatinine improving; today 1.7. Weaned sedation. Abx administered- started Vanco, Zosyn scheduled, discontinued Flagyl. # Respiratory Failure: Pt extubated and tolerating. Will make decisions on fluid once lytes are back ------ Protected Section Addendum Entered By: , RN on: 19:14 ------ Action: Hemodynamic monitoring q hour. # PPx: sc heparin tid, pneumoboots, PPI IV . Noaortic regurgitation is seen. # Renal Failure: Creatinine stable; today 1.3. Low lung volumes, bibasal effusions and atelectasis & lines and tubes as before d/w Dr 5:30p GWlms FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post line placement. # Respiratory Failure: Pt extubated and tolerating. ascites (taped at the OSH for 2.4L output), NPO, NGT to low cont suction scant amnt. ascites (taped at the OSH for 2.4L output), NPO, NGT to low cont suction scant amnt. Renal failure, acute (Acute renal failure, ARF) Assessment: BUN 58 CR 2.1. # Dispo: ICU until extubated . Tmax - 98.1 WBC-16.4, elevated LFTs although trending down, CVP 15-18 b/p 100s/60s hr -70-80s SR no ectopy noted, general edema, extr cool. (versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol. (versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol. Patent hepatic vasculature. Patent hepatic vasculature. Colonic diverticulosis is noted. Patent hepatic vasculature. Upon transfer he was normotensive but requiring the assistane of two pressors (dopa and neosynephrine). FINDINGS: Endotracheal tube, nasogastric tube, and right IJ line are again seen. Cholecystectomy clips and a trace amount of free air in the R side of the abdomen- assumed post surgical. Pancreatitis, acute Assessment: Afebrile. Pancreatitis, acute Assessment: Afebrile. Generalized edema. Generalized edema. Respiratory failure, acute (not ARDS/) Assessment: Intubated on pressure support . Respiratory failure, acute (not ARDS/) Assessment: Intubated on pressure support . Ascites present; abdomen appears firmer than yesterday and extremely distended; tender upon palpation. Ascites present; abdomen appears firmer than yesterday and extremely distended; tender upon palpation. Since , the patient was extubated, and the nasogastric tube was removed. Ascites (taped at the OSH for 2.4L output), NPO, NGT to low cont suction scant amnt. # Dispo: ICU until extubated . Right subclavian line tip terminates in mid SVC. Right subclavian line tip terminates in mid SVC. ct showed ascites, paracentesis suggested bile leak though HIDA unremarkable. ARF: has been attributed to sepsis/ATN, though urine 'lytes pending. # Renal Failure: Creatinine improving; today 1.7. # Renal Failure: Creatinine improving; today 1.7. # Renal Failure: Creatinine improving; today 1.7. # Dispo: ICU until extubated . # Dispo: ICU until extubated . # Dispo: ICU until extubated . # Dispo: ICU until extubated . - Contnue Zosyn for enterobacter and Vancomycin for possible cellulites (day 3) - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr - . - Contnue Zosyn for enterobacter and Vancomycin for possible cellulites (day 3) - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr - . - Contnue Zosyn for enterobacter and Vancomycin for possible cellulites (day 3) - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr - . | 91 | [
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416657,
"text": "Chief Complaint: Biliary sepsis, resolving.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Paracentesis yesterday, ~4 liters removed. Received 50gm of albumin.\n PMNs 863, still c/w SBP.\n D/c'ed insulin gtt, changed to RSSI.\n Started on clear liquid diet; no abdominal pain, less distension.\n 24 Hour Events:\n PARACENTESIS - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n RSSI\n Atrovent / Abuterol nebs\n Folic acid\n Thiamine\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 87 (81 - 100) bpm\n BP: 142/68(83) {118/44(54) - 162/83(99)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 1,449 mL\n PO:\n 720 mL\n 1,160 mL\n TF:\n IVF:\n 821 mL\n 289 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 1,200 mL\n Urine:\n 3,000 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG:\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, persistent discoloration c/w levido reticularis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 247 K/uL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:14.2/27.1/1.2, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n pCXR (): Essentially unchanged from 2 days ago. Persistent right\n opacity c/w right pleural effusion.\n Assessment and Plan\n CHOLANGITIS: Improved from admission, plan to continue Vanc / Zosyn\n for a total of 14 days. No plans for any intervention by Surgery or\n ERCP.\n DIABETES MELLITUS (DM), TYPE II: Changed insulin gtt to RSSI\n yesterday; sugars remain moderately elevated (in the 200s), so will\n increase RSSI for better control.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Improved, now extubated x\n 3 days. Will titrate oxygen down as tolerate.\n ALCOHOL ABUSE: On folic acid and thiamine, no evidence of withdrawal.\n PANCREATITIS, ACUTE: Symptomatically much improved, tolerating clears\n yesterday. Continue symptomatic treatment, will further advance diet.\n ANEMIA, OTHER: Stable H/H, no indication for transfusion at this\n time. Follow daily.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Creatinine stable\n for yesterday with treatement of his underlying pancreatitis and\n biliary infection. Monitor UOP and creatinine on a daily basis. Can\n likely d/c foley today.\n Will request PT consult today; stable for floor, will call out.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416660,
"text": "Chief Complaint: Biliary sepsis, resolving.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Paracentesis yesterday, ~4 liters removed. Received 50gm of albumin.\n PMNs 863, still c/w SBP.\n D/c'ed insulin gtt, changed to RSSI.\n Started on clear liquid diet; no abdominal pain, less distension.\n 24 Hour Events:\n PARACENTESIS - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n RSSI\n Atrovent / Abuterol nebs\n Folic acid\n Thiamine\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 87 (81 - 100) bpm\n BP: 142/68(83) {118/44(54) - 162/83(99)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 1,449 mL\n PO:\n 720 mL\n 1,160 mL\n TF:\n IVF:\n 821 mL\n 289 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 1,200 mL\n Urine:\n 3,000 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG:\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, persistent discoloration c/w levido reticularis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 247 K/uL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:14.2/27.1/1.2, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n pCXR (): Essentially unchanged from 2 days ago. Persistent right\n opacity c/w right pleural effusion.\n Assessment and Plan\n CHOLANGITIS: Improved from admission, plan to continue Vanc / Zosyn\n for a total of 14 days. No plans for any intervention by Surgery or\n ERCP.\n DIABETES MELLITUS (DM), TYPE II: Changed insulin gtt to RSSI\n yesterday; sugars remain moderately elevated (in the 200s), so will\n increase RSSI for better control.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Improved, now extubated x\n 3 days. Will titrate oxygen down as tolerate.\n ALCOHOL ABUSE: On folic acid and thiamine, no evidence of withdrawal.\n PANCREATITIS, ACUTE: Symptomatically much improved, tolerating clears\n yesterday. Continue symptomatic treatment, will further advance diet.\n ANEMIA, OTHER: Stable H/H, no indication for transfusion at this\n time. Follow daily.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Creatinine stable\n for yesterday with treatement of his underlying pancreatitis and\n biliary infection. Monitor UOP and creatinine on a daily basis. Can\n likely d/c foley today.\n Will request PT consult today; stable for floor, will call out.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416705,
"text": "Chief Complaint: Biliary sepsis, resolving.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Paracentesis yesterday, ~4 liters removed. Received 50gm of albumin.\n PMNs 863, still c/w SBP.\n D/c'ed insulin gtt, changed to RSSI.\n Started on clear liquid diet; no abdominal pain, less distension.\n 24 Hour Events:\n PARACENTESIS - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n RSSI\n Atrovent / Abuterol nebs\n Folic acid\n Thiamine\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 87 (81 - 100) bpm\n BP: 142/68(83) {118/44(54) - 162/83(99)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 1,449 mL\n PO:\n 720 mL\n 1,160 mL\n TF:\n IVF:\n 821 mL\n 289 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 1,200 mL\n Urine:\n 3,000 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG:\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, persistent discoloration c/w levido reticularis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 247 K/uL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:14.2/27.1/1.2, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n pCXR (): Essentially unchanged from 2 days ago. Persistent right\n opacity c/w right pleural effusion.\n Assessment and Plan\n CHOLANGITIS: Improved from admission, plan to continue Vanc / Zosyn\n for a total of 14 days. No plans for any intervention by Surgery or\n ERCP.\n DIABETES MELLITUS (DM), TYPE II: Changed insulin gtt to RSSI\n yesterday; sugars remain moderately elevated (in the 200s), so will\n increase RSSI for better control.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Improved, now extubated x\n 3 days. Will titrate oxygen down as tolerate.\n ALCOHOL ABUSE: On folic acid and thiamine, no evidence of withdrawal.\n PANCREATITIS, ACUTE: Symptomatically much improved, tolerating clears\n yesterday. Continue symptomatic treatment, will further advance diet.\n ANEMIA, OTHER: Stable H/H, no indication for transfusion at this\n time. Follow daily.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Creatinine stable\n for yesterday with treatement of his underlying pancreatitis and\n biliary infection. Monitor UOP and creatinine on a daily basis. Can\n likely d/c foley today.\n Will request PT consult today; stable for floor, will call out.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 65M EtOH dependence, recent lap chole,\n pancreatitis and SBP. Tolerated diet and large volume paracentesis\n yesterday.\n Exam notable for Tm 98.4 BP 130/87 HR 80 RR 18 with sat 97. WD man, NAD\n in chair. JVD 8cm, lungs CTA B. RRR s1s2. Soft, NT, +BS. Trace edema.\n Labs notable for WBC 13K, HCT 29, K+ 4.1, Cr 1.3, lactate 1.2.\n Agree with plan to continue antibiotics for SBP and hold on further\n imaging. His renal failure is resolving with IVF and his pancreatitis\n also appears to be subsiding despite increased PO intake. Remainder of\n plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:00 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 415864,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Tenacious\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt set on same vent settings from OSH.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Will get surgery consult today.\n Continue present ICU monitoring.\n Rsbi done ~33.\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 415872,
"text": "This is a 65 yo M w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was transferred intubated (not sedated) on AC 50% 500x22/PEEP\n 5. Required frequent suctioning during transport. Bil LS rhonchorous\n all throughout. Suctioned for small amnt of white/tan secretions. Sats\n at 98-99%. RR at 25-33.\n Action:\n Remains intubated on the same settings. Sedation was added to provide\n comfort. (Versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol.\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns resp status, wean off vent when able.\n Pancreatitis, acute\n Assessment:\n Patient w/low grade temp. Tmax 100.7 upon admission. Abd firm\n distended tender to palpation.\n Ascites (taped at the OSH for 2.4L\n output), NPO, NGT to low cont suction scant amnt. NO BS or flatus,\n elevated LFT\ns although trending down\n Action:\n continue zosyn flagyl for likely biliary sepsis, f/u sensitivities on\n enterobacter (in blood as well in biliary specimen from OSH), continue\n fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr, monitor SVO2\n from central venous catheter and goal of 70, GI and surgery consults,\n obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow in AM, labs to eval. Blood and urine cultures sent.\n Response:\n pending\n Plan:\n Monitor patient status, GI/surgery consult, ERCP??? f/u cultures\n Neuro: upon admission patient alert. Intubated and vented\n so unable\n to assess orientation. Follows simple commands. Nods his head to yes/no\n questions. Moves extr. HX of altered mental status when his sepsis was\n worsening. CT Head w/o contrast from OSH: mild inflammatory sinus\n disease. No acute intracranial abnormality.\n Cardio: upon admission on neo@ 0.8 and dopamine@5 B/P at 130\ns-140/70.\n tachycardic at low 100\ns. ST no ectopy noted. Dopamine weaned off by\n 1:30am and neo by 4am. B/P 110\ns/60\ns, HR at 80-90\ns SR w/short episode\n of ST to 160\ns. General edema - anasarca. Extr cool and mottled.\n GU: amber colored urine via foley 60-70cc/hr. bolused X1 w/500c NS for\n low UOP. Cr on was 1.1, increasing on to 1.7 and to 2.2 on\n at OSH. Urine lytes and culture sent. Renal consult???? if needed.\n Skin: ecchymotic area at the RT AC probably from previous IV site\n covered w/tegaderm from OSH. Open blister at the RT upper leg at the\n site of cath secure device.\n IV access: LT SC 3 lumen from OSH\n site looks clean no redness or\n drainage. LT AC 18G\npatent.\n Social: patient is a FULL CODE. Family was in to visit. Updated by RN\n and MD. need SW consult for peculiar family dynamic.\n"
},
{
"category": "Respiratory ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 416186,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n ABG puncture (0920am and 1149 am)\n Comments:\n Patient remains intubated and on mechanical ventilatory support, has\n been weaned to PSV 5&5 40%, had SBT for about 30 minutes, no distress\n occurred , might get extubated soon.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416345,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n Events: extubated at 1200\n Pancreatitis, acute\n Assessment:\n Abd distended, firm, +bs,+flatus, bladder pressure 16 today. Lipase up\n to 1124,amylase 323,alk phos 140,,, up significantly from yesterday\n values. Was on fentanyl 25mcg/hr which was d/c\ned prior to extubation.\n Denies any pain. No stool today, iv insulin gtt with FS stable at\n 100-110 today on units/r.\n Action:\n follow hourly FS,\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On PS 5cm, with PEEP 5cm, at the start of the day, tolerating well,\n continues with O2 sats 98-100%,\n Action:\n Extubated at 1200, placed on cool nemb face tent , strong cough,\n productive at times\n Response:\n Tolerating extubation well,\n Plan:\n Maintain O2 sats >96%,\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416055,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation and is now transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and vented on AC 40% 500x22/5, sats at high\n 90\ns-100%. Bil LS rhonchorous, diminished at the bases. Unlabored\n breathing. Suctioned for sm amnt of white thick secretions.\n Action:\n Continue w/mechanical ventialtion, suction PRN, mouth care q4hr and\n PRN, RSBI\n Response:\n Pending\n Plan:\n Continue to monitor patient resp status, wean off when able, Titrate\n PEEP up for any decrease in oxygenation\n Pancreatitis, acute\n Assessment:\n Patient with diffuse abdominal tenderness, abd firm and distended,\n ascites, BS present, NPO, NGT to LCS\nbilious output, improving labs.\n Tmax - 98.1 WBC-16.4, elevated LFT\ns although trending down, CVP 15-18\n b/p 100\ns/60\ns hr -70-80\ns SR no ectopy noted, general edema, extr\n cool.\n Action:\n NPO until post pyloric feeding tube placed ( planned for tomorrow),\n nutritional consult ordered, CT scan to evaluate for any evidence of\n necrosis or alternative intra-abdominal collection done\n negative,\n Pain control with Fentanyl for now, F/u lipase, surgical/GI/liver\n consults. Continue w/IV ABX, f/u cultures, IVF as needed to maintain\n CVP and the urine flow minimum of 30cc/hr. Insulin gtt and hourly FS.\n Response:\n improving\n Plan:\n Continue to monitor patient status, continue w/IVF and ABX, f/u\n cultures, f/u surgery/GI/liver recs. paracentesis in am ??? ERCP???\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416407,
"text": "------ Protected Section------\n Duplicate\n ------ Protected Section Error Entered By: , RN\n on: 02:19 ------\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416408,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but in the setting of fluid resuscitation, was found to\n have worsening ascites with concern for bile leak evaluated with HIDA\n scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n paracentesis\n extubated\n Pancreatitis, acute\n Assessment:\n Pt with largely distended firm abd, denies pain\n Action:\n Pt receiving vanco and zosyn, remained NPO overnight\n Response:\n Ongoing, no growth from culture data to date pt with rising lipase\n yesterday liking common bile duct obstruction\n Plan:\n f/u am labs, GI to consult, ?removing NGT and starting Pos depending on\n results of GI consult\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 1.7 trending down, u/o >100cc/hr dark yellow with sediment, CVP\n 6-11, on insulin gtt 2 u/hr\n Action:\n Hourly I/O, checking FSBS q2hr, no changes in gtt made overnight\n Response:\n Maintaining BS within normal ranges 112-124\n Plan:\n f/u am Cr, continue to monitor u/o, fluid boluses if <60cc/hr, Continue\n to monitor CVP, ?transitioning off insulin gtt\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, generalized edema with\n weeping of upper extremities and right leg, right upper leg with skin\n tears, areas with marking delineating locations of cellulititis now\n appearing mottled\n Action:\n Pt is receiving vanco as ordered, repositioning q2hrs, pt is moving\n self well in bed with 1 assist, no new areas of skin impairment noted\n Response:\n Ongoing, no further impairment as noted above\n Plan:\n Continue to monitor, repositioning frequently as tolerated, continue\n vanco\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was extubated successfully early in the shift, breath sounds\n clear and dim at bases, productive cough with thick yellow/white\n secretions, O2sats 95-100 on FT high flow aerosol\n Action:\n Titrating down O2 throughout the shift, now on 35% FT, pt likely able\n to tolerate even lower levels of supplemental O2, tent off of face much\n of the time, subjectively feeling dry and would prefer to keep the\n aerosol at this time as he is NPO\n Response:\n No resp distress, maintaining O2 sats well, breath sounds clear,\n productive cough\n Plan:\n Continue to monitor resp status, ?c/o to floor\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 416701,
"text": "This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred from\n Center in MA with biliary sepsis.\n Pt was transferred intubated. During his course pt had required\n pressers and insulin gtt for blood glucose control. Off pressers since\n . Pt has been off insulin gtt since . Pt extubated . Blood\n cultures with no growth to date. Pt with positive blood cultures from\n OSH grew out enterobacter. Pt has been seen by surgical and GI both\n indicating no intervention needed at this time. Receiving Zosyn and\n Vanco.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase 1311 this MA.\n Stable.\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of. OOB to chair today and DOE but recovers withing few minuts.\n Plan:\n Continue to monitor skin integrity, OOB to chair daily.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ETOH CIRRHOSIS;PANCREATITIS\n Code status:\n Full code\n Height:\n 71 Inch\n Admission weight:\n 123.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Oral , ETOH, Pancreatitis\n CV-PMH: Hypertension\n Additional history: hyperlipidemia, HTN, DM, complicated PNA\n w/decortication in . OA, depression\n Surgery / Procedure and date: s/p lap choly\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:148\n D:75\n Temperature:\n 96.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,870 mL\n 24h total out:\n 2,305 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:27 AM\n Potassium:\n 4.1 mEq/L\n 05:27 AM\n Chloride:\n 113 mEq/L\n 05:27 AM\n CO2:\n 24 mEq/L\n 05:27 AM\n BUN:\n 26 mg/dL\n 05:27 AM\n Creatinine:\n 1.3 mg/dL\n 05:27 AM\n Glucose:\n 250 mg/dL\n 05:27 AM\n Hematocrit:\n 29.0 %\n 05:27 AM\n Finger Stick Glucose:\n 333\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n R IJ TLC, foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 403\n Transferred to: 11R\n Date & time of Transfer: 1645\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416405,
"text": "Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, generalized edema with\n weeping of upper extremities and right leg, right upper leg with skin\n tears, areas with marking delineating locations of cellutitis now\n appearing mottled\n Action:\n Pt is receiving vanco as ordered, repositiong q2hrs, pt is moving self\n well in bed with 1 assist,\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416406,
"text": "Pancreatitis, acute\n Assessment:\n Pt with largely distended firm abd, denies pain,\n Action:\n Pt receiving vanco and zosyn, remained NPO overnight\n Response:\n Ongoing, no growth from culture data to date pt with rising lipase\n yesterday liking common bile duct obstruction\n Plan:\n f/u am labs, GI to consult, ?removing NGT and starting Pos depending on\n results of GI consult\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, generalized edema with\n weeping of upper extremities and right leg, right upper leg with skin\n tears, areas with marking delineating locations of cellulititis now\n appearing mottled\n Action:\n Pt is receiving vanco as ordered, repositioning q2hrs, pt is moving\n self well in bed with 1 assist, no new areas of skin impairment noted\n Response:\n Ongoing, no further impairment as noted above\n Plan:\n Continue to monitor, repositioning frequently as tolerated, continue\n vanco\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416235,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically vented, throughout the shift, RR: 14-21, O2sat\n 93-98%, breath sounds clear in upper airways, occasionally suctioning\n for scant thick white secretions, pt remains on fent gtt for comfort,\n pt is alert and following commands, anxious at times, mouthing words\n but this RN unable to tell what he is trying to say\n Action:\n Providing fent boluses for repositioning, pt with pain per grimace\n scale, responding well to bolusing, maintained on fent gtt overnight at\n 25mcg/kg with good effect, breathing comfortably on vent settings as\n noted above, suctioning PRN, reorienting and providing emotional\n support, am Cxray\n Response:\n Pt maintaining well on current settings, able to rest comfortably\n throughout the shift though anxious at times\n Plan:\n f/u Cxray, change settings to this am, extubation tomorrow,\n continue to monitor\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Following fluid challenge yesterday pt\ns Cr 1.8 from 1.9, u/o between\n 120-240cc/hr\n Action:\n Am labs sent, restarted IV fluids D5W 125 cc/hr, monitoring pt\ns BS\n hourly, restarted insulin gtt, titrating gtt guidelines\n Response:\n Pending, pt with excellent u/o as noted above\n Plan:\n f/u am labs, continue to monitor hourly u/o, hourly FSBS while on\n insulin gtt, titrate gtt accordingly\n Pancreatitis, acute\n Assessment:\n Afebrile, culture data to date with no growth, abd grossly distended\n and firm, pt with abd pain with activity, generlized edema with weeping\n noted, oozing serous fluid from pericentesis site\n Action:\n Monitoring throughout the shift, adm antibiotics as ordered\n Response:\n Afebrile as noted above\n Plan:\n Continue to f/u culture data, continue current antibiotic as ordered\n"
},
{
"category": "Respiratory ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 416243,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds coarse suct sm th off white sput. Pt in NARD on current\n vent settings; no vent changes required overnoc. Cont PSV/?extub today.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416514,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but in the setting of fluid resuscitation, was found to\n have worsening ascites with concern for bile leak evaluated with HIDA\n scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n paracentesis\n extubated\n Pancreatitis, acute\n Assessment:\n Abdomen remains distended and firm with good bowel sounds. Pt denies\n pain passing mod amt soft ob neg stool. NG tube d/c\nd and pt started\n on clear liquids. Remains afebrile.\n Action:\n Cont on zosyn. Vanco d/c\nd. Diet advanced.\n Response:\n Improving Tolerating advance in diet.\n Plan:\n Cont to follow labs. Advance diet as tolerated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat trending done. Cont with good UO. Lytes stable. Still with total\n body edema.\n Action:\n Monitoring uo closely. Keep depended extremities elevated\n Response:\n Improving\n Plan:\n Cont to follow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains extub with stable sats on 4l nc. Cont with productive cough\n clear white secretions.\n Action:\n Started on Q6hr nebs. Encourage coughing and deep breathing\n Response:\n Tolerating extub\n Plan:\n Advance activity as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416383,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n PARACENTESIS - At 05:30 PM 1L drained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (82 - 99) bpm\n BP: 128/85(96) {100/45(61) - 128/85(96)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (5 - 14)mmHg\n Bladder pressure: 22 (22 - 29) mmHg\n Total In:\n 4,249 mL\n 1,136 mL\n PO:\n TF:\n IVF:\n 4,209 mL\n 1,136 mL\n Blood products:\n Total out:\n 3,590 mL\n 1,020 mL\n Urine:\n 2,490 mL\n 1,020 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 650 mL\n Balance:\n 659 mL\n 116 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 613 (463 - 643) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.33/42/99./23/-3\n Ve: 11.4 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 161 K/uL\n 11.1 g/dL\n 149 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 44 mg/dL\n 118 mEq/L\n 146 mEq/L\n 34.6 %\n 21.7 K/uL\n [image002.jpg]\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n WBC\n 15.9\n 16.4\n 21.7\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n Plt\n 155\n 125\n 161\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n TCO2\n 21\n 20\n 23\n 23\n Glucose\n 9\n 149\n Other labs: PT / PTT / INR:15.3/27.4/1.4, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.1 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, but lipase trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter and Vancomycin for possible\n cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - .\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.7. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa yesterday was 0.1%. However, there may be low oncotic pressure\n affecting the kidney function as well. Will keep a CVP target of \n and follow urine output today. USG without evidence of hydronephrosis.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: NPO for now., may feed tomorrow depending of how extubation\n goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 416481,
"text": "Subjective\n Patient extubated\n Objective\n Pertinent medications: insulin gtt, thiamin, folic acid\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 110\n 06:00 AM\n BUN\n 31 mg/dL\n 04:00 AM\n Creatinine\n 1.3 mg/dL\n 04:00 AM\n Sodium\n 145 mEq/L\n 04:00 AM\n Potassium\n 3.7 mEq/L\n 04:00 AM\n Chloride\n 117 mEq/L\n 04:00 AM\n TCO2\n 23 mEq/L\n 04:00 AM\n Albumin\n 2.3 g/dL\n 04:04 AM\n Calcium non-ionized\n 7.4 mg/dL\n 04:00 AM\n Phosphorus\n 2.6 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.10 mmol/L\n 09:56 AM\n Magnesium\n 2.0 mg/dL\n 04:00 AM\n Current diet order / nutrition support: Clear liquids\n GI: Abdomen firm/distended with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 65 year old male with history of DM, etoh abuse presenting with biliary\n sepsis. Patient was extubated and diet advanced this morning to clear\n liquids. If unable to tolerate, consider SLP evaluation. Will follow\n for PO tolerance and make recommendations PRN. If needed, tube feeding\n goal is Fibersource HN at 60ml/hr x 24 hours.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Encourage PO intake of clears, if tolerated would advance as\n medically possible to low fat\n 2. will follow for plan of care\n 10:24\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416231,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically vented, throughout the shift, RR: 14-21, O2sat\n 93-98%, breath sounds clear in upper airways, occasionally suctioning\n for scant thick white secretions, pt remains on fent gtt for comfort,\n pt is alert and following commands, anxious at times, mouthing words\n but this RN unable to tell what he is trying to say\n Action:\n Providing fent boluses for repositioning, pt with pain per grimace\n scale, responding well to bolusing, maintained on fent gtt overnight at\n 25mcg/kg with good effect, breathing comfortably on vent settings as\n noted above, suctioning PRN, reorienting and providing emotional\n support, am Cxray\n Response:\n Pt maintaining well on current settings, able to rest comfortably\n throughout the shift though anxious at times\n Plan:\n f/u Cxray, change settings to this am, extubation tomorrow,\n continue to monitor\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Following fluid challenge yesterday pt\ns Cr 1.8 from 1.9, u/o between\n 120-240cc/hr\n Action:\n Am labs sent, restarted IV fluids D5W 125 cc/hr, monitoring pt\ns BS\n hourly, restarted insulin gtt, titrating gtt guidelines\n Response:\n Pending, pt with excellent u/o as noted above\n Plan:\n f/u am labs, continue to monitor hourly u/o, hourly FSBS while on\n insulin gtt, titrate gtt accordingly\n Pancreatitis, acute\n Assessment:\n Afebrile, culture data to date with no growth, abd grossly distended\n and firm, pt with abd pain with activity\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416233,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically vented, throughout the shift, RR: 14-21, O2sat\n 93-98%, breath sounds clear in upper airways, occasionally suctioning\n for scant thick white secretions, pt remains on fent gtt for comfort,\n pt is alert and following commands, anxious at times, mouthing words\n but this RN unable to tell what he is trying to say\n Action:\n Providing fent boluses for repositioning, pt with pain per grimace\n scale, responding well to bolusing, maintained on fent gtt overnight at\n 25mcg/kg with good effect, breathing comfortably on vent settings as\n noted above, suctioning PRN, reorienting and providing emotional\n support, am Cxray\n Response:\n Pt maintaining well on current settings, able to rest comfortably\n throughout the shift though anxious at times\n Plan:\n f/u Cxray, change settings to this am, extubation tomorrow,\n continue to monitor\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Following fluid challenge yesterday pt\ns Cr 1.8 from 1.9, u/o between\n 120-240cc/hr\n Action:\n Am labs sent, restarted IV fluids D5W 125 cc/hr, monitoring pt\ns BS\n hourly, restarted insulin gtt, titrating gtt guidelines\n Response:\n Pending, pt with excellent u/o as noted above\n Plan:\n f/u am labs, continue to monitor hourly u/o, hourly FSBS while on\n insulin gtt, titrate gtt accordingly\n Pancreatitis, acute\n Assessment:\n Afebrile, culture data to date with no growth, abd grossly distended\n and firm, pt with abd pain with activity, generlized edema with weeping\n noted, oozing serous fluid from pericentesis site\n Action:\n Monitoring throughout the shift, adm antibiotics as ordered\n Response:\n Afebrile as noted above\n Plan:\n Continue to f/u culture data\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416573,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient extuabted\n Micro lab closed on weekends at OSH. Need to try again to get final\n printed report of sensitivities of enterobacter.\n ERCP: no need for ERCP now since HIDA scan negative.\n Surgery: no recs\n UOP goal >50cc/hr\n INVASIVE VENTILATION - STOP 11:58 AM\n intubated priot to admission\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:44 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 11:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 85 (79 - 96) bpm\n BP: 142/64(100) {118/61(75) - 154/82(100)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (4 - 18)mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 3,766 mL\n 277 mL\n PO:\n TF:\n IVF:\n 3,706 mL\n 277 mL\n Blood products:\n Total out:\n 3,620 mL\n 1,220 mL\n Urine:\n 3,620 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 146 mL\n -943 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///23/\n Ve: 8.9 L/min\n Physical Examination\n Gen: NAD, communicative, pt uncomfrotable from distension,\n HEENT: AT/NC, PERRL, EOMI, sclera anicteric, no LAD\n CV: S1 + S2, RRR\n Pulm: coarse upper airway sounds,\n Abd: distended, + BS, non-tender to palpation, mild discomfort in\n epigastric region, +ascites, no rebound, no gaurding\n Ext: disffuse anasarca\n Neuro: AAOx3, able to follow commands\n Labs / Radiology\n 204 K/uL\n 11.3 g/dL\n 106 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 31 mg/dL\n 117 mEq/L\n 145 mEq/L\n 34.6 %\n 19.5 K/uL\n [image002.jpg]\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n WBC\n 15.9\n 16.4\n 21.7\n 19.5\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n 34.6\n Plt\n 155\n 125\n 161\n 204\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 9\n 149\n 106\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, lipase still trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter\n - d/c Vancomycin for possible cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - cont to trend LFTs and labs\n - f/u ERCP recs\n - advance diet as tolerated\n - will remove 4L paracentesis per GI\n # Respiratory Failure: Pt extubated and tolerating.\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family. No evidence of\n withdrawl.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.3. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa was 0.1%.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: Will advance as tolerated, may feed tomorrow depending of how\n extubation goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 415835,
"text": "This is a 65 yo M w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was transferred intubated (not sedated) on AC 50% 500x22/PEEP\n 5. Required frequent suctioning during transport. Bil LS rhonchorous\n all throughout. Suctioned for small amnt of white/tan secretions. Sats\n at 98-99%. RR at 25-33.\n Action:\n Remains intubated on the same settings. Sedation was added to provide\n comfort. (Versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol.\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns resp status, wean off vent when able.\n Pancreatitis, acute\n Assessment:\n Patient w/low grade temp. Tmax 100.7 upon admission. Abd firm\n distended tender to palpation.\n Ascites (taped at the OSH for 2.4L\n output), NPO, NGT to low cont suction scant amnt. NO BS or flatus,\n elevated LFT\n Action:\n continue zosyn flagyl for likely biliary sepsis, f/u sensitivities on\n enterobacter (in blood as well in biliary specimen from OSH), continue\n fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr, monitor SVO2\n from central venous catheter and goal of 70, GI and surgery consults,\n obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow in AM, labs to eval. Blood and urine cultures sent.\n Response:\n pending\n Plan:\n Monitor patient status, GI/surgery consult, ERCP??? f/u cultures\n Neuro: upon admission patient alert. Intubated and vented\n so unable\n to assess orientation. Follows simple commands. Nods his head to yes/no\n questions. Moves extr. HX of altered mental status when his sepsis was\n worsening. CT Head w/o contrast from OSH: mild inflammatory sinus\n disease. No acute intracranial abnormality.\n Cardio: upon admission on neo@ 0.8 and dopamine@5 B/P at 130\ns-140/70.\n tachycardic at low 100\ns. ST no ectopy noted. Dopamine weaned off by\n 1:30am and neo by 4am. B/P 110\ns/60\ns, HR at 80-90\ns SR w/short episode\n of ST to 160\ns. General edema - anasarca. Extr cool and mottled.\n GU: amber colored urine via foley 60-70cc/hr. bolused X1 w/500c NS for\n low UOP. Cr on was 1.1, increasing on to 1.7 and to 2.2 on\n at OSH. Urine lytes and culture sent. Renal consult???? if needed.\n Skin: ecchymotic area at the RT AC probably from previous IV site\n covered w/tegaderm from OSH. Open blister at the RT upper leg at the\n site of cath secure device.\n IV access: LT SC 3 lumen from OSH\n site looks clean no redness or\n drainage. LT AC 18G\npatent.\n Social: patient is a FULL CODE. Family was in to visit. Updated by RN\n and MD. need SW consult for peculiar family dynamic.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416635,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n Therapeutic paracentesis, removed 4L of fluids and given 50gm albumin\n Ascitic fluid: poly: 863 --> SBP on zosyn\n d/c insulin ggt, on ISS\n started on clear liquids and advance as tolerate --> pt tolerating\n clears\n PARACENTESIS - At 07:05 PM\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Pt denies abdominal pain. Patient tolerating clear liquids, requesting\n to eat more.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (81 - 100) bpm\n BP: 147/69(89) {118/44(54) - 162/130(135)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 968 mL\n PO:\n 720 mL\n 800 mL\n TF:\n IVF:\n 821 mL\n 168 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 940 mL\n Urine:\n 3,000 mL\n 940 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, comforatable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t)\n Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\n poor inspiratory effort\n Abdominal: Non-tender, Bowel sounds present, Distended, No(t) Tender: ,\n Obese, + ascites, firm, dressing over paracentesis site minimally\n saturated\n Extremities: anasarca\n Skin: Not assessed, livideo reticularis\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 9.7 g/dL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n CHOLANGITIS\n DIABETES MELLITUS (DM), TYPE II\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Sepsis/pancreatitis: growing enterobacter from biliary tract fluid\n and blood. Liver enzymes stable and pancreatic enzymes have stabilized\n and are trending down. Low likelihood of bile duct leak with a negative\n HIDA scan. Patient has been off pressors for 48 hours and extubated.\n Pt had paracentesis and removed 4L fluid. Ascitic fluid: poly: 863 -->\n SBP on zosyn\n Low protein 1.5. --> t/c SBP ppx, SAAG >1.1 hepatic etiology (ascites\n albumin <1.0)\n d/c insulin ggt, on ISS\n - Contnue Zosyn for enterobacter and SBP\n - t/c SBP ppx because low protein in ascitic fluid (1.5)\n - f/u peritoneal fluid cultures\n - cont to trend LFT and labs\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - patient tolerating clears and may advance as tolerated.\n # Respiratory Failure: Pt extubated and tolerating. Currently on NC\n .\n # DM: holding home meds. Currently on RISS\n - cont RISS\n - will add lantus today since patient no longer NPO\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family. No evidence of\n withdrawl.\n -thiamine, folate\n .\n # Renal Failure: Creatinine stable; today 1.3. Most likely pre-renal in\n the setting of sepsis since it is slowly improving with fluids and FeNa\n was 0.1%.\n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine\n .\n # FEN: Clears currently, will advance as tolerated\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, PPI\n .\n # Code: FULL\n .\n # Dispo: patient can be called out to floor if tolerating diet and\n stable\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 416579,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416580,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 416581,
"text": "This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred from\n Center in MA with biliary sepsis.\n Pt was transferred intubated. During his course pt had required\n pressers and insulin gtt for blood glucose control. Off pressers since\n . Pt has been off insulin gtt since . Pt extubated . Blood\n cultures with no growth to date. Pt with positive blood cultures from\n OSH grew out\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 416582,
"text": "This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred from\n Center in MA with biliary sepsis.\n Pt was transferred intubated. During his course pt had required\n pressers and insulin gtt for blood glucose control. Off pressers since\n . Pt has been off insulin gtt since . Pt extubated . Blood\n cultures with no growth to date. Pt with positive blood cultures from\n OSH grew out\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 416583,
"text": "This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred from\n Center in MA with biliary sepsis.\n Pt was transferred intubated. During his course pt had required\n pressers and insulin gtt for blood glucose control. Off pressers since\n . Pt has been off insulin gtt since . Pt extubated . Blood\n cultures with no growth to date. Pt with positive blood cultures from\n OSH grew out enterobacter. Pt has been seen by surgical and GI both\n indicating no intervention needed at this time. Receiving Zosyn and\n Vanco.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416584,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but in the setting of fluid resuscitation, was found to\n have worsening ascites with concern for bile leak evaluated with HIDA\n scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n paracentesis\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds clear, maintaining sats >95% on NC 2L, productive\n congested cough, thick white/yellow secretions\n Action:\n Encouraging pt to TCDB\n Response:\n Pt moving secretions well\n Plan:\n Titrate O2 as tolerated, continue to encourage TCDB as secretions\n persist\n Pancreatitis, acute\n Assessment:\n Pt with grossly distended abd, generalized edema, lipase continues to\n rise recently 1300\n Action:\n Pt is receiving zosyn as ordered, am labs drawn, paracentesis \n performed d/t increased pt discomfort, 4L removed, tolerated procedure\n well, pleural fluid sent for cultures and cytology, pt received 50 gm\n albumin IV post paracentesis as ordered\n Response:\n Pt discomfort resolved with paracentesis, resting comfortably\n Plan:\n f/u lab data including pleural fluid cultures and cytology, continue\n zosyn as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt admitted from OSH with elevated Cr, now trending down 1.3 most\n recent result, u/o ~100cc/hr\n Action:\n Today pt starting enteral diet, started on clear liquids, continuing to\n monitor I/O\n Response:\n Cr trending down as noted above, pt tolerating clear liquid diet well\n Plan:\n Continue to monitor dailly labs, continue to follow u/o and I/O,\n advance diet as tolerated\n Impaired Skin Integrity\n Assessment:\n Pt with generalized pitting edema as noted above, several areas of\n impaired skin integrity, right upper thigh with tape/skin tears,\n weeping from this site, pt also with areas outlined on thighs and abd,\n on admission theses areas appeared red/cellulitic, now mottled, pt\n turning self in bed and moving well\n Action:\n Monitoring areas of impaired integrity, pt had been receiving vanco for\n ? cellulitis, vanco d/c\nd today after three day course\n Response:\n No dramatic changes noted in areas, no further skin impairments to\n speak of\n Plan:\n Continue to monitor skin integrity, OOB to chair when able to tolerate\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416102,
"text": "Chief Complaint: biliary sepsis/pancreatitis\n 24 Hour Events:\n ULTRASOUND - At 11:00 AM\n MULTI LUMEN - START 05:21 PM\n MULTI LUMEN - STOP 10:29 PM\n Patient got RIJ placed yesterday. Appeared to be about 5 cm too far in\n so was pulled back 5 cm. No official read on chest x-ray from\n radiology, but per ICU team looks okay to use. Patient evaluated by\n surgery, ERCP, and liver.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 11:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.3\nC (97.4\n HR: 77 (70 - 95) bpm\n BP: 95/51(61) {94/50(61) - 120/73(84)} mmHg\n RR: 24 (12 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (5 - 18)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 5,961 mL\n 1,178 mL\n PO:\n TF:\n IVF:\n 5,731 mL\n 1,178 mL\n Blood products:\n 200 mL\n Total out:\n 1,616 mL\n 1,055 mL\n Urine:\n 1,516 mL\n 605 mL\n NG:\n 100 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n 4,345 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 16\n PIP: 36 cmH2O\n Plateau: 26 cmH2O\n SpO2: 99%\n ABG: 7.37/34/108/22/-4\n Ve: 11.6 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: tense, distended, minimal bowel sounds, ascites, scrotal\n edema\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 125 K/uL\n 10.4 g/dL\n 98 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 31.7 %\n 16.4 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n WBC\n 22.1\n 15.9\n 16.4\n Hct\n 41.7\n 37.1\n 31.7\n Plt\n 189\n 155\n 125\n Cr\n 2.1\n 2.1\n 2.1\n 1.9\n TCO2\n 21\n 20\n Glucose\n 227\n 208\n 188\n 98\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.7 mg/dL, Mg++:2.4 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy now with septic\n shock thought to be due to enterobacter from the biliary tract. Patient\n also with gallstone pancreatitis, which may be contributing to the\n shock physiology. He has cirrhosis with ascities, which clouds the\n picture of the septic shock. Right now he is off pressors and doing\n better. SVO2 above goal.\n - Continue Zosyn for enterobacter and biliary source flora\n - Stop flagyl since it adds no coverage over zosyn (except C diff)\n - Continue fluid boluses for MAP >60 and SBP >100\n - Change central line changed yesterday\n - Add vancomycin for gram positive coverage until cultures grow out;\n concern for cellulites vs. inflammatory response\n - CT scan - IMPRESSION: 1. Ascites. 2. Nodular appearance of the liver\n surface, suggestive of cirrhosis. 3. Foley catheter balloon inflated at\n the base of the bladder, near the\n junction with the prostatic urethra, clinical correlation is\n recommended to exclude incorrect placement. 4. Small bilateral pleural\n effusions, right greater than left, with partially\n visualized consolidative right basilar airspace disease, atelectasis\n versus pneumonia. No non-contrast CT evidence of pancreatitis, as\n questioned.\n - abdominal echo - IMPRESSION: 1. Patent hepatic vasculature. 2.\n Diffusely echogenic liver parenchyma without evidence for focal liver\n lesions. 3. Marked amount of ascites. 4. Normal appearing kidneys\n without evidence for hydronephrosis. 5. No gallstones.\n - no new micro data\n - Surgery was consulted and said that not currently surgical issue\n - seen by liver - said to check hepatitis serologies, , anti-smooth\n muscle antibody which are pending, plan for diagnostic and therapeutic\n paracentesis sunday (tomorrow)\n - patient got IV albumin yesterday in hopes to keep some intravascular\n fluid\n .\n # Respiratory Failure: Likely due to fluid overload and pleural\n effusions tracking up from ascites. Patient is intubated. At this\n current juncture he will need fluid repletion for the above and will\n diurese after he begins to improve.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n .\n # Crit drop\n - HCt this morning significantly decreased\n - no bowel movements yet, will guiac if has some, no obvious source of\n bleeding\n - will re-check PM cbc\n - draw coags this morning\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n - would consider transitioning back to regular meds\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH, currently 1.9. Very likely secondary to sepsis as\n well as large amount of ascites and hepatorenal syndrome physiology.\n However, sepsis physiology needs to be ruled out.\n -follow urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n # FEN: NPO for now, ordered nutrition consult, will likely require\n post-pyloric feeding, so will plan to try to get IR to place this\n morning and then begin feeding\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, PPI IV\n .\n # Code: FULL\n .\n # Dispo: ICU\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416456,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient extuabted\n Micro lab closed on weekends at OSH. Need to try again to get final\n printed report of sensitivities of enterobacter.\n ERCP: no need for ERCP now since HIDA scan negative.\n Surgery: no recs\n UOP goal >50cc/hr\n INVASIVE VENTILATION - STOP 11:58 AM\n intubated priot to admission\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:44 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 11:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 85 (79 - 96) bpm\n BP: 142/64(100) {118/61(75) - 154/82(100)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (4 - 18)mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 3,766 mL\n 277 mL\n PO:\n TF:\n IVF:\n 3,706 mL\n 277 mL\n Blood products:\n Total out:\n 3,620 mL\n 1,220 mL\n Urine:\n 3,620 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 146 mL\n -943 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///23/\n Ve: 8.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 204 K/uL\n 11.3 g/dL\n 106 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 31 mg/dL\n 117 mEq/L\n 145 mEq/L\n 34.6 %\n 19.5 K/uL\n [image002.jpg]\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n WBC\n 15.9\n 16.4\n 21.7\n 19.5\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n 34.6\n Plt\n 155\n 125\n 161\n 204\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 9\n 149\n 106\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, but lipase trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter and Vancomycin for possible\n cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - .\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.7. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa yesterday was 0.1%. However, there may be low oncotic pressure\n affecting the kidney function as well. Will keep a CVP target of \n and follow urine output today. USG without evidence of hydronephrosis.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: NPO for now., may feed tomorrow depending of how extubation\n goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416652,
"text": "Chief Complaint: Biliary sepsis, resolving.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Paracentesis yesterday, ~4 liters removed. Received 50gm of albumin.\n PMNs 863, still c/w SBP.\n D/c'ed insulin gtt, changed to RSSI.\n Started on clear liquid diet; no abdominal pain, less distension.\n 24 Hour Events:\n PARACENTESIS - At 07:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 87 (81 - 100) bpm\n BP: 142/68(83) {118/44(54) - 162/83(99)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 1,449 mL\n PO:\n 720 mL\n 1,160 mL\n TF:\n IVF:\n 821 mL\n 289 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 1,200 mL\n Urine:\n 3,000 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, persistent discoloration c/w levido reticularis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 247 K/uL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:14.2/27.1/1.2, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n CHOLANGITIS\n DIABETES MELLITUS (DM), TYPE II\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 415950,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n ABG puncture (1220)\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n revealed clear upper lungs, diminished left base and rhoncherous right\n base, suctioned intermittently for moderate to small amounts of thick\n white secretion, FiO2 weaned down from 50 to 40%, SPO2 remains upper\n 90s, traveled to Cat Scan at 1300 for abdominal scan to rule out\n abscess, will continues to be followed.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416217,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n Afebrile. NBP 100-110/50-60. NSR 80-90\ns. Rare PVC\ns. CVP 11-14. Bowel\n pressure 29. Ascites present; abdomen appears firmer than yesterday and\n extremely distended; tender upon palpation. Bowel sounds present (+)\n flatus. NGT clamped- only scant amounts of brown drainage suctioned\n earlier and evidence of irritation r/t suction. Generalized edema. Skin\n pale and cool. Cap refill <3. Bilateral pedal pulses dopplerable. UO\n 80-120 cc/hr, urine clear with sediment. Insulin drip currently at 2\n unit/hr. Hct in early AM dropped to 31.7 from 37.1. WBC increased from\n 15.9 to 16.4.\n Action:\n Hemodynamic monitoring q hour. Blood sugars q hour- titrated insulin\n drip as needed (off 8am-1pm, restarted at 1pm due to BS of 158 most\n likely resulting from the D5W @ 125 cc/hr started at 1200). Coags\n drawn. ABX administered. 25 mcg/hr Fentanyl for pain. Protonix started.\n Response:\n Afebrile. CVP 14. Ascites continues- abdomen remains to be tender and\n firm. Flatus increasing in frequency. PT 17.6 PTT 47.6 INR 1.6\n Plan:\n Continue hemodynamic monitoring. Blood sugars q hour- tirate insulin\n drip as needed. Abx. Follow up HCT @ 1500. Paracentesis and Albumin\n either later today or tomorrow? Continue with D5W @ 125 cc/hr for 2 L.\n Assess for bowel movement. Bolus as necessary. Monitor pain and treat\n as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on pressure support . MV Tidal volume 500-600. RR\n 20. Latest ABG (taken after 1 hour of ) 7.33/42/99. Upper lung\n fields clear; diminished at bases. Small amounts of thin white\n secretions suctioned. Off Versed- currently on 25 mcg/hr of Fentanyl.\n Action:\n Weaned vent setting while monitoring ABG\ns as appropriate. Weaned\n sedation. Turned pt q 2 hours. RSBI at 1400 which was 40. Pt did well\n with SBT- Tidal volume 50 RR 20 MV 11.\n Response:\n Remains stable on pressure support .\n Plan:\n Paracentesis wanted prior to exubation b/c of size of abdomen and its\n effect on work of breathing. Exubate?\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO 80-120 cc/hr. Urine yellow with sediment. BUN 56. CR 1.9. Bladder\n pressure 29.\n Action:\n Monitoring UO q hour. IVF maintenance.\n Response:\n UO increasing. Urine appears a clearer yellow in color. BUN and CR\n trending down.\n Plan:\n Continue to monitor UO and BUN and CR.\n ------ Protected Section ------\n Addendum to above note\n Nursing Progress note 1500\n1900\n Paracentesis done by Dr. and Dr. at 1700 tolerated well.\n Drained 650cc, sent for culture,gram stain and cell count. Wife\n visiting most of afternoon and updated by RN and Dr. .\n NS fluid bolus 500cc given x2 urine output 100cc immediately after\n boluses. Then serum lytes with osmolity sent along with urine lytes and\n osmos\n. Will make decisions on fluid once lytes are back\n ------ Protected Section Addendum Entered By: , RN\n on: 19:14 ------\n"
},
{
"category": "General",
"chartdate": "2120-11-11 00:00:00.000",
"description": "ICU Event Note",
"row_id": 416480,
"text": "Clinician: Attending\n Critical Care\n Extubated and urine output starting to increase although WBC remains\n 19k. Per surgery and GI will begin enteral feeding today. Remains on\n abx. Holding on repeat paracentesis unless he starts to get more SOB.\n Remains tenuous from resp standpoint but hopefully improving without\n further interventions. ERCP wants to defer procedure until he is more\n stable.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 415925,
"text": "Chief Complaint: Transfer from OSH with Sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 08:46 PM\n INVASIVE VENTILATION - START 09:00 PM\n intubated priot to admission\n MULTI LUMEN - START 09:07 PM\n URINE CULTURE - At 02:01 AM\n BLOOD CULTURED - At 04:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:50 PM\n Piperacillin/Tazobactam (Zosyn) - 12:54 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.1\nC (98.7\n HR: 96 (89 - 121) bpm\n BP: 122/66(78) {100/44(54) - 143/78(93)} mmHg\n RR: 30 (20 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 560 mL\n 1,377 mL\n PO:\n TF:\n IVF:\n 560 mL\n 1,377 mL\n Blood products:\n Total out:\n 460 mL\n 630 mL\n Urine:\n 160 mL\n 530 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 100 mL\n 747 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 510) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 98%\n ABG: 7.32/39/58/20/-5\n Ve: 11.1 L/min\n PaO2 / FiO2: 116\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Distended, Tender: All over; not rebound\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 155 K/uL\n 12.0 g/dL\n 208 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 120 mEq/L\n 149 mEq/L\n 37.1 %\n 15.9 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n WBC\n 22.1\n 15.9\n Hct\n 41.7\n 37.1\n Plt\n 189\n 155\n Cr\n 2.1\n 2.1\n TCO2\n 21\n Glucose\n 227\n 208\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.3\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy now with septic\n shock thought to be due to enterobacter from the biliary tract. Patient\n also with gallstone pancreatitis, which may be contributing to the\n shock physiology. He has cirrhosis with ascities, which clouds the\n picture of the septic shock. Right now he is off pressors and doing\n better. SVO2 above goal.\n - Continue Zosyn for enterobacter and biliary source flora\n - Stop flagyl since it adds no coverage over zosyn (except C diff)\n - Continue fluid boluses for MAP >60 and SBP >100\n - Re-start pressor if unable to keep goals\n - Change central line\n - Add vancomycin for gram positive coverage while cultures come back;\n concern for cellulites vs. inflammatory response\n - CT scan for eval for abcess/hemorrhage, cysts associated with\n pancreatitis\n - Surgery consult\n .\n # Respiratory Failure: Likely due to fluid overload and pleural\n effusions tracking up from ascites. Patient is intubated. At this\n current juncture he will need fluid repletion for the above and will\n diurese after he begins to improve.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH. Very likely secondary to sepsis as well as large\n amount of ascites and hepatorenal syndrome physiology. However, sepsis\n physiology needs to be ruled out.\n -follow urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n # FEN: NPO for now\n .\n # Access: Left subclavian\n .\n # PPx: sc heparin tid, pneumoboots, PPI IV daily\n .\n # Code: FULL\n .\n # Dispo: ICU\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 09:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 415930,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 123.7 kg\n 37.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 159\n 89kg\n Diagnosis: ETOH Cirrhosis, pancreatitis\n PMH : ETOH abuse, DM 2, PNA, biliary colic, s/p CCY, OA\n Food allergies and intolerances: none noted.\n Pertinent medications: fent, midazolam, RISS, FA, thiamine, vanco.\n Labs:\n Value\n Date\n Glucose\n 208 mg/dL\n 04:21 AM\n Glucose Finger Stick\n 220\n 11:08 AM\n BUN\n 58 mg/dL\n 04:21 AM\n Creatinine\n 2.1 mg/dL\n 04:21 AM\n Sodium\n 149 mEq/L\n 04:21 AM\n Potassium\n 4.1 mEq/L\n 04:21 AM\n Chloride\n 120 mEq/L\n 04:21 AM\n TCO2\n 20 mEq/L\n 04:21 AM\n PO2 (arterial)\n 58 mm Hg\n 09:06 PM\n PCO2 (arterial)\n 39 mm Hg\n 09:06 PM\n pH (arterial)\n 7.32 units\n 09:06 PM\n pH (urine)\n 5.5 units\n 11:08 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 09:06 PM\n Albumin\n 1.8 g/dL\n 04:21 AM\n Calcium non-ionized\n 6.5 mg/dL\n 04:21 AM\n Phosphorus\n 3.3 mg/dL\n 04:21 AM\n Magnesium\n 2.4 mg/dL\n 04:21 AM\n ALT\n 34 IU/L\n 04:21 AM\n Alkaline Phosphate\n 116 IU/L\n 04:21 AM\n AST\n 71 IU/L\n 04:21 AM\n Amylase\n 194 IU/L\n 08:52 PM\n Total Bilirubin\n 0.8 mg/dL\n 04:21 AM\n Triglyceride\n 85 mg/dL\n 08:52 PM\n WBC\n 15.9 K/uL\n 04:21 AM\n Hgb\n 12.0 g/dL\n 04:21 AM\n Hematocrit\n 37.1 %\n 04:21 AM\n Current diet order / nutrition support: NPO.\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1780-2225kcals (BEE x or / 20-25 cal/kg)\n Protein: 71-135 (0.8-1.5 g/kg)\n Fluid: per team.\n Specifics:\n 65 YO male with hx of ETOH Cirrhosis w/ pancreatitis, and now with new\n ascites & currently intubated. Consulted for low albumin\ncause may be\n multifactorial. Recommend TF if remains intubated in the next 24hrs.\n Will not be able to maximize protein d/t current elevated BUN/Creat\n ?d/t decreased renal fxn vs dehydration. Suggest Fibersource HN at\n goal 60mL/hr (1728kcal/76g protein). Will optimize protein once\n BUN/Great are within acceptable ranges.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If remains intubated for the next 24hrs, place TF access,\n preferably PPFT/NJ & start TF: Fibersource HN, start at 10mL/hr,\n advance by 10mL Q4-6 hrs to goal 60mL/hr\n 2. check TF tolerance via GI fxn/symptoms\n 3. adjust free water boluses per hydration\n 4. Monitor renal fxn; monitor & replete lab PRN\n 5. would adjust TF goal rate to optimize protein once BUN/Creat\n is wnl\ns (high protein supps if on po\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416002,
"text": "Significant Events:\n Abdominal ultrasound and CT in AM.\n Right IJ CVL placed- CXR taken to confirm placement.\n Pancreatitis, acute\n Assessment:\n Afebrile. Tmax 99 oral. NBP 100-120/60\ns. NSR 80-90\ns. CVP 11.\n Extremities cool. Cap refill <3. Generalized edema. Ascites- positive\n bowel sounds, tympanic, and very tender upon palpation. Bladder\n pressure 20. NGT to cont low wall suction draining moderate amounts of\n bilious fluid. Blood sugars remained above 200 for the early part of\n the day, insulin drip started and blood sugars are now trending down-\n currently in the mid 100\ns. Erythematous and warm area noted on the\n upper abdomen. Both knees also noted to be red and warm to the touch.\n 0500 labs- Lipase 237, LDH 366, AST 71, ALT 34, Total Bili 0.8, Alb\n 1.8.\n Action:\n Bolused 500 cc of LR x 2 (AM sodium was 149). Started IVF D51/2NS at\n 250 cc/hr for 2 L. NGT to LWS, maintain NPO resting gut. Insulin drip\n started- Blood sugars q hour. Abx administered- started Vanco, Zosyn\n scheduled, discontinued Flagyl. 50 grams of Alb given. Pain control\n with Fentanyl 50-75 mcg/hr and Versed 2 mg/hr. Erythema of the abdomen\n and knees were marked outlining the borders.\n Response:\n Remains afebrile. CVP responded to boluses and IVF increasing from 5 to\n 11. Ascites continues along with bilious drainage from NGT. Blood\n sugars are trending down with insulin drip. Erythema of abdomen\n slightly beyond borders marked in AM. 1700 labs- NA 147, K 3.7\n Plan:\n Monitor CVP. Fluid bolus if urine trends down <60 cc/hr and/or CVP\n trends down with goal of . Monitor abdomen and OGT drainge. Watch\n lytes and LFT\ns. Pain management with Fentanyl. Blood sugars q hour\n making changes to insulin drip as necessary. Follow bladder pressures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on A/C Fi02 40%, TV 500, RR 22, PEEP 5. Sp02 98%. Lungs\n rhonchus in upper fields, diminished at bases. Observed MV . PIP\n 25-30. Scant clear and thick secretions suctioned. ABG at 1300-\n 7.37/34/108.\n Action:\n Suctioned as necessary. Oral care.\n Response:\n Remains stable on vent- ABG WNL.\n Plan:\n Plan is to keep pt vented as we do not know about possible ERCP???\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 58 CR 2.1. UO 50-90 cc/hr. Urine amber and clear turning more\n yellow.\n Action:\n Fluid boluses equal I L LR. Monitored hourly UO.\n Response:\n UO did not respond much to boluses- saw more of a change in CVP. Urine\n becoming more yellow and clear.\n Plan:\n Continue to monitor BUN and CR. Hourly output and boluses as needed to\n keep UO at least 60 cc/hr.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416006,
"text": "65 yo Male admitted from outside hospital with biliary sepsis,\n pancreatitis s/p lap chole which found infected gallbladder and\n necrotic liver. PHM- diabetes (oral agents), ETOH use, HTN,\n hyperlipidemia, PNA with decortication, and depression.\n Significant Events:\n Abdominal ultrasound and CT in AM.\n Right IJ CVL placed- CXR taken to confirm placement.\n Wife in and out of room for most of day- flat affect seems\n extremely anxious. Son also involved but did not come in.\n Pancreatitis, acute\n Assessment:\n Afebrile. Tmax 99 oral. NBP 100-120/60\ns. NSR 80-90\ns. CVP 11.\n Extremities cool. Cap refill <3. Generalized edema. Ascites- positive\n bowel sounds, tympanic, and very tender upon palpation. Bladder\n pressure 20. NGT to cont low wall suction draining moderate amounts of\n bilious fluid. Blood sugars remained above 200 for the early part of\n the day, insulin drip started and blood sugars are now trending down-\n currently in the mid 100\ns. Erythematous and warm area noted on the\n upper abdomen. Both knees also noted to be red and warm to the touch.\n 0500 labs- Lipase 237, LDH 366, AST 71, ALT 34, Total Bili 0.8, Alb\n 1.8.\n Action:\n Bolused 500 cc of LR x 2 (AM sodium was 149). Started IVF D51/2NS at\n 250 cc/hr for 2 L. NGT to LWS, maintain NPO resting gut. Insulin drip\n started- Blood sugars q hour. Abx administered- started Vanco, Zosyn\n scheduled, discontinued Flagyl. 50 grams of Alb given. Pain control\n with Fentanyl 50-75 mcg/hr and Versed 2 mg/hr. Erythema of the abdomen\n and knees were marked outlining the borders.\n Response:\n Remains afebrile. CVP responded to boluses and IVF increasing from 5 to\n 11. Ascites continues along with bilious drainage from NGT. Blood\n sugars are trending down with insulin drip. Erythema of abdomen\n slightly beyond borders marked in AM. 1700 labs- NA 147, K 3.7\n Plan:\n Monitor CVP. Fluid bolus if urine trends down <60 cc/hr and/or CVP\n trends down with goal of . Monitor abdomen and OGT drainge. Watch\n lytes and LFT\ns. Pain management with Fentanyl. Blood sugars q hour\n making changes to insulin drip as necessary. Follow bladder pressures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on A/C Fi02 40%, TV 500, RR 22, PEEP 5. Sp02 98%. Lungs\n rhonchus in upper fields, diminished at bases. Observed MV . PIP\n 25-30. Scant clear and thick secretions suctioned. ABG at 1300-\n 7.37/34/108.\n Action:\n Suctioned as necessary. Oral care.\n Response:\n Remains stable on vent- ABG WNL.\n Plan:\n Plan is to keep pt vented as we do not know about possible ERCP???\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 58 CR 2.1. UO 50-90 cc/hr. Urine amber and clear turning more\n yellow.\n Action:\n Fluid boluses equal I L LR. Monitored hourly UO.\n Response:\n UO did not respond much to boluses- saw more of a change in CVP. Urine\n becoming more yellow and clear.\n Plan:\n Continue to monitor BUN and CR. Hourly output and boluses as needed to\n keep UO at least 60 cc/hr.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416286,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n PARACENTESIS - At 05:30 PM 1L drained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (82 - 99) bpm\n BP: 128/85(96) {100/45(61) - 128/85(96)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (5 - 14)mmHg\n Bladder pressure: 22 (22 - 29) mmHg\n Total In:\n 4,249 mL\n 1,136 mL\n PO:\n TF:\n IVF:\n 4,209 mL\n 1,136 mL\n Blood products:\n Total out:\n 3,590 mL\n 1,020 mL\n Urine:\n 2,490 mL\n 1,020 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 650 mL\n Balance:\n 659 mL\n 116 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 613 (463 - 643) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.33/42/99./23/-3\n Ve: 11.4 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 161 K/uL\n 11.1 g/dL\n 149 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 44 mg/dL\n 118 mEq/L\n 146 mEq/L\n 34.6 %\n 21.7 K/uL\n [image002.jpg]\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n WBC\n 15.9\n 16.4\n 21.7\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n Plt\n 155\n 125\n 161\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n TCO2\n 21\n 20\n 23\n 23\n Glucose\n 9\n 149\n Other labs: PT / PTT / INR:15.3/27.4/1.4, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.1 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416287,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n PARACENTESIS - At 05:30 PM 1L drained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (82 - 99) bpm\n BP: 128/85(96) {100/45(61) - 128/85(96)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (5 - 14)mmHg\n Bladder pressure: 22 (22 - 29) mmHg\n Total In:\n 4,249 mL\n 1,136 mL\n PO:\n TF:\n IVF:\n 4,209 mL\n 1,136 mL\n Blood products:\n Total out:\n 3,590 mL\n 1,020 mL\n Urine:\n 2,490 mL\n 1,020 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 650 mL\n Balance:\n 659 mL\n 116 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 613 (463 - 643) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.33/42/99./23/-3\n Ve: 11.4 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 161 K/uL\n 11.1 g/dL\n 149 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 44 mg/dL\n 118 mEq/L\n 146 mEq/L\n 34.6 %\n 21.7 K/uL\n [image002.jpg]\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n WBC\n 15.9\n 16.4\n 21.7\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n Plt\n 155\n 125\n 161\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n TCO2\n 21\n 20\n 23\n 23\n Glucose\n 9\n 149\n Other labs: PT / PTT / INR:15.3/27.4/1.4, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.1 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy now with septic\n shock thought to be due to enterobacter from the biliary tract. Patient\n also with gallstone pancreatitis, which may be contributing to the\n shock physiology. He has cirrhosis with ascities, which clouds the\n picture of the septic shock. Right now he is off pressors and doing\n better. SVO2 above goal.\n - Continue Zosyn for enterobacter and biliary source flora\n - Stop flagyl since it adds no coverage over zosyn (except C diff)\n - Continue fluid boluses for MAP >60 and SBP >100\n - Change central line changed yesterday\n - Add vancomycin for gram positive coverage until cultures grow out;\n concern for cellulites vs. inflammatory response\n - CT scan - IMPRESSION: 1. Ascites. 2. Nodular appearance of the liver\n surface, suggestive of cirrhosis. 3. Foley catheter balloon inflated at\n the base of the bladder, near the\n junction with the prostatic urethra, clinical correlation is\n recommended to exclude incorrect placement. 4. Small bilateral pleural\n effusions, right greater than left, with partially\n visualized consolidative right basilar airspace disease, atelectasis\n versus pneumonia. No non-contrast CT evidence of pancreatitis, as\n questioned.\n - abdominal echo - IMPRESSION: 1. Patent hepatic vasculature. 2.\n Diffusely echogenic liver parenchyma without evidence for focal liver\n lesions. 3. Marked amount of ascites. 4. Normal appearing kidneys\n without evidence for hydronephrosis. 5. No gallstones.\n - no new micro data\n - Surgery was consulted and said that not currently surgical issue\n - seen by liver - said to check hepatitis serologies, , anti-smooth\n muscle antibody which are pending, plan for diagnostic and therapeutic\n paracentesis sunday (tomorrow)\n - patient got IV albumin yesterday in hopes to keep some intravascular\n fluid\n - cont albumin, today is day , need to re-order\n - start on Ppi \n .\n # Respiratory Failure: Intubated likely in the setting of sepsis.\n Likely due to fluid overload and pleural effusions tracking up from\n ascites. Patient is intubated. As off pressors and not requiring too\n much in the way of pressure support currently.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n - for now will try to wean sedation and consider spontaneously\n breathing trial\n .\n # Crit drop\n - HCt this morning significantly decreased\n - no bowel movements yet, will guiac if has some, no obvious source of\n bleeding\n - will re-check PM cbc\n - INR this morning 1.6, consider vit K as needed if bleeding becomes a\n problem\n - would consult with liveer\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH, currently 1.9. Very likely secondary to sepsis as\n well as large amount of ascites and hepatorenal syndrome physiology.\n However, sepsis physiology needs to be ruled out.\n -follow urine lytes\n FeNa 0.1% consistent mostly with prerenal\n physiology, low urine sodium\n - will check in touch with liver regarding treatment\n -abdominal ultrasound without evidence of hydronephrosis bilaterally\n -foley in place making good urine\n -continue hydration\n .\n # FEN: NPO for now, ordered nutrition consult, will likely require\n post-pyloric feeding, so will plan to try to get IR to place this\n morning and then begin feeding\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 415914,
"text": "Chief Complaint: Sepsis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:46 PM\n INVASIVE VENTILATION - START 09:00 PM\n intubated priot to admission\n MULTI LUMEN - START 09:07 PM\n URINE CULTURE - At 02:01 AM\n BLOOD CULTURED - At 04:28 AM\n Pressors weaned off overnight\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:54 AM\n Metronidazole - 08:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (99\n HR: 92 (89 - 121) bpm\n BP: 118/59(73) {100/44(54) - 143/78(93)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 9 (3 - 12)mmHg\n Total In:\n 560 mL\n 2,528 mL\n PO:\n TF:\n IVF:\n 560 mL\n 2,498 mL\n Blood products:\n Total out:\n 460 mL\n 775 mL\n Urine:\n 160 mL\n 675 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 100 mL\n 1,753 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 510) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 99%\n ABG: 7.32/39/58/20/-5\n Ve: 11.1 L/min\n PaO2 / FiO2: 116\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Distended, Tender: Significantly tender\n diffusely\n Extremities: Right: 2+, Left: 2+\n Skin: Patient with erythema and warmth in patellar areas bilaterally,\n he has anterior abdominal wall region with similar area of erythema and\n warmth. No discomfort with passive ROM of the knee joint.\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.0 g/dL\n 155 K/uL\n 208 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 120 mEq/L\n 149 mEq/L\n 37.1 %\n 15.9 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n WBC\n 22.1\n 15.9\n Hct\n 41.7\n 37.1\n Plt\n 189\n 155\n Cr\n 2.1\n 2.1\n TCO2\n 21\n Glucose\n 227\n 208\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.3\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.3 mg/dL\n Imaging: CXR--Right sided effusion, NGT and ETT in good position and\n left SCL crossing midline and in good position.\n Assessment and Plan\n 65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation and is now transferred to for further care.\n The source of the respiratory failure may well be a combination of the\n ascites and likely SBP compromising ventilatory mechanics but also with\n significant concern for evolution of non-cardiogenic edma/. For\n management will-->\n 1)Sepsis-Multiple possible sources with concern for peritonitis,\n pancreatitis and possible persistent insult from GNR's of biliary\n source. In addition, he has evidence of cellulitis in abdominal wall\n as well as lower extermities raising concern for possible metastatic\n source of infection.\n -Zosyn/Flagyl and will expand to Vanco/Zosyn/Flagyl\n -ERCP team in to evaluate and follow patient for possible ERCP with\n cholangiogram to evaluate for source of leak in the setting of ascitic\n fluid findings\ninitial conclusion is to continue with current plan of\n care and defer ERCP at this time given minimal evidece of leak\n -Pancreatitis will be treated as below\n -SBP in the setting of cirrhosis is of concern as well in contributing\n to sepsis\n -Cellulitis suggestion will be followed closely and treated with\n coverage extended to gram positive organisms with Vancomycin\n -Repeat CT scan for follow up evaluation for evolution of pancreatitis\n or to evaluate for flluid collections within abdomen\n -Surgery evaluation for support with the pacreatitis\n -IVF as needed to maintain CVP and the urine flow minimum of 30cc/hr\n for now.\n 2)Respiratory Failure-Minimal evidence of airflow obstruction or\n increased resistance suggesting is loss of pulmonary compliance\n contributing. Oxygenation able to be supported with 0.5 FIO2 and Pplat\n at 22 suggesting resonable levels of support.\n -Continue with A/C support\n -Titrate PEEP up for any decrease in oxygenation\n 3)Pancreatitis--Patient with diffuse abdominal tenderness noted, Lipase\n has improved upon comparison with OSH lab studies.\n -Favor post pyloric feeding if tube able to be placed and for support\n -CT scan to evaluate for any evidence of necrosis or alternative\n intra-abdominal collection\n -Pain control with Fentanyl for now\n -npo until post pyloric feeds in place\n -F/U Lipase\n 4)Cholelithiasis\nERCP team to follow\n 5)EtOH Abuse--Hospitalized for 5 days and no symptoms seen at this\n time.\n ICU Care\n Nutrition: npo for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 09:07 PM-_Will need resite of CVL given OSH\n placement\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 416077,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds improve with suct mod th tan sput. OETT migrated out;\n advanced without any difficulty. Pt in NARD on current vent settings;\n no vent changes required overnoc. RSBI misleading this AM; overall Ve\n low despite good RSBI value. Cont mech vent support.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416082,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation and is now transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and vented on AC 40% 500x22/5, sats at high\n 90\ns-100%. Bil LS rhonchorous, diminished at the bases. Unlabored\n breathing. Suctioned for sm amnt of white thick secretions.\n Action:\n Continue w/mechanical ventilation, suction PRN, mouth care q4hr and\n PRN, RSBI\n Response:\n Pending\n Plan:\n Continue to monitor patient resp status, wean off when able, Titrate\n PEEP up for any decrease in oxygenation\n Pancreatitis, acute\n Assessment:\n Patient with diffuse abdominal tenderness, abd firm and distended,\n ascites, BS present, NPO, NGT to LCS\nbilious output, improving labs.\n Tmax - 98.1 WBC-16.4, elevated LFT\ns although trending down, CVP 15-18\n b/p 100\ns/60\ns hr -70-80\ns SR no ectopy noted, general edema, extr\n cool.\n Action:\n NPO until post pyloric feeding tube placed ( planned for tomorrow),\n nutritional consult ordered, CT scan to evaluate for any evidence of\n necrosis or alternative intra-abdominal collection done\n negative,\n Pain control with Fentanyl for now, F/u lipase, surgical/GI/liver\n consults. Continue w/IV ABX, f/u cultures, IVF as needed to maintain\n CVP and the urine flow minimum of 30cc/hr. Insulin gtt and hourly FS.\n Response:\n improving\n Plan:\n Continue to monitor patient status, continue w/IVF and ABX, f/u\n cultures, f/u surgery/GI/liver recs. paracentesis in am ??? ERCP???\n * K-3.7 this am started to replete w/40 meq of kcl. Na-147 remains\n elevated. Consider D5W for IVF.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 415898,
"text": "Chief Complaint: Transfer from OSH with Sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 08:46 PM\n INVASIVE VENTILATION - START 09:00 PM\n intubated priot to admission\n MULTI LUMEN - START 09:07 PM\n URINE CULTURE - At 02:01 AM\n BLOOD CULTURED - At 04:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:50 PM\n Piperacillin/Tazobactam (Zosyn) - 12:54 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.1\nC (98.7\n HR: 96 (89 - 121) bpm\n BP: 122/66(78) {100/44(54) - 143/78(93)} mmHg\n RR: 30 (20 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 560 mL\n 1,377 mL\n PO:\n TF:\n IVF:\n 560 mL\n 1,377 mL\n Blood products:\n Total out:\n 460 mL\n 630 mL\n Urine:\n 160 mL\n 530 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 100 mL\n 747 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 510) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 98%\n ABG: 7.32/39/58/20/-5\n Ve: 11.1 L/min\n PaO2 / FiO2: 116\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Distended, Tender: All over; not rebound\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 155 K/uL\n 12.0 g/dL\n 208 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 120 mEq/L\n 149 mEq/L\n 37.1 %\n 15.9 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n WBC\n 22.1\n 15.9\n Hct\n 41.7\n 37.1\n Plt\n 189\n 155\n Cr\n 2.1\n 2.1\n TCO2\n 21\n Glucose\n 227\n 208\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.3\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 09:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 415899,
"text": "Chief Complaint: Transfer from OSH with Sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 08:46 PM\n INVASIVE VENTILATION - START 09:00 PM\n intubated priot to admission\n MULTI LUMEN - START 09:07 PM\n URINE CULTURE - At 02:01 AM\n BLOOD CULTURED - At 04:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:50 PM\n Piperacillin/Tazobactam (Zosyn) - 12:54 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.1\nC (98.7\n HR: 96 (89 - 121) bpm\n BP: 122/66(78) {100/44(54) - 143/78(93)} mmHg\n RR: 30 (20 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 560 mL\n 1,377 mL\n PO:\n TF:\n IVF:\n 560 mL\n 1,377 mL\n Blood products:\n Total out:\n 460 mL\n 630 mL\n Urine:\n 160 mL\n 530 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 100 mL\n 747 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 510) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 98%\n ABG: 7.32/39/58/20/-5\n Ve: 11.1 L/min\n PaO2 / FiO2: 116\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Distended, Tender: All over; not rebound\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 155 K/uL\n 12.0 g/dL\n 208 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 120 mEq/L\n 149 mEq/L\n 37.1 %\n 15.9 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n WBC\n 22.1\n 15.9\n Hct\n 41.7\n 37.1\n Plt\n 189\n 155\n Cr\n 2.1\n 2.1\n TCO2\n 21\n Glucose\n 227\n 208\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.3\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.3 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Pancreatitis and Biliary Sepsis - patient likely has biliary sepsis\n given history as well as enterobacter in blood as well as in biliary\n specimen from initial presentation. Also has pancreatitis related to\n gallstones. He also has a large amount of ascites that is infected,\n possibily primarily versus secondary bacterial peritonitis. In this\n setting it is more likely secondary. The patient is hypotensive\n requring pressors.\n -surveillance cultures, will need to obtain OSH records of bacterial\n sensitivities\n -continue zosyn flagyl for likely biliary sepsis\n -f/u sensitivities on enterobacter\n -continue fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr\n -monitor SVO2 from central venous catheter and goal of 70\n -contact ERCP fellow regarding further management given worsening\n sepsis and 3 episodes of gallstone pancreatitis\n -send sputum cultures and obtain CXR, add vancomycin if spikes\n empirically\n -send C diff if diarrhea and send a u/a and urine culture\n -given the increase in intraabdominal ascites possibilities are of a\n bile leak, a aberrant duct or a pancreatic duct disruption due to\n apparently 3 episodes of gallstone pancreatitis. He had a negative\n HIDA scan but it is possible he had a pancreatic duct disruption that\n was not seen or that his bile leak stopped by the time he had his scan,\n less likely this was a false negative HIDA scan. Per ERCP fellow this\n is unlikely given the negative HIDA scan and more likely he has\n pancreatitis with massive third spacing given the background of ETOH\n cirrhosis.\n -call surgery consult in a.m. (Dr. service)\n -obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow\n .\n # Respiratory Failure: Likely due to fluid overload and pleural\n effusions tracking up from ascites. Patient is intubated. At this\n current juncture he will need fluid repletion for the above and will\n diurese after he begins to improve.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n .\n # DM: on oral hypoglycemics at home.\n -RISS\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH. Very likely secondary to sepsis as well as large\n amount of ascites and hepatorenal syndrome physiology.\n -send urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n # FEN: NPO for now\n .\n # Access:\n .\n # PPx: sc heparin tid, pneumoboots, PPI IV daily\n .\n # Code: FULL\n .\n # Dispo: ICU\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 09:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 415811,
"text": "This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was transferred intubated (not sedated) on AC 50% 500x22/PEEP\n 5. Required frequent suctioning during transport. Bil LS rhonchorous\n all throughout. Suctioned for small amnt of white/tan secretions.\n Action:\n Remains intubated on the same settings. Sedation was added to provide\n comfort. (versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol.\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns resp status, wean off vent when able.\n Pancreatitis, acute\n Assessment:\n Patient w/low grade temp. Tmax 100.7 upon admission. Abd firm\n distended tender to palpation.\n ascites (taped at the OSH for 2.4L\n output), NPO, NGT to low cont suction scant amnt. NO BS or flatus,\n elevated LFT\n Action:\n continue zosyn flagyl for likely biliary sepsis, f/u sensitivities on\n enterobacter( in blood as well in biliary specimen from OSH), continue\n fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr, monitor SVO2\n from central venous catheter and goal of 70, GI and surgery consults,\n obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow in AM, labs to eval. blood and urine cultures sent.\n Response:\n pending\n Plan:\n Monitor patient status, GI/surgery consult, ERCP??? f/u cultures\n Neuro: upon admission patient alert. Intubated and vented\n so unable\n to assess orientation. Follows simple commands. Nods his head to yes/no\n questions. Moves extr. HX of altered mental status when his sepsis was\n worsening.\n # DM: on oral hypoglycemics at home.\n -RISS\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH. Very likely secondary to sepsis as well as large\n amount of ascites and hepatorenal syndrome physiology.\n -send urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 415813,
"text": "This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was transferred intubated (not sedated) on AC 50% 500x22/PEEP\n 5. Required frequent suctioning during transport. Bil LS rhonchorous\n all throughout. Suctioned for small amnt of white/tan secretions. Sats\n at 98-99%. RR at 25-33.\n Action:\n Remains intubated on the same settings. Sedation was added to provide\n comfort. (versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol.\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns resp status, wean off vent when able.\n Pancreatitis, acute\n Assessment:\n Patient w/low grade temp. Tmax 100.7 upon admission. Abd firm\n distended tender to palpation.\n ascites (taped at the OSH for 2.4L\n output), NPO, NGT to low cont suction scant amnt. NO BS or flatus,\n elevated LFT\n Action:\n continue zosyn flagyl for likely biliary sepsis, f/u sensitivities on\n enterobacter( in blood as well in biliary specimen from OSH), continue\n fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr, monitor SVO2\n from central venous catheter and goal of 70, GI and surgery consults,\n obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow in AM, labs to eval. blood and urine cultures sent.\n Response:\n pending\n Plan:\n Monitor patient status, GI/surgery consult, ERCP??? f/u cultures\n Neuro: upon admission patient alert. Intubated and vented\n so unable\n to assess orientation. Follows simple commands. Nods his head to yes/no\n questions. Moves extr. HX of altered mental status when his sepsis was\n worsening. CT Head w/o contrast from OSH: mild inflammatory sinus\n disease. No acute intracranial abnormality.\n Cardio: upon admission on neo@ 0.8 and dopamine@5 b/p at\n 130\ns-140\ns/70. tachycardic at low 100\ns. ST no ectopy noted. Dopamin\n weaned off by 1:30am and neo decresed to 0.2/hr. B/P 110\ns/60\ns, HR at\n 80-90\ns SR w/short episode of ST to 160\ns. General edema - anasarca.\n Extr cool and mottled.\n GU: amber colored urine via foley 60-70cc/hr. bolused X1 w/500c NS for\n low UOP. Cr on was 1.1, increasing on to 1.7 and to 2.2 on\n at OSH. Urine lytes and culture sent. Renal consult ???? if\n needed.\n Skin: ecchymotic area at the RT AC probably from previous IV site\n covered w/tegaderm from OSH. No other skin impairments noted.\n IV access: LT SC 3 lumen from OSH\n site looks clean no redness or\n drainage. LT AC 18G\npatent.\n Social: patient is a FULL CODE. Family was in to visit. Updated by RN\n and MD. need SW consult for peculiar family dynamic.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416263,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically vented, throughout the shift, RR: 14-21, O2sat\n 93-98%, breath sounds clear in upper airways, occasionally suctioning\n for scant thick white secretions, pt remains on fent gtt for comfort,\n pt is alert and following commands, anxious at times, mouthing words\n but this RN unable to tell what he is trying to say\n Action:\n Providing fent boluses for repositioning, pt with pain per grimace\n scale, responding well to bolusing, maintained on fent gtt overnight at\n 25mcg/kg with good effect, breathing comfortably on vent settings as\n noted above, suctioning PRN, reorienting and providing emotional\n support, am Cxray\n Response:\n Pt maintaining well on current settings, able to rest comfortably\n throughout the shift though anxious at times\n Plan:\n f/u Cxray, change settings to this am, extubation tomorrow,\n continue to monitor\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Following fluid challenge yesterday pt\ns Cr 1.8 from 1.9, u/o between\n 120-240cc/hr\n Action:\n Am labs sent, restarted IV fluids D5W 125 cc/hr, monitoring pt\ns BS\n hourly, restarted insulin gtt, titrating gtt guidelines\n Response:\n Pending, pt with excellent u/o as noted above\n Plan:\n f/u am labs, continue to monitor hourly u/o, hourly FSBS while on\n insulin gtt, titrate gtt accordingly\n Pancreatitis, acute\n Assessment:\n Afebrile, culture data to date with no growth, abd grossly distended\n and firm, pt with abd pain with activity, generlized edema with weeping\n noted, oozing serous fluid from pericentesis site\n Action:\n Monitoring throughout the shift, adm antibiotics as ordered\n Response:\n Afebrile as noted above\n Plan:\n Continue to f/u culture data, continue current antibiotic as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416351,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n Events: extubated at 1200\n Pancreatitis, acute\n Assessment:\n Abd distended, firm, +bs,+flatus, bladder pressure 16 today. Lipase up\n to 1124,amylase 323,alk phos 140,,, up significantly from yesterday\n values. Was on fentanyl 25mcg/hr which was d/c\ned prior to extubation.\n Denies any pain. No stool today, iv insulin gtt with FS stable at\n 100-110 today on units/r.\n Action:\n follow hourly FS,\n Response:\n Worsening LFT\ns and pancreatic,\n Plan:\n Keep NPO for now, watch lab values closely, nutrition will need to be\n addressed if levels cont to be elevated, cont IV insulin to maintain\n tight glycemic control,\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output initially 200cc/hr now more like 70-80cc/hr, light yellow\n to yellow in color, creat 1.7 with BUN 48\n Action:\n Cont D5\n NS at 125cc/hr x 2liters (second liter went up at 1700)\n Response:\n Slowly improving renal function\n Plan:\n Would cont to closely monitor urine output, would fluid bolus pt for\n urine less than 60cc/hr. monitor labs,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On PS 5cm, with PEEP 5cm, at the start of the day, tolerating well,\n continues with O2 sats 98-100%,\n Action:\n Extubated at 1200, placed on cool nemb face tent , strong cough,\n productive at times\n Response:\n Tolerating extubation well,\n Plan:\n Maintain O2 sats >96%, encourage cough and deep breath, wean FIO2 as\n tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416669,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n Therapeutic paracentesis, removed 4L of fluids and given 50gm albumin\n Ascitic fluid: poly: 863 --> SBP on zosyn\n d/c insulin ggt, on ISS\n started on clear liquids and advance as tolerate --> pt tolerating\n clears\n PARACENTESIS - At 07:05 PM\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Pt denies abdominal pain. Patient tolerating clear liquids, requesting\n to eat more.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (81 - 100) bpm\n BP: 147/69(89) {118/44(54) - 162/130(135)} mmHg\n RR: 23 (11 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (8 - 21)mmHg\n Total In:\n 1,741 mL\n 968 mL\n PO:\n 720 mL\n 800 mL\n TF:\n IVF:\n 821 mL\n 168 mL\n Blood products:\n 200 mL\n Total out:\n 7,000 mL\n 940 mL\n Urine:\n 3,000 mL\n 940 mL\n NG:\n Stool:\n Drains:\n 4,000 mL\n Balance:\n -5,259 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, comforatable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t)\n Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\n poor inspiratory effort\n Abdominal: Non-tender, Bowel sounds present, Distended, No(t) Tender: ,\n Obese, + ascites, firm, dressing over paracentesis site minimally\n saturated\n Extremities: anasarca\n Skin: Not assessed, livideo reticularis\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 247 K/uL\n 9.7 g/dL\n 250 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 113 mEq/L\n 141 mEq/L\n 29.0 %\n 13.6 K/uL\n [image002.jpg]\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n 05:27 AM\n WBC\n 16.4\n 21.7\n 19.5\n 13.6\n Hct\n 31.7\n 35.2\n 34.6\n 34.6\n 29.0\n Plt\n 125\n 161\n 204\n 247\n Cr\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 188\n 98\n 119\n 149\n 106\n 250\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:28/47, Alk Phos / T\n Bili:162/1.0, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:281 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n CHOLANGITIS\n DIABETES MELLITUS (DM), TYPE II\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Sepsis/pancreatitis: growing enterobacter from biliary tract fluid\n and blood. Liver enzymes stable and pancreatic enzymes have stabilized\n and are trending down. Low likelihood of bile duct leak with a negative\n HIDA scan. Patient has been off pressors for 48 hours and extubated.\n Pt had paracentesis and removed 4L fluid. Ascitic fluid: poly: 863 -->\n SBP on zosyn\n Low protein 1.5. --> t/c SBP ppx, SAAG >1.1 hepatic etiology (ascites\n albumin <1.0)\n d/c insulin ggt, on ISS\n - Contnue Zosyn for enterobacter and SBP x 14 days\n - t/c SBP ppx because low protein in ascitic fluid (1.5)\n will f/u with liver recs\n - f/u peritoneal fluid cultures\n - cont to trend LFT and labs\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - patient tolerating clears and may advance as tolerated.\n # Respiratory Failure: Pt extubated and tolerating. Currently on NC\n .\n # DM: holding home meds. Currently on RISS\n - cont RISS\n - will add lantus today since patient no longer NPO\n will dose based\n on SS usage\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family. No evidence of\n withdrawl.\n -thiamine, folate\n .\n # Renal Failure: Creatinine stable; today 1.3. Most likely pre-renal in\n the setting of sepsis since it is slowly improving with fluids and FeNa\n was 0.1%.\n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine\n .\n # FEN: Clears currently, will advance as tolerated\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, PPI\n .\n # Code: FULL\n .\n # Dispo: patient can be called out to floor if tolerating diet and\n stable, will get PT consult\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036455,
"text": " 4:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p IJ placement\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, pancreatitis, and cirrhosis\n REASON FOR THIS EXAMINATION:\n s/p IJ placement\n ______________________________________________________________________________\n WET READ: GWp FRI 5:32 PM\n New R IJ catheter tip projects over right atrium. Low lung volumes, bibasal\n effusions and atelectasis & lines and tubes as before d/w Dr 5:30p\n GWlms\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post line placement.\n\n COMPARISON: , 5:53 a.m.\n\n FINDINGS: As compared to the previous radiograph, a central venous access\n line has been placed over the right internal jugular vein. The tip of the\n line projects over the inflow tract of the right atrium. The course of the\n catheter is unremarkable, no indications of pneumothorax or other\n complications. Unchanged radiographic aspect of the other monitoring and\n support devices. The remaining radiographic features are unchanged.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2120-11-15 00:00:00.000",
"description": "Report",
"row_id": 87817,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pleural effusion , hypoxia .\nHeight: (in) 73\nWeight (lb): 230\nBSA (m2): 2.29 m2\nBP (mm Hg): 119/76\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mild\npulmonary hypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-19 00:00:00.000",
"description": "GALLBLADDER SCAN",
"row_id": 1038349,
"text": "GALLBLADDER SCAN Clip # \n Reason: C/B BILIARY SEPSIS S/P CCY EVAL FOR BILE LEAK\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 4.2 mCi Tc-m DISIDA ();\n HISTORY: 65 yo man s/p cholecystectomy with bilirubin the ascitic fluid.\n\n INTERPRETATION: Serial images over the abdomen were obtained for 90 minutes. A\n static lateral image was also displayed. There is normal uptake of tracer into\n the hepatic parenchyma. Normal tracer activity is noted in the small bowel.\n There is no scintigraphic evidence of extravasation or biliary leak.\n\n IMPRESSION: No scintigraphic evidence of biliary leak during the time of study.\n\n\n , M.D.\n , M.D. Approved: 3:18 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1037730,
"text": " 8:45 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had a malpositioned picc,52cm,it was repositioned and \n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with Bacteremia who needs picc line for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a malpositioned picc,52cm,it was repositioned and needs tip\n confirmation,please page at with wet read,thanks.\n ______________________________________________________________________________\n WET READ: JXKc FRI 9:27 PM\n PICC line in mid SVC. Interval removal of right subclavian line. No other\n short interval change. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Repositioned left PICC.\n\n Left PICC tip is in mid SVC. Interval removal of right subclavian line, no\n other interval change compared to prior study from three hours earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036920,
"text": ", MED 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n PFI REPORT\n The patient was extubated, and the nasogastric tube was removed. Right\n pleural effusion increased, now large, with adjacent alveolar opacity.\n Atelectasis at the left base is unchanged. Vascular congestion persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1036338,
"text": " 9:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: WORSENING ASCITES .BILIARY SEPSIS\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with worsening ascites and biliary sepsis. Also worsening\n renal failure\n REASON FOR THIS EXAMINATION:\n evaluate for CBD stone and CBD diameter, also please evaluate liver and with\n doppler for hepatic and portal flow. Also please evaluate for hydro.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 12:40 PM\n PFI: There are no stones. The main portal vein, left portal vein were\n visualized and are patent. The right hepatic vein and middle hepatic vein and\n left hepatic vein are all patent. There is a marked amount of ascites. The\n hepatic arteries are patent.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL ULTRASOUND\n\n HISTORY: 65-year-old man with worsening ascites and biliary sepsis. Also,\n worsening renal failure. Evaluate for CBD stone and CBD diameter. Please\n also evaluate liver with Doppler for hepatic and portal flow. Please also\n evaluate for hydro.\n\n COMPARISONS: None.\n\n FINDINGS: The liver is coarse and diffusely echogenic, making the liver\n parenchyma difficult to penetrate and fully evaluate with ultrasound. There\n are no focal liver lesions identified. The main portal vein, left portal\n vein, right hepatic, middle hepatic, right hepatic veins are all patent. The\n hepatic arteries are patent. There is normal hepatopetal flow. There is a\n marked amount of ascites. There is no intrahepatic biliary or extrahepatic\n biliary dilatation. There are no stones visualized within the gallbladder.\n The common bile duct measures 4 mm. There is a 3 x 2.1 cm hypoechoic\n structure adjacent to the liver and right kidney, which could represent a\n focal pocket of ascites.\n\n The right kidney measures 11.8 cm and left kidney measures 11.0 cm. There are\n no stones, masses, or hydronephrosis. The spleen is normal in echotexture and\n measures 10.8 cm. The pancreas was not visualized on this study.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Diffusely echogenic liver parenchyma without evidence for focal liver\n lesions.\n 3. Marked amount of ascites.\n 4. Normal appearing kidneys without evidence for hydronephrosis.\n 5. No gallstones.\n (Over)\n\n 9:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: WORSENING ASCITES .BILIARY SEPSIS\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1036339,
"text": ", S. MED 9:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: WORSENING ASCITES .BILIARY SEPSIS\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with worsening ascites and biliary sepsis. Also worsening\n renal failure\n REASON FOR THIS EXAMINATION:\n evaluate for CBD stone and CBD diameter, also please evaluate liver and with\n doppler for hepatic and portal flow. Also please evaluate for hydro.\n ______________________________________________________________________________\n PFI REPORT\n PFI: There are no stones. The main portal vein, left portal vein were\n visualized and are patent. The right hepatic vein and middle hepatic vein and\n left hepatic vein are all patent. There is a marked amount of ascites. The\n hepatic arteries are patent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036510,
"text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval infiltrates, consolidation,effusion\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with sepsis s/p intubation\n REASON FOR THIS EXAMINATION:\n Eval infiltrates, consolidation,effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, status post intubation.\n\n FINDINGS: Endotracheal tube, nasogastric tube, and right IJ line are again\n seen. The proximal portion of the IJ line has been repositioned, but however\n the distal tip projects at the same location, within the distal SVC. There is\n stable pulmonary edema. There is a right pleural effusion. The cardiac and\n mediastinal contours are stable, and the osseous structures are unchanged.\n\n IMPRESSION: Stable pulmonary edema, with right pleural effusion. Stable\n tubes and lines.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036919,
"text": " 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:23 AM\n The patient was extubated, and the nasogastric tube was removed. Right\n pleural effusion increased, now large, with adjacent alveolar opacity.\n Atelectasis at the left base is unchanged. Vascular congestion persists.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 65-year-old man with biliary sepsis, assess for interval\n change.\n\n Since , the patient was extubated, and the nasogastric tube\n was removed. Right central venous line is in unchanged position. Note that\n the left costophrenic angle was excluded.\n\n Right pleural effusion increased, now large, with adjacent alveolar opacity.\n Atelectasis at the left base is unchanged. Vascular congestion persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036631,
"text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: vented\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with DM,etoh abuse p/w biliary sepsis, intubated.\n REASON FOR THIS EXAMINATION:\n vented\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Biliary sepsis, intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices are in unchanged position. The extent of the right-sided pleural\n effusion and the subsequent right-sided atelectasis is unchanged. Also\n unchanged is the moderate hypoventilation at the left lung base and the size\n of the cardiac silhouette. There is no evidence of newly occurred focal\n parenchymal opacity suggestive of pneumonia. Unchanged moderate pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036246,
"text": " 10:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for ARDS or for pneumonia or pulm edema.\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, on ventilator, pancreatitis.\n REASON FOR THIS EXAMINATION:\n please evaluate for ARDS or for pneumonia or pulm edema.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 12:51 PM\n Moderate right pleural effusion and small left pleural effusion, bibasilar\n atelectasis and mild pulmonary vascular congestion. Endotracheal tube and\n nasogastric tube in good position.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside AP chest radiograph.\n\n HISTORY: 65-year-old man with sepsis and pancreatitis. Question of ARDS.\n\n COMPARISON: No prior radiographs are available for comparison.\n\n FINDINGS: Endotracheal tube ends 4.5 cm cranial to the carina. Nasogastric\n tube courses into the stomach and off the field of view. Left subclavian\n central line ends at the distal left brachiocephalic vein.\n\n There is a moderate right and tiny left pleural effusion. Bibasilar\n atelectasis is seen, right greater than left. There is mild pulmonary vascular\n congestion. Lungs are otherwise clear. Cardiac contours are obscured by\n adjacent atelectasis, but there is likely mild cardiomegaly. Mediastinal\n contours are unremarkable. Visualized soft tissue structures are normal.\n\n IMPRESSION:\n 1. Moderate right pleural effusion, small left pleural effusion with\n associated bibasilar atelectasis.\n 2. Mild pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036247,
"text": ", S. MED 10:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for ARDS or for pneumonia or pulm edema.\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, on ventilator, pancreatitis.\n REASON FOR THIS EXAMINATION:\n please evaluate for ARDS or for pneumonia or pulm edema.\n ______________________________________________________________________________\n PFI REPORT\n Moderate right pleural effusion and small left pleural effusion, bibasilar\n atelectasis and mild pulmonary vascular congestion. Endotracheal tube and\n nasogastric tube in good position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036284,
"text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ET tube plcmt, pulm edema or infiltrate\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, on ventilator, pancreatitis.\n REASON FOR THIS EXAMINATION:\n eval for ET tube plcmt, pulm edema or infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 12:51 PM\n No appreciable change compared to the prior radiograph.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The ET tube tip is difficult to evaluate due to rotation of the patient, but\n is most likely about 7 cm above the carina. The NG tube tip is at the\n proximal stomach. The cardiomediastinal silhouette is stable. Note is made\n that the left costophrenic angle was not included in the field of view, but\n within the limitation of the current study, bibasilar opacities did not\n significantly change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036285,
"text": ", S. MED 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ET tube plcmt, pulm edema or infiltrate\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, on ventilator, pancreatitis.\n REASON FOR THIS EXAMINATION:\n eval for ET tube plcmt, pulm edema or infiltrate\n ______________________________________________________________________________\n PFI REPORT\n No appreciable change compared to the prior radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1036483,
"text": " 8:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p right IJ now pulled back approximately 5 cm.\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with biliary sepsis, pancreatitis now with new RIJ\n REASON FOR THIS EXAMINATION:\n s/p right IJ now pulled back approximately 5 cm.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Biliary sepsis, pancreatitis. IJ line pulled back, followup.\n\n COMPARISON: , 5:03 p.m.\n\n As compared to the previous radiograph, the right-sided central venous access\n line has been pulled back. The line tip now projects over the middle SVC, at\n the level of the right main bronchus. There is no evidence of pneumothorax.\n Otherwise, the radiograph is unchanged, except that because of patient\n position the entire right-sided hemithorax appears slightly denser than on the\n previous examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1036368,
"text": " 12:10 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate abdomen and pelvis\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with PMH of cirrhosis s/p cholecystectomy now with sepsis ?\n pancreatitis/ SBP\n REASON FOR THIS EXAMINATION:\n Please evaluate abdomen and pelvis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BMzb FRI 6:25 PM\n Ascites. Nodular appearance of the liver surface, suggesting cirrhosis. No\n non-contrast CT evidence of pancreatitis, as questioned. Foley catheter\n balloon is inflated at the low base of the bladder, near the junction with the\n prostatic urethra, clinical correlation for malpositioning is recommended.\n Small bilateral pleural effusions, right greater than left, with consolidative\n right basilar airspace disease, atelectasis versus pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, cholecystectomy, now with sepsis, question pancreatitis\n or SBP.\n\n TECHNIQUE: Helical acquisition through the abdomen and pelvis was performed\n without contrast material.\n\n FINDINGS:\n\n ABDOMEN: There are small bilateral pleural effusions, right greater than\n left, with partially imaged consolidative right basilar airspace disease,\n atelectasis versus pneumonia. There is ascites, with a prominent perihepatic\n component. The gallbladder is surgically absent. A nasogastric tube extends\n into the gastric lumen. There is a nodular appearance of the hepatic surface.\n The solid and hollow organs are otherwise within normal limits allowing for\n non-contrast technique. There is no free air. There are degenerative changes\n of the spine.\n\n PELVIS: Ascites is present. Colonic diverticulosis is noted. A Foley\n catheter is in place, with the balloon inflated at the low base of the\n bladder, near the prostatic urethra. The pelvic viscera are otherwise within\n normal limits, allowing for non-contrast technique. Atherosclerotic\n calcifications are seen within the abdominal aorta and iliac arteries. There\n are degenerative changes of the spine.\n\n IMPRESSION:\n\n 1. Ascites.\n\n 2. Nodular appearance of the liver surface, suggestive of cirrhosis.\n\n 3. Foley catheter balloon inflated at the base of the bladder, near the\n (Over)\n\n 12:10 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate abdomen and pelvis\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n junction with the prostatic urethra, clinical correlation is recommended to\n exclude incorrect placement.\n\n 4. Small bilateral pleural effusions, right greater than left, with partially\n visualized consolidative right basilar airspace disease, atelectasis versus\n pneumonia. No non-contrast CT evidence of pancreatitis, as questioned.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1037700,
"text": " 5:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a left sided picc line placed,52cm and needs tip conf\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with Bacteremia who needs picc line for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,52cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n WET READ: JXKc FRI 9:08 PM\n Left PICC line tip terminates likely in the right subclavian or in the right\n brachiocephalic vein and should be withdrawn and repositioned. Right\n subclavian line tip terminates in mid SVC. A moderately large right pleural\n effusion is slightly smaller in size from , with atelectasis of both\n lung bases. -jkang. Findings discussed with from IV team at 6 p.m.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess PICC.\n\n Left PICC terminates in the right subclavian or in the right brachiocephalic\n vein and should be withdrawn and re-positioned. Right subclavian line tip\n terminates in mid SVC. Moderate to large right pleural effusion is slightly\n smaller in size from associated with adjacent atelectasis. Small left\n pleural effusion with minimal atelectasis on the left base is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-08 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1036369,
"text": ", S. MED 12:10 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate abdomen and pelvis\n Admitting Diagnosis: ETOH CIRRHOSIS;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with PMH of cirrhosis s/p cholecystectomy now with sepsis ?\n pancreatitis/ SBP\n REASON FOR THIS EXAMINATION:\n Please evaluate abdomen and pelvis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PFI REPORT\n Ascites. Nodular appearance of the liver surface, suggesting cirrhosis. No\n non-contrast CT evidence of pancreatitis, as questioned. Foley catheter\n balloon is inflated at the low base of the bladder, near the junction with the\n prostatic urethra, clinical correlation for malpositioning is recommended.\n Small bilateral pleural effusions, right greater than left, with consolidative\n right basilar airspace disease, atelectasis versus pneumonia.\n\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 415855,
"text": "This is a 65 yo M w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient was transferred intubated (not sedated) on AC 50% 500x22/PEEP\n 5. Required frequent suctioning during transport. Bil LS rhonchorous\n all throughout. Suctioned for small amnt of white/tan secretions. Sats\n at 98-99%. RR at 25-33.\n Action:\n Remains intubated on the same settings. Sedation was added to provide\n comfort. (Versed at 2/hr), suctioned PRN, mouth care PRN, vap protocol.\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns resp status, wean off vent when able.\n Pancreatitis, acute\n Assessment:\n Patient w/low grade temp. Tmax 100.7 upon admission. Abd firm\n distended tender to palpation.\n Ascites (taped at the OSH for 2.4L\n output), NPO, NGT to low cont suction scant amnt. NO BS or flatus,\n elevated LFT\ns although trending down\n Action:\n continue zosyn flagyl for likely biliary sepsis, f/u sensitivities on\n enterobacter (in blood as well in biliary specimen from OSH), continue\n fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr, monitor SVO2\n from central venous catheter and goal of 70, GI and surgery consults,\n obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow in AM, labs to eval. Blood and urine cultures sent.\n Response:\n pending\n Plan:\n Monitor patient status, GI/surgery consult, ERCP??? f/u cultures\n Neuro: upon admission patient alert. Intubated and vented\n so unable\n to assess orientation. Follows simple commands. Nods his head to yes/no\n questions. Moves extr. HX of altered mental status when his sepsis was\n worsening. CT Head w/o contrast from OSH: mild inflammatory sinus\n disease. No acute intracranial abnormality.\n Cardio: upon admission on neo@ 0.8 and dopamine@5 B/P at 130\ns-140/70.\n tachycardic at low 100\ns. ST no ectopy noted. Dopamine weaned off by\n 1:30am and neo by 4am. B/P 110\ns/60\ns, HR at 80-90\ns SR w/short episode\n of ST to 160\ns. General edema - anasarca. Extr cool and mottled.\n GU: amber colored urine via foley 60-70cc/hr. bolused X1 w/500c NS for\n low UOP. Cr on was 1.1, increasing on to 1.7 and to 2.2 on\n at OSH. Urine lytes and culture sent. Renal consult???? if needed.\n Skin: ecchymotic area at the RT AC probably from previous IV site\n covered w/tegaderm from OSH. Open blister at the RT upper leg at the\n site of cath secure device.\n IV access: LT SC 3 lumen from OSH\n site looks clean no redness or\n drainage. LT AC 18G\npatent.\n Social: patient is a FULL CODE. Family was in to visit. Updated by RN\n and MD. need SW consult for peculiar family dynamic.\n"
},
{
"category": "General",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Generic Note",
"row_id": 415794,
"text": "TITLE:\n Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 66M EtOH abuse, DM, cirrhosis, admitted elsewhere with biliary colic 2\n weeks ago - lap chole. discharged though returned septic, thought to be\n due to retianed stone and pancreatitis. blood cultures grew\n enterobacter. ct showed ascites, paracentesis suggested bile leak\n though HIDA unremarkable. intubated and required pressors.\n Exam notable for Tm 100.7 HR 99 BP 132/63 RR 22 with 97 sat on\n AC22/500/5/.5\n intubated, sedated though following commands, anasarca, distended\n tender abdomen\n Labs notable for WBC 22K, HCT 42 , Na 147 ,K+ 4 , HCO3 20 ,Cr 2.1 ,\n INR 1.6, TBili 1, lipase 246\n Imaging: abd/pelvic ct - pleural effusions, atelectasis, increased\n ascites, normal pancreas\n HIDA - no leak seen\n CXR reviewed - R>L effusion, ett and cvl ok\n Problems:\n bacteremia, septic shock - likely biliary in origin\n ? bile leak\n respiratory failure\n renal insufficiency\n DM\n EtOH abuse\n Cirrhosis\n pancreatitis\n Agree with plan to continue antibiotics, follow cultures, wean pressors\n as tolerated, consider U/S, likely ERCP, wean vent, check gas, eventaul\n diuresis though keep volume replete for now, insulin, change cvl\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 37 min\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 415795,
"text": "Chief Complaint: Transfer from OSH with Sepsis\n HPI:\n This is a 65 yoM w/ a PMHx of ETOH abuse and DM who is transferred\n from Center in MA with biliary sepsis. He is\n transferred intubated.\n .\n In summary the patient's relatively complicated past hospital course\n began when he had biliary colic like symptoms and presented to an OSH\n roughly 10 days ago. On he underwent a CT scan which\n visualized a stone within the cystic duct. He then went for\n cholecystectomy, an inflamed gallbladder and cirrhotic liver were noted\n by the surgeon intraop. At that time his LFTs were elevated and his T\n bili was 3.0 so there was a thought of a common duct stone but there\n was no intraop cholangiogram performed given the inability to lift the\n cirrhotic liver laparascopically. He underwent a cholecystectomy and\n began to improve and was discharged home. He then returned to the\n hospital very ill. He presented with shock and a lipase of 14,000,\n also his transaminases were both around the 200 range, and a bili of\n 3.0. In hindsight it was thought that she likely had stones in her\n common bile duct and now was presenting with biliary sepsis. Her blood\n cultures from this admission had grown enterobacter and from her\n previous admission she had a gall bladder decompression and the bile\n had also grown enterobacter. He was treated with IVF and antibiotics\n and was improving. At that time he was sent for an MRCP which he was\n unable to tolerated given the inability to hold his breath for 15-20\n seconds. Later he began having increasing epigastric pain and\n confusion and was transferred to the ICU, during this time his urine\n output had decreased to 100cc/8hrs and his HR had increased but BP was\n stable, this was despite aggressive fluid repletion. There was also an\n increase in his intraabdominal ascites and there was a thought that he\n had a biliary system leak- he underwent a HIDA scan which was negative\n for CBD obstruction or a bile leak. He then underwent a paracentesis\n and had 2.5 liters of bilious fluid removed with a bili of 2.8 and a\n lipase of 7000, also there were 8000 WBC and 80% PMNs. The patient\n then had worsening hypoxia thought to be due to massive fluid\n resuscitation that he was requiring and he was intubated. Post\n intubation he became more hypotensive and required more fluid and\n pressors. Upon transfer he was normotensive but requiring the\n assistane of two pressors (dopa and neosynephrine).\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:50 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Dopamine - 3 mcg/Kg/min\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:29 AM\n Other medications:\n Home medications:\n Lisinopril\n Zocor\n Zantac\n ASA\n Glucotrol\n Metformin\n Lexapro\n .\n Inpatient Medications:\n Dopamine\n Neo-synephrine\n Lovenox\n Hydroxyzine\n ISS\n Ativan\n Flagyl 500mg IV q6hrs\n Zosyn 3.75 IV q6hrs\n Vitamin K 10mg sc x 3 days\n Protonix 40mg IV bid\n Past medical history:\n Family history:\n Social History:\n DM\n ETOH abuse in past- per wife abstinent x few weeks\n PNA in past s/p decortication for empyema\n Biliary colic now s/p CCY\n Anxiety\n Osteoarthritis\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: ETOH abuse, per report by wife several weeks without ETOH use.\n Review of systems:\n Flowsheet Data as of 12:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.3\nC (99.1\n HR: 98 (98 - 121) bpm\n BP: 141/75(88) {118/44(54) - 143/78(93)} mmHg\n RR: 23 (20 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 561 mL\n 76 mL\n PO:\n TF:\n IVF:\n 561 mL\n 76 mL\n Blood products:\n Total out:\n 460 mL\n 75 mL\n Urine:\n 160 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 101 mL\n 1 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 510 (510 - 510) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.32/39/58/20/-5\n Ve: 11.6 L/min\n PaO2 / FiO2: 116\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 189 K/uL\n 13.6 g/dL\n 227 mg/dL\n 2.1 mg/dL\n 55 mg/dL\n 20 mEq/L\n 118 mEq/L\n 4.0 mEq/L\n 147 mEq/L\n 41.7 %\n 22.1 K/uL\n [image002.jpg]\n \n 2:33 A9/25/ 08:52 PM\n \n 10:20 P9/25/ 09:06 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 22.1OSH:\n Peritoneal Fluid:\n WBC 8,250. 80% PMNs. T bili 2.9.\n Hct\n 41.7\n Plt\n 189\n Cr\n 2.1\n TC02\n 21\n Glucose\n 227\n Other labs: PT / PTT / INR:17.8/29.6/1.6, ALT / AST:34/89, Alk Phos / T\n Bili:146/1.0, Amylase / Lipase:194/246, Differential-Neuts:86.8 %,\n Lymph:9.6 %, Mono:3.3 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:2.0\n g/dL, LDH:488 IU/L, Ca++:6.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.4 mg/dL\n Fluid analysis / Other labs: OSH:\n Peritoneal Fluid:\n WBC 8,250. 80% PMNs. T bili 2.9.\n Imaging: CT scan abd / pelvis w/ PO contrast :\n increase in bilateral pleural effusions with significant RLL\n atelectasis at the lung bases that has significantly increased compared\n to prior study of . A significant increase in free fluid in the\n peritoneal cavity as well as in the pelvis, possible etiologies include\n ascites and bowel leak, and appear less likely to be a hemorrhage given\n Hounsfield unit measurements. Cholecystectomy clips and a trace amount\n of free air in the R side of the abdomen- assumed post surgical. No\n bowel obstruction. Pancreas as can be visualized without IV contrast\n appears unremarkable.\n .\n HIDA scan: : No evidence of bile leak.\n .\n CT Head w/o contrast: mild inflammatory sinus disease. No acute\n intracranial abnormality.\n .\n Imaging:\n CXR: R layering effusion, ET tube and NGT in good placement\n Microbiology: bile: enterobacter\n blood: enterobacter\n no sensitivities available\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Pancreatitis and Biliary Sepsis - patient likely has biliary sepsis\n given history as well as enterobacter in blood as well as in biliary\n specimen from initial presentation. Also has pancreatitis related to\n gallstones. He also has a large amount of ascites that is infected,\n possibily primarily versus secondary bacterial peritonitis. In this\n setting it is more likely secondary. The patient is hypotensive\n requring pressors.\n -surveillance cultures, will need to obtain OSH records of bacterial\n sensitivities\n -continue zosyn flagyl for likely biliary sepsis\n -f/u sensitivities on enterobacter\n -continue fluid resuscitation, goal CVP 8-12 and goal UOP > 30cc/hr\n -monitor SVO2 from central venous catheter and goal of 70\n -contact ERCP fellow regarding further management given worsening\n sepsis and 3 episodes of gallstone pancreatitis\n -send sputum cultures and obtain CXR, add vancomycin if spikes\n empirically\n -send C diff if diarrhea and send a u/a and urine culture\n -given the increase in intraabdominal ascites possibilities are of a\n bile leak, a aberrant duct or a pancreatic duct disruption due to\n apparently 3 episodes of gallstone pancreatitis. He had a negative\n HIDA scan but it is possible he had a pancreatic duct disruption that\n was not seen or that his bile leak stopped by the time he had his scan,\n less likely this was a false negative HIDA scan. Per ERCP fellow this\n is unlikely given the negative HIDA scan and more likely he has\n pancreatitis with massive third spacing given the background of ETOH\n cirrhosis.\n -call surgery consult in a.m. (Dr. service)\n -obtain an abdominal ultrasound to evaluate liver, CBD, hepatic and\n portal flow\n .\n # Respiratory Failure: Likely due to fluid overload and pleural\n effusions tracking up from ascites. Patient is intubated. At this\n current juncture he will need fluid repletion for the above and will\n diurese after he begins to improve.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n .\n # DM: on oral hypoglycemics at home.\n -RISS\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH. Very likely secondary to sepsis as well as large\n amount of ascites and hepatorenal syndrome physiology.\n -send urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n # FEN: NPO for now\n .\n # Access:\n .\n # PPx: sc heparin tid, pneumoboots, PPI IV daily\n .\n # Code: FULL\n .\n # Dispo: ICU\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 09:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416130,
"text": "Chief Complaint: biliary sepsis/pancreatitis\n 24 Hour Events:\n ULTRASOUND - At 11:00 AM\n MULTI LUMEN - START 05:21 PM\n MULTI LUMEN - STOP 10:29 PM\n Patient got RIJ placed yesterday. Appeared to be about 5 cm too far in\n so was pulled back 5 cm. No official read on chest x-ray from\n radiology, but per ICU team looks okay to use. Patient evaluated by\n surgery, ERCP, and liver.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 11:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.3\nC (97.4\n HR: 77 (70 - 95) bpm\n BP: 95/51(61) {94/50(61) - 120/73(84)} mmHg\n RR: 24 (12 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (5 - 18)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n This AM bladder pressure CVP\n Total In:\n 5,961 mL\n 1,178 mL\n PO:\n TF:\n IVF:\n 5,731 mL\n 1,178 mL\n Blood products:\n 200 mL\n Total out:\n 1,616 mL\n 1,055 mL\n Urine:\n 1,516 mL\n 605 mL\n NG:\n 100 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n 4,345 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: Pressure support \n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 16\n PIP: 36 cmH2O\n Plateau: 26 cmH2O\n SpO2: 99%\n ABG: 7.34/40/96/23\n Ve: 11.6 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: obese, intubated, sedated, follows some commands\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: tense, distended, minimal bowel sounds, ascites, scrotal\n edema\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 125 K/uL\n 10.4 g/dL\n 98 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 31.7 %\n 16.4 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n WBC\n 22.1\n 15.9\n 16.4\n Hct\n 41.7\n 37.1\n 31.7\n Plt\n 189\n 155\n 125\n Cr\n 2.1\n 2.1\n 2.1\n 1.9\n TCO2\n 21\n 20\n Glucose\n 227\n 208\n 188\n 98\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.7 mg/dL, Mg++:2.4 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy now with septic\n shock thought to be due to enterobacter from the biliary tract. Patient\n also with gallstone pancreatitis, which may be contributing to the\n shock physiology. He has cirrhosis with ascities, which clouds the\n picture of the septic shock. Right now he is off pressors and doing\n better. SVO2 above goal.\n - Continue Zosyn for enterobacter and biliary source flora\n - Stop flagyl since it adds no coverage over zosyn (except C diff)\n - Continue fluid boluses for MAP >60 and SBP >100\n - Change central line changed yesterday\n - Add vancomycin for gram positive coverage until cultures grow out;\n concern for cellulites vs. inflammatory response\n - CT scan - IMPRESSION: 1. Ascites. 2. Nodular appearance of the liver\n surface, suggestive of cirrhosis. 3. Foley catheter balloon inflated at\n the base of the bladder, near the\n junction with the prostatic urethra, clinical correlation is\n recommended to exclude incorrect placement. 4. Small bilateral pleural\n effusions, right greater than left, with partially\n visualized consolidative right basilar airspace disease, atelectasis\n versus pneumonia. No non-contrast CT evidence of pancreatitis, as\n questioned.\n - abdominal echo - IMPRESSION: 1. Patent hepatic vasculature. 2.\n Diffusely echogenic liver parenchyma without evidence for focal liver\n lesions. 3. Marked amount of ascites. 4. Normal appearing kidneys\n without evidence for hydronephrosis. 5. No gallstones.\n - no new micro data\n - Surgery was consulted and said that not currently surgical issue\n - seen by liver - said to check hepatitis serologies, , anti-smooth\n muscle antibody which are pending, plan for diagnostic and therapeutic\n paracentesis sunday (tomorrow)\n - patient got IV albumin yesterday in hopes to keep some intravascular\n fluid\n - cont albumin, today is day , need to re-order\n - start on Ppi \n .\n # Respiratory Failure: Intubated likely in the setting of sepsis.\n Likely due to fluid overload and pleural effusions tracking up from\n ascites. Patient is intubated. As off pressors and not requiring too\n much in the way of pressure support currently.\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n - for now will try to wean sedation and consider spontaneously\n breathing trial\n .\n # Crit drop\n - HCt this morning significantly decreased\n - no bowel movements yet, will guiac if has some, no obvious source of\n bleeding\n - will re-check PM cbc\n - INR this morning 1.6, consider vit K as needed if bleeding becomes a\n problem\n - would consult with liveer\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH, currently 1.9. Very likely secondary to sepsis as\n well as large amount of ascites and hepatorenal syndrome physiology.\n However, sepsis physiology needs to be ruled out.\n -follow urine lytes\n FeNa 0.1% consistent mostly with prerenal\n physiology, low urine sodium\n - will check in touch with liver regarding treatment\n -abdominal ultrasound without evidence of hydronephrosis bilaterally\n -foley in place making good urine\n -continue hydration\n .\n # FEN: NPO for now, ordered nutrition consult, will likely require\n post-pyloric feeding, so will plan to try to get IR to place this\n morning and then begin feeding\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 416133,
"text": "Subjective\n pt intubated/sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 122, 121, 108, 99, 88, 87, 76, 84, 112, 124\n \n Glucose Finger Stick\n 128\n 12:00 PM\n BUN\n 56 mg/dL\n 04:04 AM\n Creatinine\n 1.9 mg/dL\n 04:04 AM\n Sodium\n 147 mEq/L\n 04:04 AM\n Potassium\n 3.7 mEq/L\n 04:04 AM\n Chloride\n 119 mEq/L\n 04:04 AM\n TCO2\n 22 mEq/L\n 04:04 AM\n PO2 (arterial)\n 99. mm Hg\n 12:02 PM\n PCO2 (arterial)\n 42 mm Hg\n 12:02 PM\n pH (arterial)\n 7.33 units\n 12:02 PM\n pH (urine)\n 5.5 units\n 11:08 AM\n CO2 (Calc) arterial\n 23 mEq/L\n 12:02 PM\n Albumin\n 1.8 g/dL\n 04:21 AM\n Calcium non-ionized\n 6.7 mg/dL\n 04:04 AM\n Phosphorus\n 2.8 mg/dL\n 04:04 AM\n Ionized Calcium\n 1.10 mmol/L\n 09:56 AM\n Magnesium\n 2.4 mg/dL\n 04:04 AM\n ALT\n 34 IU/L\n 04:21 AM\n Alkaline Phosphate\n 116 IU/L\n 04:21 AM\n AST\n 71 IU/L\n 04:21 AM\n Amylase\n 194 IU/L\n 08:52 PM\n Total Bilirubin\n 0.8 mg/dL\n 04:21 AM\n Triglyceride\n 85 mg/dL\n 08:52 PM\n WBC\n 16.4 K/uL\n 04:04 AM\n Hgb\n 10.4 g/dL\n 04:04 AM\n Hematocrit\n 31.7 %\n 04:04 AM\n Current diet order / nutrition support: NPO x/ meds\n GI: Abd: firm/dist/ascites/hypo bs\n Assessment of Nutritional Status\n Specifics:\n Consulted for TF recs. Would consider ppft placement (instead of\n feeding via NGT) given increased tolerance c/ ascites and\n pancreatitis. K repletion noted. To get 2 L D5W for hypernatremia.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Other: Rec place ppft, once placed and checked rec Fibersource HN\n @10mL/hr to increase 10 mL q 6 hr to goal 60mL/hr (1728 kcals/76 gr aa)\n Flush c/ 150mL H2Oq 4 hr\n No residuals c/ ppft, monitor tolerance via abd exam, BM's- hold if abd\n exam worsens\n BG and lyte management as you are\n Will follow- please page c/ ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416141,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n Afebrile. NBP 100-110/50-60. NSR 80-90\ns. Rare PVC\ns. CVP 11-14. Bowel\n pressure 29. Ascites present; abdomen appears firmer than yesterday and\n extremely distended; tender upon palpation. Bowel sounds present (+)\n flatus. NGT clamped- only scant amounts of brown drainage suctioned\n earlier and evidence of irritation r/t suction. Generalized edema. Skin\n pale and cool. Cap refill <3. Bilateral pedal pulses dopplerable. UO\n 80-100 cc/hr, urine clear with sediment. Insulin drip currently at 1\n unit/hr. Hct in early AM dropped to 31.7 from 37.1. WBC increased from\n 15.9 to 16.4.\n Action:\n Hemodynamic monitoring q hour. Blood sugars q hour- titrated insulin\n drip as needed (off 8am-1pm, restarted at 1pm due to BS of 158 most\n likely resulting from the D5W @ 125 cc/hr started at 1200). Coags\n drawn. ABX administered.\n Response:\n Afebrile. CVP 14. Ascites continues- abdomen remains to be tender and\n firm.\n Plan:\n Continue hemodynamic monitoring. Blood sugars q hour- tirate insulin\n drip as needed. Abx. Follow up HCT @ 1500. Paracentesis and Albumin\n either later today or tomorrow? Continue with D5W @ 125 cc/hr for 2 L.\n Bolus an necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on pressure support . T\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416145,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n Afebrile. NBP 100-110/50-60. NSR 80-90\ns. Rare PVC\ns. CVP 11-14. Bowel\n pressure 29. Ascites present; abdomen appears firmer than yesterday and\n extremely distended; tender upon palpation. Bowel sounds present (+)\n flatus. NGT clamped- only scant amounts of brown drainage suctioned\n earlier and evidence of irritation r/t suction. Generalized edema. Skin\n pale and cool. Cap refill <3. Bilateral pedal pulses dopplerable. UO\n 80-100 cc/hr, urine clear with sediment. Insulin drip currently at 1\n unit/hr. Hct in early AM dropped to 31.7 from 37.1. WBC increased from\n 15.9 to 16.4.\n Action:\n Hemodynamic monitoring q hour. Blood sugars q hour- titrated insulin\n drip as needed (off 8am-1pm, restarted at 1pm due to BS of 158 most\n likely resulting from the D5W @ 125 cc/hr started at 1200). Coags\n drawn. ABX administered. 25 mcg/hr Fentanyl for pain.\n Response:\n Afebrile. CVP 14. Ascites continues- abdomen remains to be tender and\n firm. Flatus increasing in frequency. PT 17.6 PTT 47.6 INR 1.6\n Plan:\n Continue hemodynamic monitoring. Blood sugars q hour- tirate insulin\n drip as needed. Abx. Follow up HCT @ 1500. Paracentesis and Albumin\n either later today or tomorrow? Continue with D5W @ 125 cc/hr for 2 L.\n Assess for bowel movement. Bolus an necessary. Monitor pain and treat\n as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on pressure support . MV Tidal volume 500-600. RR\n 20. Upper lung fields clear; diminished at bases. Off Versed-\n currently on 25 mcg/hr of Fentanyl.\n Action:\n Weaned vent setting while monitoring ABG\ns as appropriate. Weaned\n sedation. Turned pt q 2 hours.\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO 80-100 cc/hr. Urine yellow with sediment. BUN 56. CR 1.9. Bladder\n pressure 29.\n Action:\n Monitoring UO q hour. IVF maintenance.\n Response:\n UO increasing. Urine appears a clearer yellow in color. BUN and CR\n trending down.\n Plan:\n Continue to monitor UO and BUN and CR.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416146,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n Afebrile. NBP 100-110/50-60. NSR 80-90\ns. Rare PVC\ns. CVP 11-14. Bowel\n pressure 29. Ascites present; abdomen appears firmer than yesterday and\n extremely distended; tender upon palpation. Bowel sounds present (+)\n flatus. NGT clamped- only scant amounts of brown drainage suctioned\n earlier and evidence of irritation r/t suction. Generalized edema. Skin\n pale and cool. Cap refill <3. Bilateral pedal pulses dopplerable. UO\n 80-100 cc/hr, urine clear with sediment. Insulin drip currently at 1\n unit/hr. Hct in early AM dropped to 31.7 from 37.1. WBC increased from\n 15.9 to 16.4.\n Action:\n Hemodynamic monitoring q hour. Blood sugars q hour- titrated insulin\n drip as needed (off 8am-1pm, restarted at 1pm due to BS of 158 most\n likely resulting from the D5W @ 125 cc/hr started at 1200). Coags\n drawn. ABX administered. 25 mcg/hr Fentanyl for pain.\n Response:\n Afebrile. CVP 14. Ascites continues- abdomen remains to be tender and\n firm. Flatus increasing in frequency. PT 17.6 PTT 47.6 INR 1.6\n Plan:\n Continue hemodynamic monitoring. Blood sugars q hour- tirate insulin\n drip as needed. Abx. Follow up HCT @ 1500. Paracentesis and Albumin\n either later today or tomorrow? Continue with D5W @ 125 cc/hr for 2 L.\n Assess for bowel movement. Bolus an necessary. Monitor pain and treat\n as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on pressure support . MV Tidal volume 500-600. RR\n 20. Latest ABG (taken after 1 hour of ) 7.33/42/99. Upper lung\n fields clear; diminished at bases. Small amounts of thin white\n secretions suctioned. Off Versed- currently on 25 mcg/hr of Fentanyl.\n Action:\n Weaned vent setting while monitoring ABG\ns as appropriate. Weaned\n sedation. Turned pt q 2 hours.\n Response:\n Remains stable on pressure support .\n Plan:\n Spontaenous breathing trial and paracentesis recommended prior to\n exubation b/c of size of abdomen and its effect on work of breathing.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO 80-100 cc/hr. Urine yellow with sediment. BUN 56. CR 1.9. Bladder\n pressure 29.\n Action:\n Monitoring UO q hour. IVF maintenance.\n Response:\n UO increasing. Urine appears a clearer yellow in color. BUN and CR\n trending down.\n Plan:\n Continue to monitor UO and BUN and CR.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416150,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n Afebrile. NBP 100-110/50-60. NSR 80-90\ns. Rare PVC\ns. CVP 11-14. Bowel\n pressure 29. Ascites present; abdomen appears firmer than yesterday and\n extremely distended; tender upon palpation. Bowel sounds present (+)\n flatus. NGT clamped- only scant amounts of brown drainage suctioned\n earlier and evidence of irritation r/t suction. Generalized edema. Skin\n pale and cool. Cap refill <3. Bilateral pedal pulses dopplerable. UO\n 80-120 cc/hr, urine clear with sediment. Insulin drip currently at 2\n unit/hr. Hct in early AM dropped to 31.7 from 37.1. WBC increased from\n 15.9 to 16.4.\n Action:\n Hemodynamic monitoring q hour. Blood sugars q hour- titrated insulin\n drip as needed (off 8am-1pm, restarted at 1pm due to BS of 158 most\n likely resulting from the D5W @ 125 cc/hr started at 1200). Coags\n drawn. ABX administered. 25 mcg/hr Fentanyl for pain. Protonix started.\n Response:\n Afebrile. CVP 14. Ascites continues- abdomen remains to be tender and\n firm. Flatus increasing in frequency. PT 17.6 PTT 47.6 INR 1.6\n Plan:\n Continue hemodynamic monitoring. Blood sugars q hour- tirate insulin\n drip as needed. Abx. Follow up HCT @ 1500. Paracentesis and Albumin\n either later today or tomorrow? Continue with D5W @ 125 cc/hr for 2 L.\n Assess for bowel movement. Bolus as necessary. Monitor pain and treat\n as necessary.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on pressure support . MV Tidal volume 500-600. RR\n 20. Latest ABG (taken after 1 hour of ) 7.33/42/99. Upper lung\n fields clear; diminished at bases. Small amounts of thin white\n secretions suctioned. Off Versed- currently on 25 mcg/hr of Fentanyl.\n Action:\n Weaned vent setting while monitoring ABG\ns as appropriate. Weaned\n sedation. Turned pt q 2 hours. RSBI at 1400 which was 40. Pt did well\n with SBT- Tidal volume 50 RR 20 MV 11.\n Response:\n Remains stable on pressure support .\n Plan:\n Paracentesis wanted prior to exubation b/c of size of abdomen and its\n effect on work of breathing. Exubate?\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO 80-120 cc/hr. Urine yellow with sediment. BUN 56. CR 1.9. Bladder\n pressure 29.\n Action:\n Monitoring UO q hour. IVF maintenance.\n Response:\n UO increasing. Urine appears a clearer yellow in color. BUN and CR\n trending down.\n Plan:\n Continue to monitor UO and BUN and CR.\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416032,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation and is now transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and vented on AC 40% 500x22/5, sats at high\n 90\ns-100%. Bil LS rhonchorous, diminished at the bases. Unlabored\n breathing. Suctioned for sm amnt of white thick secretions.\n Action:\n Continue w/mechanical ventialtion, suction PRN, mouth care q4hr and\n PRN, RSBI\n Response:\n Pending\n Plan:\n Continue to monitor patient resp status, wean off when able, Titrate\n PEEP up for any decrease in oxygenation\n Pancreatitis, acute\n Assessment:\n Patient with diffuse abdominal tenderness, abd firm and distended,\n ascites, BS presenrt, NPO, NGT to LCS\nbilious output, improving labs.\n Tmax - 98.1 WBC-15.9, elevated LFT\ns although trending down\n Action:\n NPO until post pyloric feeding tube placed ( planned for tomorrow),\n nutritional consult ordered, CT scan to evaluate for any evidence of\n necrosis or alternative intra-abdominal collection done\n negative,\n Pain control with Fentanyl for now, F/u lipase, surgical/GI/liver\n consults. Continue w/IV ABX, f/u cultures, IVF as needed to maintain\n CVP and the urine flow minimum of 30cc/hr..\n Response:\n improving\n Plan:\n Continue to monitor patient status, continue w/IVF and ABX, f/u\n cultures, f/u surgery/GI/liver recs. paracentesis in am ??? ERCP???\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416033,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but the, in the setting of fluid resuscitation, was found\n to have worsening ascites with concern for bile leak evaluated with\n HIDA scan which was negative. He, however, had progressive hypoxemia\n requiring intubation and is now transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and vented on AC 40% 500x22/5, sats at high\n 90\ns-100%. Bil LS rhonchorous, diminished at the bases. Unlabored\n breathing. Suctioned for sm amnt of white thick secretions.\n Action:\n Continue w/mechanical ventialtion, suction PRN, mouth care q4hr and\n PRN, RSBI\n Response:\n Pending\n Plan:\n Continue to monitor patient resp status, wean off when able, Titrate\n PEEP up for any decrease in oxygenation\n Pancreatitis, acute\n Assessment:\n Patient with diffuse abdominal tenderness, abd firm and distended,\n ascites, BS present, NPO, NGT to LCS\nbilious output, improving labs.\n Tmax - 98.1 WBC-15.9, elevated LFT\ns although trending down, CVP 15-18\n b/p 100\ns/60\ns hr -70-80\ns SR no ectopy noted, general edema, extr\n cool.\n Action:\n NPO until post pyloric feeding tube placed ( planned for tomorrow),\n nutritional consult ordered, CT scan to evaluate for any evidence of\n necrosis or alternative intra-abdominal collection done\n negative,\n Pain control with Fentanyl for now, F/u lipase, surgical/GI/liver\n consults. Continue w/IV ABX, f/u cultures, IVF as needed to maintain\n CVP and the urine flow minimum of 30cc/hr. Insulin gtt and hourly FS.\n Response:\n improving\n Plan:\n Continue to monitor patient status, continue w/IVF and ABX, f/u\n cultures, f/u surgery/GI/liver recs. paracentesis in am ??? ERCP???\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416228,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416229,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically vented, throughout the shift, RR: 14-21, O2sat\n 93-98%, breath sounds clear in upper airways, occasionally suctioning\n for scant thick white secretions, pt remains on fent gtt for comfort,\n pt is alert and following commands, anxious at times, mouthing words\n but this RN unable to tell what he is trying to say\n Action:\n Providing fent boluses for repositioning, pt with pain per grimace\n scale, responding well to bolusing, maintained on fent gtt overnight at\n 25mcg/kg with good effect, breathing comfortably on vent settings as\n noted above, suctioning PRN,\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416318,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PARACENTESIS - At 05:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Fentanyl - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:24 AM\n Pantoprazole (Protonix) - 08:37 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 81 (81 - 99) bpm\n BP: 118/61(75) {100/45(61) - 141/85(96)} mmHg\n RR: 14 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 7 (5 - 18)mmHg\n Bladder pressure: 16 (16 - 22) mmHg\n Total In:\n 4,249 mL\n 1,899 mL\n PO:\n TF:\n IVF:\n 4,209 mL\n 1,839 mL\n Blood products:\n Total out:\n 3,590 mL\n 1,690 mL\n Urine:\n 2,490 mL\n 1,690 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 650 mL\n Balance:\n 659 mL\n 209 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 643) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.33/42/99./23/-3\n Ve: 8.9 L/min\n PaO2 / FiO2: 248\n Physical Examination\n Overweight, interactive, intubated, follows commands\n Lungs scattered coarse BS\n CV RRR\n Abd +bs, nontender\n Ext: boots, calves nontender, trace-1+ edema\n Skin: pockets of erythema over abdomen and both knee joints, unchanged\n Labs / Radiology\n 11.1 g/dL\n 161 K/uL\n 149 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 44 mg/dL\n 118 mEq/L\n 146 mEq/L\n 34.6 %\n 21.7 K/uL\n [image002.jpg]\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n WBC\n 15.9\n 16.4\n 21.7\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n Plt\n 155\n 125\n 161\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n TCO2\n 21\n 20\n 23\n 23\n Glucose\n 9\n 149\n Other labs: PT / PTT / INR:15.3/27.4/1.4, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.1 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.0 mg/dL\n Urine Cx: S.aureus\n Bd Cx: Enterobacter\n CXR today: not back yet\n Assessment and Plan\n 65 year old male with EtOH abuse and DM s/p recent lap choly\n Post-op he developed biliary Enterobacter sepsis, pancreatitis and\n ascites in the context of cirrhotic liver previously noted intra-op-\n seen by ERCP/Liver who felt cirrhosis had acutely decompensated after\n surgery\n Today: LFT\ns slightly up most noticably lipase, WBC increasing\n *Respiratory failure: occurred in the context of volume overload/sepsis\n Currently tolerating CPAP without problems\n Aim to extubate today\n *Enterobacter biliary sepsis\n On zosyn. Paracentesis performed\n yesterday showed improvement in nature of fluid.\n *Cellulitis: on vanco\n *ARF: Cr unchanged or slowly decreased. As some concern for\n pancreatitis worsening, would favor fluids if urine output begins to\n drop.\n *Pancreatitis: numbers increasing again today, reason unclear. f/u\n consult recs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416118,
"text": "65 yo male with history of ETOH abuse and diabetes transferred from\n Center with biliary sepsis. Patient had initial\n presentation with biliary obstruction (Cystic duct stone) and with mild\n trans-aminitis he had cholecystostomy followed by lap CCY. He was then\n discharged to home and found upon repeat admission to have acute\n pancreatitis and Enterobacter bacteremia leading to sepsis. He did\n have modest initial improvement but the, in the setting of fluid\n resuscitation, was found to have worsening ascites with concern for\n bile leak evaluated with HIDA scan which was negative. He, however,\n had progressive hypoxemia requiring intubation and is now transferred\n to for further care.\n Pancreatitis, acute\n Assessment:\n NBP 100-110/50-60. NSR\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 416126,
"text": "Chief Complaint: resp failure, sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 yo m with ETOH cirrhosis and DM admitted from OSH with biliary\n sepsis- biliary colic sx's s/p CCY, returned to hospital in shock\n 5 days later +Enterobacter. Worsened despite abx , fluids. Intubated\n during hospital course.\n Since tx: seen by liver/ERCP and surgery: consensus thoughts were\n of post-op pancreatitis, secondary peritonitis but not felt that\n invasive intervention warranted\n 24 Hour Events:\n ULTRASOUND - At 11:00 AM\n MULTI LUMEN - START 05:21 PM\n MULTI LUMEN - STOP 10:29 PM\n *right IJ placed\n *Weaned off pressors\n History obtained from Medical records, ICU housetstaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 11:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n thiamine, chlorhexidine, insulin gtt as needed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 82 (70 - 88) bpm\n BP: 107/58(69) {94/50(61) - 115/73(80)} mmHg\n RR: 14 (12 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 13 (10 - 18)mmHg\n Bladder pressure: 29 (20 - 29) mmHg\n Total In:\n 5,961 mL\n 1,717 mL\n PO:\n TF:\n IVF:\n 5,731 mL\n 1,677 mL\n Blood products:\n 200 mL\n Total out:\n 1,616 mL\n 1,325 mL\n Urine:\n 1,516 mL\n 875 mL\n NG:\n 100 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n 4,345 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 467 (467 - 467) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 16\n PIP: 16 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: 7.34/40/95./22/-3\n Ve: 9.6 L/min\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: No(t) Clear : ), coarse BS on left\n Abdominal: Soft, Bowel sounds present, Distended, large tense abdomen\n with ascites\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing, diff\n Musculoskeletal: No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Purposeful, Sedated, No(t) Paralyzed, Tone:\n Normal\n Labs / Radiology\n 10.4 g/dL\n 125 K/uL\n 98 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 31.7 %\n 16.4 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n WBC\n 22.1\n 15.9\n 16.4\n Hct\n 41.7\n 37.1\n 31.7\n Plt\n 189\n 155\n 125\n Cr\n 2.1\n 2.1\n 2.1\n 1.9\n TCO2\n 21\n 20\n 23\n Glucose\n 227\n 208\n 188\n 98\n Other labs: PT / PTT / INR:17.6/47.6/1.6, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.7 mg/dL, Mg++:2.4 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n 65 year old male with EtOH abuse, transferred from OSH with\n Enterobacter sepsis s/p CCY.\n 1. Biliary sepsis\n *Enterbacter sepsis s/p CCY; currently without pressor requirements\n *Appr consult recs; plan continued abx with paracentesis\n 2. Cirrhosis: bloodwork pending for further eval; could be due to EtOH\n Plan dx/therapeutic paracentesis\n 3. Pancreatitis: lipases decreasing\n 4. Resp failure: on minimal vent requirements and following commands\n Attempt SBT and eval for extubation\n 5. Anemia/drop in Hct: unclear cause as no obvious bleeding. Recheck\n hct and add PPI\n 6. ARF: has been attributed to sepsis/ATN, though urine 'lytes pending.\n 7. DM: insulin gtt as needed\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416127,
"text": "Chief Complaint: biliary sepsis/pancreatitis\n 24 Hour Events:\n ULTRASOUND - At 11:00 AM\n MULTI LUMEN - START 05:21 PM\n MULTI LUMEN - STOP 10:29 PM\n Patient got RIJ placed yesterday. Appeared to be about 5 cm too far in\n so was pulled back 5 cm. No official read on chest x-ray from\n radiology, but per ICU team looks okay to use. Patient evaluated by\n surgery, ERCP, and liver.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 11:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.3\nC (97.4\n HR: 77 (70 - 95) bpm\n BP: 95/51(61) {94/50(61) - 120/73(84)} mmHg\n RR: 24 (12 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 10 (5 - 18)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n This AM bladder pressure CVP\n Total In:\n 5,961 mL\n 1,178 mL\n PO:\n TF:\n IVF:\n 5,731 mL\n 1,178 mL\n Blood products:\n 200 mL\n Total out:\n 1,616 mL\n 1,055 mL\n Urine:\n 1,516 mL\n 605 mL\n NG:\n 100 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n 4,345 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: Pressure support \n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 16\n PIP: 36 cmH2O\n Plateau: 26 cmH2O\n SpO2: 99%\n ABG: 7.34/40/96/23\n Ve: 11.6 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: obese, intubated, sedated, follows some commands\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: tense, distended, minimal bowel sounds, ascites, scrotal\n edema\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 125 K/uL\n 10.4 g/dL\n 98 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 31.7 %\n 16.4 K/uL\n [image002.jpg]\n 08:52 PM\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n WBC\n 22.1\n 15.9\n 16.4\n Hct\n 41.7\n 37.1\n 31.7\n Plt\n 189\n 155\n 125\n Cr\n 2.1\n 2.1\n 2.1\n 1.9\n TCO2\n 21\n 20\n Glucose\n 227\n 208\n 188\n 98\n Other labs: PT / PTT / INR:19.1/33.8/1.8, ALT / AST:34/71, Alk Phos / T\n Bili:116/0.8, Amylase / Lipase:194/237, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:1.8 g/dL, LDH:366 IU/L, Ca++:6.7 mg/dL, Mg++:2.4 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy now with septic\n shock thought to be due to enterobacter from the biliary tract. Patient\n also with gallstone pancreatitis, which may be contributing to the\n shock physiology. He has cirrhosis with ascities, which clouds the\n picture of the septic shock. Right now he is off pressors and doing\n better. SVO2 above goal.\n - Continue Zosyn for enterobacter and biliary source flora\n - Stop flagyl since it adds no coverage over zosyn (except C diff)\n - Continue fluid boluses for MAP >60 and SBP >100\n - Change central line changed yesterday\n - Add vancomycin for gram positive coverage until cultures grow out;\n concern for cellulites vs. inflammatory response\n - CT scan - IMPRESSION: 1. Ascites. 2. Nodular appearance of the liver\n surface, suggestive of cirrhosis. 3. Foley catheter balloon inflated at\n the base of the bladder, near the\n junction with the prostatic urethra, clinical correlation is\n recommended to exclude incorrect placement. 4. Small bilateral pleural\n effusions, right greater than left, with partially\n visualized consolidative right basilar airspace disease, atelectasis\n versus pneumonia. No non-contrast CT evidence of pancreatitis, as\n questioned.\n - abdominal echo - IMPRESSION: 1. Patent hepatic vasculature. 2.\n Diffusely echogenic liver parenchyma without evidence for focal liver\n lesions. 3. Marked amount of ascites. 4. Normal appearing kidneys\n without evidence for hydronephrosis. 5. No gallstones.\n - no new micro data\n - Surgery was consulted and said that not currently surgical issue\n - seen by liver - said to check hepatitis serologies, , anti-smooth\n muscle antibody which are pending, plan for diagnostic and therapeutic\n paracentesis sunday (tomorrow)\n - patient got IV albumin yesterday in hopes to keep some intravascular\n fluid\n - cont albumin, today is day , need to re-order\n - start on Ppi \n .\n # Respiratory Failure: Intubated likely in the setting of sepsis.\n Likely due to fluid overload and pleural effusions tracking up from\n ascites. Patient is intubated. As off pressors likely consider\n -continue to monitor volume status and diurese eventually but for now\n will give volume for pancreatitis / biliary sepsis\n -in addition possible that patient had aspiration pneumonitis versus\n pneumonia given his altered mental status when his sepsis was\n worsening, would continue to follow fever curve and secretions and send\n a sputum culture if increase in secretions.\n .\n # Crit drop\n - HCt this morning significantly decreased\n - no bowel movements yet, will guiac if has some, no obvious source of\n bleeding\n - will re-check PM cbc\n - draw coags this morning\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n - would consider transitioning back to regular meds\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH, currently 1.9. Very likely secondary to sepsis as\n well as large amount of ascites and hepatorenal syndrome physiology.\n However, sepsis physiology needs to be ruled out.\n -follow urine lytes\n -obtain abdominal ultrasound to evaluate kidneys\n -foley in place\n -maintain hydration as above using CVP and UOP as parameters\n .\n # FEN: NPO for now, ordered nutrition consult, will likely require\n post-pyloric feeding, so will plan to try to get IR to place this\n morning and then begin feeding\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, PPI IV\n .\n # Code: FULL\n .\n # Dispo: ICU\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416368,
"text": "Chief Complaint: Sepsis\n 24 Hour Events:\n PARACENTESIS - At 05:30 PM 1L drained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:30 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 06:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 89 (82 - 99) bpm\n BP: 128/85(96) {100/45(61) - 128/85(96)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 11 (5 - 14)mmHg\n Bladder pressure: 22 (22 - 29) mmHg\n Total In:\n 4,249 mL\n 1,136 mL\n PO:\n TF:\n IVF:\n 4,209 mL\n 1,136 mL\n Blood products:\n Total out:\n 3,590 mL\n 1,020 mL\n Urine:\n 2,490 mL\n 1,020 mL\n NG:\n 450 mL\n Stool:\n Drains:\n 650 mL\n Balance:\n 659 mL\n 116 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 613 (463 - 643) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.33/42/99./23/-3\n Ve: 11.4 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 161 K/uL\n 11.1 g/dL\n 149 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 44 mg/dL\n 118 mEq/L\n 146 mEq/L\n 34.6 %\n 21.7 K/uL\n [image002.jpg]\n 09:06 PM\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n WBC\n 15.9\n 16.4\n 21.7\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n Plt\n 155\n 125\n 161\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n TCO2\n 21\n 20\n 23\n 23\n Glucose\n 9\n 149\n Other labs: PT / PTT / INR:15.3/27.4/1.4, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:82.0 %,\n Band:2.0 %, Lymph:13.0 %, Mono:2.0 %, Eos:0.0 %, Lactic Acid:1.2\n mmol/L, Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.1 mg/dL, Mg++:2.4 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, but lipase trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter and Vancomycin for possible\n cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - .\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Cr on was 1.1, increasing on to 1.7 and to\n 2.2 on at OSH, currently 1.9. Very likely secondary to sepsis as\n well as large amount of ascites and hepatorenal syndrome physiology.\n However, sepsis physiology needs to be ruled out.\n -follow urine lytes\n FeNa 0.1% consistent mostly with prerenal\n physiology, low urine sodium\n - will check in touch with liver regarding treatment\n -abdominal ultrasound without evidence of hydronephrosis bilaterally\n -foley in place making good urine\n -continue hydration\n .\n # FEN: NPO for now, ordered nutrition consult, will likely require\n post-pyloric feeding, so will plan to try to get IR to place this\n morning and then begin feeding\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:06 PM\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416434,
"text": "65 yo male with history of EtOH abuse now transferred from Center with sepsis. Patient had initial presentation with\n biliary obstruction (Cystic duct stone) and with mild trans-aminitis he\n had cholecystostomy followed by lap CCY. He was then discharged to\n home and found upon repeat admission to have acute pancreatitis and\n Enterobacter bacteremia leading to sepsis. He did have modest initial\n improvement but in the setting of fluid resuscitation, was found to\n have worsening ascites with concern for bile leak evaluated with HIDA\n scan which was negative. He, however, had progressive hypoxemia\n requiring intubation,transferred to on for further care,and\n possible ERCP.\n paracentesis\n extubated\n Pancreatitis, acute\n Assessment:\n Pt with largely distended firm abd, denies pain\n Action:\n Pt receiving vanco and zosyn, remained NPO overnight\n Response:\n Ongoing, no growth from culture data to date pt with rising lipase\n yesterday liking common bile duct obstruction\n Plan:\n f/u am labs, GI to consult, ?removing NGT and starting Pos depending on\n results of GI consult\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 1.7 trending down, u/o >100cc/hr dark yellow with sediment, CVP\n 6-11, on insulin gtt 2 u/hr\n Action:\n Hourly I/O, checking FSBS q2hr, no changes in gtt made overnight\n Response:\n Maintaining BS within normal ranges 112-124\n Plan:\n f/u am Cr, continue to monitor u/o, fluid boluses if <60cc/hr, Continue\n to monitor CVP, ?transitioning off insulin gtt\n Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, generalized edema with\n weeping of upper extremities and right leg, right upper leg with skin\n tears, areas with marking delineating locations of cellulititis now\n appearing mottled\n Action:\n Pt is receiving vanco as ordered, repositioning q2hrs, pt is moving\n self well in bed with 1 assist, no new areas of skin impairment noted\n Response:\n Ongoing, no further impairment as noted above\n Plan:\n Continue to monitor, repositioning frequently as tolerated, continue\n vanco\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was extubated successfully early in the shift, breath sounds\n clear and dim at bases, productive cough with thick yellow/white\n secretions, O2sats 95-100 on FT high flow aerosol\n Action:\n Titrating down O2 throughout the shift, now on 35% FT, pt likely able\n to tolerate even lower levels of supplemental O2, tent off of face much\n of the time, subjectively feeling dry and would prefer to keep the\n aerosol at this time as he is NPO\n Response:\n No resp distress, maintaining O2 sats well, breath sounds clear,\n productive cough\n Plan:\n Continue to monitor resp status, ?c/o to floor\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 416443,
"text": "Chief Complaint:\n HPI:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:30 PM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 11:25 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 87 (79 - 96) bpm\n BP: 154/71(89) {118/61(75) - 154/82(97)} mmHg\n RR: 23 (14 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 4 (4 - 18)mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 3,766 mL\n 207 mL\n PO:\n TF:\n IVF:\n 3,706 mL\n 207 mL\n Blood products:\n Total out:\n 3,620 mL\n 900 mL\n Urine:\n 3,620 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 146 mL\n -693 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///23/\n Ve: 8.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 204 K/uL\n 11.3 g/dL\n 106 mg/dL\n 1.3 mg/dL\n 31 mg/dL\n 23 mEq/L\n 117 mEq/L\n 3.7 mEq/L\n 145 mEq/L\n 34.6 %\n 19.5 K/uL\n [image002.jpg]\n \n 2:33 A9/26/ 04:21 AM\n \n 10:20 P9/26/ 12:42 PM\n \n 1:20 P9/26/ 03:40 PM\n \n 11:50 P9/27/ 04:04 AM\n \n 1:20 A9/27/ 09:56 AM\n \n 7:20 P9/27/ 12:02 PM\n 1//11/006\n 1:23 P9/27/ 02:34 PM\n \n 1:20 P9/27/ 05:30 PM\n \n 11:20 P9/28/ 03:40 AM\n \n 4:20 P9/29/ 04:00 AM\n WBC\n 15.9\n 16.4\n 21.7\n 19.5\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n 34.6\n Plt\n 155\n 125\n 161\n 204\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n TC02\n 20\n 23\n 23\n Glucose\n 9\n 149\n 106\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, but lipase trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter and Vancomycin for possible\n cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - .\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.7. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa yesterday was 0.1%. However, there may be low oncotic pressure\n affecting the kidney function as well. Will keep a CVP target of \n and follow urine output today. USG without evidence of hydronephrosis.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: NPO for now., may feed tomorrow depending of how extubation\n goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 416557,
"text": "Chief Complaint:\n HPI:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:30 PM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 11:25 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 87 (79 - 96) bpm\n BP: 154/71(89) {118/61(75) - 154/82(97)} mmHg\n RR: 23 (14 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 4 (4 - 18)mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 3,766 mL\n 207 mL\n PO:\n TF:\n IVF:\n 3,706 mL\n 207 mL\n Blood products:\n Total out:\n 3,620 mL\n 900 mL\n Urine:\n 3,620 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 146 mL\n -693 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///23/\n Ve: 8.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 204 K/uL\n 11.3 g/dL\n 106 mg/dL\n 1.3 mg/dL\n 31 mg/dL\n 23 mEq/L\n 117 mEq/L\n 3.7 mEq/L\n 145 mEq/L\n 34.6 %\n 19.5 K/uL\n [image002.jpg]\n \n 2:33 A9/26/ 04:21 AM\n \n 10:20 P9/26/ 12:42 PM\n \n 1:20 P9/26/ 03:40 PM\n \n 11:50 P9/27/ 04:04 AM\n \n 1:20 A9/27/ 09:56 AM\n \n 7:20 P9/27/ 12:02 PM\n 1//11/006\n 1:23 P9/27/ 02:34 PM\n \n 1:20 P9/27/ 05:30 PM\n \n 11:20 P9/28/ 03:40 AM\n \n 4:20 P9/29/ 04:00 AM\n WBC\n 15.9\n 16.4\n 21.7\n 19.5\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n 34.6\n Plt\n 155\n 125\n 161\n 204\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n TC02\n 20\n 23\n 23\n Glucose\n 9\n 149\n 106\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, but lipase trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter and Vancomycin for possible\n cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - .\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.7. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa yesterday was 0.1%. However, there may be low oncotic pressure\n affecting the kidney function as well. Will keep a CVP target of \n and follow urine output today. USG without evidence of hydronephrosis.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: NPO for now., may feed tomorrow depending of how extubation\n goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD on:\n 18:19 ------\n"
},
{
"category": "Physician ",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 416560,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient extuabted\n Micro lab closed on weekends at OSH. Need to try again to get final\n printed report of sensitivities of enterobacter.\n ERCP: no need for ERCP now since HIDA scan negative.\n Surgery: no recs\n UOP goal >50cc/hr\n INVASIVE VENTILATION - STOP 11:58 AM\n intubated priot to admission\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:44 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 11:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 85 (79 - 96) bpm\n BP: 142/64(100) {118/61(75) - 154/82(100)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (4 - 18)mmHg\n Bladder pressure: 16 (16 - 16) mmHg\n Total In:\n 3,766 mL\n 277 mL\n PO:\n TF:\n IVF:\n 3,706 mL\n 277 mL\n Blood products:\n Total out:\n 3,620 mL\n 1,220 mL\n Urine:\n 3,620 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 146 mL\n -943 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: ///23/\n Ve: 8.9 L/min\n Physical Examination\n Gen: NAD, communicative, pt uncomfrotable from distension,\n HEENT: AT/NC, PERRL, EOMI, sclera anicteric, no LAD\n CV: S1 + S2, RRR\n Pulm: coarse upper airway sounds,\n Abd: distended, + BS, non-tender to palpation, mild discomfort in\n epigastric region, +ascites, no rebound, no gaurding\n Ext: disffuse anasarca\n Neuro: AAOx3, able to follow commands\n Labs / Radiology\n 204 K/uL\n 11.3 g/dL\n 106 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 31 mg/dL\n 117 mEq/L\n 145 mEq/L\n 34.6 %\n 19.5 K/uL\n [image002.jpg]\n 04:21 AM\n 12:42 PM\n 03:40 PM\n 04:04 AM\n 09:56 AM\n 12:02 PM\n 02:34 PM\n 05:30 PM\n 03:40 AM\n 04:00 AM\n WBC\n 15.9\n 16.4\n 21.7\n 19.5\n Hct\n 37.1\n 31.7\n 35.2\n 34.6\n 34.6\n Plt\n 155\n 125\n 161\n 204\n Cr\n 2.1\n 2.1\n 1.9\n 1.8\n 1.7\n 1.3\n TCO2\n 20\n 23\n 23\n Glucose\n 9\n 149\n 106\n Other labs: PT / PTT / INR:15.1/26.5/1.3, ALT / AST:35/81, Alk Phos / T\n Bili:140/0.8, Amylase / Lipase:, Differential-Neuts:92.9 %,\n Band:2.0 %, Lymph:4.1 %, Mono:2.3 %, Eos:0.6 %, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:349 IU/L, Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 65 yoM w/ a h/o DM and ETOH abuse presenting from an outside\n hospital with biliary sepsis.\n .\n Plan:\n # Septic shock/pancreatitis: Patient with colecystecomy s/p ERCP at\n OSH, now growing enterobacter from biliary tract fluid and blood. Liver\n enzymes stable, lipase still trending up today. Low likelihood of bile\n duct leak with a negative HIDA scan. Patient has been off pressors for\n 48 hours and ventilatory stand point is improving.\n - Contnue Zosyn for enterobacter\n - d/c Vancomycin for possible cellulites (day 3)\n - Continue fluid bolus for MAP >60 or SBP >100 or UOP <30cc/hr\n - cont to trend LFTs and labs\n - f/u ERCP recs\n - advance diet as tolerated\n # Respiratory Failure: Now on with RSBI of 35. Patient awake and\n with minimal secretions and good gag reflex. Good candidate for\n extuabtion today.\n - Extubate later today\n .\n # DM: on oral hypoglycemics at home.\n -Insulin drip, since patient in anasarca here and hold home medicines\n especially in the setting of continued D5W administration\n .\n # ETOH abuse: Admitted to OSH on , no withdrawal noted at OSH\n and he is nearing the end of the window for ETOH withdrawal but also he\n has been not drinking for several weeks per his family.\n -thiamine, folate\n .\n # Renal Failure: Creatinine improving; today 1.7. Most likely pre-renal\n in the setting of sepsis since it is slowly improving with fluids and\n FeNa yesterday was 0.1%. However, there may be low oncotic pressure\n affecting the kidney function as well. Will keep a CVP target of \n and follow urine output today. USG without evidence of hydronephrosis.\n -CVP goal \n -UOP goal 30cc/hr\n -Continue hydration PRN\n -Trend creatinine; if not going down may try albumin\n .\n # FEN: NPO for now., may feed tomorrow depending of how extubation\n goes.\n .\n # Access: LIJ\n .\n # PPx: sc heparin tid, pneumoboots, not written for Ppi will start\n .\n # Code: FULL\n .\n # Dispo: ICU until extubated\n .\n # Comm: wife \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
}
] |
57,321 | 171,040 | 53 year old Male with PMH of HTN, DMII, HLD, non-ischemic CM EF of 15%, a-fib, and PHTN that presented after 2 month chronic decompensation and 2 days of chest pain found to be tachycardic s/p multiple PEA arrests with resuscitation. . # PEA Arrest, Cardiogenic Shock, Biventricular Heart Failure: Dr. (pt's PCP) checked an EKG that showed a rate of 138, that was interpreted as sinus tachycardia with no signs of ischemia. He was given a nitroglycerin tab, which resolved his chest pain, as well as a chewable aspirin. He was supposed to get 25mg of lopressor in the office, but it was unclear if he got it prior to transfer. Pt was transferred to ED, where there was concern for STEMI with ST elevations in lead V4 on transport, however, the initial EKG in the ED showed tachycardia with ST depressions in V6. Initial vitals were HR 133, BP 101/71, RR 28, SaO2 100% RA, T 96.5, HR 130s. He had persistent chest pain with nausea and vomiting in the ED and there was a question of EKGs showeing possible a-flutter. Pt recieved 1 tab of nitro and lopressor 5mg IV x2; however, his SBP dropped to the 60's and he became unresponsive and pulseless, in PEA arrest. CPR was initiated, he recieved 2 mg of epinephrine, 1mg of atropine, 1 of bicarb, and then a bicarb drip was started. He was coded for 7 minutes. He was intubated and placed on dopamine and levophed drips and transferred to the CCU. Vitals post arrest on transfer were HR 84, BP 109/70, O2 Sat 97% TV 500, PEEP 5, RR 14, and Fi02 100%. . Pt was found to be in cardiogenic shock. Likely etiology was decompensated heart failure with poor forward flow and resultant end organ ischemia vs. myocardial infarction. He had documented stenosis of 80% in the RCA, and a last documented EF of 15%. On admission his lactate was 8.5 with a creatinine of 1.7 and transaminitis. His white count was normal on admission but then began to rise. However, given aspiration and findings on CT of apical right sided consolidation that was likely aspiration related, PNA could not be ruled out. He was given broad spectrum antibiotics to cover for potential sepsis which consisted of vanc/levo/cefepime in the ED and then was changed to vanc/zosyn/cefepime on the floor. . On the floor he was intubated, sedated, and on dopamine and levophed drips. A triple lumen RIJ was placed at the bedside. Dobutamine was added with a goal of transitioning the dopamine to dobutamine and was started on cooling protocol; however, the patient became bradycardic to the 40's and pulses were lost. Chest compressions were iniated, he was given epinephrine and bicarb. Pulses returned, and he was maintaining pressures in the 120s. He had blood in his endotracheal tube as well as his OG tube. He became bradycardic a 2nd time, pulses were lost and CPR was initiated again and pt was started on an epinephrine drip with return of pulse and pressure. At this point, pt was sent to the cath lab for tandem heart placement. . After placement of , pt was transeferred back to the CCU. On arrival he had 2.5LPM circulation off of pressors but circulation began to slow below 2LPM and MAPs began to drop to the 50s. He again became pulseless and CPR was initiated. He was given multiple rounds of epinephrine, atropine, bicarb, magnesium, and calcium and chest compressions. He was started back on dopamine, epinephrine, and levophed. A bedside echo showed compression of the LA and LV by a massively dilated RA and RV from circulation. The cannula was withdrawn from the LA and positioned in the RA and it was hooked up to ECMO. Pt marginally improved after readjustment of and initiation of ECMO. Milrinone was started while on ECMO and he was requiring 0.5mcg/kg/min and at first did not tolerate turning down the flow of the tandem heart, but over the course of a few days, the and ECMO were able to be removed while maintaining the dose of milrinone. He was continuing to require milrinone for ionotropic support of his poor EF. Prior to extubation he was started on nitrous oxide in order to try and decrease his PA pressures. He showed some improvement, but not did not get his Wood's units for PVR less than 5. He was placed on sildenafil, and tolerated the medication well. After extubation, his mental status steadily improved, and his pressures improved as well. He was diuresesd with a lasix drip because he appeared fluid overloaded with pulmonary edema and a 10kg increase from his admission weight. On , he was extubated and mentally at baseline. In the interval between extubation and discharge, clinical management was directed at optimizing volume status and preparing the patient for discharge on a medication regimen amenable to his tenuous social situation in the absence of insurance. For social reasons, milrinone was titrated down; the patient tolerated this well. Sildenafil was continued and the patient was discharged on a dose of Sildenafil 40mg TID. IV Lasix was transitioned to Torsemide, which was titrated to 10 mg PO daily prior to discharge. The patient was also discharged on Lisinopril 5 mg, as well as Warfarin 2 mg PO daily and Aspirin 81 mg daily. His home dose of Digoxin 0.125mg daily was restarted the day of discharge. . # Coagulopathy: Pt had a supratherapeutic INR on coumadin at 7.4 on admission. He was ordered for FFP to correct his coagulopathy. He had blood in his OG and ET tubes, with a HCT drop. There was concern for alveolar hemmorrhage based on CT findings but pt had also aspirated. Over the course of his the first 24hrs he was given 2 units FFP and 2 units PRBC. HCT improved but did not bump appropriately. Given extracorporal blood volume in ECMO, possible continued bleeding due to high INR and pt's critical status, an additional 3 units of PRBCs were given over the next 24hrs. HCT improved to >30. Pt was switched to heparin gtt for continued anticoagulation needs given ECMO and immobility. Heparin was discontinued once his INR was therapeutic. . # Longterm anticoagulation (history of LV thrombus, depressed LVEF): Discharged with an INR of 1.8 and plans to follow-up 2 days after discharge with his primary cardiologist. . # Shock Liver: In the acute setting following the hemodynamic interventions discussed above, the patient's LFTs reflected shock liver. On admission ALT/AST/AP/TB were 384* 240* 114 1.8*, respectively. AST/ALT peaked at 3041* 3843*, respectively. AP peaked at 227. TB peaked at 27.8 with a DBili peak of 22.5 from 5.4 on . Prior to dicharge LFTS were all showing a normalizing trend, with ALT/AST/AP/TB 62* 53* 158* 11.1* 6.9* respectively on . He was still moderately jaundiced on examination on discharge. . # Acute Kidney Injury: In the acute setting following the hemodynamic interventions discussed above, the patient's Cr and BUN elevated, reflecting due to decreased effective circulatory volume. Cr peaked at 2.1 on before normalizing to 0.9 on . In the setting of aggressive diuresis, his Cr steadily rose to 2.8, at which point diuresis was held and the patient was allowed to re-equilibrate prior to starting him on his discharge regimen of Torsemide detailed above. . # Acid-Base Derangements: Anion Gap metabolic acidosis with a lactate of 8.5 on admission with increase on subsequent ABGs and persistent bicarb of . Likely etiologies include end organ ischemia from cardiogenic shock and sepsis. Chest X-Ray on admission was clear but in ED patient vomited and possibly aspirated. CT chest showed right apical dense consolidation and infectious etiology could not be ruled out. As above, broad spectrum antibiotics, vanc, cefepime, levo were started in ED and then switched to vanc zosyn and levo on the floor for better anaerobe coverage. The patient was briefly on a bicarb drip and the acidosis improved. However, the patient then developed an alkalosis which was believed to be attributed to over ventilation and the bicarb drip. Bicarb drip was stopped, diamox was given and ventilation was marginally decreased. ABG's normalized. . # Hyperkalemia and Electrolytes Derangements: Potassium elevated to a peak of 8.0 and fluctuated between 3.4 and 8.0 before normalizing and stabilizing. He has recieved insulin and glucose as well as calcium gluconate as well as a bicarb drip. The patient's K improved to within normal ranges and he was repleted as needed. Other electrolytes were also monitored and repleted as needed. . # Dyslipidemia: Was on a statin on admission, but this was discontinued in the setting of the patient's shock liver. He was NOT discharged on a statin in the setting of his resolving shock liver. A statin should be started as an outpatient to optimize his risk profile. . # Thrombocytopenia: Etiology was thought to be due to invasive hemodynamic support; platelets nadired at 28, after which he was transfused 1 unit of platelets and his count continued to recover to within normal limits upon discharge. . # Anemia: Etiology was thought to be due to macrovascular hemolysis in the setting of invasive hemodynamic support. Transfused a total of 8 units of pRBCs to maintain sufficient oxygen tissue delivery; 6 of these units were given in the acute setting of his hemodynamic instability. . # Leukocytosis: In the acute setting, leukocytosis was thought to be potentially due to systemic infection concerning for sepsis. Empiric broad spectrum antibiotics were started for coverage of gram negative, positive, and resistant organisms, then stopped once it was clear that the patient's shock was cardiogenic. The leukocytosis showed a trend toward normalization until circa , when multifocal infiltrates on CXR and uptrending leukocytosis raised concern for Pneumonia. The latter trend resolved with the antibiotic regimen detailed below for Pneumonia. . # Pneumonia: During his CCU course, was treated with an 8 day course of vancomycin, cefepime, and levofloxacin for suspected ventilator versus hospital acquired pneumonia. His pneumonia clinically resolved, with the patient remaining afebrile after the course's completion and with his leukocytosis showing a trend toward resolution as well. Initial respiratory cultures showed ASPERGILLUS FUMIGATUS 10,000-100,000 ORGANISMS/ML but subsequent beta glucan and beta glucaminase cultures were negative. All blood cultures were negative as well. . # DMII: Glucose was initially elevated in house. ISS was started and blood glucose was monitored Q6 finger sticks. He was discharged on glipizide 2.5mg ER daily upon discharge. . # Right arm edema: During his CCU course, was found to have right arm edema; an ultrasound study was negative for venous thrombosis. . # Left foot pain: In the period following his acute hemodynamic lability, the patient was found to have left foot pain on exam, most pronounced over the left greater toe. Colchicine was started empirically for 2 days but discontinued after uric acid was found to be wnl and a translator helped clarify that he was having tingling sensations rather than tenderness/pain. . # Loose stool: Had several episodes of loose stool in the interval immediately following him being started on colchicine. Stool normalized after stopping colchicine. C.Dif negative. . The patient was full code for this admission. | There is a trivial/physiologic pericardialeffusion.IMPRESSION: Biventricular dilatation and severe hypokinesis. The right ventricular cavity is mildly dilated withmild global free wall hypokinesis. There is abnormalsystolic septal motion/position consistent with right ventricular pressureoverload. of the aorta and branches with partial occlusion of SMA and right iliac artery. Abnormal systolic septal motion/position consistent with RVpressure overload.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is nopericardial effusion.IMPRESSION: Biventricular dilatation with severe biventricular systolicdysfunction. Mild (1+) MR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left ventricular cavity is dilated. Sinus rhythm with borderline sinus tachycardia and A-V conduction delay. Left ventricularhypertrophy with ST-T wave abnormalities. Cannot exclude AS.Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right ventricular cavity is moderately dilatedwith severe global free wall hypokinesis. Trace aorticregurgitation is seen. Moderately dilated LV cavity.Severely depressed LVEF.RIGHT VENTRICLE: Mildly dilated RV cavity. Left ventricular hypertrophy. There is mild pulmonary arterysystolic hypertension. Moderate tricuspid regurgitation with at least mild pulmonaryhypertension.Compared with the prior study (images reviewed) of , image quality isbetter. ABDOMEN: Evaluation of the viscera is suboptimal due to arterial phase of post-contrast image acquisition. Additional areas of nodular (Over) 1:17 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: eval for acute process Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) opacity along the periphery of the right upper, middle, and lower lobes are seen. The left ventricular cavity ismoderately dilated. The left ventricular cavity ismoderately dilated. There is a wire/catheter passing through the right atrium intothe right ventricle.Compared with the prior study (images reviewed) of , number andquality of images are much more limited on the current study. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild(1+) mitral regurgitation is seen. Periportal edema is seen. The tricuspid valve leaflets are mildly thickened.Moderate [2+] tricuspid regurgitation is seen. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Moderate [2+] TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Sinus tachycardia. Left anterior fascicular block and possible additionalintraventricular conduction delay. Moderate [2+] tricuspid regurgitation isseen. Dilated cardiomyopathy. There is nopericardial effusion.IMPRESSION: Severe LV systolic function, mildly improved compared to prevousstudy. Moderately dilated LV cavity.Severely depressed LVEF. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe athero calcs. Left atrial abnormality. Left atrial abnormality. Sinus tachycardia and frequent atrial ectopy. Overall haziness of the lung fields with areas of septal thickening bilaterally suggest fluid overload. Diffuse ST-T wave abnormalities. Left axis deviation may be due to left anterior fascicularblock and possible inferior myocardial infarction of indeterminate age.ST-T wave abnormalities are primary and suggest myocardial ischemia. Intraventricular conductiondelay with left axis deviation may be due to left anterior fascicular block andpossible additional intraventricular conduction delay. There are aortic calcifications. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Sinus rhythm with A-V conduction delay. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The rightventricle is more dilated with evidence of pressure-volume overload.Consequently, the left ventricle is compressed and less dilated on the currentstudy. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right ventricular cavity ismarkedly dilated with severe global free wall hypokinesis. Significant pulmonic regurgitation is seen. Moderate [2+] TR.Severe PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. No resting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Nonspecific bilateral perinephric stranding is seen. There are atherosclerotic changes along the right renal artery, with suggestion of narrowing at the origin. Overall left ventricular systolic function is severelydepressed (LVEF= %). Overall left ventricular systolic function is severelydepressed (LVEF= %). Severe global RV free wallhypokinesis.AORTA: Normal aortic diameter at the sinus level. Intraventricular conduction delay. Right ventricular function.Height: (in) 70Weight (lb): 172BSA (m2): 1.96 m2BP (mm Hg): 104/68HR (bpm): 90Status: InpatientDate/Time: at 10:37Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. On coronal image 400B, image 33, narrowing of right upper lobe bronchus extending to the area of consolidation is seen, which could be due to mucus plugging. Severe pulmonary hypertension andmoderate TR have persisted. Evidence of right heart failure is seen with reflux into the hepatic veins. Since theprevious tracing of same date sinus rhythm has replaced atrial flutter,QRS voltage is less prominent and further ST-T wave changes are present.TRACING #2 Left anterior fascicularblock. There is severe pulmonary artery systolic hypertension. Scattered colonic diverticula are seen. Cannot exclude myocardial ischemia.Clinical correlation is suggested. There are severe atherosclerotic changes of bilateral iliac arteries with extensive mural thrombus, particularly along the right common iliac artery with focal areas of near complete occlusion along the distal (Over) 1:17 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: eval for acute process Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) right common iliac artery, (series 5, image 91) and proximal right external iliac artery (series 5, image 96), with reconstitution seen more distally. | 12 | [
{
"category": "Radiology",
"chartdate": "2133-08-12 00:00:00.000",
"description": "CTA PELVIS W&W/O C & RECONS",
"row_id": 1153632,
"text": " 1:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: eval for acute process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with chest pain, cardiac arrest, INR 7.4. Cr 1.7- getting IVF,\n please do not delay scan\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VSFa WED 2:33 PM\n 1. Right lung opacities more prominent in the upper lobe, most likely\n atelectasis/collapse, given the short term development since prior xray two\n hours prior but aspiration and associated infectious cannot be excluded.\n 2. Mild opacifications in the left lung is likely atelectasis, but aspiration\n and infection cannot be ruled out.\n 3. Marked calcified atherosclerosis at the coronaries.\n Severe athero calcs. of the aorta and branches with partial occlusion of SMA\n and right iliac artery.\n 4. Main pulmonary artery is dilated. No definite PE is noted.\n 5. No aortic dissection.\n 6. Pulmonary haziness and septal thickening with GB wall edema and mesenteric\n haziness likely due to fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Non-contrast-enhanced CT of the chest and CTA of the chest, abdomen and\n pelvis.\n\n CLINICAL INFORMATION: 53-year-old male with history of chest pain, cardiac\n arrest, elevated INR.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images of the chest, abdomen and pelvis were\n obtained following the administration of 130 cc of Optiray intravenous\n contrast. No oral contrast was administered. CT of the chest was also\n obtained prior to contrast administration.\n\n FINDINGS:\n\n CHEST: Large area of opacification involving the right upper lobe,\n predominantly posteriorly, is seen. Given short-term development since chest\n radiograph performed on the same date at 11:48 a.m. (2 hrs prior), findings\n are concerning for aspiration with possible partial right upper lobe\n collapse(although no significant shift of midline structure), superimposed\n infection is not excluded. On coronal image 400B, image 33, narrowing of\n right upper lobe bronchus extending to the area of consolidation is seen,\n which could be due to mucus plugging. Plate-like areas of opacification in\n the anterior right upper to middle lobe (series 5, image 22), may represent\n atelectasis, although infection is not excluded. Additional areas of nodular\n (Over)\n\n 1:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: eval for acute process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n opacity along the periphery of the right upper, middle, and lower lobes are\n seen. Additionally, on series 5, image 19, a subtle 4-5 mm ground-glass\n opacity is seen in the left upper lobe. While findings may relate to\n infectious and/or aspiration, follow-up to resolution is recommended to\n exclude underlying pulmomary lesion. Atelectasis along the dependent portion\n of the right greater than left lower lobes is also seen. Overall haziness of\n the lung fields with areas of septal thickening bilaterally suggest fluid\n overload. No pleural or pericardial effusion is seen.\n\n Extensive coronary artery calcifications are seen. AICD lead is seen\n extending into the right ventricle. There is cardiomegaly. Evidence of right\n heart failure is seen with reflux into the hepatic veins. The main pulmonary\n artery is enlarged, measuring up to 3.8 cm in diameter. The right main\n pulmonary artery is also enlarged, measuring 3.4 cm in diameter. No evidence\n of pulmonary embolism is seen, although evaluation of the subsegmental\n branches is slightly suboptimal due to patient motion. No evidence of acute\n aortic dissection is seen. There are aortic calcifications. A prominent\n right paratracheal lymph node measures 1.2 cm in short axis (series 5, image\n 17). No hilar or axillary lymphadenopathy is seen. The esophagus is\n patulous, but thin-walled. Endotracheal tube is seen, terminating just below\n the level of the clavicles. A left subclavian central venous catheter\n terminates at the cavoatrial junction.\n\n ABDOMEN: Evaluation of the viscera is suboptimal due to arterial phase of\n post-contrast image acquisition. Periportal edema is seen. The spleen,\n pancreas, adrenal glands, and kidneys are unremarkable. The gallbladder is\n relatively collapsed and full of stones. There is evidence of gallbladder\n wall edema. Mesenteric haziness is seen throughout, which may be due to fluid\n overload. Nonspecific bilateral perinephric stranding is seen. There is no\n hydronephrosis. There are severe atherosclerotic changes of the aorta and its\n branches. The origin of the celiac axis, SMA, and left renal artery are\n patent. Severe atherosclerotic changes are seen along the proximal SMA where\n there is mural thrombus causing significant narrowing (series 5, image 64) of\n the SMA, flow/contrast is seen distal to this. There are atherosclerotic\n changes along the right renal artery, with suggestion of narrowing at the\n origin. Atherosclerotic changes of the are also noted with the origin not\n optimally assessed, but appearing patent.\n\n PELVIS: The appendix is not identified in the right lower quadrant, but there\n are no inflammatory changes in the right lower quadrant to suggest acute\n appendicitis. Foley catheter is within a partially collapsed bladder. Air is\n seen in the nondependent portion of the bladder, likely due to\n instrumentation. There are severe atherosclerotic changes of bilateral iliac\n arteries with extensive mural thrombus, particularly along the right common\n iliac artery with focal areas of near complete occlusion along the distal\n (Over)\n\n 1:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: eval for acute process\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right common iliac artery, (series 5, image 91) and proximal right external\n iliac artery (series 5, image 96), with reconstitution seen more distally.\n Very trace pelvic free fluid is seen. Mesenteric haziness is also noted in\n the pelvis, which may relate to fluid overload. There is no bowel\n obstruction. The prostate is mildly prominent. The seminal vesicles are\n symmetric. Scattered colonic diverticula are seen. There is apparent minimal\n thickening of the ascending , although this may relate to\n underdistension.\n\n OSEOUS STRUCTURES: No evidence of acute fracture or dislocation is seen.\n Punctate sclerotic focus in the right femoral head and in the left iliac \n may represent a bone island in the absence of known malignancy.\n\n IMPRESSION:\n 1. Large area of posterior right upper lobe opacification, developed in the\n interval since chest radiograph 2 hours previous, findings most likely due to\n aspiration/partial right upper lobe collapse, particularly given short term\n development. Superimposed infectious process is not excluded. Evidence of\n narrowing of a right upper lobe bronchus, which could be due to chronic\n inflammation or mucous plugging, other process not excluded. Additional areas\n of nodular opacity bilaterally, as above, infectious process not excluded.\n Recommend follow-up to resolution.\n 2. Evidence of fluid overload with diffuse pulmonary haziness, septal\n thickening, gallbladder wall edema, and mesenteric haziness. Cardiomegaly with\n findings concerning for right heart failure.\n 3. Enlarged main and right pulmonary artery suggesting pulmonary arterial\n hypertension.\n 4. Severe atherosclerosis of the coronary arteries, at the aorta and its main\n branches, with focal areas of near complete occlusion in the right common and\n right external iliac arteries (with distal reconstitution) and with\n significant narrowing of the proximal SMA. No evidence of acute aortic\n dissection.\n 5. Minimal apparent thickening of the ascending , relate to\n underdistention.\n\n"
},
{
"category": "Echo",
"chartdate": "2133-08-27 00:00:00.000",
"description": "Report",
"row_id": 78079,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Dilated cardiomyopathy. Right ventricular function.\nHeight: (in) 70\nWeight (lb): 172\nBSA (m2): 1.96 m2\nBP (mm Hg): 104/68\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 10:37\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nSeverely depressed LVEF.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nSevere PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The left atrium is elongated. Left\nventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is severely\ndepressed (LVEF= %). The right ventricular cavity is mildly dilated with\nmild global free wall hypokinesis. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. The\nmitral valve appears structurally normal with trivial mitral regurgitation.\nTrivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is\nseen. There is severe pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Severe LV systolic function, mildly improved compared to prevous\nstudy. RV function mild depressed, markedly improved. Severe pulmonary\nhypertension.\n\nCompared to study performed on , the RV is slightly smaller and its\nfunction slightly better. The LV is similar. Severe pulmonary hypertension and\nmoderate TR have persisted.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-08-13 00:00:00.000",
"description": "Report",
"row_id": 78080,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Dilated cardiomyopathy.\nHeight: (in) 70\nWeight (lb): 172\nBSA (m2): 1.96 m2\nBP (mm Hg): 85/69\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:26\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nSeverely depressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is severely\ndepressed (LVEF= %). The right ventricular cavity is moderately dilated\nwith severe global free wall hypokinesis. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. Significant pulmonic regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Biventricular dilatation with severe biventricular systolic\ndysfunction. Moderate tricuspid regurgitation with at least mild pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , image quality is\nbetter. The findings are similar with the exception that there does not appear\nto be significant septal flattening on the current study (likely due to the\nTandem heart off-loading the right ventricle). As a result, the measured LV\ndilatation has increased.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-08-13 00:00:00.000",
"description": "Report",
"row_id": 78081,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 65\nWeight (lb): 171\nBSA (m2): 1.85 m2\nBP (mm Hg): 68/50\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 00:44\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Dilated LV cavity. Severe global LV hypokinesis.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot exclude AS.\nTrace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left ventricular cavity is dilated. There is severe global left\nventricular hypokinesis (LVEF = %). The right ventricular cavity is\nmarkedly dilated with severe global free wall hypokinesis. There is abnormal\nsystolic septal motion/position consistent with right ventricular pressure\noverload. The aortic valve leaflets (3) are mildly thickened. The study is\ninadequate to exclude significant aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Biventricular dilatation and severe hypokinesis. Mild mitral\nregurgitation. There is a wire/catheter passing through the right atrium into\nthe right ventricle.\n\nCompared with the prior study (images reviewed) of , number and\nquality of images are much more limited on the current study. The right\nventricle is more dilated with evidence of pressure-volume overload.\nConsequently, the left ventricle is compressed and less dilated on the current\nstudy. Biventricular function is probably worse. The previously mentioned\nstrands on the catheter are not visible on the current study.\n\nTHIS STUDY WAS LOADED INTO ECHOPACS AS TWO SEPARATE STUDIES\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-18 00:00:00.000",
"description": "Report",
"row_id": 190139,
"text": "Sinus tachycardia. Intraventricular conduction delay. Left anterior fascicular\nblock. Compared to the previous tracing of there is no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-18 00:00:00.000",
"description": "Report",
"row_id": 190140,
"text": "Sinus tachycardia and frequent atrial ectopy. Left atrial abnormality. Low limb\nlead voltage. Left ventricular hypertrophy. Compared to the previous tracing\nof the atrial rate has increased. Ventricular pacing is no longer\nrecorded.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-15 00:00:00.000",
"description": "Report",
"row_id": 190141,
"text": "Predominantly ventricular paced rhythm with intermittent native conduction.\nCompared to the previous tracing intermittent native conduction is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-14 00:00:00.000",
"description": "Report",
"row_id": 190142,
"text": "Lead V6 is missing. Regular ventricular pacing. Compared to the previous\ntracing there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-13 00:00:00.000",
"description": "Report",
"row_id": 190143,
"text": "Ventricular paced rhythm with intermittent intrinsically conducted beats which\nshow left axis deviation. ST-T wave abnormalities and probable prolonged\nQTc interval. Since the previous tracing of ventricular paced rhythm is\nnow present.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-12 00:00:00.000",
"description": "Report",
"row_id": 190144,
"text": "Sinus rhythm with A-V conduction delay. Left atrial abnormality. Right\nbundle-branch block. Left axis deviation may be due to left anterior fascicular\nblock and possible inferior myocardial infarction of indeterminate age.\nST-T wave abnormalities are primary and suggest myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of same date further\nA-V conduction delay, right bundle-branch block and further ST-T wave\nabnormalities are all now present.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-12 00:00:00.000",
"description": "Report",
"row_id": 190146,
"text": "Atrial flutter with rapid ventricular response. Intraventricular conduction\ndelay with left axis deviation may be due to left anterior fascicular block and\npossible additional intraventricular conduction delay. Left ventricular\nhypertrophy with ST-T wave abnormalities. Cannot exclude myocardial ischemia.\nClinical correlation is suggested. Since the previous tracing of atrial\nflutter and further ST-T wave changes are both now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2133-08-12 00:00:00.000",
"description": "Report",
"row_id": 190145,
"text": "Sinus rhythm with borderline sinus tachycardia and A-V conduction delay. Left\natrial abnormality. Left anterior fascicular block and possible additional\nintraventricular conduction delay. Diffuse ST-T wave abnormalities. Cannot\nexclude myocardial ischemia. Clinical correlation is suggested. Since the\nprevious tracing of same date sinus rhythm has replaced atrial flutter,\nQRS voltage is less prominent and further ST-T wave changes are present.\nTRACING #2\n\n"
}
] |
30,890 | 126,522 | 72 yo F with history of pericardial effusion s/p pericardiocentesis on , aortitis, diabetes and new renal failure transferred from surgery for further management. #. Pericardial effusion - Unclear etiology. Low voltage on EKG. Fluid from pericardiocentesis showed reactive fluid but negative for malignant cells. +MSSA treated with IV vancomycin for 5 days. Antibiotics d/c'd as positive culture felt to be contaminant given sparse growth and the patient's very stable clinical picture. Patient also was myoplasma + which was also felt to be a false positive. Was treated with 2 days of doxcycline that was also d/c'd. Repeat ECHO showed only small pericardial effusion that was smaller with each repeat scan. Histo, Legionella, and current EBV infxn negative. No Bence proteins in urine. Cryptococcus negative. - Pleural Fluid, smear negative for TB, culture still pending - Lyme Ab was negative #. Aortitis - found by CT chest. ANCA, C3/C4, , ACA, RPR, TB smear all negative. Temporal biopsy negative for diagnostic abnormalities. No role for steroids felt to be warranted. CRP 252 at peak, 46 later in hospital course. #. Acute renal failure - Patient with acute rise in Cr from 0.7 on to 2.4-2.7. It was 1.7 on discharge. No evidence of hydronephrosis or mass on renal ultrasound. No improvement with IVFs, in fact, worsened volume overload. FeNa was <1%. Likely the combined result of contrast, cardiac cath and vancomycin, slowly improving. Renal followed the patient while here and aided in management. UPEP also tested and negative. Patient will need repeat chem-7 within a week of discharge. #. s/p R CVA w/ resolving L hemiparesis -The patient had possible episode of TIA while in hospital on , with possible paresthesia but no neurological residual deficits. She was continued on aspirin. #. Urinary Tract Infection - Had an E.coli pansensitive UTI, treated with 5 days of Cipro # Volume overload- Patient autodiuresed but did have residual lower extremity edema on discharge. Her CXR showed small bilateral pleural effusions and interstitial pattern. BNP was checked day prior to discharge and was 2449. She was given lasix. On discharge, ambulatory O2 sat was in the mid 90 %. #. DM- was on a RISS initially but fingersticks were well controlled. #. HTN- patient was continued on atenolol which was started at a lower dose but uptitrated back up to 50mg daily before discharged # Elevated alkaline phosphatase-AP peaked at 519, last value 222. GGT was 149. This will need to be further worked up as an outpatient. #. FEN- Cardiac heart healthy diet. Electrolytes repleted prn. #. PPx- Heparin Sc, senna, colace | Normaltricuspid valve supporting structures.PERICARDIUM: Small to moderate pericardial effusion. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: Moderate pericardial effusion. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Large pericardial effusion. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. No MVP.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.PERICARDIUM: Moderate pericardial effusion. Normal ascending aortadiameter. There is a moderate sizedpericardial effusion measuring 1 cm anterior to the right ventricle, 1.6 cmposterior to the RA, 1.2 cm posterior to the inferolateral wall.. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Moderate mitral annularcalcification. There is brief right atrial andventricular invagination consistent with elevated intrapericardial pressures. Normal global and regional biventricular systolic function. BriefRA diastolic collapse.Conclusions:Right ventricular chamber size and free wall motion are normal. Mild mitral annularcalcification. Mild mitral annularcalcification. The aortic valve leaflets are mildlythickened. The estimated pulmonary artery systolic pressure isnormal. Calcified tips ofpapillary muscles.PERICARDIUM: Small pericardial effusion. Suboptimal technical quality, a focal LV wallmotion abnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Focal calcifications in aortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Noaortic regurgitation is seen. There is a small pericardial effusion.The effusion appears circumferential. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Moderate pericardial effusion. The tortuous aorta is again noted, unchanged . There is a moderate sized pericardial effusion with evidenceof stranding/organization. Mild (1+) mitralregurgitation is seen. Mild (1+) mitralregurgitation is seen. Trace aortic regurgitation is seen. There is a moderate sized pericardial effusion. There is a moderate sized pericardial effusion. There are bilateral pleural effusions and slight diffuse interstitial and alveolar edema with no overt vascular congestion. The aortic valve leaflets (3) are mildlythickened. PA and lateral radiographs of the chest again demonstrate prominent aortic knob, unchanged from . The mitral valve leaflets are mildlythickened. CT OF THE CHEST: There is a suggestion of circumferential delayed enhancement surrounding the aorta from the root across the arch along its descending portion to roughly the level of the celiac axis, possibly below. There are small bilateral pleural effusions, unchanged. The echo findings are suggestive but not diagnostic ofpericardial constriction.Compared with the prior study (images reviewed) of , there is now anechodensity in the pericardial space at the left ventricular apex. Moderately thickened aortic valveleaflets. There is minimal stranding surrounding the descending aorta. There is brief right atrialdiastolic collapse.Compared with the prior study (images reviewed) of , the pericardialeffusion has reaccumulated and is 1.8 cm in greatest dimensioncircumferentially (greatest toward the apex). Right ventricle appears slightly underexpanded onthe subcostal views, but on apical views no right atrial or right ventriculardiastolic collapse is seen.IMPRESSION: Large circumferential pericardial effusion without frank tamponadephysiology. There is a small to moderate sized pericardialeffusion. No right atrial or right ventriculardiastolic collapse is seen.Compared with the prior study (images reviewed) of , the pericardialeffusion is slightly smaller. PT TO HAVE ECHO TODAY AND TEMPORAL ARTERY BIOSPY- ADD ON FOR OR.RESP: LS CLR, BASES DIM. + pp by dopplerresp: LS clear with dim bases. jp's to bulb sxn w/scant serosang drainage this shift. updatept with low UO today - team aware. possible afib, 90s-low 100s at time of this note, w/bp 80s-90s, PA aware, labs sent. abd firm distended. pp by doppler.resp. EXTREMS W/D. pt given fluid bolus x3. ECHO x 2 today -> pt continues to have pericardial effusion. afebrile.Resp: Ls clr bilaterally-bases dim. perrl.CV: 1st deg avb hr 80s-90s; pr int. +BS, ABD SOFT, NT, ND. RESUME PO INTAKE. There is a moderatesized pericardial effusion. rehab screen. +CSM. Pericardial drain intact draining small amts of serosang fluid.RESP: LSCTA. O2SATS MID 90S INITIALLY, LOW 90S ONCE ASLEEP~ADDED 2L NC OVERNOC W/IMPROVED SATS TO HIGH 90S. resume po intake when appropriate. perrl.Cv: sr hr 70s-80s, no ectopy. pt was admitted there after a follow up echo which showed a large effusion. bs present. 0.23-0.25, w/occas to freq pvc's. Q8H HEPARINIZED NS FLUSH OF PERICARDIAL DRAIN. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 58Weight (lb): 100BSA (m2): 1.36 m2BP (mm Hg): 94/57HR (bpm): 75Status: InpatientDate/Time: at 15:05Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Moderate pericardial effusion. pulses by doppler. PULSES BY DOPPLER. returns to baseline once calm. pericardial drain left intact. wean vent as tolerated. continue w/plan of care. +pp. +PP. abd soft, nt, nd. pt remains on 2 L nc. foley to gravity-oliguric this shift. perciadial drain flushed with heparinized saline as ordered Q8H. Non productive cough.GI: Abd soft +BS. PERICARDIAL DRAIN PATENT, DRAINED SM AMT SEROSANG FLUID THIS SHIFT, FLUSHED W/HEPARINIZED NS PER ORDER. PERRL.CV: SR HR 70S-80S. MAE and able to follow commandsCv; pt remains NSR, no ectopy noted. UO adequateendo: elvated bs treated with ss reg insulinid: afebrile. Sinus rhythm. Sinus rhythmLow precordial lead QRS voltages - is nonspecificModest nonspecific precordial/anterior T wave changesSince previous tracing of , rate faster and right precordial T wavechanges slightly more prominent foley to gravity, huo clr yellow, but low overnoc-marginal improvement after fluid bolus-will continue to monitor.Endo: bs monitored per ss-required rssi coverage overnoc.Social: family visited @ shift change, updated. continues on Cipro and vanco. pt remains on cipro for UTI. pt to go to OR today for temporal artery biospy. BP 80S-90S INITIALLY, 100S AFTER D5.45NS MAINTENANCE FLUID STARTED. HUO MARGINAL EARLY IN SHIFT, SLIGHTLY IMPROVED AFTER D5.45NS INFUSING @ 50CC/HR.ENDO: BS PER SS PROTOCOL-REQUIRED RSSI COVERAGE OVERNOC.ID: LOW GRADE TEMP THIS AM-650MG PO TYLENOL GIVEN. HR 79-84 NSR. Small amount o of edema noted legs. draining moderate amount of serousanginous fluid. updateskin: psoriasis noted over skin pt started on vanco this am -> pt grew out gram + cocci in clusters in pericardial fluidplan: repeat echo in am, ? | 33 | [
{
"category": "Radiology",
"chartdate": "2194-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978365,
"text": " 10:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: admit w/pericardial effusion\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n admit w/pericardial effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient with pericardial effusion.\n\n No prior films are available for comparison.\n\n AP upright film was evaluated. The heart size is dramatically enlarged with\n globular shape consistent with known pericardial effusion. The aorta is\n tortuous and calcified. There is also dilatation of the right upper\n mediastinum which might be related to engorgement of mediastinal veins.\n\n The evaluation of the lungs demonstrate linear interstitial abnormalities\n which might be consistent with mild pulmonary edema. No sizeable pleural\n effusion is demonstrated. Right lower lobe retrocardiac opacity might\n represent atelectasis. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 980177,
"text": " 3:10 PM\n CHEST (PA & LAT) Clip # \n Reason: ?interval progression of pulmonary edema\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with pericardial effusion, aortitis and persistent\n leukocytosis, basilar crackles\n REASON FOR THIS EXAMINATION:\n ?interval progression of pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess pulmonary edema. Leukocytosis.\n\n PA AND LATERAL CHEST. There are bilateral pleural effusions and slight\n diffuse interstitial and alveolar edema with no overt vascular congestion.\n The heart is equivocally enlarged with dilated descending thoracic aorta.\n Since exam two days ago () the interstitial edema and effusions\n have diminished.\n\n IMPRESSION: Improving CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-01 00:00:00.000",
"description": "MRI CHEST/MEDIASTINUM W/O & W/CONTRAST",
"row_id": 978502,
"text": " 4:54 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess for aortitis\n Admitting Diagnosis: PLEURAL EFFUSION\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with pericardial effusion and possible aortitis\n REASON FOR THIS EXAMINATION:\n assess for aortitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pericardial effusion and possible aortitis, assess for aortitis.\n\n COMPARISON: None. The patient underwent CT at the Hospital prior to\n this examination, but the images and report are currently unavailable for\n review. By report of the clinician, the examination showed findings\n suggestive of aortitis.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n chest and upper abdomen, including dynamic images obtained prior to, during,\n and after the uneventful intravenous administration of 0.1 mmol/kg\n gadolinium-DTPA. Subtraction images were generated on a separate workstation.\n\n FINDINGS: The examination is markedly limited due to non-breathhold\n technique. There is a large pericardial effusion. The ascending aorta is\n minimally ectatic, measuring approximately 3.1 cm in diameter. There is\n nearly circumferentially mural thickening involving the aorta from the aortic\n root to the level of the celiac trunk. Within the descending aorta just\n distal to the isthmus, the aortic mural thickening is more hemi\n circumferential, involving primarily the anterior and left posterolateral\n aspects of the wall, with relative sparing of the posteromedial aortic wall.\n Post-contrast images, while markedly limited due to non-breathhold technique,\n demonstrate probable enhancement of the aortic mural thickening.\n\n Note is made of a bovine arch configuration of the aortic arch, with common\n origin of the right brachiocephalic and left common carotid arteries. The\n celiac trunk, superior mesenteric artery, and bilateral renal arteries appear\n grossly patent, although evaluation is limited.\n\n The imaged portion of the liver, spleen, pancreas, adrenal glands, and kidneys\n appear unremarkable. Signal void within the renal collecting systems likely\n reflects the presence of excreted CT contrast from the previously performed\n CT.\n\n IMPRESSION: Markedly limited examination. Large pericardial effusion.\n Aortic mural thickening extending from the aortic root to the celiac trunk\n with probable enhancement, features that could correlate with aortitis,\n although evaluation is markedly limited.\n\n If possible, it would be helpful to obtain the images of the CT performed on\n the same date for further assessment. In consultation with Dr. ,\n (Over)\n\n 4:54 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess for aortitis\n Admitting Diagnosis: PLEURAL EFFUSION\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n it is suggested that the patient return for non-contrast CT of the chest and\n upper abdomen to evaluate for the possible presence of delayed enhancement, a\n feature that may suggest aortitis. These results were discussed with \n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 978530,
"text": " 9:12 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for aortitis. please scan to include renal artery lev\n Admitting Diagnosis: PLEURAL EFFUSION\n Field of view: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with pericardial effusion/? aortitis. Had contrast \n REASON FOR THIS EXAMINATION:\n assess for aortitis. please scan to include renal artery level\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with pericardial effusion and question of\n aortitis on MRI of the chest. Recent iodine contrast was given on the 13th.\n Please assess for delayed enhancement of the aortic wall.\n\n COMPARISON: The previous CT is not available for review. However, the MRI of\n the chest done the same day was reviewed.\n\n TECHNIQUE: Non-contrast CT of the chest was performed and images were also\n displayed in the coronal and sagittal reformations.\n\n CT OF THE CHEST: There is a suggestion of circumferential delayed enhancement\n surrounding the aorta from the root across the arch along its descending\n portion to roughly the level of the celiac axis, possibly below. There is\n minimal stranding surrounding the descending aorta. There is also soft tissue\n surrounding the aortic arch in the prevascular region.\n\n Again seen is a large pericardial effusion, simple fluid attenuation. Within\n the heart, there is calcification of the coronary arteries as well as around\n the aortic valve. There is diffuse ground-glass opacity and interstitial\n markings within the lungs bilaterally, worse on the right. No pleural\n effusions are seen. There is mild atelectasis. No pathologic axillary,\n mediastinal, or hilar lymphadenopathy is seen.\n\n Given the limitations of a non-contrast study, the visualized liver parenchyma\n appears unremarkable. There is high density within the gallbladder suggesting\n the vicarious excretion of contrast. Contrast is also seen within the only\n partially imaged renal pelvises bilaterally. The spleen and pancreas appear\n unremarkable, as do the few loops of bowel which are visualized in the\n abdomen.\n\n OSSEOUS STRUCTURES: There is sclerosis, somewhat patchy in appearance within\n the upper sternum as well as within the T11 vertebral body.\n\n IMPRESSION:\n\n 1. Delayed circumferential enhancement involving the ascending aorta, the\n arch, as well as the descending aorta at least to the level of the celiac\n artery, with soft tissue thickening particularly prominent along the\n descending aorta and distal arch, are suggestive of aortitis.\n\n (Over)\n\n 9:12 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for aortitis. please scan to include renal artery lev\n Admitting Diagnosis: PLEURAL EFFUSION\n Field of view: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Large simple pericardial effusion.\n\n 3. Diffuse bilateral ground-glass opacities in the lung are most suggestive\n of interstitial pulmonary edema.\n\n 4. Sclerotic focus within the T11 vertebral body as well as within the\n sternum. Correlation with bone scan recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-09 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 979655,
"text": " 4:03 PM\n RENAL U.S. Clip # \n Reason: hydro\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with with rising creatinine\n REASON FOR THIS EXAMINATION:\n hydro\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND AT 1603 HOURS.\n\n HISTORY: Rising creatinine.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 10.6 cm in length. The left kidney\n measures similarly at 10.6 cm. Both demonstrate normal renal architecture.\n There is no hydronephrosis or underlying renal mass lesion. No perinephric\n fluid collections are identified. Incidental note is made of bilateral\n pleural effusions. The bladder is incompletely distended but otherwise\n unremarkable. Normal vascularity is evident by color Doppler imaging.\n\n IMPRESSION: No hydronephrosis or perinephric fluid collection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 979742,
"text": " 3:16 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for volume overload, pna\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with pericardial effusion, aortitis and persistent\n leukocytosis, basilar crackles\n REASON FOR THIS EXAMINATION:\n eval for volume overload, pna\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Pericardial effusion, aortitis and persistent leukocytosis.\n Bibasilar crackles.\n\n CHEST PA AND LATERAL\n\n The heart is enlarged, tortuosity of the aorta is present. There is a new\n onset of diffuse interstitial markings with bilateral pleural effusions\n consistent with cardiac failure.\n\n IMPRESSION: Acute cardiac failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979785,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? failure\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Findings were discussed with Dr. at the time of\n dictation.\n\n\n\n 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? failure\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman admitted with pericardial effusion, aortitis with acute\n onset dyspnea.\n REASON FOR THIS EXAMINATION:\n ? failure\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Dyspnea in a patient with pericardial effusion and\n aortitis.\n\n PORTABLE AP CHEST RADIOGRAPH COMPARED TO .\n\n Overall increase in bilateral perihilar opacities and lower lobe\n consolidations is due to worsening of pulmonary edema accompanied by most\n likely bibasilar atelectasis and pleural effusion. This worsening can be\n appreciated although in presence of low lung volumes , decreased in the\n meantime interval. There is no pneumothorax. The tortuous aorta is again\n noted, unchanged . Marked cardiomegaly is demonstrated although precise\n evaluation of the heart size is difficult due to bibasilar atelectasis.\n\n IMPRESSION: Worsening pulmonary edema accompanied by increased bibasilar\n atelectasis and pleural effusion.\n\n Low lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-07 00:00:00.000",
"description": "BONE SCAN",
"row_id": 979168,
"text": "BONE SCAN Clip # \n Reason: 72YR OLD W/AORITIS/PERICARDIAL EFFUSIONS. ? LYTIC LESIONS ON CT SCAN FROM OSH. ASSESS FOR LESIONS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 26.0 mCi Tc-m MDP ();\n HISTORY: 72 year old man with aortitis/pericardial effusions and ? lytic\n lesions on CT scan from outside hospital.\n\n INTERPRETATION: Whole body images of the skeleton were obtained in anterior and\n posterior projections. Spot views of the chest, abdomen, and knees were also\n obtained.\n\n There is focal uptake of tracer in the T11 vertebral body and well as faint\n uptake in T8 and T9. These correlate with sclerotic lesions seen on chest CT of\n . Focus of uptake in the sternum is felt to be within the\n sterno-manubrial join. No definite correlate to the sternal lesions on CT is\n identified. There is intense uptake both distal femurs and proximal tibias as\n well as the left patella. Less intense uptake is also identified in the mid and\n distal tibias.\n\n Uptake over the left chest on the posterior view is felt to represent\n contamination as it does not correspond to any anatomic structures.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion. Uptake in the kidneys is particularly dense which may be secondary to\n dehydration.\n\n IMPRESSION: 1. Focal tracer uptake mild in the T8, 9, and most prominently T11\n vertebral bodies which corresponds to the sclerotic lesions seen on CT. The\n appearance is nonspecific and no additional spinous uptake is identified. 2.\n Intense tracer uptake around both knees. This appearance could be secondary to\n bone infarcts and would be an usual distribution for metastatic disease. There\n is also uptake along both mid and distal tibias. Correlation with bilateral knee\n and tibia radiographs is recommended.\n\n\n , M.D.\n , M.D. Approved: TUE 3:13 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 980624,
"text": " 11:41 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusions.\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with pericardial effusion, aortitis and basilar crackles\n REASON FOR THIS EXAMINATION:\n evaluate for effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Effusion. Aortitis.\n\n PA and lateral radiographs of the chest again demonstrate prominent aortic\n knob, unchanged from . Abnormal interstitial pattern involving both\n lungs remains unchanged when compared with multiple previous studies including\n . There are small bilateral pleural effusions, unchanged. No\n consolidation is identified. The T11 sclerosis seen on the CT exam of\n is not appreciated on the current radiographs, likely due to\n overlying soft tissue. Trachea is midline. No pneumothorax.\n\n IMPRESSION:\n\n No interval change.\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-05 00:00:00.000",
"description": "Report",
"row_id": 83546,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 100/42\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RV\ndiastolic collapse.\n\nConclusions:\nLeft ventricular systolic function is hyperdynamic (EF>75%). Right ventricular\nchamber size and free wall motion are normal. There is a moderate sized\npericardial effusion measuring 1 cm anterior to the right ventricle, 1.6 cm\nposterior to the RA, 1.2 cm posterior to the inferolateral wall.. The effusion\nappears circumferential. No right ventricular diastolic collapse is seen.\nBrief RA collapse is seen.\n\nCompared with the prior study (images reviewed) of , the effusion is\nslightly smaller. No right ventricular invagination is seen on the current\nstudy.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-05 00:00:00.000",
"description": "Report",
"row_id": 83547,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Prior pericardiocentesis.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 132/76\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 12:02\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential.\nStranding is visualized within the pericardial space c/w organization. Brief\nRA diastolic collapse.\n\nConclusions:\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. The tricuspid valve leaflets are\nmildly thickened. There is a moderate sized pericardial effusion with evidence\nof stranding/organization. The effusion appears circumferential. There is\nbrief right ventricular invagination (clip ). There is brief right atrial\ndiastolic collapse.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion has reaccumulated and is 1.8 cm in greatest dimension\ncircumferentially (greatest toward the apex). There is brief right atrial and\nventricular invagination consistent with elevated intrapericardial pressures.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-07 00:00:00.000",
"description": "Report",
"row_id": 83342,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for reaccumulation of pericardial fluid post removal of drainage catheter.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 98/55\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 00:36\nTest: Portable TTE (Focused views)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is a moderate sized pericardial effusion. The effusion is echo\ndense, consistent with blood, inflammation or other cellular elements. There\nare no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-01 00:00:00.000",
"description": "Report",
"row_id": 83343,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 134\nBSA (m2): 1.61 m2\nBP (mm Hg): 115/60\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 10:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter\n(1.5-2.5cm) with <50% decrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. Effusion circumferential. No RA or RV\ndiastolic collapse.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is\n11-15mmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%) Right ventricular chamber size and\nfree wall motion are normal. There are three aortic valve leaflets. The aortic\nvalve leaflets are moderately thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is a large circumferential pericardial effusion\n(maximal dimension 2.7 cm). Right ventricle appears slightly underexpanded on\nthe subcostal views, but on apical views no right atrial or right ventricular\ndiastolic collapse is seen.\n\nIMPRESSION: Large circumferential pericardial effusion without frank tamponade\nphysiology. Normal global and regional biventricular systolic function.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-12 00:00:00.000",
"description": "Report",
"row_id": 83413,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 56\nWeight (lb): 148\nBSA (m2): 1.56 m2\nBP (mm Hg): 128/64\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 10:35\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. Effusion\necho dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade. No RA or RV diastolic collapse. No\nsignificant respiratory variation in mitral/tricuspid valve flows.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF 70%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets appear structurally normal with good leaflet excursion. The mitral\nvalve leaflets are mildly thickened. There is a small pericardial effusion.\nThe effusion appears circumferential. The effusion is echo dense, consistent\nwith blood, inflammation or other cellular elements. There are no\nechocardiographic signs of tamponade. No right atrial or right ventricular\ndiastolic collapse is seen.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is slightly smaller.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-08 00:00:00.000",
"description": "Report",
"row_id": 83509,
"text": "PATIENT/TEST INFORMATION:\nIndication: F/u Pericardial effusion .\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 98/58\nStatus: Inpatient\nDate/Time: at 10:38\nTest: TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nEffusion echo dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade. No RA or RV diastolic collapse.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF 70%). Right\nventricular chamber size and free wall motion are normal. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is a small to moderate sized pericardial\neffusion. The effusion appears circumferential. The effusion is echo dense,\nconsistent with blood, inflammation or other cellular elements. There are no\nechocardiographic signs of tamponade. No right atrial or right ventricular\ndiastolic collapse is seen.\n\nCompared with the findings of the prior study (images reviewed) of , the pericardial effusion is somewhat smaller.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-04 00:00:00.000",
"description": "Report",
"row_id": 83579,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/p PCI.\nHeight: (in) 56\nWeight (lb): 100\nBSA (m2): 1.32 m2\nBP (mm Hg): 118/61\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:54\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Suboptimal technical quality, a focal LV wall\nmotion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-07 00:00:00.000",
"description": "Report",
"row_id": 83518,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 100/48\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No echocardiographic signs of\ntamponade. Echo findings are suggestive but not diagnostic of constriction.\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. The mitral valve leaflets are\nmildly thickened. There is a moderate sized pericardial effusion. The effusion\nis echo dense, consistent with blood, inflammation or other cellular elements.\nThere is a 3 x 1 cm echodensity in the pericardial space adjacent to the\ninferior left ventricular apex which could be a blood clot or accumulation of\ncellurlar elements. (see image 29 and 30). There are no echocardiographic\nsigns of tamponade. The echo findings are suggestive but not diagnostic of\npericardial constriction.\n\nCompared with the prior study (images reviewed) of , there is now an\nechodensity in the pericardial space at the left ventricular apex. There is\nalso a more prominent \"septal bounce\" which could be consistent with\npericardial constriction.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 83519,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 58\nWeight (lb): 100\nBSA (m2): 1.36 m2\nBP (mm Hg): 94/57\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No RV diastolic collapse. Sgnificant,\naccentuated respiratory variation in mitral/tricuspid valve inflows, c/w\nimpaired ventricular filling.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There is a moderate\nsized pericardial effusion. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. No right ventricular diastolic\ncollapse is seen.\n\nCompared with the prior study (images reviewed) of , no change.\n\nIMPRESSION: Moderate circumfirential pericardial effusion without overt\nechocardiographic signs of tamponade.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-04 00:00:00.000",
"description": "Report",
"row_id": 1658411,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\n16:15 arrived from Cardiac Cath lab post pericardialcentesis with pigtail drain placed.\n\nNEURO: A&Ox3. Speech clear. Primary language is Italian, but speaks English fluently. Answers most questions appropriately. Follows commands consistently. MAE in bed.\n\nCARDIAC: Tmax 97.8. HR 79-84 NSR. SBP 118-144. +PP. +CSM. Pericardial drain intact draining small amts of serosang fluid.\n\nRESP: LSCTA. Sat 95-100% on RA. Non productive cough.\n\nGI: Abd soft +BS. NPO.\n\nGU: FOley intact draining clear yellow urine. 1830 foley changed.\n\nINTEG: Psoriasis on all 4 ext. Patient denies any itching or discomfort. Pigtail site intact.\n\nPLAN: Monitor overnight and possible transfer to 2 in the am. Monitor hemodynamics and for pain. Provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-05 00:00:00.000",
"description": "Report",
"row_id": 1658412,
"text": "Neuro: A&O X3, denies pain or discomfort, MAE's well, immobile until per standard of care post cardiac cath, pt participating in plan of care and verbalizes understanding\n\nResp: lungs clear throughout, SPO2 driftrd down to low 80's when sleeping, added O2 at 2 LPM via NC with good results, SPO2 >95%\n\nCardiac: SR, no ectopy noted, AM labs pending, right groin.. no evidence of hematom or bleeding, good circulation LE's, pericardical drain flushed with sterile NS X2, drained <50cc serosang drainage\n\nGI: + BS all 4 quads, tolerating clear liquids well, declining solids at this time, diet regular cardiac\n\nGU: foley to gravity draining clear yellow urine > 25cc/hr\n\nEndo: SSRI per per protocol\n\nSocial: pt's dtr and updated on condition and plan\n\nPlan: ? ECHO thin AM and then D/C pericardial drain, monitor labs and vitals and treat as indicated and as ordered, ? transfer to 2, get OOB, increase diet and activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-05 00:00:00.000",
"description": "Report",
"row_id": 1658413,
"text": "7am-7pm update\nneuro: pt alert and orientated x3. MAE and able to follow commands. denies pain\n\nCv: pt remains NSR, no ectopy noted. HR 60-80's. BP 90-130's/50-70's. ECHO x 2 today -> pt continues to have pericardial effusion. pericardial drain left intact. draining moderate amount of serousanginous fluid. perciadial drain flushed with heparinized saline as ordered Q8H. drain kept to gravity. + pp by doppler\n\nresp: LS clear with dim bases. pt on room air, o2 sats > 93%.\n\ngi/gu: pt with + bs. poor appetite. pt had 1 episode of nausea and vomitted ~ 50 cc's clear fluid. foley draining clear yellow urine. UO adequate\n\nendo: elvated bs treated with ss reg insulin\n\nid: afebrile. pt remains on cipro for UTI. pt started on vanco this am -> pt grew out gram + cocci in clusters in pericardial fluid\n\nplan: repeat echo in am, ?? dc pericardial drain in am, antiobiotics, flush pericardial drain as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-05 00:00:00.000",
"description": "Report",
"row_id": 1658414,
"text": "update\nskin: psoriasis noted over skin\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 1658415,
"text": "PLEASE DISREGARD ENTIRE NOTE-ENTERED ON WRONG PATIENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-01 00:00:00.000",
"description": "Report",
"row_id": 1658409,
"text": "Mrs is a pleasant 72 year old lady transfered from Hospital for further workup of a very larger pericardial effusion. pt was admitted there after a follow up echo which showed a large effusion. A CT scan was done which showed ? low density soft tissue or fluid surrounding the aorta, difuse interstitial disease and multiple Sclerotic spine lesions suspicious of metastaic disease. pt states she has been improving nicely since her stroke in of 07, alittle short of breath recently but denies any pain and feels fine now. pt has significant psorisis with scratch marks all over her body states she was to see the skin doctor next week. She had a stroke in of 07 with Left sided weakness but that has improved significantly since.\n\nNeuro: pleasant Italian women who has a thick accent but does speak and understand english. Alert and oriented. Knowsh she is in but does not remember the name of hospital\nResp: O2 sats 94-98% on room air. Breath sounds clear\nC/V: Heart rate in the 70's normal sinus rhythm no ectopy. Blood pressure 130's down to 90's when sleeping. No significant difference noted with blood pressure in each arm\nGI: pt npo for now pending workup results.\nGU: Foley cath placed pt passing clear yellow urine. Culture and urinalysis sent to lab.\nSkin: pt has mod to severe psorisis all over body with scratch marks from itiching. pt does not use any special creams. Small amount o of edema noted legs. pt wearing elasitc stockings.\nPlan: NPO for now D5 1/2 ns with 20 meq kcl at 50cc/hr overnight. NPO for now pending review of CT scan. Foley to gravity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-01 00:00:00.000",
"description": "Report",
"row_id": 1658410,
"text": "nursing note 7a to 3p:\nallergies:NKDA\n\nneuro: a&ox3, Italian female that understands & speaks fluent English, independent & mae's extremities, OOB to chair for most of day, family visited\n\nresp: sats>96%ra, rr wnl, lungs cta\n\ncardio: hr 60's nsr w/no ectopy, known pericardial effusion (significant by echo today ) w/no tamponade, patient hemodynamically stable ?? cancer d/t lesions seen on scan, had Rheumatology consult today recommended MRA which is pending, nbp>105, recieving IV potassium @ 50cc/hr into peripheral, made need pericardial window or tap @ some point, eczema located on the majority of skin\n\ngu/gi: foley w/fair UO, abdomen soft & non-tender w/+ bowel sounds, no bm, currently NPO\n\nendo: DM, covered by sliding scale not given full dose since NPO\n\nplan/goal: MRA w/contrast, change NPO status if no MRA today, con't monitoring hemodynamics\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 1658418,
"text": "7am-7pm update\nneuro: pt alert and orieanted x3. MAE and able to follow commands\n\nCv; pt remains NSR, no ectopy noted. HR 70-80's. BP 80-100's/50-60's. atenolol PO held this am due to low BP - team aware. K 3.1 this am -> treated with 40 meq kcl PO. ECHO done early afternoon. cardiology removed pericardial drain after ECHO. plan for Repeat ECHO this evening. pericardial fluid sent to lab for CX. pt remain on maintance fluid at 50 cc/hr. pp by doppler.\n\nresp. Ls clear with fine bibasilar crackles this afternoon. (team aware). pt remains on 2 L nc. O2 sats > 94%\n\ngi/gu: pt with + bs. NPO today for temporal artery biospy - biospy canceled this evening and rescheduled for tomorrow. plan for NPO after midnight tonight. pt had 1 episode of nausea - treated with reglan\n\nendo: bs treated with ss reg insulin as ordered\n\nID: afebrile. continues on Cipro and vanco. pericardial fluid sent for cx\n\nskin: trunk and extremities covered with psoriasis\n\nplan: repeat ECHO this evening, NPO after midnight for temporal artery biospy, on call for bone scan, continue maintance fluid overnight, antiobiotics, monitor vitals\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 1658419,
"text": "update\npt with low UO today - team aware. pt given fluid bolus x3. UO improved this evening - see flowsheet\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-07 00:00:00.000",
"description": "Report",
"row_id": 1658420,
"text": "Neuro: pt a&ox3, slept well overnoc, arouses easily to voice. maes to command. denies pain. perrl.\n\nCv: sr hr 70s-80s, no ectopy. bp 80s initially, maps mid 50s-PA aware, 500cc fluid bolus given w/improvement in sbp to 90s-100s & maps >60 remains on maintenance fluid 50cc/hr d5.45 NS. pulses by doppler. ECHO done @ bedside, no signs of ^ pericardial effusion per PA . pt to go to OR today for temporal artery biospy. pt to also have bone scan today. afebrile.\n\nResp: Ls clr bilaterally-bases dim. o2sats >95% on 2l nc. rr teens-20s. no c/o sob.\n\nGi/gu: pt tolerated sm amts soup, pudding @ shift change, no c/o nausea. npo after midnight; bs present. abd soft, nt, nd. foley to gravity, huo clr yellow, but low overnoc-marginal improvement after fluid bolus-will continue to monitor.\n\nEndo: bs monitored per ss-required rssi coverage overnoc.\n\nSocial: family visited @ shift change, updated. no phone calls this shift.\n\nPlan: continue monitoring cardioresp status, labs, huo. prepare for OR & bone scan. resume po intake when appropriate. support & update pt & family. continue w/plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 1658416,
"text": "Neuro: pt trached, alert initially @ shift change, dozed on/off throughout night easily arouses to voice. maes to command, nods approp to questions, mouthes words to communicates needs. encouraged use of letter board w/some success. roxicet given for abd pain w/good effect-pt points to location of pain. perrl.\n\nCV: 1st deg avb hr 80s-90s; pr int. 0.23-0.25, w/occas to freq pvc's. bp stable initially 100s-120s at rest, up to 150's when coughing or turning. returns to baseline once calm. possible afib, 90s-low 100s at time of this note, w/bp 80s-90s, PA aware, labs sent. +pp. jp's to bulb sxn w/scant serosang drainage this shift. afebrile.\n\nresp: ls course, o2sats >95% on cpap 50%/10/15PS. rr 20s. poorly tolerates turning or laying flat, becomes tachypneic. sxn'd copious amts thk yellow-tan secretions. abgs pending.\n\ngi/gu: tolerating tf nutren renal w/beneprotein additive @ goal=50cc/hr. bs present. abd firm distended. no c/o nausea. sm amt stool smear on pad, otherwise no bm. foley to gravity-oliguric this shift. no hd today.\n\nendo: bs per ss protocol-required rssi coverage overnoc.\n\nsocial: wife called, updated, plans to call in AM.\n\nPlan: continue monitoring cardioresp status, labs, sxn prn. wean vent as tolerated. ? rehab screen. continue support & update family re: status & plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-08-06 00:00:00.000",
"description": "Report",
"row_id": 1658417,
"text": "NEURO: PT IS ITALIAN SPEAKING, BUT UNDERSTANDS AND IS ABLE TO FLUENTLY SPEAK ENGLISH. A&OX3. SLEPT WELL OVERNIGHT, AROUSES EASILY TO VOICE. MAES TO COMMAND. DENIES PAIN. PERRL.\n\nCV: SR HR 70S-80S. NO ECTOPY. BP 80S-90S INITIALLY, 100S AFTER D5.45NS MAINTENANCE FLUID STARTED. PULSES BY DOPPLER. EXTREMS W/D. PERICARDIAL DRAIN PATENT, DRAINED SM AMT SEROSANG FLUID THIS SHIFT, FLUSHED W/HEPARINIZED NS PER ORDER. UNABLE TO ASPIRATE PERICARDIAL FLUID-PA AWARE. PT TO HAVE ECHO TODAY AND TEMPORAL ARTERY BIOSPY- ADD ON FOR OR.\n\nRESP: LS CLR, BASES DIM. O2SATS MID 90S INITIALLY, LOW 90S ONCE ASLEEP~ADDED 2L NC OVERNOC W/IMPROVED SATS TO HIGH 90S. RR 20S. PT STATES BREATHING COMFORTABLE, NO C/O SOB.\n\nGI/GU: NPO EXCEPT MEDS AFTER MIDNIGHT FOR OR PROCEDURE. +BS, ABD SOFT, NT, ND. NO C/O NAUSEA. HUO MARGINAL EARLY IN SHIFT, SLIGHTLY IMPROVED AFTER D5.45NS INFUSING @ 50CC/HR.\n\nENDO: BS PER SS PROTOCOL-REQUIRED RSSI COVERAGE OVERNOC.\n\nID: LOW GRADE TEMP THIS AM-650MG PO TYLENOL GIVEN. PT ON PO CIPRO, IV VANCO.\n\nSKIN: PSORIASIS OVER TORSO & EXTREMITIES-PT INDICATES NO DISCOMFORT.\n\nSOCIAL: DAUGHTER & SON CALLED, UPDATED. PT CONSENTED TO ANESTHESIA FOR OR PROCEDURE TODAY.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS, HUO. ECHO TODAY. Q8H HEPARINIZED NS FLUSH OF PERICARDIAL DRAIN. PREPARE FOR OR. RESUME PO INTAKE. SUPPORT & UPDATE PT & FAMILY RE: STATUS & PLAN OF CARE. SEE CAREVUE FLOWSHEETS & FOR FURTHER DETAILS & INFORMATION.\n"
},
{
"category": "ECG",
"chartdate": "2194-08-11 00:00:00.000",
"description": "Report",
"row_id": 220408,
"text": "Sinus rhythm\nLow precordial lead QRS voltages - is nonspecific\nModest nonspecific precordial/anterior T wave changes\nSince previous tracing of , rate faster and right precordial T wave\nchanges slightly more prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-04 00:00:00.000",
"description": "Report",
"row_id": 220409,
"text": "Sinus rhythm\nLow QRS voltages in precordial leads - is nonspecific and could be normal\nvariant\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2194-07-31 00:00:00.000",
"description": "Report",
"row_id": 220410,
"text": "Sinus rhythm. Low QRS voltage in the precordial leads. Modest inferior T wave\nchanges which are non-specific. No previous tracing available for comparison.\n\n"
}
] |
8,282 | 101,586 | The patient was transferred from after stab wounds to the axilla & back. He was noted to have an approximately T4 level immediately after he was stabbed. He was hemodynamically stable during transfer and remained so throughout his stay. Chest CT in the ED revealed left pneumo/hemothorax and a left chest tube was placed in the ED with approximately 500mL bloody return. He was admitted to the neuro ICU and was seen by neurosurgery. He was started on IV steroids as per protocol, and was continued on keflex IV. MR cord laceration at T5/6. On HD 2 he was transferred to the floor. His Cspine was cleared and he was fitted with a TLSO brace and seen by PT/OT who worked on transfers and ADLs. He was started on a bowel/bladder regimen. Neurosurgery stated that there was no surgical intervention indicated. On HD 6 patient was changed from SQ Heparin tid to Lovenox 30mg qd; the decision to place IVC filter was deferred early during his hospitalization. He was transferred to rehab for cord injuries. | IMPRESSION: Persistent small left apical pneumothorax status post left chest tube removal. Additionally, there is a small left pleural effusion, with suggestion of puncture of the parietal pleura and the visceral pleura, as there is an apparent small hematoma in the very base of the posterior base of the left lung. To CT of abd & pelvis this am with preliminary showing no organ nor bowel injury. CT OF THE PELVIS WITH IV CONTRAST: The bowel loops are unremarkable. Subcutaneous emphysema again seen along the left lateral chest wall. There is mild subcutaneous emphysema in the left chest wall. There also appears to be a small posterior epidural collection as described above, which likely represents hematoma. A tiny apical pneumothorax is noted. IMPRESSION: 1) Subcutaneous emphysema in the soft tissues of the left chest and back, with tiny left pleural effusion and hematoma in left lung. CT OF THE ABDOMEN WITH IV CONTRAST: There is air in the subcutaneous tissues of the left lateral chest and back. A tiny apical pneumothorax is noted on the left. No contraindications for IV contrast FINAL REPORT INDICATION: Recent stab wound. 11:32 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: occult left colon injury? (Over) 11:32 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: occult left colon injury? IMPRESSION: Persistent pneumothorax, of similar size. There is a small amount of air in the upper thoracic spinal canal. The presence of an expansile hematoma or edema cannot be excluded by this study, however. COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and compared with the previous study of . Subcutaneous emphysema is again noted on the left side. There is a similar appearance of the chest tube in the left hemithorax. There is a probable small pneumothorax. Pulmonary vasculature is within normal limits. MRI shows cord injury. TECHNIQUE: Multiplanar T1 and T2-weighted images of the thoracic spine. Assess for pneumothorax. Distal ureters are within normal limits. IMPRESSION: Slightly increased small left apical pneumothorax, please see comment. The heart and mediastinum are within normal limits. AP and lateral views of the thoracic spine shows normal alignment. A left-sided rib fracture is noted. IMPRESSION: Left-sided chest tube is seen, with the tip positioned in the left middle lung zone adjacent to the mediastinum. The heart, great vessels and pericardium appear unremarkable without evidence of aortic injury. PA & LATERAL CHEST: The left chest tube has been removed since the prior day. A questionable presence of deep sulcus sign at the left base is also observed, also concerning for pneumothorax. The cardiac and mediastinal contours are unchanged. Also, a pneumothorax, with chest tube to water seal. A nondisplaced rib fracture is seen along the posterior 8th rib. The cardiac and mediastinal contours are within normal limits. IMPRESSION: Soft tissue gas as described consistent with stab wound. The dura also appears displaced slightly ventrally, and there is fluid seen in the dorsal aspect of the epidural space from the T5 through T7 levels. Stab wound near CT insertion site clean also with sm amt drainage. Had MRI for that, did not require surgery, only casted. Limited views of the upper abdomen are unremarkable. The lung lesion can only be seen on the coronal and sagittal planes. PORTABLE AP CHEST RADIOGRAPH: A left-sided chest tube is seen with the tip positioned in the left middle lung zone. There is a large pneumothorax with an air fluid level and dependent pleural effusion, probably representing hemorrhage. IMPRESSION: Negative examination of the thoracic spine. On the axial images, there is apparent disruption of the dorsal aspect of the dura. Again, there is no free fluid in the abdomen. Normal strength in arms, but some pain with raising L arm due to wounds & CT. Morphine 2 mg IV relieves back and Left sided pain. The heart and pulmonary vascularity remain within normal limits. The left chest tube remains in place. Plan for spinal injury not finalized. Mid back stab wound is clean, draining serosanguinous fluid, DSD in place. However, there is no impingement on spinal cord as a result of this small collection, presumed hematoma. The spleen, adrenals, kidneys, pancreas, stomach, small bowel, and colon, specifically the splenic flexure, are unremarkable. The cardiac and mediastinal contours are unremarkable. 3:33 AM CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # Reason: 24M trauma, ? Small amounts of gas are seen near T5-T6, with one bubble within the spinal canal. Splinting CT site decreases pain on coughing. The liver contains a small 5-mm low-density lesion within segment V/VI, too small to fully characterize. For further evaluation, a CT could be helpful if there is concern for pneumothorax. There is patchy density overlying the left mid lung field. Please evaluate for retroperitoneal injury. The lung windows demonstrate large pneumothorax with pleural effusions. Pt continues to have no sensation below mid chest. Although CT is not able to resolve intrathecal detail, no gross hematoma is seen. CT OF THE CHEST WITH IV CONTRAST: These images demonstrate air dissecting through the subcutaneous tissues of the upper back and under the scapula and into the lateral subcutaneous tissues of the axilla. | 11 | [
{
"category": "Radiology",
"chartdate": "2194-07-24 00:00:00.000",
"description": "T-SPINE",
"row_id": 870284,
"text": " 1:53 PM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: with TLSO brace s/p stab injury\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with\n REASON FOR THIS EXAMINATION:\n with TLSO brace s/p stab injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 24-year-old status post stab wound injury.\n\n AP and lateral views of the thoracic spine shows normal alignment. There is\n no evidence of compression fractures; however, the body of T1 and T2 are not\n included on the lateral view. The pedicles are intact. The interspaces are\n well maintained.\n\n IMPRESSION: Negative examination of the thoracic spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-20 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 869753,
"text": " 2:36 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: CT to water seal, assess for interval change\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with hemothorax\n REASON FOR THIS EXAMINATION:\n CT to water seal, assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemothorax.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n The left chest tube remains in place. There is slight increase in left apical\n pneumothorax (10%).\n\n The lungs are clear otherwise. The heart and mediastinum are within normal\n limits. There is mild subcutaneous emphysema in the left chest wall.\n\n IMPRESSION: Slightly increased small left apical pneumothorax, please see\n comment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "MR THORACIC SPINE",
"row_id": 869479,
"text": " 5:40 AM\n MR THORACIC SPINE Clip # \n Reason: S/P STABBING TO T-6.\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with stabbing to mid thoracic spine with defecit below nipple\n line, cord injury evident\n REASON FOR THIS EXAMINATION:\n assess for hematoma, cord injury, fluid level\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 24-year-old post-stabbing to the mid thoracic spine with\n deficit (? sensory or motor) below the nipple line.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted images of the thoracic spine.\n\n Comparison is made to CT of the thoracic spine performed two hours earlier.\n\n FINDINGS: At the T5-6 level, increased linear signal intensity is seen within\n the spinal cord on T2 and STIR weighted images. On the axial images, there is\n apparent disruption of the dorsal aspect of the dura. The dura also appears\n displaced slightly ventrally, and there is fluid seen in the dorsal aspect of\n the epidural space from the T5 through T7 levels. This fluid demonstrates\n increased signal intensity on T1 and T2-weighted images. However, there is no\n impingement on spinal cord as a result of this small collection, presumed\n hematoma. The spinal canal is normal in caliber, and there is no evidence of\n neural foraminal abnormality.\n\n The vertebral bodies are normal in height and alignment with preservation of\n disc space height. No signal abnormalities are identified within the\n vertebral bodies or intervertebral discs. Increased T2 and STIR signal\n intensity is seen in the soft tissues of the paraspinal muscles in the T5\n through T7 region.\n\n IMPRESSION:\n\n Evidence of dorsal dural tear at the T5-6 level with laceration of the spinal\n cord at this level. There also appears to be a small posterior epidural\n collection as described above, which likely represents hematoma. Increased\n signal intensity within the soft tissues is consistent with edema.\n\n These findings were discussed with Dr. at the time of\n interpretation.\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 869515,
"text": " 11:32 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: occult left colon injury?\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with stab wounds 2cm inferior to the left scapula\n REASON FOR THIS EXAMINATION:\n occult left colon injury?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent stab wound. Please evaluate for retroperitoneal injury.\n\n COMPARISON: None.\n\n TECHNIQUE: After administration of oral, IV and rectal contrast, a\n multidetector scanner was used to obtain contiguous axial images from the lung\n bases to the pubic symphysis with coronal and sagittal reformats.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is air in the subcutaneous tissues\n of the left lateral chest and back. Additionally, there is a small left\n pleural effusion, with suggestion of puncture of the parietal pleura and the\n visceral pleura, as there is an apparent small hematoma in the very base of\n the posterior base of the left lung. There is no free fluid in the abdomen.\n The liver contains a small 5-mm low-density lesion within segment V/VI, too\n small to fully characterize. The spleen, adrenals, kidneys, pancreas,\n stomach, small bowel, and colon, specifically the splenic flexure, are\n unremarkable. Again, there is no free fluid in the abdomen. No\n lymphadenopathy is identified.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bowel loops are unremarkable. There\n is no free fluid in the pelvis. Distal ureters are within normal limits. The\n bladder has a Foley and nondependent air within it. No lymphadenopathy is\n seen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.\n\n Coronal and sagittal reformats confirm the findings above. MPR value 5. The\n lung lesion can only be seen on the coronal and sagittal planes.\n\n IMPRESSION:\n 1) Subcutaneous emphysema in the soft tissues of the left chest and back,\n with tiny left pleural effusion and hematoma in left lung.\n 2) No evidence of splenic, left kidney, or colonic injury. No evidence of\n abdominal organ injury.\n\n (Over)\n\n 11:32 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: occult left colon injury?\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 869474,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for position\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with s/pLchesttube placement\n REASON FOR THIS EXAMINATION:\n eval for position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate chest tube placement.\n\n COMPARISON: CT scan from the same day, .\n\n PORTABLE AP CHEST RADIOGRAPH: A left-sided chest tube is seen with the tip\n positioned in the left middle lung zone. A small amount of subcutaneous air\n is seen adjacent to the entry point. A tiny apical pneumothorax is noted. No\n pleural effusion is seen. The cardiac and mediastinal contours are within\n normal limits. A left-sided rib fracture is noted. The soft tissues are\n otherwise normal. Pulmonary vasculature is within normal limits.\n\n IMPRESSION: Left-sided chest tube is seen, with the tip positioned in the\n left middle lung zone adjacent to the mediastinum. A tiny apical pneumothorax\n is noted on the left. A left-sided rib fracture is also noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 870132,
"text": " 12:42 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for ptx\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with s/p L chest tube d/c'd today\n REASON FOR THIS EXAMINATION:\n assess for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left chest tube removal. Assess for pneumothorax.\n\n COMPARISON: .\n\n PA & LATERAL CHEST: The left chest tube has been removed since the prior day.\n The small left apical pneumothorax of approximately 15% persists. Subcutaneous\n emphysema is again noted on the left side. The heart and pulmonary\n vascularity remain within normal limits. There is no lung consolidation.\n\n IMPRESSION: Persistent small left apical pneumothorax status post left chest\n tube removal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 870042,
"text": " 5:07 PM\n CHEST (PA & LAT) Clip # \n Reason: CT to water seal, interval change\n Admitting Diagnosis: STAB WOUNDS-CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with hemothorax\n\n REASON FOR THIS EXAMINATION:\n CT to water seal, interval change\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATIONS: 24-year-old man with hemothorax. Also, a pneumothorax, with\n chest tube to water seal.\n\n CHEST, PA AND LATERAL: Comparison is made to . There is a similar\n appearance of the chest tube in the left hemithorax. The cardiac and\n mediastinal contours are unchanged. The lungs are clear. Subcutaneous\n emphysema again seen along the left lateral chest wall.\n\n A persistent pneumothorax of similar appearance is seen, although more\n difficult to evaluate because of the lordotic orientation of the film.\n\n IMPRESSION: Persistent pneumothorax, of similar size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 869470,
"text": " 3:34 AM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Known rib fx and ? T3 transection, please get fine-cut windo\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with stab wound.\n REASON FOR THIS EXAMINATION:\n Known rib fx and ? T3 transection, please get fine-cut windows of t3-t6.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: A 24-year-old man with stab wounds.\n\n There were reported to be two stab wounds from the posterior chest on the left\n side in the upper thoracic zone below the scapula, as well as a stab wound\n through the midline into the upper thoracic spine into the spinal canal by\n history.\n\n CT OF THE CHEST WITH IV CONTRAST: These images demonstrate air dissecting\n through the subcutaneous tissues of the upper back and under the scapula and\n into the lateral subcutaneous tissues of the axilla.\n\n The heart, great vessels and pericardium appear unremarkable without evidence\n of aortic injury. The right lung is clear. There is a large pneumothorax\n with an air fluid level and dependent pleural effusion, probably representing\n hemorrhage. There is also density in the lingula, probably a lung laceration\n or contusion.\n There is a small amount of air in the upper thoracic spinal canal.\n\n No fracture is identified.\n\n Limited views of the upper abdomen are unremarkable.\n\n No contrast extravasation is seen.\n\n BONE WINDOWS: No fractures seen.\n\n SAGITTAL AND CORONAL REFORMATS: The sagittal and coronal reformats confirm\n the axial findings.\n\n\n\n\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "CT T-SPINE W/ CONTRAST",
"row_id": 869469,
"text": " 3:33 AM\n CT T-SPINE W/ CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 24M trauma, ? T3 transection, please assess for neck injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with stab wound.\n REASON FOR THIS EXAMINATION:\n 24M trauma, ? T3 transection, please assess for neck injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATIONS: A 24-year-old man with stab wound and question of a transection\n at T3.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial CT images of the thoracic spine were obtained, and sagittal\n and coronal reconstructions were also performed.\n\n FINDINGS: There is no evidence of a fracture, dislocation or bony\n destruction. Small amounts of gas are seen near T5-T6, with one bubble\n within the spinal canal. This region also shows air in the subcutaneous\n overlying soft tissues of the back. The largest concentration of gas extends\n from around T5 through T6.\n\n Although CT is not able to resolve intrathecal detail, no gross hematoma is\n seen. The presence of an expansile hematoma or edema cannot be excluded by\n this study, however.\n\n The lung windows demonstrate large pneumothorax with pleural effusions. Please\n see the report of the chest CT of the same day for further details.\n\n IMPRESSION: Soft tissue gas as described consistent with stab wound. No\n evidence of metallic foreign body or fracture. Cord compression cannot be\n excluded by this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-18 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 869468,
"text": " 3:03 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: stabing to chest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with stabing to chest\n REASON FOR THIS EXAMINATION:\n stabing to chest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: A 24-year-old man with stab wounds to the chest.\n\n CHEST, SUPINE: There are no prior studies available for comparison. The\n cardiac and mediastinal contours are unremarkable. There is patchy density\n overlying the left mid lung field. A nondisplaced rib fracture is seen along\n the posterior 8th rib. There is a probable small pneumothorax. A questionable\n presence of deep sulcus sign at the left base is also observed, also\n concerning for pneumothorax. For further evaluation, a CT could be helpful if\n there is concern for pneumothorax.\n\n PELVIS, AP PORTABLE: The examination is carried out on the trauma board.\n There is no evidence of fracture, dislocation or bony destruction.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-07-18 00:00:00.000",
"description": "Report",
"row_id": 1372197,
"text": "T-SICU Nsg Admit NOte\n Pt is a 24 yo man who was stabbed in back with spinal cord injury. Pt was at a bar and attempted to assist friend as friend was being attacked, pt then became object of attacks by 3 young men with knives and pt received 3 stab wounds, one wound to middle back caused immediate loss of movement and sensation in legs, and pt fell to ground. Pt remembers incident clearly and was frightened by how much he was bleeding and that he couldn't feel his legs. Incident occured in Haveril and was first brought to . Pt med flighted here to .\n Pt has 2 sisters and 11 brothers and living parents. mother, one sister and several brothers in to visit today. Pt works for a construction company and lives in the of house where his sister lives on . Pt had planned to start school soon. Pt smokes about pack cigarettes per day, uses marijuana and drinks socially. He takes no routine meds and has no known allergies.\nPt broke his L foot within last year. Had MRI for that, did not require surgery, only casted.\n Pt continues to have no sensation below mid chest. PT not able to move toes, nor feet, nor legs. One time pt felt he was moving toes, but no movement could be seen. To CT of abd & pelvis this am with preliminary showing no organ nor bowel injury. Pt had CT and MRI of spine prior to arrival in T-SICU. MRI shows cord injury. Pt has L pneumo/hemothorax with L Chest tube to 20 cm suc. and intermittent small air leak. Mid back stab wound is clean, draining serosanguinous fluid, DSD in place. Stab wound near CT insertion site clean also with sm amt drainage.\n Pt alert, articulate, Ox3. Normal strength in arms, but some pain with raising L arm due to wounds & CT. Morphine 2 mg IV relieves back and Left sided pain. Pain esp with coughing.\\\n Pt has medium strong spont cough. Splinting CT site decreases pain on coughing.\n Pt able to drink 900cc of Redi-cat contrast for CT scan. OTherwise, pt NPO. LR at 125cc/hr.\nA: Appropriately worried young man, articulate, lots of family support. Plan for spinal injury not finalized. Pt currently on bedrest with log roll precautions and C-collar in place.\nP: continue informational support to pt & family.\n\n\n"
}
] |
10,916 | 183,540 | 81 y/o female with PMH significant for type 2 DM, HTN, hypercholesterolemia, and iron deficiency anemia admitted on with PNA and hypoglycemia, evaluated for GIB with EGD and colonoscopy and found to have malignant lesion in colon, to be followed by surgery outpatient for possible resection. . # GI Malignancy: Pt had colonoscopy and EGD on and was found to have polyps in the rectum (biopsy), 3cm ulcerated malignant appearing mass in the ascending colon (biopsy), otherwise normal colonoscopy to cecum. EGD with normal esophagus, stomach, and duodenum. Pt had CT abd in for abdominal pain which revealed normal bowel and no enlarged lymph nodes. CT abdomen w/ contrast for staging during current admission revealed cratered lesion in ascending colon characteristic of malignancy, without enlarged lymph nodes. Pt evaluated with pre-op CXR which revealed mild CHF and persistent LLL opacity. As pneumonia had not resolved, pt will followup with Dr. from Surgery outpatient within 1 week. Consultation by surgery with impression that she would be a candidate for operation. Colon biopsy path pending on discharge. . # Hypoglycemia: Acute issue that necessitated patient's admission to the MICU. She received 10 units of humalog insulin as her platelet and glucose counts were mistaken for each other. The patient was briefly on a D10 drip and required Q1H then Q2H FS. She has now recovered and is back on her regular home insulin regimen. Blood sugars remaining stable, pt asymptomatic. . # LLL PNA: Likely community acquired PNA. Retrocardiac oppacity on her CXR. Sats stable on RA. Completed azithromycin x 7 days. Symptomatic rx with expectorant, lozenges, nebs prn. Monitor oxygen sats at rest and with ambulation. Pt remained afebrile without leukocytosis. . # Iron deficiency anemia/Chronic GIB: Pt with iron deficiency anemia and guiac positive stools. No past EEG or colonoscopy. Pt transfused with 3u pRBC during hospital course. No persistent BRBPR. Hct remaining stable post transfusion and pt hemodynamically stable. Tolerating PO intake. PPI . Held coumadin pending GI outpatient eval on . Continued on ferrous sulfate 325 mg daily. Bowel regimen with colace, senna. . # Atrial fib Holding coumadin, cont beta blocker. INR intially supratherapeutic and reversed with FFP and vitamin K. Now within normal range as off coumadin pending GI workup. Continue beta blocker for rate control. Coumadin held during hospital course and restarted on discharge, pending future surgery. . # CRI Baseline creatinine of 1.4-1.6. Pt is currently at her baseline. Foley DC'd post admission to medicine floor. Adequate urine output. UA negative, though with large number of RBCs likely from traumatic foley. Avoided nephrotoxic drugs. Monitor UOP and renal function. Consider switching from atenolol to metoprolol outpatient. . # Code status: Full code . # DISPO: Followup with Surgery and PCP . Regular INR checks by VNA to ensure within therapeutic range. | LS diminished w/ ins/exp wheezes @ times (inhaler prn). Pt was given maalox w/ lidocaine in ED w/ little effect. Pt c/o HA..given tyelenol po w/ good effect.Resp: LS clear w/ some expiratory wheezes to bilateral apices, diminished to bases. Baseline artifactProbable atrial fibrillation although baseline artifact makes assessmentdifficultModest low amplitude T waves with prolonged Q-Tc interval - may bedrug/metabolic/electrolyte effectSince previous tracing of , rhythm now appear to be atrial fibrillation BS hypoactive. Pt tolerating diabetic/low NA diet. Started on bowel regimine. 7a-7p MICU Nursing Progress NoteEvents: Blood sugars have been in the 100's-200's today; started back on RISS this am, as pt is taking po's w/o difficulty. Pt has received a total of 2 units PRBC for initial HCT (in ED) of 21.1; HCT then up to 26.9 this am; repeat HCT this afternoon was 25.7; due for next HCT @ 20:00.GI/GU: Abdomen obese, otherwise benign. Pt tolerating Low Na/Diabetic diet w/o difficulty. Pt c/o abd pain. + LLL PNA on CXR (being tx'ed w/ azithro/ceftriaxone).CV: HR 60's-70's, AFib on monitor, no ectopy noted. Low grade temps today.Social: Pt is a full code. Probable ectopic atrial rhythm or accelerated junctional rhythmModest low amplitude T waves with prolonged Q-Tc interval - may be in partdrug/metabolic/electrolyte effectSince previous tracing of , ectopic atrial rhythm present andventricular ectopy not seen Pt given 1 unit of PRBCs for HCT of 21.1. k in the ED. Given 1 unit of PRBCs @ 2400 for HCT of 23.0...post-transfusion HCT 26.9. Given vit. Pt given 1 amp of D50, followed by D10W @ 30cc/h. PPP bilaterally.GI/GU: Abd soft/obese. NIBP 120's-150's / 40's-80's. Foley intact, draining adequate amts of clear/yellow urine.Endo: Fingersticks QID; BS ranging 100's-200's today; RISS initiated this am.Lines: #20G PIV Right HandID: Continues on Ceftriaxone/Azithro for LLL PNA. AFIB, rare ectopy. RR regular 18-24bpm.CV: BP 111-150s/40s-80s, HR 60-70s, brief periods of HR between 100-102 last eve. Bisacodyl given per her request. Pt notes that she has had epigastric abd pain w/ no relation to food. c/o to floor today. Tylenol given for H/A w/ good effect.Resp: Pt breathing spontaneously on RA, RR teens-20's, sats 95-98%. Pt HOH. Nursing progress note (7pm-7am):Pt presented to ED w/ c/o cough & diffuse body aches since . Urine clear/yellow, U/O adequate.FEN: BS 53-246. Finger Sticks QID. Pt had 1 brown, guaiac + stool today. Pt also given ceftriaxone/azithromycin for LLL PNA noted on CXR. MAE, follows commands, very HOH. O2 sats 99-100% on 2L NC, now on RA sating between 96-98%. Pt called out to the floor; awaiting available bed; tx note started.Review of Systems:Neuro: Pt alert, oriented x 3. HCT this am = 26.9; repeat ~ 8 hrs later = 25.7 (pt due for next HCT @ 20:00). Pt also c/o runny nose, congestion, & productive cough. In , pt noted to have guiac positive brown stool. Pt follows commands, MAE. Platelets of 512 mistaken in the ED for glucose level...pt was given 10 units of Humalog (blood sugar was 63). Pt's glucose level came up to the 200s, then dropped again to the 60s. PT/PTT pending. Pt stated she has been constipated and believes that is why she has abdominal pain (pt had BM in the ED), then states she has not eaten all day. Pt transferred to MICU6 for further monitoring.Review of systems:Neuro: Pt A&O x 3. Cont to monitor BS Q 2hrs for goal of 120-160.Access: 20g PIV to RUE.Social: Daughter at bedside when pt arrived to unit.Code status: full code.Plan: Cont to monitor Blood sugars q2H, monitor HCT, monitor resp status, monitor labs, ? Pt has a strong, productive cough>>white sputum. Given atrovent neb tx this am, as well as MDI last evening. No visitors today, though RN spoke w/ pt's daughter over the phone and updated her on poc/pt's condition.Plan: Continue Abx for PNA; Serial HCTs q 8 hr (next due @ 20:00); transfuse prn; hold Coumadin until HCT stabilizes; continue to monitor blood sugars and cover prn; routine ICU care and monitoring; tx to floor when bed available. Strong productive cough of whitish/yellow sputum. Pt given Dextrose 10% last evening for 2 hrs...sugars increased quickly to 160s. Team aware, no further action at this time. Pain radiates to back. No c/o N/V. Pt very talkative, but pleasant. | 4 | [
{
"category": "ECG",
"chartdate": "2186-12-13 00:00:00.000",
"description": "Report",
"row_id": 301864,
"text": "Probable ectopic atrial rhythm or accelerated junctional rhythm\nModest low amplitude T waves with prolonged Q-Tc interval - may be in part\ndrug/metabolic/electrolyte effect\nSince previous tracing of , ectopic atrial rhythm present and\nventricular ectopy not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2186-12-13 00:00:00.000",
"description": "Report",
"row_id": 301865,
"text": "Baseline artifact\nProbable atrial fibrillation although baseline artifact makes assessment\ndifficult\nModest low amplitude T waves with prolonged Q-Tc interval - may be\ndrug/metabolic/electrolyte effect\nSince previous tracing of , rhythm now appear to be atrial fibrillation\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-12-14 00:00:00.000",
"description": "Report",
"row_id": 1405905,
"text": "7a-7p MICU Nursing Progress Note\n\nEvents: Blood sugars have been in the 100's-200's today; started back on RISS this am, as pt is taking po's w/o difficulty. Finger Sticks QID. HCT this am = 26.9; repeat ~ 8 hrs later = 25.7 (pt due for next HCT @ 20:00). Pt called out to the floor; awaiting available bed; tx note started.\n\nReview of Systems:\n\nNeuro: Pt alert, oriented x 3. MAE, follows commands, very HOH. Tylenol given for H/A w/ good effect.\n\nResp: Pt breathing spontaneously on RA, RR teens-20's, sats 95-98%. LS diminished w/ ins/exp wheezes @ times (inhaler prn). Pt has a strong, productive cough>>white sputum. + LLL PNA on CXR (being tx'ed w/ azithro/ceftriaxone).\n\nCV: HR 60's-70's, AFib on monitor, no ectopy noted. NIBP 120's-150's / 40's-80's. Pt has received a total of 2 units PRBC for initial HCT (in ED) of 21.1; HCT then up to 26.9 this am; repeat HCT this afternoon was 25.7; due for next HCT @ 20:00.\n\nGI/GU: Abdomen obese, otherwise benign. Pt tolerating Low Na/Diabetic diet w/o difficulty. Pt had 1 brown, guaiac + stool today. Bisacodyl given per her request. Foley intact, draining adequate amts of clear/yellow urine.\n\nEndo: Fingersticks QID; BS ranging 100's-200's today; RISS initiated this am.\n\nLines: #20G PIV Right Hand\n\nID: Continues on Ceftriaxone/Azithro for LLL PNA. Low grade temps today.\n\nSocial: Pt is a full code. No visitors today, though RN spoke w/ pt's daughter over the phone and updated her on poc/pt's condition.\n\nPlan: Continue Abx for PNA; Serial HCTs q 8 hr (next due @ 20:00); transfuse prn; hold Coumadin until HCT stabilizes; continue to monitor blood sugars and cover prn; routine ICU care and monitoring; tx to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-12-14 00:00:00.000",
"description": "Report",
"row_id": 1405904,
"text": "Nursing progress note (7pm-7am):\n\nPt presented to ED w/ c/o cough & diffuse body aches since . Pt notes that she has had epigastric abd pain w/ no relation to food. Pain radiates to back. Pt has not noticed any changes in stool. Pt also c/o runny nose, congestion, & productive cough. In , pt noted to have guiac positive brown stool. Pt given 1 unit of PRBCs for HCT of 21.1. Platelets of 512 mistaken in the ED for glucose level...pt was given 10 units of Humalog (blood sugar was 63). Pt given 1 amp of D50, followed by D10W @ 30cc/h. Pt's glucose level came up to the 200s, then dropped again to the 60s. Pt also given ceftriaxone/azithromycin for LLL PNA noted on CXR. Pt transferred to MICU6 for further monitoring.\n\nReview of systems:\n\nNeuro: Pt A&O x 3. Pt HOH. Pt follows commands, MAE. Pt very talkative, but pleasant. Pt c/o HA..given tyelenol po w/ good effect.\n\nResp: LS clear w/ some expiratory wheezes to bilateral apices, diminished to bases. Given atrovent neb tx this am, as well as MDI last evening. Strong productive cough of whitish/yellow sputum. O2 sats 99-100% on 2L NC, now on RA sating between 96-98%. RR regular 18-24bpm.\n\nCV: BP 111-150s/40s-80s, HR 60-70s, brief periods of HR between 100-102 last eve. AFIB, rare ectopy. Given 1 unit of PRBCs @ 2400 for HCT of 23.0...post-transfusion HCT 26.9. PT/PTT pending. Given vit. k in the ED. PPP bilaterally.\n\nGI/GU: Abd soft/obese. BS hypoactive. Pt tolerating diabetic/low NA diet. No c/o N/V. Pt c/o abd pain. Pt was given maalox w/ lidocaine in ED w/ little effect. Pt stated she has been constipated and believes that is why she has abdominal pain (pt had BM in the ED), then states she has not eaten all day. Started on bowel regimine. Team aware, no further action at this time. Urine clear/yellow, U/O adequate.\n\nFEN: BS 53-246. Pt given Dextrose 10% last evening for 2 hrs...sugars increased quickly to 160s. Cont to monitor BS Q 2hrs for goal of 120-160.\n\nAccess: 20g PIV to RUE.\n\nSocial: Daughter at bedside when pt arrived to unit.\n\nCode status: full code.\n\nPlan: Cont to monitor Blood sugars q2H, monitor HCT, monitor resp status, monitor labs, ? c/o to floor today.\n\n\n\n"
}
] |
77,469 | 164,145 | 85F with DM, PVD, CHF and deafness, admitted for altered mental status, found to have UTI. . #. AMS/UTI: The patient was initially agitated and complaining of back pain, which is apparently chronic for her. She was given levaquin given her history of legionella pneumonia. Her CXR was unremarkable. Her head CT did not show any new lesions. UA normal but urine culture grew micrococcus/stomatococcus >100,000. This was considered a UTI and patient was treated with ampicillin for 7 days. Blood cx all neg. Repeat urine culture was negative. WBC was normal and patient remained afebrile. . The patient's mental status began to return to her baseline. She demonstrated a significant level of underlying dementia, but also brief episodes of delirium. During these, the patient would look around the room, respond to paranoid delusions, and refuse treatment. It was thought that the patient's underlying dementia, deficiency in sensory input (severe hearing loss), resolving infection, and hospital environment all contributed to delirium. TSH was wnl. RPR was negative. B12 was normal. Vitamin D levels were pending at discharge, and the patient was treated empirically with Vitamin D and thiamine supplements. She was treated with standing Zyprexa zydis in morning and bedtime. The patient's Lasix was D/Ced since she was felt to be dry, complaining of thirst and increased BUN. Her Lasix could be restarted as outpatient if necessary. Appears euvolemic on discharge. At discharge, patient was agreeing to treatment, calm, cooperative, with no complaints. She benefitted from amplification headphones and may benefit from hearing aids if she agrees. . #. hypotension: On the medicine floor, the patient had an episode of hypotension with SBP 70's. The patient was given several IVF boluses, and when hypotension did not resolve, MICU was called to place central line and arrange transfer. Left IJ was placed and fluid resusitation continued during transfer. The patient was started on vanco/zosyn. When the patient arrived in the MICU, hypotension had resolved without any further intervention. Blood pressure remained stable for remainder of course. Vanco/Zosyn were D/Ced, and patient returned to medicine floor. She remained hemodynamically stable and afebrile for remainder of course. . # Decubitus left heel ulcer The patient was noted to have a left heel ulcer, unable to be staged without debridement. Both vascular surgery and podiatry were consulted. Both recommended holding off debridement or more extensive treatment until patient's infection resolved and placement situation stabilized. The patient is known to have severe PVD, likely not a candidate for revascularization. Dressing changes with collagenase ointment and multipodus boots should be continued, feet should be elevated. The patient should follow-up with podiatry and vascular surgery. . # DM The patient's home oral anti-hyperglycemics were held. The patient was controlled on HISS, and standing Lantus and Humalog with meals was added for improved glycemic control. . # HTN The patient's home antihypertensives were held with hypotensive episode. Home dose of lisinopril and half home dose of metoprolol was eventually restarted without issues. The patient was on Lasix at home, but in setting of hypotensive episode, this was held. A small dose (5 mg ) was tried, but patient seemed dry and BUN increased. We will hold off Lasix for now since patient euvolemic. . # Chronic systolic CHF. The patient had a TTE which showed worsening EF from 35-40% in to 20-25%. The patient was continued on lisinopril and metoprolol. Home Lasix was held. The patient did not demonstrate signs of volume overload on physical exam. The patient was restarted on ASA 81 mg. Ezetimibe was D/Ced since of little benefit to patient at this stage. . # Hypothyroidism. TSH normal. Continued home dose levothyroxine. . # Depression Continued duloxetine . #. Psychosocial: The patient had been cared for by her son, who suffers from mental illness. It was unclear if she was reliably receiving her medications or food. Social work and elder care were involved in her course. Her is her HCP. The patient's son should not be responsible for care decisions. . The patient was discharged to rehab facility (Roscommons) | -change abx to Vanc/Zosyn, and d/c ampicillin -repeat UA/Ucx # Altered mental status. Chief Complaint: Hypotension HPI: PCP: . Period of hypotension w/o hypoperfusion. Current intervention if any, listed below: 85F with DM, PVD, CHF and deafness, admitted for altered mental status, triggered and transferred to the MICU for hypotension refractory to fluid resuscitation. Current intervention if any, listed below: 85F with DM, PVD, CHF and deafness, admitted for altered mental status, triggered and transferred to the MICU for hypotension refractory to fluid resuscitation. Pt diagnosed with UTI, started on Ampicillin. Pt diagnosed with UTI, started on Ampicillin. Had been admitted on with altered mental status (subacute). Had been admitted on with altered mental status (subacute). Had been admitted on with altered mental status (subacute). Had been admitted on with altered mental status (subacute). Had been admitted on with altered mental status (subacute). Had been admitted on with altered mental status (subacute). Pulm edema vs PNA. # Hypotension-possibly sepsis, hypovolemia, effusion with tamponade physiology. Assessment and Plan HYPOTENSION (NOT SHOCK) ASSESSMENT & PLAN: 85F with DM, PVD, CHF and deafness, admitted for altered mental status, triggered and transferred to the MICU for hypotension refractory to fluid resuscitation. Since admission low grade fever x2 days, currently on d3 of Ampicillin for UTI. Since admission low grade fever x2 days, currently on d3 of Ampicillin for UTI. # Chronic systolic CHF. Pacemaker - in for intermittent AV block and bradycardia 13. Started on Po Thiamine. Left IJ triple lumen placed. Left IJ triple lumen placed. Left IJ triple lumen placed. Left IJ triple lumen placed. Left IJ triple lumen placed. Left IJ triple lumen placed. Pt has got Lt heel ulcer.Please see metavision for assessment and action. Pt has got Lt heel ulcer.Please see metavision for assessment and action. Hypotension: Likely secondary to hypovolemia vs. early sepsis. staph Ucx pending ECG: ECG today shows non-specific T wave changes relative to admission CXR. After NS 1750cc, pt had tenuous IV access, and persistantly low BP so was transferred to MICU. # DM -hold oral anti-hyperglycemics -FSBS, ISS # HTN -Lisinopril, toprol with holding parameters . Today at 4pm VS check, BP 74/p, pt triggered for hypotension. Today at 4pm VS check, BP 74/p, pt triggered for hypotension. Patient admitted from: History obtained from Family / Medical records Patient unable to provide history: dementia Allergies: Lipitor (Oral) (Atorvastatin Calcium) elevation of li Last dose of Antibiotics: Piperacillin/Tazobactam (Zosyn) - 10:16 PM Vancomycin - 11:22 PM Infusions: Other ICU medications: Other medications: Past medical history: Family history: Social History: MEDICAL & SURGICAL HISTORY: 1. PATIENT/TEST INFORMATION:Indication: Hypotension. Recently hypotensive. The severity of tricuspid regurgitation and the estimated pulmonaryartery systolic pressure are now lower.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Noted while sleeping RR would fluctuate between shallow and normal breathing w/ rare 1 2 sec apnea- no de-saturations. Moderate (2+) mitral regurgitation is seen. Trace aortic regurgitation is seen. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Demand ventricular pacing with possibly underlying atrial braydcardia.Intrinsically conducted QRS complexes seem to be of right bundle-branch blockmorphology. Sinus rhythm and ventricular paced rhythm as well as intrinsic A-V conduction.Compared to the previous tracing there is intrinsic A-V conduction as well asatrial ectopy. There is mild pulmonary artery systolic hypertension.There is no pericardial effusion.Compared with the prior study (images reviewed) of , global leftventricular systolic function is more depressed and the heart rate is nowfaster. There is moderatetricuspid regurgitation. [IntrinsicRV systolic function likely more depressed given the severity of TR].AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Right pleural effusion.Conclusions:The right atrium is moderately dilated. [Intrinsicfunction may be more depressed given the severity of tricuspid regurgitation. Left internal jugular line ends in the mid SVC. Undetermined rhythm - possible sinus rhythm with pseudo-fused ventricularlypaced beats. Marked left axis deviation and intraventricularconduction delay of left bundle-branch block type. Rightventricular chamber size is dilated with free wall hypokinesis. Addendum.patient noted to have periods of apnea but does not desaturate, RT informed, team came to review, attending awarepatient will still be DC to floor but with telemetry/team on floor informed along with RT ? RV function depressed. Pacer.Height: (in) 65Weight (lb): 168BSA (m2): 1.84 m2BP (mm Hg): 103/55HR (bpm): 75Status: InpatientDate/Time: at 15:50Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. ]The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Compared to prior tracing of there may be a few beatswhich are not paced. Since admission low grade fever x2 days, currently on d3 of Ampicillin for UTI. Central pulmonary vasculature is less engorged, but severe cardiomegaly, recently increased persists, and small bilateral pleural effusions may have decreased. Started on Po Thiamine. The mitral leaflets are mildlythickened. Pt diagnosed with UTI, started on Ampicillin. retrocardiac opacity. No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. Awaiting results cardiac echo. WET READ: EAGg SUN 10:41 PM Cardiomegaly, prominent central vessels and slight cephalization compared to prior. Demand ventricular pacing with possible underlying atrial bradycardia. Ventricular paced rhythm with atrial ectopy which is ventricular sensed withcapture. The interval changes are best explained by improving cardiac decompensation but the nature of residual opacities at both lung bases is equivocal, either atelectasis or pneumonia. Clinicalcorrelation is suggested. Sinus bradycardia, rate in the high 50's, with the short cycles beingconducted. | 21 | [
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690683,
"text": "85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1. Today around 4 pm her\n blood pressure 74/doppler. Received 1750 cc IV NS through a 22 guage\n IV. Transferred to ICU for further management. Left IJ triple lumen\n placed. Did not receive additional IVF in ICU albeit BP has ranged\n 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor - ~1500 cc\n urine out.\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690684,
"text": "85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1.Yesterday around 4 pm\n her blood pressure 74/doppler. Received 1750 cc IV NS through a 22\n guage IV. Transferred to ICU for further management. Left IJ triple\n lumen placed. Did not receive additional IVF in ICU albeit BP has\n ranged 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor -\n ~1500 cc urine out.\n"
},
{
"category": "General",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Generic Note",
"row_id": 690774,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning.\n 97.4 75 110/75\n Alert, disoriented\n Chest\n clear\n Abd soft w/o tenderness\n WBC\n 6.8\n Alert comfortable this am. Unclear what happened. Period of\n hypotension w/o hypoperfusion. Ruling out for infection, cardiac\n event. Nothing to suggest PE. Urine output good and little to suggest\n hypoperfusion excpt for a borderline lactate\n which she has had since\n admission. Will review meds as could have been a drug effect.\n Time spent 30 min\n"
},
{
"category": "Physician ",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 690739,
"text": "Chief Complaint: Hypotension\n HPI:\n PCP: \n .\n CC: .\n HPI:\n 85F with history of DM2 HTN, PVD, and AV block s/p PPM and CM with ICD\n in place who was found with AMS at home. She lives at home with her\n schizophrenic son. The fire department broke into the home, after\n neighbors heard moaning from inside, and found her in a wheelchair,\n moaning and crying.\n HCP, niece , is RN here, and describes\n patient MS over the past few months, with deafness\n (refused hearing aid) and forgetfullness. 2 weeks ago pt was awake and\n responsive, but due to worsening dementia and deafness it\n communication is difficult. She has not been in to see her PCP for\n several months and HHA services were discontinued in , altough she\n does have a weekly VNA. Apparently the house she shares with her\n schizophrenic son is in squalor, frequently without food. She is\n uncertain what medications the patient takes and if her son provides\n them for her. Patient has refused nursing home in the past.\n In the ED, initial VS: 87 160/86 18 91 FSBS 221. She was minimally\n oriented, uncooperative. She was agitated, moaning and inconsolable.\n Complained of back pain which is apparently chronic for her. She looked\n dry on exam. She was given levaquin given her history of legionella\n pneumonia in the past. Her CXR was unremarkable. Her head CT did not\n show any new lesions. UA normal. Her labs showed a normal CBC/diff,\n BUN/Cr 23/1.2, prior cr had been around 1.2-1.4. Trop 0.03 at baseline.\n She was given 2L IV NS as well as a total of 5mg haldol for agitation,\n several doses of IV morphine and 4mg of ondansetron. Social work and\n Elder care were notified of patient and will be following her care\n here. She was admitted to the medicine service for altered mental\n status and possible placement. VS at time of transfer: 99.0 76 139/57\n 12 96% on RA.\n On arrival to the floor the patient was sleeping, arousable to light\n touch. Responsive, but moaning, complaining of back pain. Communication\n difficult due to hearing loss. Not able to respond to any orientation\n questions. Pt diagnosed with UTI, started on Ampicillin.\n Since admission low grade fever x2 days, currently on d3 of Ampicillin\n for UTI. Geriatrics, Podiatry and Vascular Surgery services were\n consulted. SW c/s for placement. Today at 4pm VS check, BP 74/p, pt\n triggered for hypotension. After NS 1750cc, pt had tenuous IV access,\n and persistantly low BP so was transferred to MICU.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: dementia\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n elevation of li\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:16 PM\n Vancomycin - 11:22 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n MEDICAL & SURGICAL HISTORY:\n 1. PVD s/p bypass \n 2. DM2 with complications neuropathy\n 3. HTN\n 4. Cardiomyopathy - systolic CHF with EF 35-40%\n 5. Chronic LE edema\n 6. hyperlipidemia\n 7. osteoporosis\n 8. GERD\n 9. s/p appy\n 10. B12 deficiency\n 11. vertebral disc surgery - hardware in lumbar spine & chronic\n LBP\n 12. Pacemaker - in for intermittent AV block and\n bradycardia\n 13. Prior legionella PNA\n 14. Prior enterococcal UTI\n 15. Profoundly hard of hearing\n 16. s/p B/L cataract repair\n 17. Afib\n 18. hypothyroidism\n non-contributory\n Occupation: retired\n Drugs: denied\n Tobacco: denied\n Alcohol: denied\n Other: lives with schizophrenic son, questions have been asked\n regarding quality of home life/care.\n Review of systems: unable to assess, pt uncooperative.\n Flowsheet Data as of 06:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.1\n HR: 77 (73 - 78) bpm\n BP: 118/71(81) {93/55(63) - 128/78(88)} mmHg\n RR: 28 (0 - 29) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n CVP: 5 (3 - 9)mmHg\n Total In:\n 2,050 mL\n 53 mL\n PO:\n TF:\n IVF:\n 300 mL\n 53 mL\n Blood products:\n Total out:\n 1,330 mL\n 620 mL\n Urine:\n 130 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -567 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Pupils misshapen, s/p B/L cataract repair\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Diastolic), \n holosystolic at LLSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : ), only able to examine anteriorly\n due to patient resistance\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash: , Dry, flaking skin from inguinal area\n inferior. 1cm L heel ulceration.\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 218 K/uL\n 10.8 g/dL\n 186 mg/dL\n 0.9 mg/dL\n 13 mg/dL\n 21 mEq/L\n 111 mEq/L\n 3.9 mEq/L\n 140 mEq/L\n 34.8 %\n 6.8 K/uL\n [image002.jpg]\n \n 2:33 A8/2/ 07:10 PM\n \n 10:20 P8/2/ 07:30 PM\n \n 1:20 P8/3/ 03:19 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.8\n 6.8\n Hct\n 35.8\n 38\n 34.8\n Plt\n 222\n 218\n Cr\n 0.9\n 0.9\n TropT\n 0.04\n 0.03\n Glucose\n 151\n 186\n Other labs: PT / PTT / INR:12.8/29.3/1.1, CK / CKMB /\n Troponin-T:349/4/0.03, ALT / AST:14/27, Alk Phos / T Bili:56/0.6,\n Differential-Neuts:74.4 %, Lymph:15.8 %, Mono:4.6 %, Eos:4.6 %, Lactic\n Acid:2.6 mmol/L, Albumin:2.8 g/dL, LDH:264 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: L hemidiaphragm hazy. Pulm edema vs PNA.\n CT head- no acute process\n CT chest- B/L pleural effusions\n L foot X ray- no osteo or subcutaneous air\n Microbiology: Bcx from and pending\n Ucx from grew coag neg. staph\n Ucx pending\n ECG: ECG today shows non-specific T wave changes relative to admission\n CXR.\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n ASSESSMENT & PLAN:\n 85F with DM, PVD, CHF and deafness, admitted for altered mental status,\n triggered and transferred to the MICU for hypotension refractory to\n fluid resuscitation.\n # Hypotension-possibly sepsis, hypovolemia, effusion with tamponade\n physiology. Infectious sources include urine, Diabetic foot ulcer,\n PNA, blood. Bcx already drawn. Already received NS 1750cc on floor.\n - Currently 129/74, hold IVF if SBP>120.\n - f/u Ucx, Bcx. CXR.\n - f/u CT chest final read\n - abx for possible sepsis, change ampicillin to Vanc/Zosyn\n # UTI-Ucx positive for MICROCOCCUS/STOMATOCOCCUS SPECIES,\n STAPHYLOCOCCUS, COAGULASE NEGATIVE, currently on Ampicillin 1g q6h\n If sepsis, UTI possible cause.\n -change abx to Vanc/Zosyn, and d/c ampicillin\n -repeat UA/Ucx\n # Altered mental status. Pt w/ baseline dementia, requires family\n input.\n - possibly pt baseline, talk to family about AMS\n - sepis workup as above\n -CT head non-con\n - Fall precautions\n # Decubitus left heel ulcer\n - podiatry consulted, rec multipodus boots, elevate heels, and santyl\n - tenuous vascular status, vascular surgery c/s following\n - ankle brachial index shows severe PVD in left leg.\n # DM\n -hold oral anti-hyperglycemics\n -FSBS, ISS\n # HTN\n -Lisinopril, toprol with holding parameters\n .\n # Chronic systolic CHF. EF 35-40% by echo in .\n - encourage PO intake\n - hold lasix\n - order new echo for this AM\n # Psychosocial. Pt's home situation not safe: it is uncertain if she is\n reliably getting food or her medications.\n -plan for long term nursing home placement\n -S/w and elder services involved\n -options for placement - pt had been at house in , went\n home with son, had HHA and visiting nurse but clearly failing at home\n because son discontinued HHA in - awaiting bed there.\n - , HCP is attempting to initiate guardianship - S/W has\n given her possible contacts in community to help.\n .\n ICU Care\n Nutrition:\n Comments: Regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 07:50 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Pt niece is a\n niece here, actively involved in pt care.\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 690681,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1. Today around 4 pm her\n blood pressure 74/doppler. Received 1750 cc IV NS through a 22 guage\n IV. Transferred to ICU for further management. Left IJ triple lumen\n placed. Did not receive additional IVF in ICU albeit BP has ranged\n 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor - ~1500 cc\n urine out.\n Patient admitted from: \n History obtained from Family / Medical records\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n elevation of li\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:16 PM\n Vancomycin - 11:22 PM\n Infusions:\n Other ICU medications:\n Other medications:\n lasix\n glypizide\n hydrocodone\n tylenol\n levabunolol\n synthroid\n lisinopril\n metoprolol\n ASA\n cynacobalamin\n docusate\n senokot\n Past medical history:\n Family history:\n Social History:\n HTN\n PVD s/p bypass '\n DM, Type II\n AV block, s/p pacemaker\n Poor hearing\n Left heel ulcer\n CHF, cardiomyopathy\n Echo: EF 35-40%, PAH, RV dilatation, mod to severe TR, + MR\n GERD\n Osteoporosis\n s/p appy\n s/p vertebral disc surgery with hardware; chronic LBP\n Legionella PNA\n Hypothyroidism\n Bilateral cataracts surgery\n Noncontributory\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Lives with schizophrenic son with nursing visits; home\n in disarray; niece ICU nurse here is her HCP\n Review of systems:\n Flowsheet Data as of 01:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 75 (73 - 78) bpm\n BP: 113/78(86) {93/55(63) - 127/78(86)} mmHg\n RR: 0 (0 - 29) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n CVP: 8 (4 - 9)mmHg\n Total In:\n 2,050 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 1,330 mL\n 0 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: surgical pupils\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n dependent, No(t) Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm, left foot ulcer\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Non\n -purposeful, Tone: Not assessed, mild facial assymetry\n Labs / Radiology\n 222 K/uL\n 38\n 10.9 g/dL\n 151 mg/dL\n 0.9 mg/dL\n 15 mg/dL\n 18 mEq/L\n 112 mEq/L\n 4.0 mEq/L\n 138 mEq/L\n 7.8 K/uL\n [image002.jpg]\n 07:10 PM\n 07:30 PM\n WBC\n 7.8\n Hct\n 35.8\n 38\n Plt\n 222\n Cr\n 0.9\n TropT\n 0.04\n Glucose\n 151\n Other labs: PT / PTT / INR:13.3/26.3/1.1, CK / CKMB /\n Troponin-T:356/4/0.04, ALT / AST:14/27, Alk Phos / T Bili:56/0.6,\n Differential-Neuts:79.7 %, Lymph:12.5 %, Mono:4.0 %, Eos:3.3 %, Lactic\n Acid:2.6 mmol/L, Albumin:2.8 g/dL, LDH:264 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.7 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: Central line in SVC, no PTX, blurring of left\n hemidiaphragm.\n Chest CT: bilateral effusions, ground glass changes; minimal\n consolidation, ?atelectasis\n Head CT: No acute changes\n Foot x-ray: no evidence of osteo or subcutaneous air\n ECG: Wide complex, irregular rhythm at 75 bpm, without obvious changes\n compared to prior study (not paced).\n Assessment and Plan\n 1. Hypotension: Likely secondary to hypovolemia vs. early sepsis.\n Likely sources urine, lung, foot ulcer. Decreased BP noted on the\n floor which was not initially seemingly responsive to IVF boluses. No\n obvious ECG changes albeit abnormal ECG at baseline makes it diffficult\n to rule out ishemia. Had a positive urine culture; blood cultures on\n admission have remained negative. Upon arrival in the ICU she has had\n SBP greater than 100. Have broadened abx to vanco/zosyn; repeat urine\n and blood culutres prior to changing antibiotics.\n 2. CHF: O2 saturations stable on room air. Has component of CHF which\n may be exacerbated in the context of fluid resusitation. Given labile\n BP earlier will hold on diruesis, follow I/Os. If hemodynamically\n stable overnight will need to consider restarting afterload reduction,\n beta blocker and diuresis.\n 3. DM: Insulin sliding scale, holding oral hyperglycemics.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Multi Lumen - 07:50 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690732,
"text": "85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1.Yesterday around 4 pm\n her blood pressure 74/doppler. Received 1750 cc IV NS through a 22\n guage IV. Transferred to ICU for further management. Left IJ triple\n lumen placed. Did not receive additional IVF in ICU albeit BP has\n ranged 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor -\n ~1500 cc urine out.\n Hypotension (not Shock)\n Assessment:\n Pt BP in 70\ns on arrival to ICU which soon picked upto 100\ns systolic\n without any intervention.\n Action:\n Lt IJ inserted.No FB or pressors in ICU, received 1750cc FB on\n floor.Had CT head and chest.BC and urine culture sent.\n Response:\n CT head neg,CT chest with some pleural effusion R>L .Awaiting final\n .Hct stable at 38.Pt is alert and confused and very HOH which is\n her baseline according to her niece.\n Plan:\n Monitor BP.Follow BC.Cont IV Abx for possible pna.\n Pt has got Lt heel ulcer.Please see metavision for assessment and\n action.\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690733,
"text": "85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1.Yesterday around 4 pm\n her blood pressure 74/doppler. Received 1750 cc IV NS through a 22\n guage IV. Transferred to ICU for further management. Left IJ triple\n lumen placed. Did not receive additional IVF in ICU albeit BP has\n ranged 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor -\n ~1500 cc urine out.\n Hypotension (not Shock)\n Assessment:\n Pt BP in 70\ns on arrival to ICU which soon picked upto 100\ns systolic\n without any intervention.\n Action:\n Lt IJ inserted.No FB or pressors in ICU, received 1750cc FB on\n floor.Had CT head and chest.BC and urine culture sent.\n Response:\n CT head neg,CT chest with some pleural effusion R>L .Awaiting final\n .Hct stable at 38.Pt is alert and confused and very HOH which is\n her baseline according to her niece.\n Plan:\n Monitor BP.Follow BC. Broadened IV Abx to vanc/zosyn.\n Pt has got Lt heel ulcer.Please see metavision for assessment and\n action.\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690692,
"text": "85 y.o. woman transferred from the medical floor with hypotension. Had\n been admitted on with altered mental status (subacute). Urine\n grew coag negative staph - started on ampicillin for UTI. Blood\n cultures showed NGTD. Has had fevers to 100.1.Yesterday around 4 pm\n her blood pressure 74/doppler. Received 1750 cc IV NS through a 22\n guage IV. Transferred to ICU for further management. Left IJ triple\n lumen placed. Did not receive additional IVF in ICU albeit BP has\n ranged 93/55 to 134/69. Pulse 63 - 88. Foley placed on the floor -\n ~1500 cc urine out.\n Hypotension (not Shock)\n Assessment:\n Pt BP in 70\ns on arrival to ICU which soon picked upto 100\ns systolic\n without any intervention.\n Action:\n Lt IJ inserted.No FB or pressors in ICU, received 1750cc FB on\n floor.Had CT head and chest.BC and urine culture sent.\n Response:\n CT head neg,CT chest with some pleural effusion R>L .Awaiting final\n .Hct stable at 38.Pt is alert and confused and very HOH which is\n her baseline according to her niece.\n Plan:\n Monitor BP.Follow BC.Cont IV Abx for possible pna.\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 690790,
"text": "85F with history of DM2 HTN, PVD, and AV block s/p PPM and CM with ICD\n in place who was found with AMS at home. She lives at home with her\n schizophrenic son. The fire department broke into the home, after\n neighbors heard moaning from inside, and found her in a wheelchair,\n moaning and crying.\n HCP, niece , is RN here, and describes\n patient MS over the past few months, with deafness\n (refused hearing aid) and forgetfullness. 2 weeks ago pt was awake and\n responsive, but due to worsening dementia and deafness it\n communication is difficult. She has not been in to see her PCP for\n several months and HHA services were discontinued in , altough she\n does have a weekly VNA. Apparently the house she shares with her\n schizophrenic son is in squalor, frequently without food. She is\n uncertain what medications the patient takes and if her son provides\n them for her. Patient has refused nursing home in the past.\n In the ED, initial VS: 87 160/86 18 91 FSBS 221. She was minimally\n oriented, uncooperative. She was agitated, moaning and inconsolable.\n Complained of back pain which is apparently chronic for her. She looked\n dry on exam. She was given levaquin given her history of legionella\n pneumonia in the past. Her CXR was unremarkable. Her head CT did not\n show any new lesions. UA normal. Her labs showed a normal CBC/diff,\n BUN/Cr 23/1.2, prior cr had been around 1.2-1.4. Trop 0.03 at baseline.\n She was given 2L IV NS as well as a total of 5mg haldol for agitation,\n several doses of IV morphine and 4mg of ondansetron. Social work and\n Elder care were notified of patient and will be following her care\n here. She was admitted to the medicine service for altered mental\n status and possible placement..\n On arrival to the floor the patient was sleeping, arousable to light\n touch. Responsive, but moaning, complaining of back pain. Communication\n difficult due to hearing loss. Not able to respond to any orientation\n questions. Pt diagnosed with UTI, started on Ampicillin.\n Since admission low grade fever x2 days, currently on d3 of Ampicillin\n for UTI. Geriatrics, Podiatry and Vascular Surgery services were\n consulted. SW c/s for placement. Today at 4pm VS check, BP 74/p, pt\n triggered for hypotension. After NS 1750 bolus on floor transferred to\n MICU.\n MICU: No access to left triple lumen IJ placed. Remained normotensive\n since admission with no further intervention.\n Events: C/O in AM. Sleeping but arouses to voice. AM meds via\n crushed in applesauce, wound care done. Started on Po Thiamine. Noted\n while sleeping RR would fluctuate between shallow and normal breathing\n w/ rare 1\n 2 sec apnea- no de-saturations. UOP good and >100cc/hr.\n Awaiting cardiac echo.\n Hypotension (not Shock)\n Assessment:\n BP low of 96/45 while sleeping in AM, currently SBP while in MICU >100/\n Action:\n No interventions, cont off all BP meds\n Response:\n No acute change\n Plan:\n Cont to monitor, holding all BP medications\n"
},
{
"category": "Nutrition",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 690792,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 85F with DM, PVD, CHF and deafness, admitted for altered mental status,\n triggered and transferred to the MICU for hypotension refractory to\n fluid resuscitation. Patient seen by nutrition for poor po\n consult. RN notes, patient needs to be fed, decreased po\n was\n on diabetic/heart healthy soft diet with thin liquids. Patient has\n been NPO since transfer to ICU. RN, feeding patient pills crushed\n in applesauce, tolerating well however, patient very sleepy, difficult\n to wake up.\n Recommendations:\n 1. Resume diet when medically feasible\n recommend regular diet\n to increase menu choices\n 2. Will resume po supplement (Boost Glucose Control) when diet\n resumes\n 3. Will follow to check po\ns, page if questions *\n"
},
{
"category": "Nutrition",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 690793,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 85F with DM, PVD, CHF and deafness, admitted for altered mental status,\n triggered and transferred to the MICU for hypotension refractory to\n fluid resuscitation. Patient seen by nutrition for poor po\n consult. RN notes, patient needs to be fed, decreased po\n was\n on diabetic/heart healthy soft diet with thin liquids. Patient has\n been NPO since transfer to ICU. RN, feeding patient pills crushed\n in applesauce, tolerating well however, patient very sleepy, difficult\n to wake up.\n Recommendations:\n 1. Resume diet when medically feasible\n recommend regular diet\n to increase menu choices\n 2. Will resume po supplement (Boost Glucose Control) when diet\n resumes\n 3. Will follow to check po\ns, page if questions *\n 4. Electronically signed by , RD, LDN\n 12:49\n 5.\n 6.\n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 690812,
"text": "85F with history of DM2 HTN, PVD, and AV block s/p PPM and CM with ICD\n in place who was found with AMS at home. She lives at home with her\n schizophrenic son. The fire department broke into the home, after\n neighbors heard moaning from inside, and found her in a wheelchair,\n moaning and crying.\n HCP, niece , is RN here, and describes\n patient MS over the past few months, with deafness\n (refused hearing aid) and forgetfullness. 2 weeks ago pt was awake and\n responsive, but due to worsening dementia and deafness it\n communication is difficult. She has not been in to see her PCP for\n several months and HHA services were discontinued in , altough she\n does have a weekly VNA. Apparently the house she shares with her\n schizophrenic son is in squalor, frequently without food. She is\n uncertain what medications the patient takes and if her son provides\n them for her. Patient has refused nursing home in the past.\n In the ED, initial VS: 87 160/86 18 91 FSBS 221. She was minimally\n oriented, uncooperative. She was agitated, moaning and inconsolable.\n Complained of back pain which is apparently chronic for her. She looked\n dry on exam. She was given levaquin given her history of legionella\n pneumonia in the past. Her CXR was unremarkable. Her head CT did not\n show any new lesions. UA normal. Her labs showed a normal CBC/diff,\n BUN/Cr 23/1.2, prior cr had been around 1.2-1.4. Trop 0.03 at baseline.\n She was given 2L IV NS as well as a total of 5mg haldol for agitation,\n several doses of IV morphine and 4mg of ondansetron. Social work and\n Elder care were notified of patient and will be following her care\n here. She was admitted to the medicine service for altered mental\n status and possible placement..\n On arrival to the floor the patient was sleeping, arousable to light\n touch. Responsive, but moaning, complaining of back pain. Communication\n difficult due to hearing loss. Not able to respond to any orientation\n questions. Pt diagnosed with UTI, started on Ampicillin.\n Since admission low grade fever x2 days, currently on d3 of Ampicillin\n for UTI. Geriatrics, Podiatry and Vascular Surgery services were\n consulted. SW c/s for placement. Today at 4pm VS check, BP 74/p, pt\n triggered for hypotension. After NS 1750 bolus on floor transferred to\n MICU.\n MICU: No access to left triple lumen IJ placed. Remained normotensive\n since admission with no further intervention.\n Events: C/O in AM. Sleeping but arouses to voice. AM meds via\n crushed in applesauce, wound care done. Started on Po Thiamine. Noted\n while sleeping RR would fluctuate between shallow and normal breathing\n w/ rare 1\n 2 sec apnea- no de-saturations. UOP good and >100cc/hr.\n Awaiting results cardiac echo.\n Hypotension (not Shock)\n Assessment:\n BP low of 96/45 while sleeping in AM, currently SBP while in MICU >100/\n Action:\n No interventions, cont off all BP meds\n Response:\n No acute change\n Plan:\n Cont to monitor, holding all BP medications\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DEHYDRATION;ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 85 kg\n Daily weight:\n Allergies/Reactions:\n Lipitor (Oral) (Atorvastatin Calcium)\n elevation of li\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: CHF, Hypertension, Pacemaker\n Additional history: PVD s/p bypass 07, severe HOH, Lt heel ulcer,\n cardiomyopathy, MR, GERD, osteoporosis, vertebral disc surgery with\n hardware, legionella pna, hypothyroidism, b/l cataract surgery.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:55\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 337 mL\n 24h total out:\n 1,610 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:19 AM\n Potassium:\n 3.9 mEq/L\n 03:19 AM\n Chloride:\n 111 mEq/L\n 03:19 AM\n CO2:\n 21 mEq/L\n 03:19 AM\n BUN:\n 13 mg/dL\n 03:19 AM\n Creatinine:\n 0.9 mg/dL\n 03:19 AM\n Glucose:\n 186 mg/dL\n 03:19 AM\n Hematocrit:\n 34.8 %\n 03:19 AM\n Finger Stick Glucose:\n 153\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 2\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 690817,
"text": "Addendum\n.patient noted to have periods of apnea but does not\n desaturate, RT informed, team came to review, attending aware\npatient\n will still be DC to floor but with telemetry/team on floor informed\n along with RT ? for sleep study/auto-set\n"
},
{
"category": "Echo",
"chartdate": "2154-07-29 00:00:00.000",
"description": "Report",
"row_id": 84338,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. Diabetes. Pacer.\nHeight: (in) 65\nWeight (lb): 168\nBSA (m2): 1.84 m2\nBP (mm Hg): 103/55\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. [Intrinsic\nRV systolic function likely more depressed given the severity of TR].\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe right atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is severe global left ventricular hypokinesis.\nThe distal anterior and lateral walls contract best (LVEF = 20 %). Right\nventricular chamber size is dilated with free wall hypokinesis. [Intrinsic\nfunction may be more depressed given the severity of tricuspid regurgitation.]\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral leaflets are mildly\nthickened. Moderate (2+) mitral regurgitation is seen. There is moderate\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , global left\nventricular systolic function is more depressed and the heart rate is now\nfaster. Trace aortic regurgitation was also present on review of the prior\nstudy. The severity of tricuspid regurgitation and the estimated pulmonary\nartery systolic pressure are now lower.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-07 00:00:00.000",
"description": "Report",
"row_id": 206398,
"text": "Demand ventricular pacing with possible underlying atrial bradycardia. Compared\nto the previous tracing of there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-07-28 00:00:00.000",
"description": "Report",
"row_id": 206401,
"text": "Undetermined rhythm - possible sinus rhythm with pseudo-fused ventricularly\npaced beats. Assessment of pacemaker is indicated.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-07-25 00:00:00.000",
"description": "Report",
"row_id": 206402,
"text": "Ventricular paced rhythm with atrial ectopy which is ventricular sensed with\ncapture. Compared to the previous tracing of no diagnostic interim\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2154-07-24 00:00:00.000",
"description": "Report",
"row_id": 206403,
"text": "Sinus rhythm and ventricular paced rhythm as well as intrinsic A-V conduction.\nCompared to the previous tracing there is intrinsic A-V conduction as well as\natrial ectopy. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-02 00:00:00.000",
"description": "Report",
"row_id": 206399,
"text": "Demand ventricular pacing with possibly underlying atrial braydcardia.\nIntrinsically conducted QRS complexes seem to be of right bundle-branch block\nmorphology. Compared to prior tracing of there may be a few beats\nwhich are not paced.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-07-30 00:00:00.000",
"description": "Report",
"row_id": 206400,
"text": "Sinus bradycardia, rate in the high 50's, with the short cycles being\nconducted. The long cycles are relatively fast junctional escape since the\nmorphology appears the same as the conducted beats. During the conducted beats\nthe P-R interval is long. Marked left axis deviation and intraventricular\nconduction delay of left bundle-branch block type. Since the previous tracing\nno significant change but these findings are more appreciated on the previous\ntracing. The tracing before that suggests ventricular pacing. Since the\nQRS complexes in both tracings are similar, they all may be paced. Clinical\ncorrelation is suggested. The tracing from probably shows some\nnormally conducted beats during the recording of leads I, II and III and the\nprecordial leads. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-07-28 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1091479,
"text": " 9:05 PM\n CHEST (SINGLE VIEW); -76 BY SAME PHYSICIAN # \n Reason: eval for PNA.\n Admitting Diagnosis: DEHYDRATION;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with ?new PNA\n REASON FOR THIS EXAMINATION:\n eval for PNA.\n ______________________________________________________________________________\n WET READ: EAGg SUN 10:41 PM\n Cardiomegaly, prominent central vessels and slight cephalization compared to\n prior. ?? mild septal thickening. Would favor overhydration, but infection not\n excluded. ?? retrocardiac opacity.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:04 P.M. \n\n HISTORY: Fever. Recently hypotensive.\n\n COMPARISON: AP chest compared to 7:55 p.m. on :\n\n Heterogeneous opacification at both lung bases has improved though small areas\n of opacity remain in both. Central pulmonary vasculature is less engorged,\n but severe cardiomegaly, recently increased persists, and small bilateral\n pleural effusions may have decreased. The interval changes are best explained\n by improving cardiac decompensation but the nature of residual opacities at\n both lung bases is equivocal, either atelectasis or pneumonia. Left internal\n jugular line ends in the mid SVC. Transvenous right atrial and right\n ventricular pacer leads are unchanged over several months. No pneumothorax.\n\n"
}
] |
23,801 | 116,066 | Upon admission, on the symphysis was widely malplaced at least 4 cm and the patient was significantly symptomatic and required a pelvic bandage to relieve comfort. He remained hemodynamically stable on the day of admission. He now () presents for open reduction internal fixation ABC to pelvic fracture with plating of the symphysis. The patient tolerated the procedure well and was taken to the recovery room without incident. Dr. was present through the entire procedure. The patient was brought to CC6 and placed on lovenox for DVT prophylaxis. He was evaluated by physical therapy and occupational therapy and did well. His diabetes was kept in good control. On the patient's potassium was low at 3.0, so it was replaced with 40 mEq IV potassium. It was found to be low again on and another 40 mEq of potassium was given. His potassium stabilized with po. Hospital course was otherwise without incident. He is being discharged today to his home in stable condition. he was cleared by pt and was okay to be dc'd home with pt and ot | CT PELVIS, ORTHO: There is separation of the pubic symphysis, measuring 28 mm. TECHNIQUE: MDCT imaging of the pelvis was performed without intravenous contrast. There are bilateral fat containing inguinal hernias. There is no step off at the symphysis pubis in coronal and transverse planes. IMPRESSION: Status post ORIF of diastasis of the symphysis pubis. Frontal view of the pelvis demonstrates marked diastasis of the pubic symphysis measuring 3.8 cm. COMPARISON: AP chest x-ray, trauma, dated . No obvious traumatic injury within the chest. No obvious pneumothorax is seen. A single collection measuring 70 x 68 mm is seen superior to the right pubic ramus. Bilateral sacroiliac joints are displaced laterally, and measure 11 mm on the right, and 10 mm on the left. The cardiomediastinal silhouette is within normal limits. Open book pelvic fracture, with 28 mm separation of the pubic symphysis, 11 mm separation of the right sacroiliac joint, and 10 mm separation of the left sacroiliac joint. IMPRESSION: Diastasis of the symphysis pubis. However, the bladder is not distended with contrast and a small underlying bladder or urethral injury cannot be excluded. Osseous structures within the chest appear unremarkable. Cardiac and mediastinal contours are within normal limits allowing for technique. No fractures identified within the pelvis. Supine frontal views of the chest and pelvis on a trauma board. Limited imaging of the adjacent knee and ankle is unremarkable. There is no active contrast extracation from the bladder. No intravenous contrast was administered per protocol. IMPRESSION: No fracture. No other definite fractures are identified. There is no pulmonary edema. WET READ VERSION #1 MMBn MON 11:48 PM 1) Open book pelvic fracture with 28mm separation of pubic symphsis, and separation of bilateral SI joints. On this single image, there is no definite evidence of extravasation. 2) Suboptimal assessment of blader and bladder injruy or leak cannot be ruled out. IMPRESSION: No evidence of CHF. his injury is an open book pelvic fx.mh: niddm and htn. The right hemipelvis is somewhat superiorly displaced compared with the left. 2) No evidence of bladder injury. There are no focal lesions. No fractures are identified. There is blunting of left costophrenic sulcus which may indicate small pleural effusion. 11:55 AM PELVIS (AP, INLET & OUTLET); ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # Reason: ORIF PUBIC SYMPHYSIS Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE FINAL REPORT EXAM ORDER: Pelvis. There is a urethral catheter in place with a small amount of contrast material seen within the bladder. CHEST: A single upright AP view at 1230 hours lung volumes. Seven intra-operative views of the symphysis pubis were obtained during the open reduction and internal fixation of diastasis of symphysis pubis. Extraperitoneal high-density fluid consistent with blood. There is no evidence of active contrast extravasation, but the bladder is not distended and therefore a bladder injury cannot be excluded. 3) Large amount of extraperitoneal blood, and single large hematoma. 3) Large amount of extraperitoneal blood, and single large hematoma. Contrast is seen within a collapsed bladder. HISTORY: Status post trauma. A large collection is seen above the right superior pubic ramus, and measures 70 x 68 mm. AP AND LATERAL TIBIA/FIBULA, WITH SINGLE VIEW LEFT ANKLE: The bones are well mineralized. Sinus rhythmNormal ECGNo previous tracing available for comparison No prior studies. The exam is limited due to motion artifact. DR. DR. There is no sign of fracture or malalignment. Blood is also seen tracking into the right rectus abdominis muscle, but remains extraperitoneal. FINDINGS: Lung volumes are reduced. Retrograde contrast was injected into the bladder via a Foley catheter. High-density fluid/blood is seen throughout the subcutaneous soft tissues. he had no loc at scene and remembers all events. IMPRESSION: 1. FINAL REPORT INDICATION: 47-year-old man with pelvic fracture. The lungs appear clear. HISTORY: Increased tachycardia. pt on asa, and glucophage.pt admitted to t/sicu at 2330. pt alert and oriented times three. Two malleable plates have been inserted across the symphysis pubis with multiple cortical screws. 4. he was admitted to hospital then transfered to . 11:02 AM CHEST (PORTABLE AP) Clip # Reason: r/o pna MEDICAL CONDITION: 47 year old man with increased tachycardia REASON FOR THIS EXAMINATION: r/o pna FINAL REPORT EXAM ORDER: Chest. 9:16 PM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: 47 year old man with pelvic fracture Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE Field of view: 36 MEDICAL CONDITION: 47 year old man with pelvic fracture REASON FOR THIS EXAMINATION: 47 year old man with pelvic fracture No contraindications for IV contrast WET READ: MMBn TUE 12:06 AM 1) Open book pelvic fracture with 28mm separation of pubic symphsis, and separation of bilateral SI joints. (Over) 9:16 PM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: 47 year old man with pelvic fracture Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE Field of view: 36 FINAL REPORT (Cont) 2. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1573533,
"text": "nsg admission note:\n pt is a 47 yr old man who was in a motorcycle crash. cycle t-boned a car. he was admitted to hospital then transfered to . his injury is an open book pelvic fx.\nmh: niddm and htn. pt on asa, and glucophage.\npt admitted to t/sicu at 2330. pt alert and oriented times three. he had no loc at scene and remembers all events.\n cv stable hr sinus 80's to 90's.\nhem: hct 34 on admission to hosp now 30 times 2 checks.\nnpo abd soft hypoactive bowel sounds.\nivf at 100cs per hr.\ncovered with reg insulin per sliding scale.\nreceiving ms 5 mgs iv for pain with good effect.\ns stable with some drop in hct.\np continuw with q4 hr hct checks.\nto or on wed for repair of pelvic fx\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890003,
"text": " 11:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with increased tachycardia\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Increased tachycardia.\n\n CHEST: A single upright AP view at 1230 hours lung volumes. The\n exam is limited due to motion artifact. There is no pulmonary edema. There\n is blunting of left costophrenic sulcus which may indicate small pleural\n effusion. The cardiomediastinal silhouette is within normal limits.\n\n IMPRESSION: No evidence of CHF.\n\n\n DR. \n"
},
{
"category": "ECG",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 204260,
"text": "Sinus rhythm\nNormal ECG\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-17 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 889252,
"text": " 9:16 PM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: 47 year old man with pelvic fracture\n Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with pelvic fracture\n REASON FOR THIS EXAMINATION:\n 47 year old man with pelvic fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn TUE 12:06 AM\n 1) Open book pelvic fracture with 28mm separation of pubic symphsis, and\n separation of bilateral SI joints.\n 2) Suboptimal assessment of blader and bladder injruy or leak cannot be ruled\n out.\n 3) Large amount of extraperitoneal blood, and single large hematoma.\n WET READ VERSION #1 MMBn MON 11:48 PM\n 1) Open book pelvic fracture with 28mm separation of pubic symphsis, and\n separation of bilateral SI joints.\n 2) No evidence of bladder injury.\n 3) Large amount of extraperitoneal blood, and single large hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with pelvic fracture. Evaluate.\n\n COMPARISON: AP chest x-ray, trauma, dated .\n\n TECHNIQUE: MDCT imaging of the pelvis was performed without intravenous\n contrast. No intravenous contrast was administered per protocol. Retrograde\n contrast was injected into the bladder via a Foley catheter.\n\n CT PELVIS, ORTHO: There is separation of the pubic symphysis, measuring 28\n mm. The right hemipelvis is somewhat superiorly displaced compared with the\n left. Bilateral sacroiliac joints are displaced laterally, and measure 11 mm\n on the right, and 10 mm on the left. No fractures identified within the\n pelvis.\n\n Contrast is seen within a collapsed bladder. There is no evidence of active\n contrast extravasation, but the bladder is not distended and therefore a\n bladder injury cannot be excluded.\n\n High-density fluid/blood is seen throughout the subcutaneous soft tissues. A\n large collection is seen above the right superior pubic ramus, and measures 70\n x 68 mm. Blood is also seen tracking into the right rectus abdominis muscle,\n but remains extraperitoneal. There are bilateral fat containing inguinal\n hernias.\n\n IMPRESSION:\n 1. Open book pelvic fracture, with 28 mm separation of the pubic symphysis,\n 11 mm separation of the right sacroiliac joint, and 10 mm separation of the\n left sacroiliac joint.\n (Over)\n\n 9:16 PM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: 47 year old man with pelvic fracture\n Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. No fractures are identified.\n 3. There is no active contrast extracation from the bladder. However, the\n bladder is not distended with contrast and a small underlying bladder or\n urethral injury cannot be excluded.\n 4. Extraperitoneal high-density fluid consistent with blood. A single\n collection measuring 70 x 68 mm is seen superior to the right pubic ramus.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-17 00:00:00.000",
"description": "L TIB/FIB (AP & LAT) SOFT TISSUE LEFT",
"row_id": 889253,
"text": " 9:17 PM\n TIB/FIB (AP & LAT) SOFT TISSUE LEFT Clip # \n Reason: 47 year old man s/p motorcycle accident\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p motorcycle accident\n REASON FOR THIS EXAMINATION:\n 47 year old man s/p motorcycle accident\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man status post motorcycle accident. Evaluate.\n\n AP AND LATERAL TIBIA/FIBULA, WITH SINGLE VIEW LEFT ANKLE: The bones are well\n mineralized. There are no focal lesions. There is no sign of fracture or\n malalignment. Limited imaging of the adjacent knee and ankle is unremarkable.\n The are calcaneal bone spurs.\n\n IMPRESSION: No fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-19 00:00:00.000",
"description": "PELVIS (AP, INLET & OUTLET)",
"row_id": 889488,
"text": " 11:55 AM\n PELVIS (AP, INLET & OUTLET); ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: ORIF PUBIC SYMPHYSIS\n Admitting Diagnosis: BLUNT TRAUMA;PELVIC FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Pelvis.\n\n HISTORY: Status post trauma.\n\n Seven intra-operative views of the symphysis pubis were obtained during the\n open reduction and internal fixation of diastasis of symphysis pubis. Two\n malleable plates have been inserted across the symphysis pubis with multiple\n cortical screws. The alignment is well maintained. There is no step off at\n the symphysis pubis in coronal and transverse planes.\n\n IMPRESSION: Status post ORIF of diastasis of the symphysis pubis.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2129-10-17 00:00:00.000",
"description": "P TRAUMA #2 (AP CXR & PELVIS PORT) PORT",
"row_id": 889246,
"text": " 8:01 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) PORT Clip # \n Reason: eval chest and pelvis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with s/p mvc/pelvic fx\n REASON FOR THIS EXAMINATION:\n eval chest and pelvis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old in motor vehicle accident.\n\n Supine frontal views of the chest and pelvis on a trauma board. No prior\n studies.\n\n FINDINGS: Lung volumes are reduced. Cardiac and mediastinal contours are\n within normal limits allowing for technique. The lungs appear clear. No\n obvious pneumothorax is seen. Osseous structures within the chest appear\n unremarkable.\n\n Frontal view of the pelvis demonstrates marked diastasis of the pubic\n symphysis measuring 3.8 cm. No other definite fractures are identified.\n There is a urethral catheter in place with a small amount of contrast material\n seen within the bladder. On this single image, there is no definite evidence\n of extravasation.\n\n IMPRESSION:\n\n Diastasis of the symphysis pubis. No obvious traumatic injury within the\n chest.\n\n\n"
}
] |
4,811 | 126,022 | Further workup revealed worsening opacification in the left lower lobe, extrinsically obstructing tumor compressing on the left bronchus. She was treated with Zosyn for presumptive postobstructive pneumonia. Her course was complicated by tachycardia, atrial flutter. She was maintained on Amiodarone drip and converted to sinus within 24 hours. After ongoing discussions with the pulmonary team regarding management of the endobronchial lesion, the patient decided she did not want to be intubated (which would be required to be perform an endobronchial procedure). Her code status changed to DNR/DNI. She was maintained on steroids and antibiotics until she further decompensated for a respiratory standpoint. This further decompensation was attributed to progression of her underlying carcinoma. In discussions with the patient's family and partner, it was decided during this terminal respiratory decompensation to proceed to comfort care only. At that time, antibiotics and all other aggressive measures were withdrawn. The patient expired at 2:00 p.m. on . | Reevaluate for effusionHeight: (in) 62Weight (lb): 157BSA (m2): 1.73 m2BP (mm Hg): 154/70Status: InpatientDate/Time: at 17:34Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Plan to cont IVAB and supportive medical care as pt cont to decide on plan of care.GI- Abd soft and slightly distended, +BS, no BM. PATIENT/TEST INFORMATION:Indication: S/P pericardiocentesis.Height: (in) 62Weight (lb): 157BSA (m2): 1.73 m2BP (mm Hg): 117/89Status: InpatientDate/Time: at 09:47Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). There isno pericardial effusion.Compared with the prior report (tape unavailable) of , the modertatepericardial effusion has resolved. Pt with 1 hl #20g in r arm, MDs aware.GI- +bs, abd soft, no bm, poor appetite sec to tenous resp status. Advance to norm diet, tolerating well.GU- Adquate u/o/hr, please refer to CV for FB.Skin- Several areas of ecchymosis from cath, PICC placement and several attempts at pt has a low platelet count. Positive serum markers.Height: (in) 65Weight (lb): 180BSA (m2): 1.89 m2BP (mm Hg): 115/70HR (bpm): 100Status: InpatientDate/Time: at 03:45Test: Portable TTE(Complete)Doppler: Focused pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:The heart rate is ~100/min.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). Plan to continue to assess, care comfort focused.CV- Hemodynamically stable, HR 100-110, ST, no ectopy. Am K+ 3.2, will replete.Heme- Hct down to 26, no signs of bleeding.GI- +bs, poor appetite, taking po meds with sips, no bm.GU- Foley to cd, responded to iv lasix,(see careview).Skin- warm, dry and intact, ecchymotic area to r groin from cath procedure.Social- at bedside, multiple visitors earlier in the shift.Plan- To re-address DNI/DNR status with Pt. Overall left ventricular systolic functionis normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion.MITRAL VALVE: The mitral valve leaflets are structurally normal.PERICARDIUM: There is no pericardial effusion.Conclusions:Limited study. Thereis sustained right atrial collapse, consistent with low filling pressures orvery early tamponade.Clinical correlation and a follow-up study are suggested. BP 110's/60's.Adequate iv access- #20 PIV/4FR vaxcel PICC. There is no resting left ventricular outflowtract obstruction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve appears structurally normal with trivial mitralregurgitation.TRICUSPID VALVE: There is mild pulmonary artery systolic hypertension.PERICARDIUM: The pericardium appears thickened. Cont on IVAB to tx pna.GI- Abd soft, hypoactive BS, no BM. Nonproductive cough, rhonchorus LS throughout-diminished on L side. )ENDO: STABLE BS ON IV HYDROCORTISONE. Standing dose of ativan given at , slept in short naps, dysneic with respositioning.CV- Hr 100s - 120s, st with freq pacs, occ short burst of svt on the 150s, md aware. Needs sputum sent for pneumocystis.GI/FE - Abd soft. pt dehydrated. Hypoactive BS. Sinus tachycardiaInferior ST elevation - ? Sinus tachycardiaInferior elevation with deeper Q waves probable acute inferior infarctSince previous tracing, deeper inferior Q waves and QRS changes in lead V2 - ?lead placement -back to baseline Sinus tachycardiaInferior ST elevation - consider evolving inferior myocardial infarctionLow QRS voltages in precordial leadsSince last ECG, no significant change C enzymes sent as pt has hx of elevated troponin levels and admission EKG + ST elevations inferiorly. Drain site D+I. Protonix prophylactically. Pt takes own HRT.ID - Afeb. injury/ ischemiaLow QRS voltages in precordial leadsEarly repolarizationSince previous tracing, QRS changes in lead V2 - ? CT + for penumopericardium + LUL and LLL collapse with cut off L bronchus, neg for PE. Receiving hydrocortisone iv q8hrs. ST-T wave changes with modest inferiorST segment elevation - clinical correlation is suggested for possibleinjury/ischemia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Weak palp DP and PT pulses. ST-T wave changes with modest inferior ST segmentelevation - clinical correlation is suggested for possible acuteinjury/ischemia. ST-T wave changes with inferior ST segmentelevation - consider acute injury/ischemia. ST-T wave changes with inferior ST segmentelevation - clinical correlation is suggested for possible injury/ischemia.Since the previous tracing of no significant change.TRACING #4 Addendum - Heme - Hct 32.9 this am ( previously 42.2). MD notified. Pt has T+S in BB. Since the previous tracingof changes as outlined are now seen.TRACING #1 Diffuse audible rhonchi on lung exam. Sinus rhythm. Should pt become hypotensive or increasingly tachycardic new pericardial drain will be placed. Cardiology consulted. Pt c/o feeling less sob after drain was placed. BP 11-125/50-70 via NBP. Plan is for echo this am.HR 11-125 ST, no ectopy noted. Dry unprod cough. Since the previous tracing easrlier the same date the heartrate has decreased.TRACING #2 Pt with poor access. + pulsus paradoxes 20 pts. No ares of breakdown noted.Access - #20 peripheral iv right forearm. 7p to 7a Micu Progress NoteNeuro - Alert and oriented x 3. lead placement Current antibiotic regime consists of po bactrim and zosyn iv for PNA. Low voltages. No obvious sensory deficits.C-V - Received pt one hr after she had returned from cath lab after having her pericardial effusion tapped. Low voltage. Low voltage. Low voltage. Maintenance IV NS initiated at 150ccs/hr x 2 liters. Urine output 15-60ccs/hr via foley cath.Endo - RISS. Pt denies any episodes of CP this shift.Resp - Maintained on 100% NRB throughout the noc. remains appropriate and cooperative.cv:remains in nsr to st without ectopy,hr 100 to 112,bp stable.had ekg done this am and cardiac echo at bedside.echo revealed preserved ef about complete resolution of pericadial effusion.pericardial drain in draining small amount of blood tinged drainage.drain remains patent and has been instilled q2 hrs with heparin flush 10units per cc with total of 5cc each instillation.resp:resp rate 20 to 26,spo2 92 to 95% remains on nrb at 15/l.breath sounds rhonchorous and diminished on left lower lobe.has strong cough but nonproductive.has left lower lobe bronchous obstruction ,unsure if tumor or infection.plan for bronch today or tomorrow.platlets are low and bactrim will be dcd after bronch if neg for pcp.gi:abd large and soft with positive bowel sounds present.remains npo currently except for po meds.gu:foley to cd draining cloudy yellow urine.had lasix 20mg iv with good effect.spo2 did not improve after diureses.access:has #20 peripheral iv wnl.team to place multilumen line.social:friend called and spoke with pt.id:remains on zosyn and bactrim ds. | 21 | [
{
"category": "Radiology",
"chartdate": "2112-02-03 00:00:00.000",
"description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)",
"row_id": 783192,
"text": " 3:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs access for blood products, iv pain meds; very poor per\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with lung cancer, admitted with sob found to have progression\n of disease.\n REASON FOR THIS EXAMINATION:\n Needs access for blood products, iv pain meds; very poor peripheral access;\n failed iv attempted by iv service.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 56 y/o female with lung cancer, access for blood products, IV\n pain medications.\n\n PROCEDURE/TECHNIQUE/FINDINGS: The procedure was described to the patient and\n informed consent was obtained. Access was gained to the right basilic vein\n under son guidance as no superficial veins were palpable. A 5 French\n dual lumen PICC was advanced over a guidewire and trimmed to appropriate\n length. An X-ray obtained following placement documents the tip at the cavo-\n atrial junction. Incidental note is made of fullness in the right hilar\n region.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successfull placement of a 5 French dual lumen PICC via the\n right basilic vein, with the tip at the cavo-atrial junction, ready for use.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-03 00:00:00.000",
"description": "Report",
"row_id": 1324959,
"text": "PMICU Nursing Progress Note 7a-7p\n Review of Systems\n\nNeuro- AxOx3, emotionally labile due to very difficult end of life decision making. Appropriate affect and cooperative w/ care. PT's main support system, at bedside- plans to stay o/n. Several discussions w/ pt regarding code status today, remains full code. Plan to readdress tomorrow. Recieved 1 mg of IV ativan prior to travelling to IR today w/ good effect, also received am standing dose of PO ativan. Recieved 1 dose of oxycodone for back pn this afternoon, prior to trip to IR- otherwise no c/o pn. Plan to continue to assess, care comfort focused.\n\nCV- Hemodynamically stable, HR 100-110, ST, no ectopy. BP 110-130/50's. Pericardial drain removed today by cardiology, site has a dry sterile dsg, w/ no drainage noted since removal. HCT decreased to 27.3 since admission- plan to cont to follow.\n\n Pt remains on 15 L non-rebreather, sats high 80's-low 90's. LS diminished and rhonchorus throughout. L lung consolidation per chest xray, r/t tumor progression per team. Plan to cont IVAB and supportive medical care as pt cont to decide on plan of care.\n\nGI- Abd soft and slightly distended, +BS, no BM. Advance to norm diet, tolerating well.\n\nGU- Adquate u/o/hr, please refer to CV for FB.\n\nSkin- Several areas of ecchymosis from cath, PICC placement and several attempts at pt has a low platelet count. Cont freq truns and supportive care.\n\nPlan- Cont supportive medical care and follow up w/ pt and team on plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-04 00:00:00.000",
"description": "Report",
"row_id": 1324960,
"text": "Nursing Note: 7pm - 7am\nResp- Very dyspneic overnight, using accessory muscle to breathe, very wet, audible crackles, ivf dc'ed, lasix 20mg iv given a 0210, responded well, tfb neg 760cc at 0500. Remains on NRB 100%, strong cough, but looking more tired, MD aware, Pt and proxy both reiterated overnight that she does not want to be intubated, she wanted to be made comfortable on mso4 if she becomes unstable. NO DNI order written.\n\nN- Alert and oriented x3, very depressed at times, freinds in until mn for support, her health care proxy at bedside overnight. Standing dose of ativan given at , slept in short naps, dysneic with respositioning.\n\nCV- Hr 100s - 120s, st with freq pacs, occ short burst of svt on the 150s, md aware. Bp stable 90/54 - 112/56. Am K+ 3.2, will replete.\n\nHeme- Hct down to 26, no signs of bleeding.\n\nGI- +bs, poor appetite, taking po meds with sips, no bm.\n\nGU- Foley to cd, responded to iv lasix,(see careview).\n\nSkin- warm, dry and intact, ecchymotic area to r groin from cath procedure.\n\nSocial- at bedside, multiple visitors earlier in the shift.\n\nPlan- To re-address DNI/DNR status with Pt. Offer support to Pt and family as they make end of life decisions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 1324957,
"text": "update\n\npericardial drain remains patent with minimal drainage.right groin remains ecchymotic and ecchymosis extends to right thigh.no hematoma is felt at site.both feet slightly cool to touch with bil dp and pt pulses present.pt complaint of back pain.pt was medicated with oxycodone with good relief.dr came to speak with pt and her friend .dr explained about the bronchoscopy and explained that, patient may not be able to come off the ventilator after the procedure.dr explained about comfort measures also.pt will decide what she would like done and inform doctors .team is aware that labs were not able to be drawn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-03 00:00:00.000",
"description": "Report",
"row_id": 1324958,
"text": "Nursing Note: 7pm - 7am\nResp- remains on NRB 100%, sats in the low 90s occ desat to mid 80s with activities, very labored breathing, but Pt did indicate that she feels much better than yesterday. Still with a strong cough, no sputum, continue on Q8h hyrocortisones and iv zosyn, bactrim dc'ed.\n\nCV- Hr 90s - 110s, sr/st, no ectopy, denies cp. Bp stable; 92/49 - 115/54. Fem stick for labs done by MD, K+ back at 3.4, ivf changed to ns with 40meq kcl at 100cc/o. Poor stick, no am labs drawn. Pericardial drain in place to gravity, flushed with 5cc heparin 10u/o q2h, no drainage overnight, sm amt serosanq drainage at site, dsd changed.\n\nHeme- No signs of active bld, hct 27, plt still low at 41.\n\nN- ALert and oriented x3, teary eyed, still not sure about if she wanted to be intubated for a bronch or not as it was explained to her by her oncologist that there is a possibility she might not come off. Her friend and proxy was in til 0000, she will be back in the morning to make the decision with her. Slept in short naps after pm dose of ativan PO.\n\n Pt with 1 hl #20g in r arm, MDs aware.\n\nGI- +bs, abd soft, no bm, poor appetite sec to tenous resp status. Kept npo post mn for ? bronch today. Swallowing pills okay.\n\nGU- Voiding 30 - 40cc/o amber colored urine via foley cath.\n\nSkin- warm, dry and intact. r groin ecchymotic area, sm staining on dsg, no hematoma.\n\nSocial- Freind is her proxy, she is very involved in her care.\n\n Pt will make decision today whether she will be bronch or not, Proxy to be called if Pt condition deteriorate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-04 00:00:00.000",
"description": "Report",
"row_id": 1324961,
"text": "PMICU Nursing Progress Note 7a-7p\n\n Pt and proxy spoke with team this am with nsg present, Pt changed code status from to full to DNR/DNI. The plan is to suppport her medically for palliative purposes with a goal of stabilzing her so that she may go home with hospice support. The Hospice team is planning on coming tomorrow to evaluate her for home care.\n\nReview of Systems\n\n Pt 3, cooperative w/ care and very pleasant. No complaints of pn, cont on standing dose of PO ativan w/ good effect. PT met w/ palliative care RN today and discussed goals. Pt has had to make several difficult decisions in last several days, cont to offer emotional support. Primary support system at bedside.\n\nCV- HR 160's, aflutter, since 0730 am. SBP 70-90's/30-50's. Initally recieved adenosine to determine rhythm. Next pt recieved a total of 40 mg of IVP Diltiazem in 10 mg divided doses w/ good effect initally but consistently returned to HR 160's. PT then started on a diltiazem gtt, this was titrated up to a max of 15 mg/hr w/ no effect. Pt transitioned to amiodorone gtt. She cont to be loaded on amiodorone per protocol. At 1530, pt converted to NSR and HR returned to baseline 90-100. Currently being transfused w/ 1 U PRBC's to increase oxygen caryying capacity and decrease workload of heart.\n\nResp- Cont on 100% NRB, sats 87-92%. RR 20's, labored, denies SOB. Nonproductive cough, rhonchorus LS throughout-diminished on L side. Cont on IVAB to tx pna.\n\nGI- Abd soft, hypoactive BS, no BM. Attempting to eat sm meals.\n\nGU_ Adequate u/o/hr, yellow, clr.\n\nSkin- Intact.\n\nPlan- Cont supportive medical care o/n.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-05 00:00:00.000",
"description": "Report",
"row_id": 1324962,
"text": "Nursing Note (1900hrs-0700am)\n\nNeuro: A&ox3. Multiple visitors evening; spirits fairly good. Partner resting on cot noc. Pt slept throughout most of shift; ativan at hs.\n\nCV: Afebrile. HR 90-110's, NSR w/amiodarone 0.5mg/hr. BP 110's/60's.\nAdequate iv access- #20 PIV/4FR vaxcel PICC. Skin dry,pink.\n\nResp: LS essentially coarse throughout on NRB at 15L. (+)DOE/movement.\nHOB mx'd at 90; min tolerance to turning to left side. Maximum comfort at 90 degrees and to right or supine.\n\nGI/GU: Sipping po's noc, no N/V. Adequate u/o\n\nPlan: Hospice care facility to meet with patient & friend today. Discharge soon to cont comfort care in preferred enviroment.\n"
},
{
"category": "Echo",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 65987,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/P pericardiocentesis.\nHeight: (in) 62\nWeight (lb): 157\nBSA (m2): 1.73 m2\nBP (mm Hg): 117/89\nStatus: Inpatient\nDate/Time: at 09:47\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: The pericardium appears thickened. There is no evidence of\npericardial constriction.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nLeft ventricular chamber sizes, wall thicknesses, and systolic function are\nnormal. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal without mitral regurgitation. There is mild pulmonary artery systolic\nhypertension. The pericardium appears thickened (vs. small organized\neffusion). Septal motion and transmitral Doppler do not suggest constriction.\n\nCompared with the prior post-tap study of , thickened pericardium (vs.\nsmall organized effusion) is more apparent (likely related to technical issues\nof only subcostal views obtained on prior study and not clinical change).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-02-01 00:00:00.000",
"description": "Report",
"row_id": 65988,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Left ventricular function. Shortness of breath. Positive serum markers.\nHeight: (in) 65\nWeight (lb): 180\nBSA (m2): 1.89 m2\nBP (mm Hg): 115/70\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 03:45\nTest: Portable TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe heart rate is ~100/min.\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: The right ventricular cavity is unusually small.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nPERICARDIUM: There is a moderate sized pericardial effusion. There is\nsustained right atrial collapse, consistent with low filling pressures or very\nearly tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Emergency\nstudy performed by the cardiology fellow on call. The cardiology fellow\ninvolved with the patient's care was notified by telephone.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are\ngrossly normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. The right ventricular cavity is\nunusually small. The aortic valve leaflets appear structurally normal with\ngood leaflet excursion. No definite aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. No definite mitral regurgitation is\nseen. There is a moderate sized circumerential relatively echolucent\npericardial effusion extending ~1.5cm around the right atrium (with diastolic\ncollapse), 1.0cm anterior to the right ventricle (which appears somewhat small\nin cavity size), 2.0 cm around the right and left ventricular apex, 1-1.5cm\nlateral to the left ventricle and 1.0cm inferior to the left ventricle. There\nis sustained right atrial collapse, consistent with low filling pressures or\nvery early tamponade.\nClinical correlation and a follow-up study are suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-02-01 00:00:00.000",
"description": "Report",
"row_id": 66044,
"text": "PATIENT/TEST INFORMATION:\nIndication: metastatic lung Ca; s/p pericardiocentesis of 450 cc. Reevaluate for effusion\nHeight: (in) 62\nWeight (lb): 157\nBSA (m2): 1.73 m2\nBP (mm Hg): 154/70\nStatus: Inpatient\nDate/Time: at 17:34\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nLimited study. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral valve leaflets are structurally normal. There is\nno pericardial effusion.\n\nCompared with the prior report (tape unavailable) of , the modertate\npericardial effusion has resolved.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-01 00:00:00.000",
"description": "Report",
"row_id": 1324953,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: ALERT AND ORIENTED. PO ATIVAN THIS AM.\n PT \"TIRED\"..NO SLEEP SINCE YESTERDAY AFTERNOON.\n\n\nCV: TACHY UP TO 120. BP STABLE.\n PEAK TROPONIN 23.8\n\n\nRESP: 100% FACE MASK. RALES/RHONCHI INCREASING.\n INCREASED WORK OF BREATHING IN PM.\n SAT LOWER 88-95%. NP/JUNKY.\n\nRENAL: LABS WNL. URINE OUTPUT DROPPING OFF...\n ? LASIX VS FLUID...\n\nGI: NPO. PO PROTONIX. CA 8.4 PHOS 2.9\n\nHEME: HCT 42.2 PLT UP TO 111 FROM 44 AFTER ONE BAG PLTS.\n COAGS: 14.5 21.8 1.4\n ASA/SC HEPARIN ON HOLD PER TEAM.\n (RECEIVED ASA PO 4:30 PM YESTERDAY IN ER.)\n\nENDO: STABLE BS ON IV HYDROCORTISONE.\n TAKES OWN HORMONE REPLACEMENT THERAPY.\n\nID: AFEBRILE. WBC DOWN TO 11.7(15)\n IV ZOSYN. PO BACTRIM. DOSE PO LEVAQUIN\n X 1 YESTERAY.\n\nCX: BLOOD: PENDING.\n URINE: PENDING.\n SPUTUM: SENT.\n\nSKIN: BRUISING FROM IV SITES.\n\n\nSOCIAL: FRIEND VISITED AND CALLED.\n\nA: POOR RESP STATUS.\nP: AWAIT RESULTS OF PERICARDIAL TAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 1324954,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Alert and oriented x 3. MAE. Follows commands. No obvious sensory deficits.\n\nC-V - Received pt one hr after she had returned from cath lab after having her pericardial effusion tapped. Per report, 450 ccs of fluid was drained during the procedure. Pt wearing knee immobilizer. Remained flat x 6 hrs. No hematoma or bleeding noted from femoral site. Weak palp DP and PT pulses. Drain site D+I. Pericardial drain flushed q 2hrs with 5 ccs of 10 units heparin/ml solution. Pt has drained a total of 320 ccs bloody fluid via drain.\nAt 2130 pt sent for chest CT to r/o PE. CT + for penumopericardium + LUL and LLL collapse with cut off L bronchus, neg for PE. Cardiology consulted. Pericardial drain aspirated for air and blood by cardiologist. + pulsus paradoxes 20 pts. Plan is for echo this am.\nHR 11-125 ST, no ectopy noted. BP 11-125/50-70 via NBP. C enzymes sent as pt has hx of elevated troponin levels and admission EKG + ST elevations inferiorly. Pt denies any episodes of CP this shift.\n\nResp - Maintained on 100% NRB throughout the noc. Pt c/o feeling less sob after drain was placed. Around MN became more sob with 02 sats running 92% on 100%. Chest x-ray done and ABG obtained by MD - 7.47/31/73/23/0/ Sats continued to run 92-97% thereafter with RR in the low 20's. Of note, pt more comfortable and less tachycardic when placed on R side. Diffuse audible rhonchi on lung exam. Dry unprod cough. Needs sputum sent for pneumocystis.\n\nGI/FE - Abd soft. Hypoactive BS. Tolerated cl liqs without difficulty. No stool. Protonix prophylactically. Received 2 fluid boluses, each 250ccs for HR 120s - ? pt dehydrated. Little effect noted from boluses. Maintenance IV NS initiated at 150ccs/hr x 2 liters. Urine output 15-60ccs/hr via foley cath.\n\nEndo - RISS. Receiving hydrocortisone iv q8hrs. Pt takes own HRT.\n\nID - Afeb. Current antibiotic regime consists of po bactrim and zosyn iv for PNA. WBC pend.\n\nSkin - Numerous ecchymotic areas noted on arms bilaterally from previous iv and bld draw sites. No ares of breakdown noted.\n\nAccess - #20 peripheral iv right forearm. Pt with poor access. Very difficult bld draws.\n\nSocial - Friend who is also health care proxy visited last eve. Patient is Full Code. Pt states she wants to be intubated should it be necessary.\n\nA+P - Continue to monitor resp and c-v status closely. Should pt become hypotensive or increasingly tachycardic new pericardial drain will be placed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 1324955,
"text": "Addendum - Heme - Hct 32.9 this am ( previously 42.2). MD notified. Pt has T+S in BB. No intervention at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 1324956,
"text": "nursing progress note see careview for details.\n\nneuro:awake,alert,speech clear.follows commands and moves all extremities with appears normal strenght. remains appropriate and cooperative.\n\ncv:remains in nsr to st without ectopy,hr 100 to 112,bp stable.had ekg done this am and cardiac echo at bedside.echo revealed preserved ef about complete resolution of pericadial effusion.pericardial drain in draining small amount of blood tinged drainage.drain remains patent and has been instilled q2 hrs with heparin flush 10units per cc with total of 5cc each instillation.\n\nresp:resp rate 20 to 26,spo2 92 to 95% remains on nrb at 15/l.breath sounds rhonchorous and diminished on left lower lobe.has strong cough but nonproductive.has left lower lobe bronchous obstruction ,unsure if tumor or infection.plan for bronch today or tomorrow.platlets are low and bactrim will be dcd after bronch if neg for pcp.\n\ngi:abd large and soft with positive bowel sounds present.remains npo currently except for po meds.\n\ngu:foley to cd draining cloudy yellow urine.had lasix 20mg iv with good effect.spo2 did not improve after diureses.\n\naccess:has #20 peripheral iv wnl.team to place multilumen line.\n\nsocial:friend called and spoke with pt.\n\nid:remains on zosyn and bactrim ds.\n"
},
{
"category": "ECG",
"chartdate": "2112-02-03 00:00:00.000",
"description": "Report",
"row_id": 133718,
"text": "Sinus tachycardia\nInferior ST elevation - consider evolving inferior myocardial infarction\nLow QRS voltages in precordial leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2112-02-02 00:00:00.000",
"description": "Report",
"row_id": 133719,
"text": "Sinus tachycardia\nInferior elevation with deeper Q waves probable acute inferior infarct\nSince previous tracing, deeper inferior Q waves and QRS changes in lead V2 - ?\nlead placement -back to baseline\n\n"
},
{
"category": "ECG",
"chartdate": "2112-02-01 00:00:00.000",
"description": "Report",
"row_id": 133757,
"text": "Sinus tachycardia\nInferior ST elevation - ? injury/ ischemia\nLow QRS voltages in precordial leads\nEarly repolarization\nSince previous tracing, QRS changes in lead V2 - ? lead placement\n\n"
},
{
"category": "ECG",
"chartdate": "2112-02-01 00:00:00.000",
"description": "Report",
"row_id": 133758,
"text": "Sinus tachycardia. Low voltage. ST-T wave changes with inferior ST segment\nelevation - clinical correlation is suggested for possible injury/ischemia.\nSince the previous tracing of no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2112-01-31 00:00:00.000",
"description": "Report",
"row_id": 133759,
"text": "Sinus tachycardia. Low voltages. ST-T wave changes with modest inferior\nST segment elevation - clinical correlation is suggested for possible\ninjury/ischemia. Since the previous tracing no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2112-01-31 00:00:00.000",
"description": "Report",
"row_id": 133760,
"text": "Sinus rhythm. Low voltage. ST-T wave changes with modest inferior ST segment\nelevation - clinical correlation is suggested for possible acute\ninjury/ischemia. Since the previous tracing easrlier the same date the heart\nrate has decreased.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2112-01-31 00:00:00.000",
"description": "Report",
"row_id": 133761,
"text": "Sinus tachycardia. Low voltage. ST-T wave changes with inferior ST segment\nelevation - consider acute injury/ischemia. Since the previous tracing\nof changes as outlined are now seen.\nTRACING #1\n\n"
}
] |
96,145 | 161,427 | needs outpatient given recent PE 75 yo female with h/o DVT/PE, h/o necrotizing fasciitis, COPD, recent cholecystectomy c/b biloma/sepsis requiring ERCP and stone retrieval with stent placement. She was transferred from 1d s/p retrieval of biliary stent here at found to have ESBL Ecoli sepsis. Hospital course c/b new WMA and elevated troponins with concern for recent acute coronary event. | There is mildregional left ventricular systolic dysfunction with hypokinesis of the mid-and distal anterior septum and mid- inferior septum/inferolateral wall. Mild (1+) mitral regurgitation is seen. There is nopericardial effusion.IMPRESSION: Normal left ventricular cavity size with extensive regionalsystolic dysfunction c/w multivessel CAD (RCA and LAD distribution). There are mild-to-moderate atherosclerotic calcifications of the thoracic aorta and coronary arteries. BorderlinePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is moderately dilatedwith focal hypokinesis of the apical 2/3rds of the free wall. Right ventricular function. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - akinetic; mid inferior - hypo; mid inferolateral -hypo; anterior apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimal residual complex subhepatic collection. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Focal apical hypokinesis of RVfree wall.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Mildly dilated descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Trivial mitral regurgitationis seen. PNA/pleural edema? PNA/pleural edema? Decreased bibasilar minimal atelectasis. Rule out pulmonary edema. Non-specific inferior ST-T waveabnormalities. Moderate paraseptal and centrilobular emphysema. There isno pericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction.Compared with the prior study (images reviewed) of , overall LVsystolic function has slightly improved. Left atrial abnormality. The descendingthoracic aorta is mildly dilated. FINDINGS: There has been interval placement of a right internal jugular central venous catheter, with its tip overlying the low SVC. A right-sided central line is redemonstrated and ends at the lower SVC. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Mild regional LVsystolic dysfunction. Pulmonary embolism.Height: (in) 61Weight (lb): 120BSA (m2): 1.52 m2BP (mm Hg): 80/56HR (bpm): 109Status: InpatientDate/Time: at 12:35Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild [1+] TR. There is borderline pulmonary artery systolic hypertension. There is moderate-to-severe sigmoid colon diverticulosis without evidence of diverticulitis. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Sinus tachycardia with right bundle-branch block. The small and large bowel are nonobstructed. Left anterior fascicular block. No AR.MITRAL VALVE: Normal mitral valve leaflets. Moderate cardiomegaly with signs of moderate fluid overload. Left ventricular function. There is moderate regional left ventricular systolicdysfunction with severe hypokinesis of the inferior and inferolateral wallsand bassl 2/3rds of the anterior wall. Left axisdeviation with left anterior fascicular block. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - akinetic; basal inferior - hypo; mid inferior -akinetic; mid inferolateral - hypo; anterior apex - akinetic; inferior apex -hypo;RIGHT VENTRICLE: Moderately dilated RV cavity. A right IJ central line is seen ending at the mid SVC. The partially visualized pancreas is normal. WMA.Height: (in) 61Weight (lb): 125BSA (m2): 1.55 m2BP (mm Hg): 113/83HR (bpm): 102Status: InpatientDate/Time: at 14:36Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal LV wall thickness and cavity size. Rigthventricular free wall hypokinesis suggestive of proximal RCA disease. Sigmoid diverticulosis, but no -itis. Sigmoid diverticulosis, but no -itis. The diameters of aorta at the sinus,ascending and arch levels are normal. The right ovary is normal and located between the obturator muscle and the sigmoid colon (series 2, image 92). Possible inferior wallmyocardial infarction of indeterminate age. Theestimated pulmonary artery systolic pressure is normal. PATIENT/TEST INFORMATION:Indication: Hypotension. The lungs are more fully inflated on the present radiograph, with decreased minimal bibasilar atelectasis. There is a right IJ central line with the distal lead tip in the mid SVC. Compared to the previoustracing of right bundle-branch block pattern is no longer present.Otherwise, no other significant diagnostic change. The cardiac and mediastinal contours are normal. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. The left adrenal gland is normal. There is a superimposed moderate interstitial pulmonary edema that has not changed significantly since the previous exam. Secondary ST-T waveabnormalities. The diameters ofaorta at the sinus, ascending and arch levels are normal. Centrilobular and paraseptal emphysema is seen with a peripheral bulla at the right lung apex (series 2, image 9). Right bundle-branch block with leftanterior fascicular block. There is a right lower paratracheal lymph node measuring 12 mm (series 2, image 17). Prior cholecystectomy. COMPARISON: Chest radiographs from . The heart is moderately enlarged but unchanged compared with prior exam. There is mild prominence of the pulmonary interstitial markings, which is stable and may reflect minimal pulmonary edema. The right jugular catheter is in adequate position. BONES: There is mild anterolisthesis at L5. The cardiac contour is mildly enlarged. Otherwise, the lungs appear poorly inflated, with diffuse interstitial thickening that appears mildly improved compared with . Criteria suggest supraventriculararrhythmia with aberrancy. Right IJ catheter in satisfactory location. Occasional premature atrial contractions. Left ventricular wall thicknesses and cavitysize are normal. However, there are additional interstitial opacities that suggest a superimposed moderate pulmonary interstitial edema. Sinus rhythm. Right ventricular chambersize and free wall motion are normal. There are moderate-to-severe atherosclerotic calcifications of the abdominal aorta and the iliac arteries. The right adrenal gland is prominent, possibly due to an adenoma. No pleural effusions, unchanged right internal jugular vein catheter. No major change from the previous tracing.TRACING #1 FINDINGS: A new right-sided PICC line is noted ending approximately 3 cm distal to the cavoatrial junction. Heart size is within normal limits. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic stenosis oraortic regurgitation. Simple liver cysts. | 18 | [
{
"category": "Radiology",
"chartdate": "2104-07-20 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1246427,
"text": " 5:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Evaluate common bile duct for evidence of dilation/stones\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with recent CCY s/p stent removal by ERCP \n REASON FOR THIS EXAMINATION:\n Evaluate common bile duct for evidence of dilation/stones\n ______________________________________________________________________________\n WET READ: JBRe SUN 6:37 PM\n 1. Normal CBD.\n 2. No evidence of biloma.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old with recent cholecystectomy, status post stent\n removal by ERCP; please assess common bile duct.\n\n TECHNIQUE:\n\n -scale and color ultrasound images of the liver and gallbladder were\n obtained.\n\n COMPARISON: CT of the torso from .\n\n FINDINGS:\n\n The common bile duct measures between 6 and 7 mm, within normal limits for the\n patient's age. Multiple anechoic right and left liver lobe cysts are seen. A\n very small residual subhepatic collection with echogenic debris measures 25 x\n 13 x 18 mm (series 1, image 21). The partially visualized pancreas is\n normal.\n\n IMPRESSION:\n\n 1. No evidence of biliary dilatation.\n\n 2. Simple liver cysts.\n\n 3. Minimal residual complex subhepatic collection.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246546,
"text": " 5:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for hemorrhage\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hemotpsysi\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage\n ______________________________________________________________________________\n WET READ: YGd MON 7:14 PM\n Short interval development of streaky and reticular opacities primiarily in\n the lingula/LLL and RLL in a patient with bacteremia, recent history of\n hemoptysis, and now suspicion for myocardial infarction (per discussion with\n team). Ddx include and may be a combination of pulmonary hemorrhage, flash\n pulmonary edema due to MI, fluid overload edema, and/or infection. Right IJ\n catheter in satisfactory location. Cholecystectomy clips. Contrast in colon.\n - dw Dr. at 7p on by x \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hemoptysis, to assess for hemorrhage.\n\n FINDINGS: In comparison with study of , there has been substantial\n increase in pulmonary opacification bilaterally, especially in the left mid\n and lower zones. In view of the clinical history, this could reflect flash\n pulmonary edema related to fluid overload, possibly with secondary infection\n or pulmonary hemorrhage.\n\n Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246724,
"text": " 8:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hemoptysis and worsening respiratory status on\n anticoagulation\n REASON FOR THIS EXAMINATION:\n evidence of pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST X-RAY\n\n INDICATION: Woman with hemoptysis, worsening of respiratory status,\n anticoagulation. Rule out pulmonary edema.\n\n COMPARISON: Chest x-ray of and CT scan of .\n\n FINDINGS: This patient is known for a chronic interstitial lung disease as\n shown in the previous CT scan. However, there are additional interstitial\n opacities that suggest a superimposed moderate pulmonary interstitial edema.\n The cardiac contour is mildly enlarged. There is no pleural effusion. The\n right jugular catheter is in adequate position.\n\n CONCLUSION: The patient has a mild chronic interstitial lung disease. There\n is a superimposed moderate interstitial pulmonary edema that has not changed\n significantly since the previous exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1247267,
"text": " 9:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 44cm iv \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 44cm iv \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with recently placed PICC line. Evaluate for\n placement.\n\n COMPARISONS: Portable chest radiograph on .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: A new right-sided PICC line is noted ending approximately 3 cm\n distal to the cavoatrial junction. Otherwise, the lungs appear poorly\n inflated, with diffuse interstitial thickening that appears mildly improved\n compared with . No new focal opacities are observed. The heart is\n moderately enlarged but unchanged compared with prior exam. There is no\n pleural effusion or pneumothorax. A right-sided central line is\n redemonstrated and ends at the lower SVC.\n\n IMPRESSION: PICC line is approximately 3 cm past the cavoatrial junction.\n Otherwise, there is mild interval improvement in the pulmonary edema.\n\n These findings were communicated to on at 9:55\n a.m. by Dr. via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246718,
"text": " 11:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema, ards\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with cholangitis/sepsis s/p liters of LR and two blood\n transfusions now with hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema, ards\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pulmonary edema.\n\n FINDINGS: In comparison with the study of , there is slight improvement in\n the degree of pulmonary vascular congestion. Right IJ catheter remains in\n place. The left hemidiaphragm is more sharply seen than on the previous\n study.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-07-29 00:00:00.000",
"description": "Report",
"row_id": 104058,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. ? WMA.\nHeight: (in) 61\nWeight (lb): 125\nBSA (m2): 1.55 m2\nBP (mm Hg): 113/83\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 14:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - akinetic; mid inferior - hypo; mid inferolateral -\nhypo; anterior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with hypokinesis of the mid-\nand distal anterior septum and mid- inferior septum/inferolateral wall. The\nremaining segments contract normally (LVEF = 40%). Right ventricular chamber\nsize and free wall motion are normal. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. There is borderline pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction.\n\nCompared with the prior study (images reviewed) of , overall LV\nsystolic function has slightly improved. Regional distribution of wall motion\nabnormalities is similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-07-21 00:00:00.000",
"description": "Report",
"row_id": 104059,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Right ventricular function. Pulmonary embolism.\nHeight: (in) 61\nWeight (lb): 120\nBSA (m2): 1.52 m2\nBP (mm Hg): 80/56\nHR (bpm): 109\nStatus: Inpatient\nDate/Time: at 12:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal inferior - hypo; mid inferior -\nakinetic; mid inferolateral - hypo; anterior apex - akinetic; inferior apex -\nhypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Focal apical hypokinesis of RV\nfree wall.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nMildly dilated descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. There is moderate regional left ventricular systolic\ndysfunction with severe hypokinesis of the inferior and inferolateral walls\nand bassl 2/3rds of the anterior wall. The remaining segments contract\nnormally (LVEF = 30-35 %). The right ventricular cavity is moderately dilated\nwith focal hypokinesis of the apical 2/3rds of the free wall. The diameters of\naorta at the sinus, ascending and arch levels are normal. The descending\nthoracic aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The mitral valve leaflets are structurally normal. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with extensive regional\nsystolic dysfunction c/w multivessel CAD (RCA and LAD distribution). . Rigth\nventricular free wall hypokinesis suggestive of proximal RCA disease. Mild\nmitral regurgitation.\n\nCLINICAL IMPLICATIONS:\nThe left ventricular ejection fraction is <40%, a threshold for which the\npatient may benefit from a beta blocker and an ACE inhibitor or .\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246920,
"text": " 11:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval lungs\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n Eval lungs\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Worsening hypoxia, evaluation of the lung parenchyma.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing\n parenchymal opacities have minimally increased in size and severity. However,\n it must be considered that the lung volumes have also decreased. Moderate\n cardiomegaly with signs of moderate fluid overload. No pleural effusions,\n unchanged right internal jugular vein catheter.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-20 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1246389,
"text": " 9:33 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for pneumonia or intra-abdominal fluid collection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 75F with h/o CCY c/b biloma now w/fevers\n REASON FOR THIS EXAMINATION:\n eval for pneumonia or intra-abdominal fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 3:24 PM\n 1. No pneumonia and no abdominal fluid collections.\n 2. Chronic interstitial lung disease and moderate to severe emphysema.\n 3. Sigmoid diverticulosis, but no -itis.\n 4. Redundant foley catheter, should be retracted by multiple centimeters\n WET READ VERSION #1 JBRe SUN 1:39 PM\n 1. No pneumonia and no abdominal fluid collections.\n 2. Chronic interstitial lung disease and moderate to severe emphysema.\n 3. Sigmoid diverticulosis, but no -itis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old with history of cholecystectomy, complicated by\n biloma, now with fevers, please evaluate for pneumonia or fluid collection.\n\n TECHNIQUE: Contiguous MDCT images through the chest, abdomen and pelvis were\n performed after administration of oral contrast. No intravenous contrast was\n administered.\n Axial, coronal, and sagittal reformats were acquired.\n\n COMPARISON: Chest radiographs from .\n\n FINDINGS:\n\n CT OF THE CHEST: The thyroid gland is normal. There is no axillary\n lymphadenopathy. There is a right lower paratracheal lymph node measuring 12\n mm (series 2, image 17). There is no hilar lymphadenopathy. There are\n mild-to-moderate atherosclerotic calcifications of the thoracic aorta and\n coronary arteries. There is no pericardial and no pleural effusion.\n\n The airways are patent to a segmental level. Centrilobular and paraseptal\n emphysema is seen with a peripheral bulla at the right lung apex (series 2,\n image 9). Diffuse fibrotic changes are seen, predominantly at the lung bases.\n There is no focal lung consolidation to suggest pneumonia.\n\n A right IJ central line is seen ending at the mid SVC.\n\n CT OF THE ABDOMEN: Multiple hypoattenuating liver lesions are seen with\n Hounsfield unit measurements between 10 and 20, likely representing simple\n cysts, however a very peripheral hypoattenuating segment VI lesion is slightly\n more complex (se 2, im 54). No bile duct dilation. Prior cholecystectomy.\n\n The pancreas and spleen are normal in size. The right adrenal gland is\n prominent, possibly due to an adenoma. The left adrenal gland is normal.\n (Over)\n\n 9:33 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for pneumonia or intra-abdominal fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n A right extrarenal pelvis is seen. There is no hydronephrosis, and no\n obstructive renal stones.\n\n There is no retroperitoneal or mesenteric lymphadenopathy. There is no free\n air and no free fluid. No fluid collections. There are moderate-to-severe\n atherosclerotic calcifications of the abdominal aorta and the iliac arteries.\n\n The esophagus and stomach are unremarkable. The appeneix is normal. The small\n and large bowel are nonobstructed.\n\n CT OF THE PELVIS: There is large amount of stool in the rectum. There is\n moderate-to-severe sigmoid colon diverticulosis without evidence of\n diverticulitis.\n\n A pessary is seen in the vagina. The ovaries are seen with a 1.7 cm cyst on\n the left ovary. The right ovary is normal and located between the obturator\n muscle and the sigmoid colon (series 2, image 92).\n There is no free fluid in the pelvis.\n\n A Foley catheter is seen, redundant and curled in the bladder and should be\n retracted by a few centimeters. Postprocedural air is seen in the urinary\n bladder.\n\n BONES: There is mild anterolisthesis at L5. There are no suspicious lytic or\n sclerotic bony lesions.\n\n IMPRESSION:\n 1. Chronic interstitial lung disease, pulmonary fibrosis, without evidence of\n focal consolidation to suggest pneumonia.\n 2. Moderate paraseptal and centrilobular emphysema.\n 3. Mediastinal lymphadenopathy, likely reacitve.\n 4. No evidence of abdominal fluid collection.\n 5. Hypoattenuating liver lesions, likely representing simple cysts.\n Ultrasound is recommended for further workup.\n 6. Redundant, curled up Foley catheter in the urinary bladder, which should\n be retracted by a few centimeters.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246390,
"text": " 9:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement, ? PNA/pleural edema?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 75F with sepsis, new IJ line\n REASON FOR THIS EXAMINATION:\n line placement, ? PNA/pleural edema?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, new IJ line placement. Evaluate for pneumonia and assess\n for pulmonary edema.\n\n COMPARISON: Chest radiograph from at 12:58 a.m.\n\n FINDINGS: There has been interval placement of a right internal jugular\n central venous catheter, with its tip overlying the low SVC. There is no\n pneumothorax. The lungs are more fully inflated on the present radiograph,\n with decreased minimal bibasilar atelectasis. There is re-demonstration of\n central pulmonary vascular engorgement as well as increased conspicuity of a\n diffuse interstitial abnormality, likely reflecting worsening mild pulmonary\n edema. There are no pleural effusions. The cardiac and mediastinal contours\n are normal. There is re-demonstration of deformity of the posterior right\n fourth rib, likely relating to remote trauma.\n\n IMPRESSION:\n\n 1. Increased diffuse interstitial abnormality, likely reflecting worsening\n mild interstitial pulmonary edema.\n\n 2. Decreased bibasilar minimal atelectasis.\n\n 3. No evidence of pneumothorax, status post placement of new right IJ central\n venous catheter.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246392,
"text": " 10:31 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 75F with IJ line placement, moved back\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: Patient with IJ line placement. Re-adjusted.\n\n FINDINGS: Comparison is made to previous study performed on at\n 9:37 a.m.\n\n There is a right IJ central line with the distal lead tip in the mid SVC.\n There are no pneumothoraces. Heart size is within normal limits. Old healed\n right-sided rib fractures are seen. There is mild prominence of the pulmonary\n interstitial markings, which is stable and may reflect minimal pulmonary\n edema. There is no focal consolidation or pleural effusions.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-30 00:00:00.000",
"description": "Report",
"row_id": 304617,
"text": "Sinus tachycardia with right bundle-branch block. Secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterim change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-24 00:00:00.000",
"description": "Report",
"row_id": 304618,
"text": "Sinus tachycardia. Occasional premature atrial contractions. Left axis\ndeviation with left anterior fascicular block. Compared to the previous\ntracing of right bundle-branch block pattern is no longer present.\nOtherwise, no other significant diagnostic change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-22 00:00:00.000",
"description": "Report",
"row_id": 304619,
"text": "Sinus tachycardia. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. Compared to the previous tracing of R waves\nin the inferior leads are slightly larger.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-21 00:00:00.000",
"description": "Report",
"row_id": 304620,
"text": "Sinus tachycardia. Left atrial abnormality. Right bundle-branch block. Left\naxis deviation. Left anterior fascicular block. Possible inferior wall\nmyocardial infarction of indeterminate age. Compared to the previous tracing\nthe rate has slowed and the sinus mechanism is now more easily appreciated.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-21 00:00:00.000",
"description": "Report",
"row_id": 304621,
"text": "Wide complex tachycardia at approximately 150 beats per minute in a right\nbundle-branch block configuration. Criteria suggest supraventricular\narrhythmia with aberrancy. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-20 00:00:00.000",
"description": "Report",
"row_id": 304622,
"text": "Sinus rhythm. Right bundle-branch block. No major change from the previous\ntracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-07-20 00:00:00.000",
"description": "Report",
"row_id": 304623,
"text": "Sinus tachycardia. Right bundle-branch block. Non-specific inferior ST-T wave\nabnormalities. No major change from the previous tracing.\nTRACING #1\n\n"
}
] |
40,160 | 192,451 | Pt was admitted post-operatively from her Free microvascular fasciocutaneous flap transfer from left forearm to palate. She tolerated the procedure well, and was brought to the ICU for Q1H flap checks. After 24 hours, the patient was doing well and was transferred to the floor and started on clear liquids. On POD 2 she was noted to have increasing swelling on her R face near the operative site. The wound was opened slightly by the bedside and was found to be free from hematoma. Over the next 48 hours her swelling improved. On POD 3, the patient was tolerating applesauce and on POD4 her diet was advanced to include anything blenderized. During her entire stay she had dopplerable pulses to her temple and graft and her graft site remained pink and well-perfused. | Endocrine: RISS, Dexamethasone x 2 doses. Endocrine: RISS, Dexamethasone x 2 doses. 1 suture to R corner of mouth, area c/d/i. 1 suture to R corner of mouth, area c/d/i. 1 suture to R corner of mouth, area c/d/i. 1mg morphine sulfate administered ~q2h. 1mg morphine sulfate administered ~q2h. 1mg morphine sulfate administered ~q2h. Action: Q1 hour flap checks via Doppler and pain mgmt. +pulse w/ Doppler. +pulse w/ Doppler. Flap checks w/ Doppler q1h. Flap checks w/ Doppler q1h. Plan: Cont q1hr checks, pain control Endocrine: Dexamethasone x 2 doses. Right sided facial edema noted. Right sided facial edema noted. Right sided facial edema noted. Plan: Continue q1h flap checks w/ Doppler. Plan: Continue q1h graft checks w/ Doppler. Plan: Continue q1h graft checks w/ Doppler. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough 6. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough 6. Pt able to wiggle L fingers, unable to assess L radial pulse, nml cap refill to L side. Pt able to wiggle L fingers, unable to assess L radial pulse, nml cap refill to L side. Pt able to wiggle L fingers, unable to assess L radial pulse, nml cap refill to L side. Doppler checks q1h. Problem - of the hard palate Assessment: Pt s/p repair the oronasal fistula with a vascular forearm free flap. Problem - of the hard palate Assessment: Pt s/p repair the oronasal fistula with a vascular forearm free flap. Problem - of the hard palate Assessment: Pt s/p repair the oronasal fistula with a vascular forearm free flap. Response: Morphine with + effect on pain. Response: Morphine with + effect on pain. Response: Morphine with + effect on pain. Lines / Tubes / Drains: Foley Fluids: D5 1/2 NS, @125, KVO when taking PO Consults: Plastics Billing Diagnosis: Other: s/p free flap ICU Care Glycemic Control: Regular insulin sliding scale Lines: Arterial Line - 03:34 PM 18 Gauge - 03:35 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: H2 blocker VAP bundle: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Full code Disposition: Transfer to floor Total time spent: 31 minutes Chief Complaint: s/p L free radial forearm flap to palate HPI: 50F w/ h/o palatal ca s/p excision, now s/p L free radial forearm reconstruction Post operative day: POD#0 - Repair of oro-nasal fistula, secondary to adeno carcinoma of palate. Lines / Tubes / Drains: Foley Wounds: Imaging: Fluids: D5 1/2 NS, @125, KVO when taking PO Consults: Plastics Billing Diagnosis: Other: s/p free flap ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Arterial Line - 03:34 PM 18 Gauge - 03:35 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: H2 blocker VAP bundle: Comments: Communication: Patient discussed on interdisciplinary rounds , ICU Code status: Full code Disposition: Transfer to floor Total time spent: 31 minutes Response: +dopplerable pulse to graft site. Response: +dopplerable pulse to graft site. Action: Q1h flap checks and frequent CSM check to L hand L forearm in cast post-op. Monitor CSM to L extremity. Monitor CSM to L extremity. Monitor CSM to L extremity. Famotidine 20 mg IV Q12H 24 Hour Events: OR RECEIVED - At 03:26 PM ARTERIAL LINE - START 03:34 PM Post operative day: POD#1 - Repair of oro-nasal fistula, secondary to adeno carcinoma of palate. Famotidine 20 mg IV Q12H 24 Hour Events: OR RECEIVED - At 03:26 PM ARTERIAL LINE - START 03:34 PM Post operative day: POD#1 - Repair of oro-nasal fistula, secondary to adeno carcinoma of palate. Surgery / Procedure and date: fistula repair with radial forearm free flap. Gastrointestinal / Abdomen: Clears x 48h, then blenderized diet. Gastrointestinal / Abdomen: Clears x 48h, then blenderized diet. Rt ear incision clean with sm amt sang drainage. Right sided facial incision sutured by plastics oozing small amts sanguenous fluid at ear lobe, otherwise incision is cdi. Right sided facial incision sutured by plastics oozing small amts sanguenous fluid at ear lobe, otherwise incision is cdi. Right sided facial incision sutured by plastics oozing small amts sanguenous fluid at ear lobe, otherwise incision is cdi. S/P oronasal fistula repair with radial forearm free flap to hard palate Assessment: Flap site sutured, draining scant/small sanguineous drainage, open to air. Today she underwent a repair the oronasal fistula with a vascular forearm free flap. OxycoDONE-Acetaminophen Elixir mL PO Q4H:PRN severe pain 10. OxycoDONE-Acetaminophen Elixir mL PO Q4H:PRN severe pain 10. Response: +dopplerable pulse to flap site. +pulse w/ Doppler to flap. S/P oronasal fistula repair with radial forearm free flap to hard palate Assessment: Graft site sutured, draining scant/small sanguinous drainage, open to air. | 10 | [
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664568,
"text": "Pt is a 50 female who underwent a resection of adencarcinoma of the\n hard palate ~1yr ago. She has had a fistula since her initial surgery\n requiring her to wear an obturator. she underwent a repair the\n oronasal fistula with a vascular forearm free flap.\n PMH: of the hard palate, environmental asthma- does not\n use inhalers. No Meds.\n Problem - of the hard palate\n Assessment:\n Pt s/p repair the oronasal fistula with a vascular forearm free flap.\n Right sided facial incision sutured by plastics oozing small amts\n sanguenous fluid at ear lobe, otherwise incision is cdi. Right sided\n facial edema noted. c/o incisional pain at times. Alert,\n oriented x 3. VS and labs WNL. + bs, tolerating sips of clears. Foley\n with ample clear yellow urine output. Left forearm casted, +csm.\n Action:\n Flap pulse checks q 1 hour, csm q 2. Medicated with 1-2mg IV morphine q\n 2-3 hours.\n Response:\n Morphine with + effect on pain. Flap pulse + by Doppler q 1 hour. +csm\n L arm. Tolerating sips of water.\n Plan:\n Flap pulse checks q 2 hours, Morphine/roxicet for pain, transfer to\n floor.\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664472,
"text": "Pt is a 50 female who underwent a resection of adencarcinoma of the\n hard palate ~1yr ago. She has had a fistula since her initial surgery\n requiring her to wear an obturator. Today she underwent a repair the\n oronasal fistula with a vascular forearm free flap.\n PMH: Adenocarcima of the hard palate, environmental asthma- does not\n use inhalers. No Meds.\n S/P oronasal fistula repair with radial forearm free flap to hard\n palate\n Assessment:\n Pt has free flap to roof of mouth from lt forearm which is pink,\n sutures intact and draining sm amt serosang drainage from mouth. Rt\n ear incision clean with sm amt sang drainage. Pt c/o pain.\n Managing with mso4 prn.\n Action:\n Q1 hour flap checks via Doppler and pain mgmt.\n Response:\n Strong dopplerable pulses to graft site. Pain treated with morphine\n 2-4mg. Requiring add\nl dosing as pain persisting after 4mg mso4.\n Plan:\n Cont q1hr checks, pain control\n"
},
{
"category": "Physician ",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664556,
"text": "SICU\n HPI:\n 50F s/p L free radial forearm reconstruction of palatal defect \n excised palatal CA\n Chief complaint:\n s/p L radial forearm free flap to palate\n PMHx:\n PMH: palatal ca\n : none\n Current medications:\n 1. Heparin 5000 UNIT SC BID\n 2. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS, Continuous at 125\n ml/hr\n 3. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain\n 4.. Insulin SC (per Insulin Flowsheet) Sliding Scale\n 5. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough\n 6. Aspirin 325 mg PO DAILY\n 7. Ondansetron 4 mg IV Q8H:PRN nausea\n 8. Clindamycin 600 mg IV Q8H\n 9. OxycoDONE-Acetaminophen Elixir mL PO Q4H:PRN severe pain\n 10. Dexamethasone 8 mg IV Q8H Duration: 2 Doses\n 11. Famotidine 20 mg IV Q12H\n 24 Hour Events:\n OR RECEIVED - At 03:26 PM\n ARTERIAL LINE - START 03:34 PM\n Post operative day:\n POD#1 - Repair of oro-nasal fistula, secondary to adeno carcinoma of\n palate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:05 PM\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Morphine Sulfate - 04:21 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.4\nC (97.6\n HR: 59 (51 - 64) bpm\n BP: 140/69(95) {133/60(89) - 154/75(105)} mmHg\n RR: 17 (9 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 3,613 mL\n 694 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,613 mL\n 694 mL\n Blood products:\n Total out:\n 2,075 mL\n 1,660 mL\n Urine:\n 790 mL\n 1,660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact, No(t) Erythema, No(t) Purulent),\n +Doppler signal\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 291 K/uL\n 12.2 g/dL\n 163 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.2 %\n 14.6 K/uL\n [image002.jpg]\n 02:27 AM\n WBC\n 14.6\n Hct\n 35.2\n Plt\n 291\n Creatinine\n 0.7\n Glucose\n 163\n Other labs: Ca:9.2 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 50F s/p L free radial forearm reconstruction of\n palatal defect excised palatal CA\n Neurologic: Pain controlled, Roxicet, morphine prn. Flap checks w/\n Doppler q1h. ASA for flap.\n Cardiovascular: HD stable, no issues.\n Pulmonary: IS, On face tent b/c pt prefers humidified O2. wean to\n NC as tol. Pulm toilet.\n Gastrointestinal / Abdomen: Clears x 48h, then blenderized diet.\n Nutrition: Clear liquids, Clears x 48h, then blenderized diet.\n Renal: Foley, Adequate UO, No issues. Lytes & Cr stable.\n Hematology: Hct stable.\n Endocrine: RISS, Dexamethasone x 2 doses. Goal FS<150.\n Infectious Disease: WBC 14.6, likely reactive. Afebrile. Clindamycin\n for surgical prophylaxis.\n Lines / Tubes / Drains: Foley\n Fluids: D5 1/2 NS, @125, KVO when taking PO\n Consults: Plastics\n Billing Diagnosis: Other: s/p free flap\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:34 PM\n 18 Gauge - 03:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664512,
"text": "S/P oronasal fistula repair with radial forearm free flap to hard\n palate\n Assessment:\n Graft site sutured, draining scant/small sanguinous drainage, open to\n air. Surrounding tissue slightly bruised and edematous. +pulse w/\n Doppler.\n Roof of mouth WNL, old blood present. 1 suture to R corner of mouth,\n area c/d/i. Plastics requested NOTHING be put in patient\ns mouth, no\n temp probes or swabs\n axillary temperatures only.\n Pt complaining of constant incisional pain at worst .\n Action:\n Q1h graft checks and frequent CSM check to L hand\n L forearm in cast\n post-op.\n 1mg morphine sulfate administered ~q2h.\n Response:\n +dopplerable pulse to graft site. Pt able to wiggle L fingers, unable\n to assess L radial pulse, nml cap refill to L side.\n Pt verbalizes decreased pain w/ morphine. Pt sleeping throughout\n shift.\n Plan:\n Continue q1h graft checks w/ Doppler. Monitor CSM to L extremity.\n Assess for pain frequently, administer morphine as needed. ? use of\n PCA. Pt may go out to floor after 1530 today (24hrs post op) per\n Plastics.\n Resp: Face tent on for humidification, sats 100%.\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664511,
"text": "S/P oronasal fistula repair with radial forearm free flap to hard\n palate\n Assessment:\n Graft site sutured, draining scant/small sanguinous drainage, open to\n air. Surrounding tissue slightly bruised and edematous. +pulse w/\n Doppler.\n Roof of mouth WNL, old blood present. 1 suture to R corner of mouth,\n area c/d/i. Plastics requested NOTHING be put in patient\ns mouth, no\n temp probes or swabs\n axillary temperatures only.\n Pt complaining of constant incisional pain at worst .\n Action:\n Q1h graft checks and frequent CSM check to L hand\n L forearm in cast\n post-op.\n 1mg morphine sulfate administered ~q2h.\n Response:\n +dopplerable pulse to graft site. Pt able to wiggle L fingers, unable\n to assess L radial pulse, nml cap refill to L side.\n Pt verbalizes decreased pain w/ morphine. Pt sleeping throughout\n shift.\n Plan:\n Continue q1h graft checks w/ Doppler. Monitor CSM to L extremity.\n Assess for pain frequently, administer morphine as needed. ? use of\n PCA. Pt may go out to floor after 1530 today (24hrs post op) per\n Plastics.\n"
},
{
"category": "Physician ",
"chartdate": "2199-03-21 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 664499,
"text": "Chief Complaint: s/p L free radial forearm flap to palate\n HPI:\n 50F w/ h/o palatal ca s/p excision, now s/p L free radial forearm\n reconstruction\n Post operative day:\n POD#0 - Repair of oro-nasal fistula, secondary to adeno carcinoma of\n palate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:05 PM\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Morphine Sulfate - 08:23 PM\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: palatal ca\n : none\n Flowsheet Data as of 09:52 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 51 (51 - 63) bpm\n BP: 150/73(102) {137/60(89) - 154/75(105)} mmHg\n RR: 13 (9 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 3,333 mL\n PO:\n TF:\n IVF:\n 3,333 mL\n Blood products:\n Total out:\n 0 mL\n 1,875 mL\n Urine:\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,458 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) OG tube, R preauricular\n incision c/d/i, +Doppler\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment And Plan: 50F s/p L free radial forearm reconstruction of\n palatal defect excised palatal CA\n Neurologic: Roxicet/morphine prn. Doppler checks q1h. ASA.\n Cardiovascular: HD stable.\n Pulmonary: Stable, no issues. Pulm toilet.\n Gastrointestinal: NPO, clears in AM x 48h, then blenderized diet\n Renal: No issues.\n Hematology: No issues.\n Infectious Disease: Clinda for prophylaxis.\n Endocrine: Dexamethasone x 2 doses. RISS, goal FS<150.\n Fluids: D51/2NS + 20KCl @ 125\n Electrolytes:\n Nutrition: NPO.\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:34 PM\n 18 Gauge - 03:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664602,
"text": "Pt is a 50 female who underwent a resection of adencarcinoma of the\n hard palate ~1yr ago. She has had a fistula since her initial surgery\n requiring her to wear an obturator. she underwent a repair the\n oronasal fistula with a vascular forearm free flap.\n PMH: of the hard palate, environmental asthma- does not\n use inhalers. No Meds.\n Problem - of the hard palate\n Assessment:\n Pt s/p repair the oronasal fistula with a vascular forearm free flap.\n Right sided facial incision sutured by plastics oozing small amts\n sanguenous fluid at ear lobe, otherwise incision is cdi. Right sided\n facial edema noted. c/o incisional pain at times. Alert,\n oriented x 3. VS and labs WNL. + bs, tolerating sips of clears. Foley\n with ample clear yellow urine output. Left forearm casted, +csm.\n Action:\n Flap pulse checks q 1 hour, csm q 2. Medicated with 1-2mg IV morphine q\n 2-3 hours.\n Response:\n Morphine with + effect on pain. Flap pulse + by Doppler q 1 hour to\n right temple. +csm L arm. Tolerating sips of water.\n Plan:\n Flap pulse checks q 2 hours, Morphine/roxicet for pain, transfer to\n floor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PALATE CANCER/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 61 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: adeno carcinoma of palate, High Cholesterol, Lung\n disease, environmental asthma, cholecystecomy.\n Surgery / Procedure and date: fistula repair with radial\n forearm free flap.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:69\n Temperature:\n 97.8\n Arterial BP:\n S:130\n D:61\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 56 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n Face tent\n O2 saturation:\n 99% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 2,231 mL\n 24h total out:\n 3,845 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:27 AM\n Potassium:\n 4.3 mEq/L\n 02:27 AM\n Chloride:\n 108 mEq/L\n 02:27 AM\n CO2:\n 24 mEq/L\n 02:27 AM\n BUN:\n 9 mg/dL\n 02:27 AM\n Creatinine:\n 0.7 mg/dL\n 02:27 AM\n Glucose:\n 163 mg/dL\n 02:27 AM\n Hematocrit:\n 35.2 %\n 02:27 AM\n Finger Stick Glucose:\n 120\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: husband has bag of clothes, one bag still in pre-op\n holding\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: t/sicu\n Transferred to: cc612\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664593,
"text": "Pt is a 50 female who underwent a resection of adencarcinoma of the\n hard palate ~1yr ago. She has had a fistula since her initial surgery\n requiring her to wear an obturator. she underwent a repair the\n oronasal fistula with a vascular forearm free flap.\n PMH: of the hard palate, environmental asthma- does not\n use inhalers. No Meds.\n Problem - of the hard palate\n Assessment:\n Pt s/p repair the oronasal fistula with a vascular forearm free flap.\n Right sided facial incision sutured by plastics oozing small amts\n sanguenous fluid at ear lobe, otherwise incision is cdi. Right sided\n facial edema noted. c/o incisional pain at times. Alert,\n oriented x 3. VS and labs WNL. + bs, tolerating sips of clears. Foley\n with ample clear yellow urine output. Left forearm casted, +csm.\n Action:\n Flap pulse checks q 1 hour, csm q 2. Medicated with 1-2mg IV morphine q\n 2-3 hours.\n Response:\n Morphine with + effect on pain. Flap pulse + by Doppler q 1 hour to\n right temple. +csm L arm. Tolerating sips of water.\n Plan:\n Flap pulse checks q 2 hours, Morphine/roxicet for pain, transfer to\n floor.\n"
},
{
"category": "Nursing",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664521,
"text": "S/P oronasal fistula repair with radial forearm free flap to hard\n palate\n Assessment:\n Flap site sutured, draining scant/small sanguineous drainage, open to\n air. Surrounding tissue slightly bruised and edematous. +pulse w/\n Doppler to flap.\n Roof of mouth WNL, old blood present. 1 suture to R corner of mouth,\n area c/d/i. Plastics requested NOTHING be put in patient\ns mouth, no\n temp probes or swabs.\n Pt complaining of constant incisional pain at worst .\n Action:\n Q1h flap checks and frequent CSM check to L hand\n L forearm in cast\n post-op.\n 1mg morphine sulfate administered ~q2h.\n Response:\n +dopplerable pulse to flap site. Pt able to wiggle L fingers, unable\n to assess L radial pulse, nml cap refill to L side.\n Pt verbalizes decreased pain w/ morphine. Pt sleeping throughout\n shift.\n Plan:\n Continue q1h flap checks w/ Doppler. Monitor CSM to L extremity.\n Assess for pain frequently, administer morphine as needed. ? use of\n PCA. Pt may go out to floor after 1530 today (24hrs post op) per\n Plastics.\n"
},
{
"category": "Physician ",
"chartdate": "2199-03-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664523,
"text": "SICU\n HPI:\n 50F s/p L free radial forearm reconstruction of palatal defect \n excised palatal CA\n Chief complaint:\n s/p L radial forearm free flap to palate\n PMHx:\n PMH: palatal ca\n : none\n Current medications:\n 1. Heparin 5000 UNIT SC BID\n 2. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS, Continuous at 125\n ml/hr\n 3. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain\n 4.. Insulin SC (per Insulin Flowsheet) Sliding Scale\n 5. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough\n 6. Aspirin 325 mg PO DAILY\n 7. Ondansetron 4 mg IV Q8H:PRN nausea\n 8. Clindamycin 600 mg IV Q8H\n 9. OxycoDONE-Acetaminophen Elixir mL PO Q4H:PRN severe pain\n 10. Dexamethasone 8 mg IV Q8H Duration: 2 Doses\n 11. Famotidine 20 mg IV Q12H\n 24 Hour Events:\n OR RECEIVED - At 03:26 PM\n ARTERIAL LINE - START 03:34 PM\n Post operative day:\n POD#1 - Repair of oro-nasal fistula, secondary to adeno carcinoma of\n palate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:05 PM\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Morphine Sulfate - 04:21 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.4\nC (97.6\n HR: 59 (51 - 64) bpm\n BP: 140/69(95) {133/60(89) - 154/75(105)} mmHg\n RR: 17 (9 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 3,613 mL\n 694 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,613 mL\n 694 mL\n Blood products:\n Total out:\n 2,075 mL\n 1,660 mL\n Urine:\n 790 mL\n 1,660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact, No(t) Erythema, No(t) Purulent),\n +Doppler signal\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 291 K/uL\n 12.2 g/dL\n 163 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 9 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.2 %\n 14.6 K/uL\n [image002.jpg]\n 02:27 AM\n WBC\n 14.6\n Hct\n 35.2\n Plt\n 291\n Creatinine\n 0.7\n Glucose\n 163\n Other labs: Ca:9.2 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 50F s/p L free radial forearm reconstruction of\n palatal defect excised palatal CA\n Neurologic: Pain controlled, Roxicet, morphine prn. Flap checks w/\n Doppler q1h. ASA for flap.\n Cardiovascular: HD stable, no issues.\n Pulmonary: IS, On face tent b/c pt prefers humidified O2. wean to\n NC as tol. Pulm toilet.\n Gastrointestinal / Abdomen: Clears x 48h, then blenderized diet.\n Nutrition: Clear liquids, Clears x 48h, then blenderized diet.\n Renal: Foley, Adequate UO, No issues. Lytes & Cr stable.\n Hematology: Hct stable.\n Endocrine: RISS, Dexamethasone x 2 doses. Goal FS<150.\n Infectious Disease: WBC 14.6, likely reactive. Afebrile. Clindamycin\n for surgical prophylaxis.\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, @125, KVO when taking PO\n Consults: Plastics\n Billing Diagnosis: Other: s/p free flap\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:34 PM\n 18 Gauge - 03:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
}
] |
20,689 | 129,027 | This is a 54 year old man who presented from an outside hospital with a grade 3 splenic laceration status-post a motorcycle crash. Upon arrival to he was found to be hypotensive with a hematocrit of 12 and was immediately transfused with 6 units of PRBC. Plain film imaging was done and the patient was taken emergently to the operating room where he underwent an exploratory laparotomy with splenectomy. Of note, due to inability to secure an airway the patient underwent an emergency cricothyroidotomy with tracheostomy tube placement. The patient was transferred to the intensive care unit post-operatively where he remained for 18 days. His post-operative course was notable for hypotension which initially required pressor support (an echocardiogram was done which was normal) and ventilary dependence. He was started on trophic tube feeds via a post-pyloric dobhoff tube on post-operative day 4. He was treated empirically with Zosyn for 2 weeks for presumed aspiration pneumonia. He had a right groin hematoma (secondary to traumatic femoral line placement) which was drained at the bedside on post-operative day 10. He was weaned off his ventilary support after 2 weeks. He was cleared from his C-collar by post-operative day 17. A neurology consultation was requested for altered mental status and aggitation on post-operative day 18; workup with EEG revealed non-specific deep midline subcortical dysfunction. He passed a swallow study and his diet was advanced to a regular diet on post-operative day 20. Physical therapy worked with the patient throughout his hospital course and found him to progress to near baseline by discharge. He was discharged to home on post-operative day 25 with a visiting nurse aid for tracheostomy tube care. Upon discharge he had scheduled follow-up with trauma surgery to have his trach removed. | WBC 16K.CV-Stable- 70's NSR, BP 110-120/80-90 w/ very dampened aline R radial. Completed course of Zosyn, continues on vanco. Will follow with Albuterol MDI prn. Pneumoboots intact, Heparin SC TID.GI: Abd firm, distended. KUB done-results pnd. MD paged, rec'd orders for Haldol 1mg IV MRx1 (done)--pt less restless at this time. One port at KVO for abx, currenly on Vanco, Zosyn for ongoing elevated WBC and fever. RLE hematoma tapped earlier, DSD intact. Standing and PRN ativan dose d/t hx of ETOH abuse. GI: Abd lg/soft, bs +. Pt tol at present.ID- afebrile. Also recieving prn Haldol which helps with agitation.CV: HR 70-80 SR no ectopy. area I&D'd with cx sent. Replete lytes accordingly. Abd with ecchymotic area. CT of abd done; results pending.ID: Afebrile. Levophed drip to maintain MAP's >70. L subclavian TLC. Monitor o2 sats/respitory effort, albuterol nebs prn. Felt to be hemaotma. Belly is, however, slightly more distended this am , currently on redular doses of metoclopramide and will start qd bisacodyl today. + flatus on occ w/o relief of distension. ABLE TO WEAN PROPOFOL PRN...THEN RESUMED. Zosyn abx coverage started.ENDO...Coverage per RISS. Heparin SC TID, Pneumoboots intact.GI: Abd firm, distended, tender. HAS BEEN SUCTIONED APPROX. IVF at KVO.RESP...Stable after initial desaturation. Pt with episodic abd distress probably r/t retained air/stool. LASIX DOEAGE HAS BEEN D/C'D AT THIS TIME. Continues on zoxyn coverage.ENDO...Coverage per RISS. Pt cont to have firm distended abd with hypoactive bowel sounds. Coags normal with INR 1.2. Resp Carept. Resp Carept. Resp CarePt. NGT to LWS with scant bilious drg. REMAINS AFEBRILE AND ON ZOSYN.SKIN: ABD INCISION W/ STAPLES. HAS BEEN SEDATED ON ATIVAN 2MG ROUTINE AND PRN DOSAGE, WITH DESIRED EFFECTS REACHED. KUB pnd as well. Abd firm and distended. Suction for mod amt of tan secertions. Sxn'd for scant tan thick.abgs:adequately oxygenated compensated resp. THIAMINE/FOLATE/MVI.HEME: HCT STABLE. TRAUMA SICU NPNO:NEURO: PT CONT ON ATIVAN ATC AND TOLERATING IT WELL. Actively repleting CA++, K+ and mag. TOLERATING THIS WELL.GU/GI; PT. Zosyn abx coverage. Reglan ongoing; erythropmycin po added. IV zosyn continues.Endo: Coverage per RISS. Albuterol MDI given Q4hr. Venodynes in place.Resp: LS course to dm bilaterally. Easily palpable peripheral pulses.RESP... See above note on initial oxygenation issues. K 4.0 TODAY.GI- ABD SOFT DISTENDED WITH POS BS. ?Restart TF's. SC HEPARIN.ENDO: BS STABLE. Resp carePt. IV lasix as above.Heme: Heparin SQ continues. Abd midline incicsion unchanged, stapled and OTA with sm dsd at distal end. IV ZOSYN CONTINUES.SKIN: ABD INCISION WNL. PRN albuterol given per RT.GI...Abd remains distended, but softer than before. IV pepcid continues. Heparin sub q continues. 8.0 portex trach in place. Continue to follow.Serial HCT's stable.REVIEW of SYSTEMS:Neuro...Minimal sedation with low dose propofol. Repeat Abg within normal limits with last PaO2 82. IVF at kvo rate.I&O negative for the day.K+ repletedID- afebrile; zosyn continuesGI- abd firm/distended & distant bowel sounds. C COLLAR.CV: HR AND BP STABLE. CONTINUES ON ATIVAN 1MG QID. Synthroid continues.Skin: Midline abd incision with staples, C&D and OTA with small dsd at distal end draining sm amt serous drainage. LEVO/PROPOFOL WEANED OFF. ZOLOFT.CV: LEVO WEANED OFF. Wean as tol with diuresis. Levophed gtt restarted at d/t low BP (SBP low 80's). BS CLEAR ANTERIORLY DIMINISHED AT THE BASES.CARDIAC- HR 78-103. Abd firm, distended. Hypoactive BS.GU: Continues with decreased UO. L sided neglect per PT scan done). CXR DONE. Abd incision staples D&I.ID - T max 99.2 PO. Dobhoff and NGT clamped. REMAINS WITH LOW UO.GI: NGT REPLACED WITH PEDITUBE..AND TF RESUMED WITH IV REGLAN..HAD HIGH RESIDUALS ON DAYS. LOW BP.P: FOLLOW UO. PRN ATIVAN DC'D. Placement checked by air bolus.GU - UOP adequate, now is diuresing from lasix.Skin - Eccymotic areas on LE, sides of abdomen. THIAMINE/FOLATE/MVI/FAMOTIDINE.HEME: LABS STABLE. Wifa called for update.Plan - Pt continues to be agitated, does very well on low dose propofol gtt. Right LE hematoma covered by DSD. CLONIDINE PATCH PLACED TODAY. Ambu/syringe @ hob. RESEDATED FOR TEE. Bilateral pleural effusions with posterior layering and obscuration of the diaphragmatic contours is noted. The prominent poorly tortuous thoracic aorta is again demonstrated. The tip of the right subclavian central venous line is now in the lower superior vena cava. Tortuous thoracic aorta is unchanged. FINDINGS: Single AP portable view of the chest is performed in lordotic position. A tracheostomy tube and left- sided central venous catheter are again seen and unchanged in position. The previously-noted tracheostomy tube, central venous catheter, and feeding tube are unchanged in position. A small 13 mm oval non-enhancing lesion is seen on the right paratracheal representing a lymph node. The previously identified left-sided subclavian line appears to have been removed.There is left lower lobe atelectasis. Left pleural effusion is noted. A tracheostomy tube terminates above the carina. Mediastinal and cardiac contours are unchanged, accounting for differences in positioning. Status post splenectomy and tracheostomy with right upper lobe aspiration. There is evidence of silhouetting and obscuration of the aortic knuckle. The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. Again there is obscuration of the aortic notch and prominence of the mediastinal contour, unchanged. Mild(1+) mitral regurgitation is seen. Vertebral bodies C1 through T1 are visualized on the neutral view. CT OF THE PELVIS WITH CONTRAST: There is free fluid within the pelvis. Mild (1+)mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: A transesophageal echocardiogram was performed in thelocation listed above. Low-attenuation fluid is seen within the splenectomy bed which appears unchanged. A left pleural effusion is present.Conclusions:The left atrium is normal in size. The tracheostomy tube is unchanged. Mild mitral regurgitation. There is no resting left ventricular outflowtract obstruction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The ascending, transverse and descending thoracic aorta are normal indiameter and free of atherosclerotic plaque.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal. | 104 | [
{
"category": "Nursing/other",
"chartdate": "2101-09-09 00:00:00.000",
"description": "Report",
"row_id": 1533844,
"text": "Nursing Progress Note: 1900-0700\n53y.o male s/p mca on . required exploratory lap for splenic bleed. s/p spleenectomy and trach d/t difficult airway access.\n\nNeuro: Pt requiring frequent doses of Haldol, Ativan, and Morphine to keep sedated/comfortable on the vent. Pt wakes up with discomfort and anxiety/ throws legs over rail. +follows commands x 4 extremities. PERRL2.\n\nCV: SB 50's-NSR 60's. BP 90/50's. +2 pitting edema in extremities. Goal is to keep pt 2L negative. Diamox given X1 and lasix given 20mg . Afebrile. Right SC TLC, all ports flushed and patent.\n\nRESP: Pt trached, vented on CPAP +10 +10 50's. Rate 20's. TV 500's. Lungs clear, coarse in lower lobes. SX trach for minimal clear white. Sats >95%. Bilat pleural effusions present on cxray, ?tap in future. (?Left ~400cc).\n\nGI: OGT- clamped. Placement confirmed with air bolus. Feeding tube infusing promote with fiber, residuals <10cc. Increased feeding q4hrs to max 70cc. Currently at 60cc, tolerated well. Spoke with MD, did not give TPN since pt is tolerating TF. Rectal bag draining golden liquid stool.\n\nGU: Foley draining amber urine, adequate amounts. Pt had period of bloody urine, MD aware. Flushed foley, cleared urine.\n\nID: COnt Antibx treatment: Vanco and Zosyn.\n\nMS: Bilat lower extremities ecchymotic. Abd with ecchymotic area. RLE hematoma tapped earlier, DSD intact. Right groin with drainage bag from previous trauma line seeping serous drainage.\n\nSOCIAL: Continue to keep family updated and informed of patient's status.\n\nPlan: Cont to trach collar patient as tolerated. OOB- chair as tolerated. Cont to give MSO4, Ativan, and Haldol prn to keep pt from getting agitated. Keep pt 2L negative, access fluid status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-09 00:00:00.000",
"description": "Report",
"row_id": 1533845,
"text": "Respiratory Care\nPt remained on pressure support 10/10/50% with no remarkable changes overnight. O2 sat 95-97%. Suctioning minimal amounts of white/clear secretions. RSBI=50. Plan is to wean with trach collar trials later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-09 00:00:00.000",
"description": "Report",
"row_id": 1533846,
"text": "Resp Care\n\nPt was weaned to trach mask and has been on for 4 hrs at the time of this note. Pt is on high flow neb and 80% fio2. Spo2 has been 91-94%. Pt is being suctioned for small amts of thick white sputum. Bs are generally clear but occcasionally with rhonchi when suctioning is required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-08 00:00:00.000",
"description": "Report",
"row_id": 1533843,
"text": "MICU Nursing Progress Note- 7a-7p TSICU Care Team\nCont to require anti-aggitaion and antianxiety rx. On Trach mask .70 for >2hours this pm-oob>chair.\n\nNeuro-\nREquires ativan 4mg q2-3h, haldol 4mg q2-3 hr and mso4 q4 to maintain non aggitated, cooperative state. not FC, MAE, purposeful movement.\nResp-\nCPAP required to ventilate vs abd distension. SAT 94-96%. BS clear upper, course diminished lower. TRANSITIONED to .70 trach mask this pm @ OOB chair. tolerated atleast 2h until 1700- refer to flowsheet for details. Goal is to keep pt dry w/ daily lasix and Diamox added today. Bilat effusions present; may be tapped in future, ?~ amt L=400cc.\nFluids-\nGoal to duirese pt to 2L neg/day. 750cc negative at present. Diamox given @1700. Lytes- K3.4, repleated w/ 40 kcl.\nGI-\n+ BS, + liquid brown stool via leaking FIB. Attempt to retry tube feeding tolerance today. TF rpomote w/ fiber restart, 10cc to start x3hr tol well, advanced to 40cc/hr @1600, goal 60 cc/hr. TPN written to start if TF not tolerated. Pt tol at present.\nID-\n afebrile. Vanco ^ 1250 r/t low trough level. WBC 16K.\nCV-\nStable- 70's NSR, BP 110-120/80-90 w/ very dampened aline R radial. REdressed x3 today.\nAccess-\nR radial aline dampened, taped securely- not sutured in. OOzing serous/sang fluid at site. R central line 3 lumen RSC-wnl.\n\nGirlfriend visiting this am. Very supportive and w/ pt.\nA/P\nNeuro- Cont to be disoriented and aggitated requiring regular q2hr anti- anxiety, anti-aggitation and pain rx. Cont prn.\nResp-\nCPAP , OOB amap to assist w/ weaning to trach mask.\nFluids- goal 2L negative, diamox started today in additionto qd lasix.\nGI-TF @40/hr, to assess toleration in attemt to avoid TPN tonight.\nID- monitor temp and levels.\nsocial- Cont to keep pt and family informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-12 00:00:00.000",
"description": "Report",
"row_id": 1533856,
"text": "NPN 7p-7a\nNeuro: Pt. varies between periods of agitation and sleeping. At times trying to get out of bed-requiring hand restraints and a posy. He is attempting to mouth words but difficult to understand. Requiring Morphine 5mg, Ativan , Haldol 2mg and Fentanyl-50mcg to keep him from attempting to climb out of the bed.\n\nResp: Tolerating 40% trach mask. Has strong cough able to cough out secretions. Sputum is white. Small amounts of sputum.\n\nCV: HR 55 when asleep. 80's SR when awake. No ectopy. BP 90-110/70. Will obtain am labs. K, Mg, and Ca can be repleted per sliding scale if needed.\n\nGI: Tube feeds off since noon due to high residuals. Restarted at 4 when residuals were 10. Continues to have large amounts of liquid stool. Mushroom cath inserted. Had abdominal ct MD-looks improved. ? reason for high aspirates. Would check frequently as pt. had episode of vomitting on Saturday.\n\nID: Afebrile. Off all antibiotics.\n\nSocial: Can transfer to floor if sitter is available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-12 00:00:00.000",
"description": "Report",
"row_id": 1533857,
"text": "addendum\nPt. tube feed residuals after 1 1/2 hours of infusing at 45cc/hr was 100cc. Tube feeds off at 6- per Trauma Sicu resident begin again in 1 hour at 50cc/hr.\nAlso K this am 3.7-will hang 20 of KCL-will need another 20 and also need to replace Mg. per sliding scale for Mg. 1.7\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-12 00:00:00.000",
"description": "Report",
"row_id": 1533858,
"text": "See data, MD notes/orders. Neuro: Alert following commands this morning. He was taken for flex/ex films and able to cooperate. Results are pending. He become progressively aggitated this afternoon, able to follow commands inconsistently. Restraints off for most of shift are now back in place for safety, sitter at bedside. CV:SR/ST no ectopy. Sbp 90's-120's. Pulm: Remains on trach mask with 02 sats 92-100%. 02 at 40%. Lungs coarse/clear bilaterally. GU: Foley catheter dc'd at 1430. Meatus red and painful with some dried exudate noted. Site cleaned, abx ointment applied. GI: Abd lg/soft, bs +. Rectal tube in place draining goldish liquid stool. Pt. Pulled feeding tube out earlier in shift, team aware, IVF initiated for hydration. Family in to visit. P: Continue to orient, utilize haldol/ativan as ordered. Attempt to help pt resume normal sleep/wake cycle. D/c C-collar when films cleared/as ordered. Monitor o2 sats/respitory effort, albuterol nebs prn. Updtate team if no void by 2200. Continue IFV while tube feeds off, speech eval when collar off. Keep family up to date on plan of care. R: As above, transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-06 00:00:00.000",
"description": "Report",
"row_id": 1533837,
"text": "NPN 7a-7p\nNeuro: Varies between being sedated and agitated. Has received fair amount of sedation today with various procedures so is more sedated than agitated. Moving all extremities. Following commands inconsistently. Sedated with 4-8mg of ativan and MS04 for leg pain. Also recieving prn Haldol which helps with agitation.\n\nCV: HR 70-80 SR no ectopy. SBP 150-160 when agitated, 120 when sedated. Goal to have pt 1-2L negative today-currenlty 1L negative.\n\nResp: Attemped trach mask this am but dropped sats to 80's. Had bronch this am to visualize airways and get good sputum samples as his WBC has remained elevated and consolidation on CXR has not totally cleared. Results pnd. Sx for moderate amounts of thick yellowish sputum. Good cough. Currently on 50% PSV 10 and 10 PEEP. Will plan to wean PSV tomorrow.\n\nID: Tmax 100 axillary. Added vanco today to broaden coverage. Noted to have red, raised area on R calf with redness around central area of redness. area I&D'd with cx sent. Had ultrasound of legs. ? hematoma. compression sleeves off. Triple lumen changed today to R subclavin.\n\nSkin: Abdominal staples without drainage-no redness. R groin draining moderate amounts of serous drainage. Bruising on R flank has not increased in size.\n\nGI: Small amount of liquid stool today. Abdomen slightly firm and distended but bowel sounds present. Feeding tube infusing promote with fiber-rate increased to 30cc/hr. NGT clamped-to be used for decompression.\n\nSocial: wife and girlfriend in to visit separately today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-07 00:00:00.000",
"description": "Report",
"row_id": 1533838,
"text": "Progress Note: 7p-7a\nS/P Spleenectomy due to laceration secondary to motorcycle accident , with trach during OR for difficult airway access\n\nPatient stable overnight. See carevue for objective data\n\nNeuro: patient continues to have ongoing agititation at times but does settle with ativan and morphine. Received regular dose ativan as well as one 3 mg prn dose. Medicated with morphine 5mg X2 overnight. Patient spont opens eye and at 0400 assessment obeyed commands, squeezed hands and wiggled toes. Able to move all extremities.\n\nCV: normotensive and in NSR. Has right subclavian TLC, all ports functional. One port at KVO for abx, currenly on Vanco, Zosyn for ongoing elevated WBC and fever. Temp Max 100.7, given tylenol at 0400, dropped to 99.7.\n\nResp: continues on cpap, PS decreased to 5 from 10 at 2100 and am blood gas unremarkable. maintained Sp02 at 95-98%. Breath sounds coarse in upper lobes, decreased to bases. Plan for trach trial today, had failed yesterday due to oversedation for numerour procedures (line change X2, bronch). suctioned occasionally for thick yellow secretions.\n\nGI: Feeds, promote with fibre, currently at 60 ml and is tolerating. Belly is, however, slightly more distended this am , currently on redular doses of metoclopramide and will start qd bisacodyl today. has fecal bag in situ, small amt stool overnight. Bowel sounds present. sump clamped (for prn decompression), being fed with dubhoff. Covered with 3 units Regular insulin this am only, BS 149.\n\nGU: Goal fluid balance for 24 hours is -2L. Was 1.7 L at MN, after receiving Lasix 20IV at 2100. Received another 20 mg at 0500 with good effect.\n\nSkin: Has drainage bag to right groin site oozing serous drainage from old trauma cath site with bruising to up to right flank. Right lower leg hematoma that was aspirated yesterday for sang drainage.\nHas general anasarca, hands, feet, scrotum. Bruising to lower legs bilaterally.\n\nLabs: WBC continue to rise, 18.8 this am from 17.5 yesterday. K 3.6, currently being replaced with 40 KCl. HCt and hgb remains stable. remaining labs unremarkable.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-11 00:00:00.000",
"description": "Report",
"row_id": 1533852,
"text": "Respiratory Care:\n\nPatient trached with 8.O Portex. Pt. wearing 70% Fio2 via trach mask. Bs clear bilaterally. Sx'd for sm amount of thick white secretions. Albuterol MDI not indicated. RR 19-low 20's. O2 sats 97-99%. O2 sats much improved. Decreased Fio2 requirement. Plan: Continue to wean Fio2 as tolerated. Will follow with Albuterol MDI prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-07 00:00:00.000",
"description": "Report",
"row_id": 1533839,
"text": "\nPT MAINTAINED ON PSV VENTILATION AT 50%. VITALS STABLE WITH ACCEPTABLE SATURATIONS. B.S. BILAT AND MOSTLY CLEAR. SX FOR SM. AMTS. TRACH MASK TRIAL TODAY DID NOT GO WELL WITH PO2 DROPPING TO 66 ON 60%, PT STILL IN NEED OF PEEP. CT SCAN TODAY AS WELL WITH RESULTS PENDING. MENTAL STATUS IS UNCHANGED WITH SEDATION NEEDED FOR MANAGEMENT. PLAN IS TO CONT ON PSV VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-11 00:00:00.000",
"description": "Report",
"row_id": 1533853,
"text": "NPN 7p-7a\nNeuro: Pt. varying between awake and agitated and sleeping. Difficult to assess if he is oriented-only intermittently following commands. Given extra Ativan dose with I&D of \"blister\" on R calf.\n\nCV: HR 60-80NSR no ectopy. BP 120-130/70's. lasix d/c'd.\n\nResp: On 70% trach mask with sats 98%. SX for small amounts of clear sputum. Strong cough.\n\nGI: Had high residuals-tube feeds off most of the night. KUB done-results pnd. Abdomen soft and distended but bowel sounds present. Continues with liquid stool. Felt to be from laxative use vs. c-diff.\n\nID: Remains afebrile. Completed course of Zosyn, continues on vanco. Surgery did I & D of R leg calf and expressed multiple clots. Felt to be hemaotma. Cx sent. Groin and buttocks area still red but slightly improved.\n\nSocial: No visitors overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-11 00:00:00.000",
"description": "Report",
"row_id": 1533854,
"text": "Resp. Care:\n Pt. remains on TM-weaning fio2 as tolerated. Strong cough. Albuterol prn- without need this shift. Please see flow sheet for more information. Will cont. to follow q shift and prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-11 00:00:00.000",
"description": "Report",
"row_id": 1533855,
"text": "0700-1900 NPN\nSee carevue for subjective/objective data.\nNeuro: Pt intermittently restless in AM and early PM but managed with emotional support and q6h Ativan 1mg. To CT at 1500 tol fair with additional 1mg Ativan. Increasingly agitated after back in room--attempted repositioning, additional Ativan, OOB to chair and back to bed. T-SICU paged re: additional Ativan (had order but was from CIWA scale; wanted to inform MD of need for Ativan). Total Ativan 6mg IV given from 1500-1630 with no effect. MD paged, rec'd orders for Haldol 1mg IV MRx1 (done)--pt less restless at this time. During peak level of agitation pt required caregivers in room as sitting upright in bed, swinging legs over siderails, pulling on anything he could grasp (bedclothes, tubing, etc.). PERL, 3mm, brisk. Hand grasps, leg movements very strong. Mouthing words but not able to understand pt. Intermittent cooperation early in shift; uncooperative from 1500 to present. J collar on, collar care done.\n\nCV/Pulm: MP=NSR-ST, no ectopy noted. VSS. Remains on trach collar initially at 70%, weaned to 40%. BS clear, diminished bil. Expectorating multiple times/hr-->thick yel secretions. Trach care done.\n\nGI/GU: TF on only for 2hrs this AM--off for CT. Not restarted after CT as residuals high (bari-cat obtained). Abd soft, non-tender. Mushroom cath replaced x5--pt expelling catheter then extremely agitated so not able to replace catheter. Intermittently stooling liq golden stool. U/O qs q1-2h, amber colored with sediment. CT of abd done; results pending.\n\nID: Afebrile. Vanco DC'd.\n\nInteg: Wet to dry dsg done at 1000 to R leg--sersang drainage noted on old dsg. Gauze over site changed prn. Buttocks red, no open areas noted.\n\nPsychosocial/Plan: Emotional support given to pt and fam. Med for agitation as noted above. Will cont close observation for pt safety (writer sitting at bedside).\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533807,
"text": "TSICU NPN (0700-1900)\n(Continued)\nrrow to help sort out legal guardian situation. Updated both on current condition and plan of care.\n\nPLAN: Abd CT scan this pm. Possible swan placement after. Levophed drip to maintain MAP's >70. Montior urine output. Replete lytes accordingly. Pulmonary toilet. Provide for pt comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533808,
"text": "Resp care\nPt remains on mech vent. Switched from A/C to SIMV with plan to eventually wean rate and promote spont resp. At this time rate has not been weaned. PEEP increased to 18 to improve oxygentation. Suction creamy tan secretions. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-30 00:00:00.000",
"description": "Report",
"row_id": 1533809,
"text": "NPN TSICU 1900-0700\nEVENTS: Pt continues with decreased UO, yet improving toward end of shift. CT scan at for ? of decreased UO. Results showed no significant changes.\n\n\nREVIEW OF SYSTEMS:\n\nNEURO: Pt sedated on Propofol overnight. Able to move all four extremites. Opens eyes to voice. Pupils 3mm, reactive to light. Communicates by mouthing words, nodding head. Standing and PRN ativan dose d/t hx of ETOH abuse. PRN morphine for pain control. Pt remains on strict logroll precautions d/t spine films not yet read. J collar intact.\n\nRESP: Remains trached and vented. SIMV 500X24, PEEP 15, FIO2 50%. ABG's stable. SATS 96-99%, no respiratory distress noted. LS: clear, decreased at bases. Suctioned for thick tan/white secretions.\n\nCV: HR NSR 50-70's. Burst of wide complex SVT X 1. SBP high 90's-140's. Levophed gtt to titrate MAP >70. See careview for trends. A line with sharp wave form. R femoral trauma line. L subclavian TLC. Strong pedail pulses. CVP ranging 15-18. IVF decreased to 125cc/hr.\n\nHEME: Serial HCT's Q 6 hr. Last HCT stable at 31.5. Next HCT due at 0800. Pneumoboots intact, Heparin SC TID.\n\nGI: Abd firm, distended. Bladder pressure done X 1 with of 11. NGT to LWS with minimal bilious drainage. Hypoactive BS.\n\nGU: Remains with low UO. Ranging from 25-80cc/hr throughout shift. Urine and concentrated. Myoglobin urine results remain pending. Potassium Phosphate, Magnesium, Potassium repleted.\n\nID: TMAX 100.1. Zosyn for abx coverage.\n\nENDO: Insulin per RISS.\n\nSKIN: Abd midline incision with original DSD. Old bloody drainage outlined. Trach site with DSD, minimal serous sang drainage. RLE with contusion and blister, OTA. Backside intact.\n\nSOCIAL: No calls from family. Social worker emailed for consult d/t family dynamics.\n\nPLAN: Continue to monitor UO. Monitor BP. Titrate Levophed gtt to maintain MAP >70. Monitor serial HCT. Follow up with social worker.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-30 00:00:00.000",
"description": "Report",
"row_id": 1533810,
"text": "RESP CARE: Pt remains trached/on vent. Pt transported to CT and back on /100%02 without incident. PEEP decreased from 18 to 15 after ABGs showed a Pa02 of 191. Heated humidification added to vent circuit to help mobilize secretions. Sxd small amts tenacious yellow sputum.No RSBI due to high PEEP level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-05 00:00:00.000",
"description": "Report",
"row_id": 1533835,
"text": "TRAUMA SICU NPN\nO:\nNEURO: PT CONT ON ATIVAN ATC AND TOLERATING IT WELL. RECEIVING PRN MORPHINE AND HALDOL ALTERNATING W/ GD EFFECT. LESS AGITATED THIS PM AND ABLE TO NOD YES OR NO TO QUESTIONS. MAE AND FOLLOWS COMMANDS CONSISTENTLY. ABLE TO WIGGLE TOES, BILAT HAND GRASP AND HOLDS UP 2 FINGERS TO COMMAND. BRIEFLY ON PROPOFOL FOR CT SCAN. C-COLLAR REMAINS IN PLACE.\n\nCV: HR 60'S-80 NSR, NO ECTOPY. STABLE BP.\n\nRESP: REMAINS ON PSV WEANED DOWN TO 10 PS AND TOL WELL WITH STABLE ABG AND 02SATS. LS CLEAR, DIMINISHED AT BASES. SXNED FOR TENACIOUS, WHITE SECRETIONS. TV 500'S, RR 15.\n\nRENAL: CONT W/ ADEQUATE U/O. 2LITERS NEGATIVE SO FAR TODAY. K=3.5, REPLETED.\n\nGI: TF AT 20CC/HR WITH LOW RESIDUALS. STOOL X1, SOFT, BROWN. ABD DISTENDED, SOFT.\n\nENDO: NO SS INSULIN THIS EVE.\n\nHEME: STABLE\n\nID: CHEST CT SHOWED BILAT PLEURAL EFFUSIONS W/ ?ATELECTACIS VS CONSOLIDATION. REMAINS AFEBRILE AND ON ZOSYN.\n\nSKIN: ABD INCISION W/ STAPLES. CLEAN AND DRY. FLUID FILLED BLISTERS ON R LEG INTACT. OLD LINEE SITE W/ LGE AMT SEROUS DNGE COVERED W/ DNGE BAG, R FEMORAL AREA. BACKSIDE INTACT.\n\nSOCIAL: WIFE, IN TO VISIT. NO OTHER CALLS TONIGHT.\n\nA: LESS AGITATED. HEMODYNAMICALLY STABLE. TOLERATING SLOW PS WEAN FOR VENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-30 00:00:00.000",
"description": "Report",
"row_id": 1533811,
"text": "Resp Care\nPt remains on mech vent. Pt mode switched per team to MMV with hope to wean. Team wants min vent between 10-12 L. Breath sounds coarse bilat. Peep decreased to 12 but was not tol so returned to 15. Suction for mod amt of tan secertions. Will continue mech vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-30 00:00:00.000",
"description": "Report",
"row_id": 1533812,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL. ATIVAN AND MORPHINE PRN.\n ABLE TO WEAN PROPOFOL PRN...THEN RESUMED.\n C COLLAR INTACT. TLS CLEARED.\n\nCV: HR 50-70 SR. LEVO DRIP WEANED OFF TO KEEP\n MAP>65. LYTES REPLETED.\n ECHO DONE AGAIN TODAY... POOR QUALITY, BUT WNL.\n\nRESP: NUMEROUS VENT CHANGES. LOW PAO2... DROPS\n SATS WITH TURNING.\n\nRENAL: LABS WNL. LOW UO. WITH CVP 18.... LASIX 10 MG\n IV GIVEN.\n\nGI: IMPACT WITH FIBER AT 10. LR AT 70.\n NGT PATENT.\n THIAMINE/FOLATE/MVI.\n\nHEME: HCT STABLE. PLT WNL. BOOTS ON. SC HEPARIN.\n\nENDO: INSULIN PER SLIDING SCALE.\n\nID: LOW GRADE TEMPS. WBC 16. IV ZOSYN.\n\nSKIN: R LEG CONTUSION HEALING. BACK INTACT.\n TRACH SITE WNL.\n ABD INCISION WITH SCANT SEROUS DRAINAGE.\n\nSOCIAL: VISITED DURING DAY.\n ESTRANGED SPOUSE VISITED DURING EVES.\n\nA: STABLE S/P MOTORCYCLE CRASH.\nP: FULL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-06 00:00:00.000",
"description": "Report",
"row_id": 1533836,
"text": "pmicu nursing progress 11p-7a\nmr was transferred to the micu B from the t-sicu for continued care. he arrived in stable condition\nreview of systems\nCV-vs have been stable.\nRESP-no vent changes made overnight-he remains on 10 peep and 10 pS x 50% with rr 8-20 and tvs 450-600ccs. sats have been >95%. was sx x 2 for small amts thick tan white sputum.abg this am with Po2 85, PCo2 35 and pH 7.40.\nNEURO-has been sleeping in naps- does wake up agitated and difficult to calm down- has been getting his MSo4, ativan and haldol spaced out and when left alone is fairly calm.hands are lightly restrained. collar in place.\nID-low grade temp. wbc=17.5 this am. on zosyn.\nF/E- has had an adequate urinary output, urine dark.mild peripheral edema noted. also with fluid loss from old line site in groin-fluid was yellow but became pink after turning pt.am labs pnd\nGI-has NGT in place which is clamped. also with pedi feeding tube thru which tube feeds are infusing at 30/hr (promote with fiber). abd is large with positive bowel sounds. had a large liquid brown stool-bag in place now.on reglan.\nENDO-regular insulin as per sliding scale.\nSKIN-abd incision is stapled shut and is c,d,and i.old line site draining large amts clear yellow-pink fluid, drainage bag in place.\nnoted to have a bruise on R lower flank which was outlined.legs with multiple bruises and sores noted. collar care done.blister on R inner thigh burst-covered with tegaderm.groin looks fiery pink-nystatin cream applied.\nIV ACCESS-has a triple lumen L neck, a-line R wrist\nSOCIAL-no phone calls or visits overnight. note for is in chart.\na-other than transfer, pt had an uneventful night\nP-will continue to wean as we are able, continue to watch fevers, wbc for worsening infection, good skin care as we've been doing. medicate for pain, agitation with MSO4, ativan, haldol combo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-09 00:00:00.000",
"description": "Report",
"row_id": 1533847,
"text": "Please see data, MD notes/orders. Neuro: Alert, intermitently follows commands and nods head to y/n questions. MAE, ?weak left arm, per nn pt had soft tissue damage to left shoulder prior to accident and hospitalization. US of left arm comepleted to r/o thrombus. Pt is calm today requiring reduced amount of sedatives/anxiolytics. CV: SR/no ectopy. Sbp 90-115. Pulm: On trach mask most of the day, expectorates thick white sputum in sm quantity. 02 sats 92-95%. GU: Urine output 35-50cc/hr. Diruetic increased with one dose zaroxolyn added with uo picking up to >300cc/hr. Was noted to have hematuria in collection bag this afternoon with no clear etiology. No clots noted, hematuria cleared after diruesis with return to clear yellow. Sample sent for cx/ua. GI: BS hyperactive, abd lg/softly distended. Pt inc on gold, liquid/loose stool x3. TF at goal rate 70/hr with min residuals. Skin: Surfaces grossly intact, general edema noted. Perianal area bright red, excoriated to include scrotum, Sites cleaned gently multiple times with barrier cream and nystantin ointment/powder applied. Mso4 2mg given IVP for percieved discomfort. Endo: Per ssc. Soc: Wife in to visit, updated on pt condition, plan of care. P: Continue full support, continue trach mask trials as tolerated. Meticulous skin care, frequent postion changes. Medicate prn aggitation/pain. Rehab when medically cleared. R: As above, pt being screened for rehab, wife will phone in tomorrow for names so that she can go to the facilities before a final decision made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-10 00:00:00.000",
"description": "Report",
"row_id": 1533848,
"text": "NEURO; PT. HAS BEEN AWAKE/ALERT AND SLIGHTLY AGITATED AT TIMES. PT. HAS BEEN SEDATED ON ATIVAN 2MG ROUTINE AND PRN DOSAGE, WITH DESIRED EFFECTS REACHED. PT. HAS DENIED ANY PAIN BY NODDING HIS HEAD BACK AND FOURTH. PT. MAE'S UNDER NORMAL STRENGTH AND HAS NOT PULLED AT ANY OF HIS LINES. PT'S TMAX DURING THIS SHIFT HAS BEEN 91.4.\n\nCV; PT. HAS BEEN STABLE WITH NSR-ST 90-110, WITH NO NOTED ECTOPY. B/P HAS BEEN 120-140'S/60-80'S. PT. HAS BEEN REPLETED WITH 80MEQ KCL DUE TO LARGE URINARY OUTPUT. AM LABS ARE PENDING.\n\nRESP; PT. HAS BEEN TOLERATING TRACH CUFF SINCE YESTERDAY WITH RESP RATE STABLE IN THE 20'S AND O2 SATS >93% PT. HAS BEEN SUCTIONED APPROX. Q3-4HRS WITH MINIMAL SECRETIONS, PT. TOLERATES THIS WELL. LUNGS ARE COARSE BILAT WHILE DIMINISHED IN THE BASES. TRACH AND COLLAR CARE DONE WITH PT. TOLERATING THIS WELL.\n\nGU/GI; PT. HAS BEEN RECEIVING TUBEFEEDS AT GOAL OF 70CC/HR OF PROMOTE WITH FIBER. PT. MAINTAINS LOW RESIDUALS AND PLACEMENT OF TUBE CHECKED Q3HRS TO ENSURE PROPER PLACEMENT. BLOOD SUGARS HAVE BEEN WNL AND NO COVERAGE REQUIRED DURING THIS SHIFT. ABD. EXHIBITS HYPERACTIVE BOWEL SOUNDS AND PT. HAS HAD LARGE AMTS OF LOOSE GOLDEN STOOL. THREE OUT OF THE FOUR LAXATIVES HAVE BEEN D/ PT. HAS FOLEY CATHETER DRAINING LARGE AMT'S OF PALE YELLOW URINE, APPROX. 300-2200CC/HR. LASIX DOEAGE HAS BEEN D/C'D AT THIS TIME. AND WILL BE RE EVALUATED DURING ROUNDS.\n\nSKIN; PT. HAS A VERY EXCORIATED PERINEUM AREA AND HAS BEEN STARTED ON HYDROCORTISONE CREAM FOR ONE DAY TO AID IN HEALING PROCESS. OTHERWISE ALL INCISIONS ARE HEALING WELL, WELL APPROXIMATED, WITH NO DRAINAGE OR FOUL ODOR NOTED. ALL LINES ARE SECURELY IN PLACE AND FUNCTIONING WELL WITH IVF INFUSING.\n\nDISPO; PT. REMAINS A FULL CODE AND HAS BEEN TOLERATING HIS WEAN TO TRACH COLLAR WITHOUT INCIDENT. PT. REMAINS AWAKE ALERT AND RESTING IN BED. PT. CONTINUES ON VANCO, AND PIPERCILLIN SECONDARY TO PREIMARY DX; OF SLEENECTOMY FROM MVA. PT. WILL BE EVALUATED FOR POSSIBLE TRANSFER TO FLOOR, OF POSSIBLE REHAB FOR MONDAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-10 00:00:00.000",
"description": "Report",
"row_id": 1533849,
"text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Pt. weaned to 80% high flow trach mask yesterday. Tolerating well. RR low 20's. O2 sats 94-96%. Bs initially coarse bilaterally. Improved over course of shift. Bs becoming clear bilaterally. Albuterol MDI given x 1 via trach/ambu bag. Tolerated well. Sx'd for scant-small amounts of thick white secretions. Strong cough effort. No further changes made. Continue with High flow trach mask and wean Fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-10 00:00:00.000",
"description": "Report",
"row_id": 1533850,
"text": "7a-7p\nneuro: lethargic this am, ho aware, ATC ativan dose decreased, pt more alert this afternoon, follows simple commands, moving all extremities, pt restless, trying to sit up & get out of chair, soft hand restraints & posey on\n\ncv: hr nsr, no ectopy, sbp stable\n\nresp: on 80% high flow trach collar this am, sat 93-100, changed to 70 % trach collar with sat 99-100, bs + all lobes & course, coughing productively, mod amt loose yellow/white sputum, strong cough, rr 20-33, no resp distress noted\n\ngi: emesis x 1 this am, TF off x 2 hrs, resumed @ goal rate, incont lg amt brown liquid stool, mushroom cath placed, continues on iv pepcid \n\ngu: foley patent, clear yellow urine, good uo, iv lasix \n\nother: hydrocortisone & mycostatin cream to excoriated perineum, abd sut line ota & dry, oob via lift, tol well, k+ & mg+ repleated, bs 176 & covered with rssi, continues on iv vanco & zosyn, wife and girlfriend in & updated on pt's condition\n\nplan: tx to floor in am if resp/mental status stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-10 00:00:00.000",
"description": "Report",
"row_id": 1533851,
"text": "Resp Care\n\nPt o2 delivery system changed to cool neb from high flow. fio2 70%. Spo2 97%. Airway patent. Ambu'd 1 albuterol tx when faint wheezes auscultated\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-28 00:00:00.000",
"description": "Report",
"row_id": 1533801,
"text": "TSICU Admission Note\n(Continued)\n 36-35 range. Coags normal with INR 1.2. Heparin sub q started. Pneumo boots on.\n\nGI...Abd large, round, mildly distended. ???increase in distention this afteroon. Bladder pressures checked 23--24. Absent BS. NGT to LWS with small amts bilious drg--faintly blood tinged this afteroon. Protonix started.\n\nGU....Foley to gravity with adequate amber colored urine. Ouput trending down this afternoon, but still adequate. Actively repleting CA++, K+ and mag. Thiamine, folate, and MV's added to IVF.\n\nID...Tmax 101.1. Zosyn abx coverage started.\n\nENDO...Coverage per RISS. 2U coverage given x2.\n\nSKIN....Trach site as mentioned above. Abd with original dsg covering ex-lap incision. Small amt of serosang shadowing noted. Ecchymosis with hematoma noted to R shin. Plain films shot. Backside intact.\n\nSOCIAl...Pt's fiance with whom he lives with in for visit. His brother, sister and children also in. All were updated on condition per this nurse. Visiting hours and contact person discussed. Fiance main contact for now.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533802,
"text": "Resp Care\npt. trach'd previously written as intubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533803,
"text": "Resp Care\npt. trach'd previously written as intubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533804,
"text": "Resp Care\nPt. remains intubated/sedated on ventilator with minimal changes made this shift ( see careview for details).\nBs: coarse bilat. diminished @ bases. Sxn'd for scant tan thick.\nabgs:adequately oxygenated compensated resp. acidosis\nPlan: cont. current support, no rsbi done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533805,
"text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Pt lightly sedated on propofol. Awakes to voice, cooperative, obeys commands- graps hands, moves toes. Pt mouthing words to communicate. Able to move all four extremities without difficutly. Pupils 3mm, reactive to light. Standing ativan dose d/t history of ETOH abuse. Morphine for pain PRN. J collar intact. Strict logroll precautions maintained.\n\nRESP: Remains trached and on vent,assist control, TV 500X24, PEEP 14. FIO2 decreased to 40%, pt tolerating well. ABG's stable, SATS 95-98%. LS: course throughout, decreased at bases. Requiring minimal suctioning. Thick tan/white secretions. No respiratory distressed noted. Equal rise and fall of chest.\n\nCV: NSR 80's with no ectopy. A line with dampened wave form. Monitoring BP with NIBP. SBP 90-low 100's. Left Subclavian Trauma line, line transduced for CVP of 14. Right femoral trauma line. Last set of enzymes negative. Maintanice fluids 175cc/hr.\n\nHEME: HCT continued to cycle Q6/hr. HCT stable at 31. Heparin SC TID, Pneumoboots intact.\n\nGI: Abd firm, distended, tender. Positive BS. NGT to LWS. Bladder pressures ranging .\n\nGU: UO 20-80cc/hr throughout shift. Urine concentrated - ? bloody sediment. 1 amp Sodium Bicarb given prophylactecaly. IVF bolus given X 1 with minimal effect. Dr. aware. Myoglobin urine sent, results pending.\n\nID: TMAX 99.8. Zosyn abx coverage. WBC's 24.9 (increased from 11.8 ).\n\nENDO: insulin coverage per RISS.\n\nSKIN: Abd with original DSD from OR, old drainage outlined. RLE anterior with hematoma and blister on shin, OTA. Trach site with DSD, minimal bloody drainage. Backside intact.\n\nPLAN: Monitor UO, hydrate, continue to wean, clear spine films, serial HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 1533806,
"text": "TSICU NPN (0700-1900)\nEVENTS:\n\n***Marginal BP throughout morning with fluid boluses providing only brief increases. Levophed started to maintain MAP's >70.\n***Continued low urine output despite increasing MAP's, maintenance fluid at 250cc/hr, and fluid boluses. Urine lytes, UA, C&S sent, nothing remarkable. Myoglobin still pending. CT of abd ordered.\n\n\nREVIEW of SYSTEMS:\n\nNeuro...Sedated on propofol at 25mcg/kg/min. Opens eyes to voice, moving all extremites purposefully. Following commands at times. Mouthing and nodding to questions. More sedate this afternoon--requiring increased stimulus to arouse and inconsistently following. Morpine PRN for pain. Ativan 2mg scheduled Q4hrs for DT prevention. Remains on log roll precautions. J on. Radiology has not read spine films yet.\n\nCV...NSR with no ectopy noted. HR in 70's. Levophed started at 1100 due to marginal BP/urine output. Fluid boluses providing brief effect only. Titrated for MAP's >70. See careview for trends. MAP's since start of pressor 70-80. New L SC TLC placed over wire. CVP transduced 17-18. Easily palpable peripheral pulses. EKG done this am--unremarkable. Attempted echo this with MD unable to visualize heart. Will have technician attempt tomorrow morning. Dr. aware.\n\nRESP...Pt converted to IMV this am 500x24 with peep increased to 18 and FiO2 to 50%. ABG's stable--see careview for trends. O2 sats >96%. Lung fields coarse to clear with suctioning. Thick tan to rust colored secretions seen with suctioning. CXR reportedly showing same patchy infiltrates, R upper lobe worse. Lactate trending down 1.4 this evening.\n\nGI...Abd remains large, round, and fairly distended. Very tender with palpation. BS improving. NGT to LWS with scant bilious drg. Protonix coverage.\n\nGU...Urine outuput minimal despite increasing BP and several fluid boluses. Maintenance fluids continue to run at 250cc/hr. Output around 25-35cc/hr. Urine and cloudy. Lytes, UA, C&S sent--all unremarkable. Plan to get CT scan--if no significant changes, possible swan. KCL, Mag repleted.\n\nHEME...HCT's stable at 32--last checked at 1800. Continues on heparin sub q. Pneumo boots on.\n\nID...Tmax 99.7. Continues on zoxyn coverage.\n\nENDO...Coverage per RISS. Requiring 2U regular insulin each time.\n\nSKIN...Trach site with scant serosang drg otherwise benign. Original surgical dsg covering abd incision with old serosang shadowing. Contusion with blister to RLE. Backside otherwise intact.\n\nSOCIAL...Spoke with pt's fiance today whom informed this nurse that pt was \"legally\" seperated from his wife. has not lived with this wife for multiple years. A few hours later his wife came in--upset that she had not been notified. Spoke in length with his wife who stated they were not legally seperated. She did acknowledge that they had not lived together for a while. His fiance and his adult children insist that they are legally seperated. Informed both women that a social worker would be here \n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-03 00:00:00.000",
"description": "Report",
"row_id": 1533826,
"text": "Respiratory Care:\nPt continues to be ventilated via trach on PSV settings; please see carevue for details of settings & subsequent ABG's. Pt was OOB today; tolerated fairly well, but did have an increase in RR. No changes were made to settings. Plan to continue ventilating as ordered & wean further when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-03 00:00:00.000",
"description": "Report",
"row_id": 1533827,
"text": "T/Sicu Nsg Note\n0700>>1900\n\nEVENTS- ongoing GI patency issues\n Diamox added for cont diuresis & to rx met alkalosis\n Haldol added for increasing agitation\n\n pt more responsive today; moving more spontaneously. BUT pt with periods of increased agitation NOT controlled with pain med and unable to provide calming by verbal cues/reassurance. Ativan dose taper begun today(by 25%) and in an effort to decrease sedation with benzo's, haldol was added to therapy. Pt received 2.5mg ivp with effect>> calmed within 10 min and able to sleep comfortably for 3/hr.\nNext episode of agitation responded to 1mg haldol with settling.\nPt generally will deny incisional pain. Pt cont to have firm distended abd with hypoactive bowel sounds. Bowel regimen includes colace,reglan,erythromycin and dulcolax w/o significant effect. + flatus on occ w/o relief of distension. Lactulose added as well but NO effect yet. Pt will at times become hypertensive,tachycardic, and tachypneic when experiencing abd distress; he will also become restless in bed and pull at linens and try to sit up and put legs over edge of bed. He has attempted to communicate by mouthing words but it is difficult to dechiper. Pt becomes visably frustrated when questioned in attempt to discover problems. Pt has questioning expression when reminded where he is & what has happened to him.\n\nAtivan cont ATC q 6/hr but has been decreased to 1.5mg ivp\nMSo4 cont for analgesia but pt is receiving less dosing today d/t denial of incisional pain.\nHaldol now on order prn for agitaion...with + effect. QTC pre-haldol was .40\n\nCVS- no issues\n\nRESP- no change in vent settings today. Lungs remain coarse & decreased at bases L>R. Secretions are thick white in small amounts.\nSats remains 94 to 99 on 50% with 12 peep. PSV @ 15cm.\n\nRENAL- no lasix; diamox for ongoing diuresis\n K+ repleted\n * urine colored with sludgy/cloudy appearance\n\nGI- as noted above- firm distended abd with hypoactive bowel sounds.\n Tube feeds cont w/o residuals obtained but NO stool since yest. Slowly advancing back to goal of 80cc/hr(60cc currently) Dulcolax given w/o significant results. Mushroom catheter placed to attempt decompresion with minimal results. Lactulose given ..results pnd. KUB pnd as well. Pt with episodic abd distress probably r/t retained air/stool. Small amt of liquid stool obtained & sent for c.diff culture.\n\nID- low grade temp; zosyn cont but today is final day.\n abd incision C&D\n\n\nENDO- ssri coverage per order.\n\nSKIN- NO new issues\n\nSocial- multiple family memebers visiting today; all upset to see pt agitated. Update provided to family & reinforced.\n\nAssess- impaired gi patency>> abd distress\n agitation/frustration/discomfort r/t present circumstances\n haldol added w/effect.\n\nPlan- cont w/current plan of care\n ongoing management of abd issues\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-04 00:00:00.000",
"description": "Report",
"row_id": 1533828,
"text": "TSICU NPN (1900-0700)\nEVENTS:\n\n****KUB at 1830 showed large colonic air ileus--per Dr. . Abd firm and distended. TF's stopped. NGT inserted and placed to LWS. Rectal tube placed with initial return of large amts of liquid brown stool.\n****Episode of desaturation at beginning of shift down to 90-91%. PO2 75. Peep increased to 15 and FiO2 up to 60%. Slowly recovered back to baseline. Now back on original settings--saturating well.\n\nREVIEW of SYSTEMS:\n\nNeuro...Neurologically, pt fluctuates between periods of sound sleep and then awakens--quickly becoming agitated and restless(attempting to sit up, pulling at gown and lines, shaking in bed.) When pt is calm, he will follow simple commands, needs alot of stimulation at times to do so. Moving all extremties with equal strength. Communicating via nodding and mouthing words. When asked if in pain, he will shake head yes, but can not determine location. Morphine 5mg dose given x 3 with good effect. Continues on scheduled ativan 1.5mg Q6hrs---???possibly continue to wean this dose down today. Haldol PRN also given twice with good effect. J collar remains on.\n\nCV....NSR with no ectopy seen. HR 70-90's. BP 110-130's/60-70's. CVP running 14-18. Easily palpable peripheral pulses. IVF at KVO.\n\nRESP...Stable after initial desaturation. Currently back on CPAP--peep of 12, PS of 15 and 50%. RR 8-20's. TV's 700's. MV . Sats >95%. Am ABG 7.36/48/94/0/28. Suctioning small amts of thick white secretions via trach. Lung fields coarse bilateral upper lobes with diminished bases. Nebs PRN.\n\nGI...see above event note. NGT with 250cc bilious drg since place. Rectal tube with 400cc liquid brown stool. Abd remains firm and distended. BS present. TF's remain on hold till further notice--pedi feeding tube clamped. Pt is on reglan, colace, erythromycin for bowel remigme---??need for adjusting. Pepcid for GI protection.\n\nGU...Foley to gravity with good urine output. Diamox dosing started yesterday due to metabolic alkalosis--continues through tonight. Lasix 10mg 1x dose given at 2am per Dr. request. Pt is now 1600negative since MN. K++ being actively repleted.\n\nHEME...HCT stable at 36.1. Heparin subq on board. P boots on.\n\nID...Tmax 99.4. WBC 13.5--stable. Zosyn coarse stopped last night.\n\nENDO...Coverage per RISS.\n\nSKIN...Trach site with minimal secretions around site. Abd incision with staples, no drg or redness. Multiple ecchymotic areas. Weeping of serous fluid from old line sites--R groin, L hand. Backside otherwise intact.\n\nSOCIAL...No family contact overnight.\n\nPlAN...Provide for pt comfort and safety. Pulmonary toilet. ??possibly attempt to wean. Possibly restart TF's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-04 00:00:00.000",
"description": "Report",
"row_id": 1533829,
"text": "Resp: pt on psv 12/15/50%. Alarms on and functioning.\nAmbu/syringe @ hob. BS auscultated reveal bilateral diminished sounds, slightly coarse in apecies. Suctioned for small amounts of thick white secretions. MDI's administered Q4hrs alb with no adverse reactions. No RSBI due to ^ peep. AM ABG's 7.36/48/94/28. Plan to continue to wean as tolerated. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-04 00:00:00.000",
"description": "Report",
"row_id": 1533830,
"text": "Respiratory Care:\nPt continues to be ventilated via trach on PSV settings. No changes made to ventilator settings throughout day; MDI's given as ordered. Plan to continue ventilating & wean when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-04 00:00:00.000",
"description": "Report",
"row_id": 1533831,
"text": "Nursing Progress Note\n 0700->\n\nS/O\n\nNEURO: Pt dangerously agitated when not sedated; repeatedly swung legs up over left siderails and pushed self toattemtped sitting position. Left ankle restained to right side of bed to maintain patient safety. Bil soft wrist restraints on d/t pt attempting to pull out NGT and trach tube when wrists loosened for turning and assessments.\nHaldol 4mg IV qhr and Ativan 0.5-4mg in addition to RTC Ativan 1.5mg with sedation lasting < 2 hours. Haldol maitained at q4hr instead of increasing frequency to q2hr because QTc 0.45.\n\nRemains on c-spine precautions with J collar on at all times.\nNo neuro-motor deficits.\n\nCV: NSR, normotensive. No cardiac issues.\n\nRESP: On PSV / PEEP with spontaneous respirations and no acute distress, but tachypneic when agitated and trying to get lines, tubes and drains out.\nTrach site intact, small amnts secretions leaking from trach insertion site.\nABG pH7.34 on Diamox.\n\nGI: Abd distended, tender upon receiving pt. Pt passed large amnts of flatus, liquid stool followed by soft brown stool and softening of abd. BS positive in all quadrants; abd tenderness resolved after passage of stool.\n\nAbd incision clean,d ry, approximated.\n\nFEN: Persistent hypokalemia, repleted with KCl 60mEq for K+ = 3.3; post K+ = 3.5, and KCl repletion resumed. Mg++ 1.9 -> repleted per scale. Blood glucoses WNL.\n\nHAEM: No current issues.\n\nID: No new issues.\n\nGU: Remains on Diamox; pH 7.34. Diuresing mod to lg amnts urine, fluid balance negative.\n\n\nSKIN: Abd incision as noted. Ecchymosisscattered over back and BLE with swelling and echymosis of left ankle but no pain on movement.\n\n\nPSYCHOSOC: Girlfirend and friends at bedside. Pt became more agitated in their presence, so visits time- limited and restricted to 1 person time.\n,legal wife called, very appropriate in questions and concerns.\n\nA/P\n\nDiscuss removing some pro-motility bowel meds to prevent \"overshoot\" of ileus, resulting in frequent diarrhea.\n\nContinue fluid and electrolyte management, including hypokalemia repletion. Discuss decreasing diuretic tx with team.\n\nContinue sedation as approrpiate and ordered. Monitor QTc for 25% increase while on Haldol.\n\nContinue current care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-05 00:00:00.000",
"description": "Report",
"row_id": 1533832,
"text": "TSICU NPN (1900-0700)\nREVIEW of SYSTEMS:\n\nNeuro...Fluctuates between periods of sleep, periods of calm with blank stares and minimally responsive, and periods of extreme agitation/restlessness. When awake, pt will follow simple commands, fairly consistently. At times he has a very depressed, flat appearance with a blank stare and not tracking to speaker(on zoloft.) When agitated, he is attempting to pull out lines, sit up in bed and swinging legs over side of bed. Does not respond to redirection at these times. Continues on ATC ativan 1.5mg Q6hrs. Haldol PRN dosing also effective. Following QTC's-see careview. Morphine 5mg given x2 for pt nodding yes when asked if in pain. J collar on.\n\nCV...Hemodynamically stable. NSR with no ectopy noted. HR 70-90's. BP 110-130's/50-70's. CVP ranging . Easily palpable peripheral pulses.\n\nRESP...Continues on CPAP peep of 12, PS 15, 50%. Oxygenation remains okay--but not able to wean peep or Fio2 any further. O2 sats >94% Desats down to lower 90's with extreme agitation episodes. Quickly recovers. RR 8-12 when asleep--upper 20's to 30's with agiation. Pulling good volumes. AM ABG 7.35/39/99/-. Lung fields coarse with diminished bases. Suctioning scant to small amts of thick white secretions. PRN albuterol given per RT.\n\nGI...Abd remains distended, but softer than before. BS present to almost hyperactive. Found rectal tube out with semi-formed stool present at beginning of shift. No further stool since--tube left out. NGT to LWS with small amts of bilious drg. Pedi feeding tube clamped. Probably will restart TF's today. Remains on reglan and colace.\n\nGU...Adequate urine--yellow with some sediment. Negative 3400 yesterday. 500cc LR bolus given last night as Dr. felt pt was too negative. Diamox also stopped at that time. Early in shift K+ was 3.1--repleted with 60meq. 4.0 this am. All other lytes adequate.\n\nHEME...HCT stable at 34.6. Heparin sub q continues. Pneumoboots on.\n\nID...WBC 13.7. Tmax 99.2. Zosyn coverage restarted--wanted to continue for a full two weeks.\n\nENDO... Coverage per RISS.\n\nSKIN...Multiple areas of ecchymosis. Abd incsion with staples OTA--no redness or drg noted. R groin old line site weeping moderate amts of serous fluid. Collection bag placed over site. Trach with small amts of brownish drg around insertion site. Backside otherwise intact.\n\nSOCIAL...No family contact overnight.\n\nPLAN...Aggressive pulmonary toielt. Possibly attempt to wean settings. Provide for pt safety. ??Restart TF's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-05 00:00:00.000",
"description": "Report",
"row_id": 1533833,
"text": "Resp: pt on psv 15/12/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned small amounts of thick white secretions. MDI's administered Q4 hrs Alb with no adverse reactions. Periods of agitation when suctioning. AM ABG's 7.35/39/99/22. Will continue to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-05 00:00:00.000",
"description": "Report",
"row_id": 1533834,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: REMAINS RESTLESS, THEN AGITATED. OCCAS NODS\n TO QUESTIONS OF PAIN VS. ANXIETY.\n HALDOL/ATIVAN/MORPHINE CONTINUE...NEED TO BE\n SPACED OUT AND GIVEN FREQUENTLY, TO MAINTAIN\n ADEQUATE AWAKE STATE. ZOLOFT. C COLLAR.\n\nCV: HR AND BP STABLE. QTC WNL.\n\nRESP: TOLERATED PEEP DOWN TO 10. ADEQUATE ABG.\n DROPPED SATS TO LOW 90'S ...BUT IMPROVED\n FROM LAST WEEK.\n LAST CXR SHOWS PL EFFUSIONS AND MILD FAILURE.\n\nRENAL: K REPLETED. NO LASIX TODAY...1500 CC NEGATIVE\n SO FAR TODAY.(AND HAD 500 CC BOLUS THIS AM.)\n\nGI: PROMOTE WITH F RESUMED AT 10 VIA PEDITUBE.\n NGT CLAMPED... 750 CC OUT LAST 24 HOURS.\n LARGE LOOSE BROWN STOOL. REPEAT KUB DONE\n TODAY.\n\nHEME: LABS STABLE. BOOTS. SC HEPARIN.\n\nENDO: BS STABLE. NO SLIDING SCALE. SYNTHROID.\n\nID: LOW GRADE TEMPS. IV ZOSYN CONTINUES.\n\nSKIN: ABD INCISION WNL. BRUISES/ABRASIONS HEALING.\n\nSOCIAL: CALLED X 2 FOR UPDATE. ENCOURAGED TO\n \"TAKE A DAY FOR HERSELF\" TODAY.\n\nA: VENTED. AGITATED.\nP: SLOW VENT WEAN. CONTINUE TO GIVEN MEDS ATC..AND\n DECREASE DOSES AS ABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-02 00:00:00.000",
"description": "Report",
"row_id": 1533822,
"text": "NPN (1900-0700) Review of Systems:\n\nNeuro: Pt easily arouses, opens eyes, follows commands inconsistantly and nodds head to questions. PERRL. MAE. Pt intermittantly very agitated and restless requiring prn ativan and morphine for pain/sedation. Pt also receiving ativan ATC for dt prophylaxis. Zorloft started. C- Spine precautions maintained.\n\nCV: HR=80-90s NSR, SBP=100-130s and MAP maintained >60 without intervention. Palpable peripheral pulses. Pt received 20mg IV lasix x1 with good diuresis. Color pink, skin warm and dry. Venodyne in place on LLE. Bannana bag at KVO.\n\nREsp: LS course and dm in bilateral bases. SIMV & PS with peep=12 and ps=10 unchanged and pt tol with adequate ABG for settings. Pt suctioned for sm-mod amt thick yellow secretions. Strong cough.\n\nGI: Abd distended, +hypoactive BS. Promote with fiber advanced to goal of 80cc/hr and infusing via pedi tube. IV pepcid continues. IV reglan continues. No BM.\n\nGU: Indwelling foley patent and draining sufficient quantity of clear yellow urine. IV lasix as above.\n\nHeme: Heparin SQ continues. See careview for am labs.\n\nID: Tmax=99.6po. IV zosyn continues.\n\nEndo: Coverage per RISS. Synthroid continues.\n\nSkin: Midline abd incision with staples, C&D and OTA with small dsd at distal end draining sm amt serous drainage. Old R groin puncture site draining sm-mod serous drainage. RLE leg hematoma unchanged. Pt turned and repostioned and skin care provided.\n\nSOC: No contact from relatives overnight.\n\nPlan: Continue full support as above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-02 00:00:00.000",
"description": "Report",
"row_id": 1533823,
"text": "respiratory Care:\nPt continues to be ventilated via ventilator on PSV settings; PS decreased from 20 to 10cm with good results. Please see Carevue for details of settings & subsequent ABG's. MDI's given as ordered. Suctioned for minimal secretions. Plan to continue ventilating as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-02 00:00:00.000",
"description": "Report",
"row_id": 1533824,
"text": "T/Sicu Nsg Note\n0700>>1900\n\nEVENTS- vent mode changed to PSV with slow weaning\n bowel regimen started\n tube feeds held for large residuals..erythromycin added to reglan therapy.\n lasix for ongoing diuresis\n\n pt responds to voice after continuous verbal encouragement\n pt will weakly follows commands with all extremities after much encouragement. Pt will respond to questions intermittently with weak nodding of his head. Pt does not focus on speaker; he exhibits a distant & blank expression when he opens his eyes; his facial expressions are flat. He will confirm incisional/abd pain and will grimace rarely with activity. He has not exhibited restless or agitated behavior today. He continues on q6/hr ativan ATC for DVT prophylaxis; no prn dosing has been required. He has received mso4 10mg x3 today for pain with effect as confirmed by pt nonverbal response(nodding head yes to pain relief.)\n\nCVS- vss\n\nRESP- PSV wean begun today. Currently on PS of 10 with 12 peep & 50% fio2. RR ranges with Ve ~ 7L (Vt's >600cc). Breath sounds are coarse with decreased bases L>R. Secretions are small amts of thick white sputum; cough is strong & congested. Last ABG reveals ph wnl with pco2 of 50 and PaO2 94...no further changes in settings; abg to be rechecked tonight per ICU H.O.\n\nRenal- urine output dwindling to ~ 50cc/hr of dark yellow, cloudy urine. Lasix 20mg ivp given with mod effect. IVF at kvo rate.\nI&O negative for the day.\nK+ repleted\n\nID- afebrile; zosyn continues\n\nGI- abd firm/distended & distant bowel sounds. Tube feeds infusing at goal of 80cc/hr but residuals >200cc this am. TF's held & rechecked..but no absorption. Reglan ongoing; erythropmycin po added. Bowel meds started- colace and dulcolax. Large loose BM following dulcolax, but none since. Abd remains firmly distended. Residual disgarded and tube feeds were restarted at 20cc/hr.\npepcid q12/hr\n\nendo- ssri per order.\n\nheme- no issues\n\nskin- no new issues; rle as noted in careview assessmet.\nc-collar in place;skin intact under collar.\nsc heparin, compression boot to lle\nongoing serous draiange from iv stick sites- right groin & left hand.\n\nsocial- sig. other, wife, sister visited today; pt not very respnsive to visistors. Progress updates provided.\n\nassess- tolerating ps wean\n not tolerating tube feeds; bowel regimen initiated\n depressed/withdrawn affect\n post-op pain\n\nPlan- cont with current plan of care; wean ps as tolerated to trach mask; cont diuresis per orders; advance tf's as tolerated; ongoing pain mngmnt; ?decrease ativan dosage and manage agitation with haldol.\ncont with OOB activities.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-03 00:00:00.000",
"description": "Report",
"row_id": 1533825,
"text": "NPN (-0700) Review of Systems:\n\nNeuro: Unchanged, pt arouses to voice, follows command and nodds head to simple questions. MAE. Perrl. Pt lethargic vs restless/anxious at time. Pt medicated with atc and prn ativan and prn morphine for pain/sedation.\n\nCV: NSR with hr=80s, sbp=100-120s. Color pink, skin warm and dry. Palpable pedal pulses. Venodynes in place.\n\nResp: LS course to dm bilaterally. CPAP & PS continue, ps increased 2' acidosis and pt tolerating. Suctioned for sm amt thick yellow secretions. Strong cough.\n\nGI: Abd distended, hypoactive BS. Promote with fiber with 0-20cc residuals and advanced to 40cc/hr, plan to advance to goal as tolerated. IV reglan continues. No BM overnight, fecal inc bag in place. Colace continues.\n\nGU: Indwelling foley intact and draining amber cloudy/clear urine, sufficient UO. IV lasix 20mg x1 given with giid diuresis.\n\nHeme: SQ heparin continues.\n\nID: Tmax=100.1po. No antibiotics.\n\nEndo: Coverage per RISS.\n\nSkin: Skin warm and dry. Abd midline incicsion unchanged, stapled and OTA with sm dsd at distal end. R leg with contusion. Skin care provided and pt turned and repositioned Q2h.\n\nPlan: Continue full support as above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-28 00:00:00.000",
"description": "Report",
"row_id": 1533799,
"text": "Resp care\nPt. arrived from OR with #8 trach in place. Placed on full vent support. ABG's showing acceptable ventilation, marginal oxygenation. Multiple vent changes made(see flowsheet). Esoph. balloon placed, peep adjusted accordingly. BS coarse, sx mod thick bloody secretions. Bronch'd for sm bloody secretions. Chest CT done, results pending. TLS films also done. Will follow, wean FiO2 as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-28 00:00:00.000",
"description": "Report",
"row_id": 1533800,
"text": "TSICU Admission Note\n Pt is 54y.o. male S/P motorcycle accident at 45mph. Pt was wearing a helmet. Questionable brief LOC at the scene. Taken to OSH where CT scan showed significant splenic laceration with active bleeding. Transferred to where initial HCT in ED was 12. Given 6U FFP and rushed to OR. Difficulty obtaining airway with pt vomiting during attempts(probable aspiration.) Emergent cricothyroidotomy performed to secure airway. Exploratory laporotomy then done with splenectomy. Cricothyroidotomy was then revised to formal tracheostomy.\n\n PMH: Severe ETOH abuse--2-3pints/day. Inconsitently taking librium. Old R elbow surgery with pt not able to fully extend since. Appendectomy. Accident at work a couple of weeks ago, injuring L shoulder(severe bruising.) Allergic to red dye.\n\nUpon arrival to unit post OR pt extremely tachycardic and hypertensive. Improved with adequate sedation. ABG's showing adequate ventillation, but poor oxygenation. Multiple vent changes made. Esophogeal balloon passed with peep subsequently increased in attempts to wean FiO2 down from 100%. CXR showed R upper lobe whiteout. Bronchoscopy done with minimal blood tinged secretions seen. Recruitment breaths then given with improvement in oxygenation seen. See careview for specific ABG trends.\n\nEVENTS:\nCT angio to rule out aortic dissection--negative.\nTLS and c-spine films done.\nR tib-fib films shot.\nR femoral trauma line placed.\nMultiple fluid boluses for drifing, marginal BP.\nMildly increasing abd distention this afternoon. Bladder pressures 24 and 23. Continue to follow.\nSerial HCT's stable.\n\nREVIEW of SYSTEMS:\n\nNeuro...Minimal sedation with low dose propofol. Arouses to voice, following commands, inconsistent at times though. Moving all extremities purposefully and with good strength. Pupils equal and reactive. Gag and cough reflexes intact. When awake, nodding yes when asked if in pain. PRN MSO4 given. TLS and c-spine films done this afteroon. Remains log roll with J collar on. Started on Ativan Q4hrs due to strong alchol history.\n\nCV....After initial tachycardia, NSR seen with HR 70-80's. No ectopy noted. Fairly hypotensive this afternoon--following cuff pressures. See careview for trends. SBP down to 80's. Total of 3L in LR boluses given with good response seen after. CVP per LSC introducer line 15-20 with poor waveform. Enzymes being cycled. Flat with one set left to draw. Maintenance LR increased to 175cc/hr due to hypotension. Easily palpable peripheral pulses.\n\nRESP... See above note on initial oxygenation issues. Currently pt has weaned down to 60% FiO2 with O2 sats >94%. PO2 on ABG 80's. Remains on 14 of peep. Per report CT showed aspiration and mild pulmonary contusions. Lung fields coarse to auscultation. Suctioning small amts of old blood tinged secretions. 8.0 portex trach in place. Oozing small amts of serosang drg around trach tube site. Lactate trending down 6.5 initially down to 3.2.\n\nHEME...HCT's stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-14 00:00:00.000",
"description": "Report",
"row_id": 1533865,
"text": "FOCUS; NURSING PROGRESS NOTE\nNEURO- AGGITATION IMPROVED FROM YESTERDAY. CONTINUES ON ATIVAN 1MG QID. NO NEED FOR ADDITIONAL ATIVAN TODAY. HE MOVES ALL EDXTREMITIES. FOLLOWING COMMANDS FOR THE MOST PART CONSISTENTLY TODAY. CONTINUES IN POSEY BELT AND SAFETY DEVICES ON WRISTS. SITTER DC'D BY WHILE PATIENT IN ICU AS HIS MS IS MUCH IMPROVED FROM YESTERDAY. SITTER IS ORDERED FOR HIM WHEN HE IS ON A MED FLOOR. HE IS ORIENTED TO PERSON WHEN HE IS ABLE TO COMMUNICATE WITH PASSE VALVE IN PLACE. NOT ORIENTED TO PLACE OR DATE. EEG DONE RESULTS PENDING. USING PASSE VALVE WITH CUFF DIFLATED. AT TIMES IS HARD TO UNDERSTAND. AT OTHER TIMES HIS SPEECH IS VERY CLEAR. RESP- ON 35% TC WITH SATS 93-97%. RESP RATE IN THE 20'S WHEN RESTING UP TO THE 30'S WITH CARE BEING GIVEN TO HIM. BS CLEAR DIMINISHED AT THE BASES. COUGHINGHING AND RAISING WHITE THCIK SPUTUM FROM TRACH.\nCARDIAC- HR 70-80'S NSR WITHOUT ECTOPI. SBP 111-121. K 4.0 TODAY.\nGI- ABD SOFT DISTENDED WITH POS BS. CONTINUES NPO. AWAITING SWOLLOW EVALUATION. PASSING BROWN LIQUID STOOL VIA RECTAL MUSHROOM CATHETER.\nGU- FOLEY PATENT DRAINING CLEAR AMBER COLORED URINE AT 50-120CC/HR.\nENDO- BS 133 AT NOON TX WITH SS INSULIN.\nID- TEMP MAX 100.2. HAS SPUTUM CULT FROM YESTERDAY WITH 2+ GM NEG RODS AND 1+ GM POS COOCI. STARTED ON IV VANCO AND LEVOFLOXACIN TODAY. CL DC'D AFTER 2 PERIPHERAL #20 IV'S STARTED.\n GIRLFRIEND IN TO VISIT AND UPDATED ON PLAN OF CARE. WIFE CALLED AND WAS UPDATED THIS MORNING BY THIS NURSE. SHE WILL BE IN LATER TO VISIT.\n TRANSFER TO CC6 WHEN SITTER IS AVAILABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-14 00:00:00.000",
"description": "Report",
"row_id": 1533866,
"text": "FOCUS; ADDENDUM\nSITTER HERE. REPORT FAXED TO CC6. NURSE FROM CC6 CALLED AND HER QUESTIONS WERE ANSWERED. STILL AWAITING SWOLLOW CONSULTS. REMAINS NPO AT PRESENT. ALL MEDS THAT CAN BE ARE BEING GIVEN IV. OTHER MEDS ON HOLD. WILL TRANSFER AT 1645.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-14 00:00:00.000",
"description": "Report",
"row_id": 1533867,
"text": "FOCUS; NURSING PROGRESS NOTE\nADDENDUM\nGI- DR UP AND PLACED FT IN RIGHT NARE. AWAITING CXR TO BE DONE PORTABLE THEN PATIENT TO BE TRANSFERRED TO CC6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-31 00:00:00.000",
"description": "Report",
"row_id": 1533816,
"text": "Resp Care\nPt remains on SIMV-parameters noted. Breath sounds are coarse wheezes bilat. Suction for thick tan secretions. Albuterol MDI x 3. Pt had TEE today. Weaning from sedation. Will continue mech vent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-01 00:00:00.000",
"description": "Report",
"row_id": 1533817,
"text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Vent settings unchanged. Vt 500, Simv 20, Fio2 50%, Peep 12cm, Psv 10. Bs coarse bilaterally. Sx'd for sm amount of thick tan secretions. Albuterol MDI given Q4hr. O2 sat decreasing to 92%. Unclear etiology. O2 sats increasing back to 94%. Repeat Abg within normal limits with last PaO2 82. Increased Peep requirements to maintain adequate PaO2. CXR no consolidations or effusions. No further changes made. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-01 00:00:00.000",
"description": "Report",
"row_id": 1533818,
"text": "NPN\nN: REMAINS OFF PROPOFUL GTT AND GIVEN SCHEDULED ATIVAN AND PRN MSO4. AT TIMES WAKES ABRUPTLY AND IS VERY ANXIOUS. CALMS WITH ATIVAN AND VERBAL REASSURANCE.\nCV: HD STABLE. MAINTAINED MAP >65 ON .01MCG/KG LEVO. OFF LEVO MAPS DRIFT 50'S. K/MG REPLETED.\nR: LUNGS COURSE AND SL DIM AT BASES. REMAINS VENTED ON SIMV 20X500 WITH PEEP 12/50%. OCC DESATS 90% WITH ACTIVITY. RECOVERS AND SATS 93-98%. ABG WNL. SXN'D FOR MOD AMT THICK YELLOW SEC.\nGI: ABD FIRM/DISTENDED. REGLAN ATC. PROMOTE WITH FIBER AT 10CC/HR. TO ADVANCE.\nGU: URINE /CLEAR AND FOLEY DRAINING 25-70CC/HR.\nID: WBC 13.5 TMAX 100.\nENDO: GLUCOSE NOT REQUIRING SS COVERAGE\nSOC: NO CONTACT WITH FAMILY OVERNIGHT.\nA/P: CONT TO WEAN VENT AS TOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-01 00:00:00.000",
"description": "Report",
"row_id": 1533819,
"text": "resp care\npt continues trached and mech ventilated. no vent changes this shift. please see carevue for vent settings. b/s coarse, sxn thk yel secretions. abg acceptable. plan: cont w/mech support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-01 00:00:00.000",
"description": "Report",
"row_id": 1533820,
"text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: MORPHINE/ATIVAN PRN. PT NODS YES/NO.\n MAE. C COLLAR. ZOLOFT.\n\nCV: LEVO WEANED OFF. HR AND BP STABLE.\n LYTES REPLETED.\n\nRESP: NO VENT CHANGES. SMALL THICK YELLOW SECRETIONS.\n NO DROPPING OF SATS.\n\nRENAL: LABS WNL. LASIX 10 AND 20 IV WITH GOOD RESULTS.\n\nGI: TF'S UP TO 60...GOAL 80. NO BM.\n THIAMINE/FOLATE/MVI/FAMOTIDINE.\n\nHEME: LABS STABLE. SC HEPARIN. BOOTS ON.\n\nENDO: NO INSULIN PER SLIDING SCALE.\n TSH LEVEL HIGH 8.8 PO LEVOTHYROXINE.\n\nID: AFEBRILE. WBC DOWN.\n IV ZOSYN CONTINUES.\n\nSKIN: R LEG BRUISING HEALING WELL.\n LEFT FOOT/ANKLE NOTED TO HAVE INCREASED BRUISING...\n SICU HO AWARE...? NEEDS XRAY.\n MODERATE OOZING FROM RIGHT GROIN LINE SITE.\n ABD INCISION OTA WITH SMALL DRAINAGE AT LOWER\n ASPECT.\n\nSOCIAL: VISITED DURING DAY.\n VISITED DURING NIGHT.\n\nA: STABLE S/P MVC.\nP: DIURESE. WEAN VENT AS ABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-02 00:00:00.000",
"description": "Report",
"row_id": 1533821,
"text": "Resp: pt on simv 20/500/10/+12/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned for moderate amounts of yellow thick secretions. MDI's administered Q4 hrs alb with no adverse reactions. AM ABG's 7.38/49/92/30. No RSBI due to ^ peep. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-07 00:00:00.000",
"description": "Report",
"row_id": 1533840,
"text": "MICU NURSING PROGRESS NOTE 7A=7P\nPt is S/P motorcycle accident, laceration to spleen requiring splenectomy , difficult oral intubation, trached.\n\nNeuro - Pt becomes agitated, throwing legs over side of bed, attempting to pull out tubes. Pt sedated with ativan prn x 2 along with scheduled dose with sedation intermittently with MSO4 5 mg x 2 for abd pain with effect. Propofol gtt for CT scan, pt comfortable for scan. On return, propofol shut off, pt became very agitated, ativan and haldol not effective, propofol gtt back on 20mcg/k/min with good sedation. PERL, brisk. MAE. ? L sided neglect per PT scan done). Follows commands inconsistently. Aspen collar on.\n\nResp - Received on CPAP 5 + 10 peep, 50%. Trial TM for ~ 45\"pt RR 30s, Sats 89-90%. ABG 7.40/46/66. Placed back on previous settings.Lungs coarse. Sx x 4 sm/mod thick white secretions. Sats 93-97%.\n\nCV - BP 110-142/60-82. NSR 58-80, no ectopy. +2 anasarca. Lasix changed to , goal 2L neg. Pt is ~1200cc neg so far and he just received PM lasix, diuresing.\n\nGI - Abd distended, increased per team. +BS. Bowel meds given, large liquid brown stool via rectal bag, ~500cc. + flatus. TF off for ? ileus. Dobhoff and NGT clamped. Placement checked by air bolus.\n\nGU - UOP adequate, now is diuresing from lasix.\n\nSkin - Eccymotic areas on LE, sides of abdomen. Right LE hematoma covered by DSD. NIVS done and pending. Right groin collection bag draining serous fluid form old trauma line site. Abd incision staples D&I.\n\nID - T max 99.2 PO. On Vanco/zosyn.\n\nSocial - GF in tioday, all questions answered. Wifa called for update.\n\nPlan - Pt continues to be agitated, does very well on low dose propofol gtt. Diurese with lasix. Wean as tol with diuresis. Antibx.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-08 00:00:00.000",
"description": "Report",
"row_id": 1533841,
"text": "Respiratory Care\nPt remains on cpap/psv. O2 sats trending in low to mid 90s. Breath sounds are fairly clear. Given Albuterol inhaler q4-6 hours. Suctioned for only small amounts of clear/white sputum. Last pao2 75 on 50% +10 peep. Pressure support was increased from 5 to 10 to increase tidal volume. Repeat abg/cxr pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-08 00:00:00.000",
"description": "Report",
"row_id": 1533842,
"text": "\nPT MAINTAINED ON TM VENTILATION AT 60% HIGH FLOW AND APPEARS TO BE TOLERATING BETTER TODAY BEING IN A CHAIR. SX FOR MOD. AMTS. PT IS COMPLETELY UNMANAGEABLE WITHOUT SEDATION: PULLING OFF VENTILATOR, ATTEMPTING TO GET OUT OF CHAIR ETC.. LAST ABG SHOWED A MET. ALKALOSIS WITH GOOD OXYGENATION WHILE ON PSV VENTILATION. PLAN IS TO KEEP ALTERNATING PSV WITH T.M.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-13 00:00:00.000",
"description": "Report",
"row_id": 1533859,
"text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\npatient cont'd to be agitated most of shift requiring 1:1 care. pt restrained w/posey belt, wrist restraints and mitts on and off o/n for safety. pt swinging legs over side rails and in constant motion fighting against restraints, sideways in bed, attmpting to sit up.. medicated generously w/ativan and some haldol as ordered w/o much effect. pt does follow commands, attempts to mouth words, but ??if he is at all oriented, appears to be ?psychosis like behavior.\n\nvss overnight per carevue. resp status improved, sounds slightly wheezy at times with fighting in bed, rr up to mid 30's w/agitation. now on 35% cool neb, sats 97-100%. able to expectorate secretions, sm amt white, snx'd x2 w/nothing there.\n\npt incontinent of urine and stool. foley catheter and mushroom catheter both re-inserted by this rn w/good results. pt conts to have loose golden diarreah. uop good. conts on maint ivf d5lr w/20 kcl @60cc/hr.\n\nplan to have speech swallow study today for ?pt to start eating by mouth for nutrition/pills.. ??if plan should be reassessed at this point considering the amount of sedation he is currently recieving and his level of agitation. pt also remains called out to floor and being screened for rehab placement. continues to require however sitter plus 1:1 nursing care at this point.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-13 00:00:00.000",
"description": "Report",
"row_id": 1533860,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- PATIENT IS ALERT. AGGITATED MILDLY. MOVING ALL EXTREMITES. OBEYING COMMANDS AT TIMES INCONSISTENTLY AT OTHER TIMES IS VERY CONSISTENT. ATIVAN BEING GIVEN 1MG QID. PRN ATIVAN DC'D. HAS PRN HALDOL THAT HE HAS NOT REQUIRED THIS SHIFT. CLONIDINE PATCH PLACED TODAY. CONTINES TO NEED ARMS RESTRAINED WITH SOFT LIMB RESTRAINTS AND HAS PSOEY BELT ON. WHEN UNRESTAINED HE AT TIMES GOES FOR TRACH. POSEY MITTS PRESENTLY OFF AND HE IS NOT PULLING AT ANYTHING WITH HIS ARMS RESTRAINED. HE DOES TURN ALOT AND ATTEMPTS TO SCUTCH HIMSELF OOB. HE CONTINUES TO HAVE A SITTER.\nRESP- ON 35% TC WITH SATS HIGH 90'S TO 100%. RESP ARE IN THE 20'S AT REST AND GO UP TO THE 30'S AND EVEN 40 WHEN HE IS AGGITATED AND ATTEMPTING TO CHANGE POSITIONS IN HIS BED. HIS RESP RATE SETTLES TO THE 20'S ONCE HE GETS COMFORTABLE. HE HAS BEEN SUCTIONED FOR SCANT TO SMALL WHITE THICK SPUTUM. BS CLEAR ANTERIORLY DIMINISHED AT THE BASES.\nCARDIAC- HR 78-103. SR TO ST WITHOUT ECTOPI. SBP 130-140'S. K 3.9 THIS AM TREATED WITH 40MEQ KCL AS ORDERED.\nGI- ABD SOFT WITH POS BS. PASSING BROWN LIQUID GUIAC POS STOOL, HAD 500CC OUT THIS SHIFT. HE PULLED HIS FT LAST PM. FT LEFT OUT FOR SPEECH AND SWOLLOW EVALUATION TODAY. THEY WERE UP AND WHEN THEY PUT DOWN HIS CUFF HE COUGHED A LOT. SATS REMAINED STABLE BUT HR CREEPED UP TO THE 100'S FROM THE HIGH 80'S. CUFF WAS REINFLATED. SWOLLOW STUDY POSTPONED TILL TOMMORROW AS THEY WANT TO ASSESS HIS SWOLLOWING WITH THE CUFF DOWN. DR MADE AWARE. HE WILL CHANGE LEVOTHYROXINE AND ZANTAC TO IV MEDS SO THAT PATIENT RECEIVE THEM. PATIENT ON D5LR WITH 20MEQ KCL AT 60CC/HR.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE AT 35-60CC/HR.\nSKIN- ABD MID LINE INCISION CLEAN AND APPROXIMATED WITH STERISTIPS INTACT. RIGHT SHIN WITH OLD EXCISED HEMATOMA. HAS SMALL SLIT OPENING IN THIS AREA THAT GETS PACKED WITH NS W-D DRESSING.\nENDO- BS THIS AM 124. BS AT NOON 150 TREATED WITH SS INSULIN.\n WIFE CALLED AND WAS UPDATED ON PATIENT'S CONDITION. GIRLFRIEND IN TO SEE THE PATIENT THIS AFTERNOON. SHE WAS UPDATED BY THIS NURSE.\nDISPO- AWAITING A FLOOR BED ON TELE FLOOR. TO HAVE 1;1 SITTER.\nPLAN- SWOLLOW EVALUATION TOMMORROW. TO ATTEMPT PUTTING DOWN CUFF PERIODICALLY THROUGHOUT THE DAY/NIGHT TO SEE HOW THE PATIENT DOES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-13 00:00:00.000",
"description": "Report",
"row_id": 1533861,
"text": "FOCUS; ADDENDUM\nNEURO- WHEN SPEECH AND SWOLLOW UP THEY ATTEMPTED PASSE MUIR VLAVE. WITH THIS IN PATIENT ABLE TO TALK BUT HE MADE NO SENSE IN WHAT HE WAS SAYING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-13 00:00:00.000",
"description": "Report",
"row_id": 1533862,
"text": "FOCUS; ADDENDUM\nID- TEMP SPIKE TO 101.5. DR NOTIFIED. BC X2, URINE, SPUTUM CULT DONE. CXR DONE. DR UP TO SEE THE PATIENT. TYLENOL GIVEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-14 00:00:00.000",
"description": "Report",
"row_id": 1533863,
"text": "cv: temp 101.3 to 99.7 po. hr 102 -79 str to sr no ectopy. bp 118-130/78\n\nneuro: agitated ativan atc and prn doses times 2 . 2mg iv times 2 for the additional doses at 8 pm and 2400 with some effect but stil restless.Mae to command . unable to assesss orietation as pt intubated and restless. pt sleeping at 2 a.m. and contin ues to rest.\n\nresp: coughing and raising mod amounts thin white.via trach. o2 sats 95-96% on 35% trach mask.\n\ngu: foley draining clear yellow urine.\ngi: npo. mushroom catheter draining liquid stool.abd soft bowel sounds positive.\n\nid\" r lower leg dressing changed for small amount serosanguinous. wet to dry. abd incision open to air. steri strips inatct.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-14 00:00:00.000",
"description": "Report",
"row_id": 1533864,
"text": "focus; nursing note\nneuro- up to see patient and assess for sitter need. He is less aggitated today. Sitter canceled by until patient leaves the unit. Dr. informed of this.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-31 00:00:00.000",
"description": "Report",
"row_id": 1533813,
"text": "NPN TSICU 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Pt sedated on Propofol. Increased overnight d/t agitation. Able to move all four extremities, follows commands. Communicates by nodding head, mouthing words. Standing and PRN ativan dose d/t ETOH abuse. PRN dose given X 1. PRN Morphine for pain. J collar intact. PERRLA\n\nCV: HR NSR 50-70's, no ectopy. Levophed gtt restarted at d/t low BP (SBP low 80's). Continued overnight @ 0.04mcg/kg/min. Titrate to keep MAP >65. CVP ranging 14-18. Left subclavin TLC intact. Palpatable pedal pulses. Has right radial ABP line\n\nRESP: Trached and vented on SIMV 500X20, 12 PEEP, FIO2 50%. ABG's stable. SATS 97-99%. LS: course, diminished at bases. No respiratory distress noted. Thick white secretions from suctioning.\n\nHEME: Pneumoboots intact. Heparin SC TID.\n\nGI: TF with goal of 90cc/hr. Residuals at midnight 30cc. Residuals at 0400 170cc. TF on hold. Abd firm, distended. Hypoactive BS.\n\nGU: Continues with decreased UO. Hourly outputs ranging from 15-80. MD aware. Urine very concentrated. Magnesium and potassium repleted.\n\nID: IV zosyn for abx coverage. TMAX 99.2. WBC trending down. Rectal and nasal swab obtained for MRSA.\n\nENDO: Insulin per RISS. No coverage needed during shift.\n\nSKIN: Abd incisional site with staples OTA. Minimal drainage at base covered with DSD. Trach site with minimal drainage. RLE with contusion and blister intact, OTA. Backside intact.\n\nSOCIAL: (estranged wife) in at beginning of shift. Spoke with social worker who is planning family meeting.Brother called for update.\n\nPLAN: Continue to monitor UO and BP. Pulm toliet. Check residuals, resume TF if <150. Family meeting to be determined by SW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-31 00:00:00.000",
"description": "Report",
"row_id": 1533814,
"text": "RESP CARE:Pt remains trached/on vent on SIMV/PSV 500/20/12PEEP/10/.50 Lungs coarse bilat. Sxd small amts thick yellow sputum.No RSBI due to high PEEP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-08-31 00:00:00.000",
"description": "Report",
"row_id": 1533815,
"text": "TSICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: LESS ANXIOUS WHEN AWAKE THIS AM...WITH PROPOFOL\n OFF AND ONLY PRN MORPHINE/ATIVAN. RESEDATED FOR\n TEE. AND THIS PM...WEANED OFF PROPOFOL.\n MAE WEAKLY. NOT FOLLOWING COMMANDS..BUT DOES\n NOD APPROP TO QUESTIONS YES/NO.\n C COLLAR INTACT. ACTIVITY AS TOLERATED.\n PO ZOLOFT TO BEGIN.\n\nCV: HR 50-80 SB/SR. LEVO DRIP PRN TO KEEP MAP>65.\n\nRESP: NO VENT CHANGES. STABLE ABG. NO DROPPING OF\n SATS TODAY. THICK YELLOW SECRETIONS.\n\nRENAL: LABS WNL. REMAINS WITH LOW UO.\n\nGI: NGT REPLACED WITH PEDITUBE..AND TF RESUMED WITH\n IV REGLAN..HAD HIGH RESIDUALS ON DAYS. ABD\n INCISION INTACT..SCANT DRAINAGE AT LOWER ASPECT.\n THIAMINE/FOLATE/MVI CONTINUE WITH LR AT 80.\n\nHEME: LABS STABLE. SC HEPARIN. BOOTS ON.\n\nENDO: NO INSULIN PER SLIDING SCALE.\n\nID: LOW GRADE TEMPS. WBC DOWN TO 14.9 FROM 16.6\n IV ZOSYN DAY 4 CONTINUES.\n\nSKIN: RIGHT LEG HEMATOMA IMPROVING.\n\nSOCIAL: VISITED ON DAYS. VISITED.\n ESTRANGED WIFE VISITED ON EVES.\n\nA: CONTINUES WITH LOW UO. LOW BP.\nP: FOLLOW UO. LEVO/PROPOFOL WEANED OFF. FOLLOW BP.\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 838629,
"text": " 2:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ? L side weakness s/p prolonged hospital course after mva\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST:\n\n\n CLINICAL INDICATION: 53 y/o man with possible left sided weakness. History\n of motor vehicle accident and prolonged hospital course.\n\n TECHNIQUE: Axial 5 mm sections of the head were obtained without IV contrast\n administration. There are no prior studies of the brain for comparison.\n\n FINDINGS: There is no evidence of an intra-axial or extra-axial mass or\n hemorrhage. There is no shift of the normal midline structures. The\n grey/white matter differentiation is within normal limits. There is prominent\n mucoperiosteal thickening in both sphenoid sinuses. There is a small\n crescentic soft tissue attenuating lesion along the convexity of the left\n parietal bone in the left scalp which may represent a small scalp hematoma.\n There is no evidence of a skull fracture.\n\n IMPRESSION:\n\n No evidence of acute intracranial abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-29 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 837628,
"text": " 8:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: eval status of intra-ab inj; only w/PO contrast, if inadequa\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma, s/p ex-lap & splenectomy with hypotension\n REASON FOR THIS EXAMINATION:\n eval status of intra-ab inj; only w/PO contrast, if inadequate, then proceed\n w/IV. Pt recently had dyeload.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension in 53 year old male status post trauma with\n splenectomy.\n\n TECHNIQUE: CT imaging of the abdomen and pelvis without IV contrast.\n Comparison is made to a prior CT of the torso from . Additional\n reformatted imaging in the coronal and sagittal planes was performed.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: An NG tube passes into the stomach. A\n right common femoral vein catheter terminates within the right common femoral\n vein. Compared to the prior study, there is evidence of diffuse edema within\n the soft tissues. Within the visualized portions of the lung bases, there are\n small bilateral pleural effusions and atelectasis that is unchanged when\n compared to the prior study. The liver, pancreas, spleen, kidneys, small\n bowel and colon are unremarkable in this study limited by the lack of IV\n contrast. A single calcified gallstone is present within the gallbladder\n which is otherwise unremarkable in the study limited by lack of IV contrast.\n The patient is status post splenectomy. Low attenuation fluid and soft tissue\n density within the splenectomy bed appears unchanged in size and configuration\n when compared to the prior study. Surgical clips are present in the region of\n the splenectomy site. A small amount of pneumoperitoneum has decreased\n when compared to the prior exam. Free fluid within the deep pelvis is also\n present but is little changed when compared to the prior examination. There is\n no evidence of pneumatosis, or portal venous gas.\n\n CT OF THE PELVIS WITH CONTRAST: A foley catheter is in place within the\n depressed urinary bladder. The rectum and prostate gland are within normal\n limits with central prostatic calcifications.\n\n Bone windows show no evidence of fracture.\n\n IMPRESSION:\n\n Unchanged examination when compared to with small amount of free\n fluid within the abdomen, and unchanged atelectasis/effusion within the lung\n bases in this patient status post splenectomy.\n\n (Over)\n\n 8:04 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: eval status of intra-ab inj; only w/PO contrast, if inadequa\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-06 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 838496,
"text": " 1:17 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: RT LOWER LEG LUMP, EVAL FOR ABSCESS AT WOUND SITE\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p mva\n REASON FOR THIS EXAMINATION:\n to evaluate for abscess at wound site\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR STUDY: Evaluate for abscess at wound site.\n\n A linear transducer was used to evaluate the superficial soft tissues adjacent\n to a wound in the right lower extremity. The ultrasound shows a complex\n predominantly hypoechoic abnormality which is approximately 1.7 cm in depth 1\n cm deep to the skin this extends for approximately 6 cm in sagittal length.\n The son features are non-specific no vascular evaluation was performed\n to exclude a DVT.\n\n IMPRESSION: Approximately 6 x 1.6 cm hypoechoic structure deep to a wound in\n the right lower extremity these features are non-specific and may be due to an\n abscess a hematoma or local area of inflammation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 838402,
"text": " 5:55 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? pulmonary process\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p mvc ICU day # 10, B pulmonary effusions\n REASON FOR THIS EXAMINATION:\n ? pulmonary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53 year old male status post MVA and splenectomy with bilateral\n pleural effusions.\n\n TECHNIQUE: CT imaging of the chest performed without IV contrast. Comparison\n is made to a prior study from .\n\n A tracheostomy tube terminates above the carina. An NG tube passes into the\n stomach. A left subclavian line terminates within the region of the upper SVC.\n There is evidence of slightly increased left sided pleural effusion.\n Atelectasis within both lungs is little changed with no new areas of pulmonary\n parenchymal consolidation identified. There is no evidence of pneumothorax.\n There is no evidence of failure. No pathologically enlarged mediastinal lymph\n nodes are seen on the study limited by lack of IV contrast. No pericardial\n effusion is seen.\n\n In the visualized portions of the upper abdomen, there is evidence of\n increased fluid within the upper abdomen in the patient's splenectomy bed and\n adjacent to the liver when compared to the prior examination. A gallstone is\n seen within the gallbladder. Limited view of the liver is within normal\n limits.\n\n IMPRESSION: 1. Slightly increased moderate bilateral effusions (left greater\n than right). Increased atelectasis at the left base, decreased atelactesis at\n the right base.\n 2. Increased free fluid within the abdomen and pelvis, most prominent within\n the splenectomy site.\n 3. Cholelithiasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837598,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval central line placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n eval central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Trauma with tracheostomy and CV line placement.\n\n Tracheostomy tube is 4 cm above carina. NG tube is in antrum of stomach.\n Left subclavian CV line overlies region of junction of left brachiocephalic\n vein and SVC. No pneumothorax. Probable bibasilar atelectases essentially\n unchanged since prior film of same date. Right CPA region not included on the\n film.\n\n IMPRESSION:\n\n No significant change since prior film. No pneumothorax or evidence for new\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-07 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 838588,
"text": " 10:46 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for distension\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with abdominal\n distension.\n REASON FOR THIS EXAMINATION:\n eval for distension\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Splenectomy and abdominal distention.\n\n Feeding tube is in proximal antrum of stomach. Gas is present throughout the\n colon. The cecum is slightly distended measuring 11 cm, unchanged since the\n prior study of . Right flank and diaphragms are not included\n on the film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "RP TIB/FIB (AP & LAT) RIGHT PORT",
"row_id": 837528,
"text": " 10:53 AM\n TIB/FIB (AP & LAT) RIGHT PORT Clip # \n Reason: S/P TRAUMA\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pain status post trauma.\n\n TWO VIEWS RIGHT TIBIA/FIBULA: Views show no evidence of fracture or\n dislocation. A cortical lucency in the mid shaft of the fibula likely\n representing nutrient canal. Vascular calcifications overlie the anterior\n aspect of the tibia; these likely represent phelobliths. Vascular\n calcifications in the posterior aspect of the calf likely represent small\n arterial calcifications.\n\n IMPRESSION: No acute injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837882,
"text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u infiltrates\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n f/u infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for infiltrates.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from . The\n previously-noted tracheostomy tube, central venous catheter, and feeding tube\n are unchanged in position. The hilar and mediastinal contours are\n unchanged. Left pleural effusion is noted. There is prominence of the\n pulmonary vasculature suggesting mild failure. No pneumothorax is seen.\n\n IMPRESSION: Multiple lines and tubes are again seen and unchanged. The exam\n is relatively unchanged from the previous study, accounting for changes in\n position and technique.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-07 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 838590,
"text": " 10:59 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILAT LEG SWELLING, EVAL FOR BILAT DVT'S\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p mva, with cellulitic & swollen legs\n\n REASON FOR THIS EXAMINATION:\n eval for bilat DVT's\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL DOPPLER ULTRASOUND.\n\n INDICATION: Leg swelling.\n\n TECHNIQUE: Standard son was performed.\n\n REPORT:\n\n RIGHT SIDE: There is normal compressibility, augmentation and respiratory\n variation in the deep veins of the right leg. No evidence of deep venous\n thrombosis is identified.\n\n LEFT SIDE: There is normal augmentation, respiratory variation and\n compressibility in the deep veins of the left leg. No evidence of deep venous\n thrombosis is identified.\n\n CONCLUSION:\n\n Negative DVT study bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837513,
"text": " 8:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p L SCV cordis placement\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of CV line placement in a patient with trauma.\n\n No CV line is identified. Endotracheal tube is 3 cm above carina. NG tube is\n in fundus of stomach. Since the previous film of the same date, there is new\n evidence of consolidation/collapse of the right upper lobe. There is\n elevation of the right hemidiaphragm. Atelectasis is present at the left\n base. The prominent poorly tortuous thoracic aorta is again demonstrated.\n\n IMPRESSION:\n Development of consolidation/collapse of right upper lobe since prior film. No\n pneumothorax. Prominent thoracic aorta again demonstrated. CT scan would be\n helpful to better evaluate this patient with history of trauma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-03 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 838213,
"text": " 6:13 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for obstruction.\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with abdominal\n distension.\n REASON FOR THIS EXAMINATION:\n Please assess for obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53 year old status post MVA status post splenectomy and tracheostomy\n with abdominal distention. Please assess for obstruction.\n\n There is cecal distention that measures 14 cm in transverse diameter. A\n Dobbhoff tube is seen in the left upper quadrant. Gas is visualized in the\n transverse colon as well as the sigmoid colon. Postoperative clips are seen\n in the midline of the abdomen.\n\n IMPRESSION: Cecal distention which is most likely due to paralytic ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "PELVIS PORTABLE",
"row_id": 837514,
"text": " 8:49 AM\n PELVIS PORTABLE Clip # \n Reason: trauma pelvis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p motorcyclce accident\n REASON FOR THIS EXAMINATION:\n trauma pelvis\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS:\n\n HISTORY: Pain after motorcycle accident.\n\n SINGLE VIEW AP PELVIS shows no fractures or dislocations. The sacrum is not\n well visualized due to overlying bowel gas and surgical staples.\n\n IMPRESSION: Negative.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837527,
"text": " 10:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for RUL expansion\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p L SCV cordis placement & recruitment process\n REASON FOR THIS EXAMINATION:\n eval for RUL expansion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n Endotracheal tube is 3 cm above carina. Tip of left subclavian cord is in\n brachiocephalic vein. NG tube is in fundus of stomach. There is persistent\n consolidation/collapse of the right upper lobe and elevation of the right\n hemidiaphragm. Tortuous thoracic aorta is unchanged. No pneumothorax.\n\n IMPRESSION:\n Persistent collapse/consolidation of right upper lobe. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838490,
"text": " 12:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p L subclavian line change, ? pneumo and position\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n s/p L subclavian line change, ? pneumo and position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA, status post splenectomy, tracheostomy, with\n right upper lobe aspiration/pneumonia with new central venous line placement.\n\n CHEST X-RAY, PORTABLE AP: Two portable AP films were taken one hour apart.\n The first film demonstrates a new right subclavian central venous line with\n tip projecting slightly into the right atrium. The second film has been taken\n after this line has been pulled back slightly. The tip of the right\n subclavian central venous line is now in the lower superior vena cava. A left\n subclavian central venous line is also present with tip in the upper SVC. The\n tracheostomy tube is present with tip at the thoracic inlet. The lung volumes\n are low and there is persistent left retrocardiac opacity. There is no\n pneumothorax.\n\n IMPRESSION: Status post right subclavian central venous line placement and\n manipulation. The line tip is properly positioned with tip in the lower\n superior vena cava. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-05 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 838328,
"text": " 9:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? dilated bowel\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with abdominal\n distension.\n REASON FOR THIS EXAMINATION:\n ? dilated bowel\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN SINGLE FILM:\n\n HISTORY: trauma and splenectomy with abdominal distention.\n\n Gas is present throughout the colon. The cecum is slightly dilated measuring\n 11 cm in diameter, reduced since the prior study of at which time it\n measured 14 cm. Feeding tube is in the distal body of stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837773,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Status post MVA. Status post splenectomy and tracheostomy with\n right upper lobe aspiration. Check for infiltrate/effusion.\n\n PORTABLE AP CHEST: A single, AP supine image. Comparison is made to the prior\n study from taken semi-upright. The tip of the tracheostomy tube, the\n NG line, and the left subclavian central line appear well positioned. The\n lungs are poorly inflated. No definite pneumonic consolidation or pleural\n effusion is identified. The pulmonary vessels are unremarkable and do not\n indicate cardiac failure.\n\n IMPRESSION: No definite lung consolidation or pleural effusion. Lines appear\n in satisfactory positions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838694,
"text": " 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with aspiration pneumonia post-MVA and splenectomy.\n\n TECHNIQUE: Standard chest radiograph was performed.\n\n COMPARISON: Study compared to exam from .\n\n The tracheostomy is again identified in good position, 3.5 cm above the\n carina. Poor inspiratory effort. A right-sided IJ line is in situ. There is a\n wide- bore NG tube identified with its tip coursing below the hemidiaphragm.\n\n There is evidence of silhouetting and obscuration of the aortic knuckle. This\n may represent air space consolidation or focal atelectasis in the left lower\n lobe. The previously\n identified left-sided subclavian line appears to have been removed.There is\n left lower lobe atelectasis. No pneumothorax is seen. The lungs appear\n grossly clear although poorly inflated.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837827,
"text": " 2:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? position dub hoff tube\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n ? position dub hoff tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff tube placement.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from the same day, \n at 05:56. There has been interval removal of an NGT in a patient with a\n Dobbhoff feeding tube, which extends beyond the inferior margin of the image\n field, but is likely positioned in the stomach. A tracheostomy tube and left-\n sided central venous catheter are again seen and unchanged in position.\n Bilateral pleural effusions with posterior layering and obscuration of the\n diaphragmatic contours is noted. Mediastinal and cardiac contours are\n unchanged, accounting for differences in positioning. No pneumothorax is\n seen.\n\n IMPRESSION: Interval placement of an NGT with a Dobbhoff feeding tube.\n Bilateral pleural effusions are seen. The remainder of the exam is unchanged\n from previous study, taking into account differences in position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 837541,
"text": " 12:59 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS\n Reason: ? aortic disection\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p mvc noted to have widened mediastinum.\n\n REASON FOR THIS EXAMINATION:\n ? aortic disection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post trauma, widened mediastinum on chest x-ray.\n\n COMPARISON: No previous CT studies for comparison.\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest, abdomen\n to mid pelvis were obtained, in 5 mm slices. IV non-contrast ionic was\n administered due to the rapid rate of bolus injection. No oral contrast was\n used.\n\n FINDINGS: An ET tube is seen in good position. NG tube down to the stomach.\n\n CHEST: The heart, pericardium and great vessels are normal in appearance. The\n aorta is of normal caliber throughout. A small 13 mm oval non-enhancing\n lesion is seen on the right paratracheal representing a lymph node. There is\n no stranding of adjacent fat. There is no evidence of aortic dissection.\n Multiple shotty lymph nodes are seen in paratracheal region. There are no\n hilar nodes. A very small amount of pleural effusion is seen on the left\n side. There is no evidence of pneumothorax. Bibasilar and small right apical\n atelectasis are seen, representing atelectatic changes due to poor post-op\n respiration or due to aspiration.\n\n ABDOMEN AND UPPER PELVIS: Skin surgical clips on the anterior lower abdomen\n and small amount of pneumoperitoneum post surgery. Small amount of free fluid\n is seen in the abdomen and pelvis. The patient is post splenectomy. Small\n calculus is seen within the gallbladder. The liver, pancreas, adrenal glands\n are unremarkable. There is no biliary dilatation. The kidneys are normal with\n hydronephrosis. A few diverticula are seen in the sigmoid colon.\n Sessile exostosis on the right iliac measuring approximately 2 cm.\n\n IMPRESSION:\n\n Post splenectomy. A small amount of fluid and free air are expected post-\n operative findings.\n\n Bibasilar and small right apical atelectatic changes.\n\n No evidence of aortic dissection or aneurysm.\n\n (Over)\n\n 12:59 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS\n Reason: ? aortic disection\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837496,
"text": " 3:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: repeat to verify mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n repeat to verify mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST\n\n INDICATION: Followup chest x-ray to evaluate mediastinum which may have been\n related to technique on prior exam, trauma.\n\n FINDINGS: A single portable view of the chest is improved in technique since\n the previous exam, no longer seen in lordotic position. Still, however, there\n is accentuation of the upper mediastinum. This is most likely related to a\n tortuous aorta but trauma-related pathology cannot be excluded. In addition,\n there is increased linear opacity in the right upper lobe probably related to\n atelectasis. No pneumothorax or pleural effusions are identified. The\n trachea does not appear deviated.\n\n IMPRESSION:\n\n 1. Prominent upper mediastinum likely related to tortuous aorta. However,\n given the patient's history of trauma, a CT of the chest is recommended to\n exclude pathologic abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837495,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n AP PORTABLE CHEST\n\n INDICATION: Trauma.\n\n FINDINGS: Single AP portable view of the chest is performed in lordotic\n position. Accounting for this, this may be cause for accentuation of the\n upper mediastinum. In addition, a tortuous aorta is likely. There are\n increased right upper lobe linear opacities, likely atelectasis. There are no\n pleural effusions or pneumothorax. No fracture is seen. The pulmonary\n vasculature is within normal limits. The trachea is not deviated.\n\n IMPRESSION:\n\n 1. Repeat view of the chest is recommended (without lordotic positioning) for\n better evaluation of the mediastinum. Please see clip for\n further information.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837583,
"text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? change RUL and B basilar atelectasis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with RUL\n aspiration pneumonia/atelectasis\n REASON FOR THIS EXAMINATION:\n ? change RUL and B basilar atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Trauma with splenectomy, tracheostomy and pneumonia.\n\n Tracheostomy tube is 4 cm above the carina. NG tube is in the stomach. Since\n the prior film of there has been resolution of the right upper lobe\n collapse and right upper lobe is now well aerated with minimal residual\n atelectasis. There is slight elevation of the right hemidiaphragm. No\n pneumothorax and no new lung lesions.\n\n IMPRESSION:\n\n Almost complete resolution of right upper lobe collapse with minimal residual\n atelectasis in the right upper lobe. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-08-28 00:00:00.000",
"description": "C-SPINE, TRAUMA",
"row_id": 837543,
"text": " 1:27 PM\n C-SPINE, TRAUMA; T-SPINE Clip # \n L-SPINE (AP & LAT)\n Reason: Cervical spine PA+LAT to r/o spinal fracture/dislocation\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy\n REASON FOR THIS EXAMINATION:\n Cervical spine PA+LAT to r/o spinal fracture/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain.\n\n Two views of the cervical spine show no fractures. There is grade I\n anterolisthesis of C2 on C3. Uncovertebral spurring is present.\n\n Two views of the thoracic spine show degenerative changes of the lower\n thoracic vertebrae, without evidence of fracture or dislocation. There is\n apparent widening of the mediastinum, which is better evaluated on the chest-\n x-ray obtained 30 mintues prior.\n\n Two views of the lumbar spine show decreased disc height at L4-L5. No\n fractures or dislocations are noted.\n\n Incidental note is made of nasogastric tube in the stomach, contrast in the\n urinary collecting system, and staples overlying the anterior abdomen.\n\n IMPRESSION: No fractures. Mild cervical spine anterolisthesis. Degenerative\n changes.\n\n"
},
{
"category": "Echo",
"chartdate": "2101-08-30 00:00:00.000",
"description": "Report",
"row_id": 76900,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 73\nWeight (lb): 220\nBSA (m2): 2.24 m2\nBP (mm Hg): 98/57\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 10:40\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nNo parasternal views available.\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size and free\nwall motion are normal. There is an anterior space which most likely\nrepresents a fat pad.\nIf more definitive information regarding ventricular function is desired, a\nradionuclide ventriculogram or TEE are suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 76901,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p motor vehicle accident. Left ventricular function. ?pericardial effusion.\nHeight: (in) 71\nWeight (lb): 242\nBSA (m2): 2.29 m2\nBP (mm Hg): 127/74\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 16:34\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nDue to suboptimal technical quality, no deterimination of ventricular cavity\nsize, systolic function, or the presence/absence of pericardial disease could\nbe determined.\nIf clinically indicated, a follow-up study by lab son or a TEE are\nsuggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2101-08-31 00:00:00.000",
"description": "Report",
"row_id": 76849,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease. Poor TTE wndows\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 95/60\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 14:18\nTest: Portable TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient is intubated, ventilated on a c-spine collar sedated with propofol\ninfusion\nLEFT ATRIUM: The left atrium is normal in size. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No atrial septal defect is seen by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. The physician caring\nfor the patient was notified of the echocardiographic results by e-mail. The\nechocardiographic results were reviewed with the houseofficer caring for the\npatient. A left pleural effusion is present.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are structurally normal. Mild\n(1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular systolic function. Mild mitral regurgitation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-16 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 839571,
"text": "\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess swallowing\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p mcc, w/ trach\n REASON FOR THIS EXAMINATION:\n assess swallowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess swelling, patient is post MVA with tracheostomy.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was performed in conjunction with the\n speech therapist. Varying consistencies of barium were administered. There\n is an occasional penetration of thin liquids due to spill over from the oral\n cavity. There is no evidence of aspiration. There is minimal residual within\n the vallecula and puriform sinuses.\n\n IMPRESSION:\n\n 1. No evidence of aspiration.\n 2. Occasional penetration of thin liquid.\n 3. Please see the speech pathologist report for further detail.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-12 00:00:00.000",
"description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS",
"row_id": 839094,
"text": " 10:57 AM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: eval for instability\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n eval for instability\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma, evaluate for instability.\n\n COMPARISON: .\n\n CERVICAL SPINE WITH ADDITIONAL FLEXION AND EXTENSION VIEWS: These views are\n slightly limited by patient positioning. Vertebral bodies C1 through T1 are\n visualized on the neutral view. However on the flexion-extension views the C7\n T1 vertebral bodies are obscured. There is no evidence of fracture or\n prevertebral soft tissues swelling. There is minimal disc space loss, endplate\n sclerosis and anterior osteophyte formation involving the C3 through C7\n levels. No clear malalignment is identified.\n\n IMPRESSION: No spondylolisthesis demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839390,
"text": " 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff position\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy s/p\n dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Feeding tube placement in patient with trauma and splenectomy.\n\n Distal end of feeding tube is in region of pyloroduodenal junction but still\n all contained within the stomach. Tracheostomy tube is 3 cm above carina. No\n pneumothorax. Discoid atelectasis is present in the left lower zone and\n additional atelectasis is present in the left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-10 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 838984,
"text": " 10:38 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with abdominal\n distension.\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN:\n\n INDICATION: 53 y/o man s/p MVA s/p splenectomy and tracheostomy. Abdominal\n distention.\n\n COMMENTS: Portable AP supine radiograph of the abdomen is reviewed. There are\n multiple surgical staples in the midline abdomen. There is also rectal tube\n overlying the symphysis pubis. There is diffuse dilatation of the small bowel\n and colon indicating ileus. The radiograph is suboptimal due to patient motion\n and body habitus.\n\n The previously identified dilated cecum has been improved on this radiograph.\n\n IMPRESSION: Ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839425,
"text": " 6:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with fever\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Fever. Check Dobbhoff placement.\n\n PORTABLE AP CHEST: A single supine view of the lower chest and upper abdomen\n shows a Dobbhoff tube with the tip likely in the second portion of the\n duodenum. There is residual left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839270,
"text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p MVA, s/p splenectomy and tracheostomy with fever.\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever, trauma. Splenectomy and tracheostomy.\n\n AP CHEST: Comparison is made with . The tracheostomy tube is\n unchanged. The right central venous catheter is also unchanged. Again there\n is obscuration of the aortic notch and prominence of the mediastinal contour,\n unchanged. The cardiac contour is stable. The NG tube has been removed.\n There is left lower lobe atelectasis. No vascular congestion. The left\n costophrenic angle is not imaged but there is no right effusion.\n\n IMPRESSION:\n\n No significant change or acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-09 00:00:00.000",
"description": "PL UNILAT UP EXT VEINS US PORT LEFT",
"row_id": 838813,
"text": " 9:24 AM\n UNILAT UP EXT VEINS US PORT LEFT Clip # \n Reason: eval for dvt\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with L UE swelling, weakness\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53 year old man with left upper extremity swelling, and weakness.\n Please evaluate for deep vein thrombosis.\n\n COMPARISON: None.\n\n FINDINGS: -scale and Doppler son of the left upper extremity\n included the basilic, cephalic, brachial, axillary, subclavian, internal\n jugular veins were performed. The right subclavian vein was also\n interrogated. Normal flow, augmentation, compressibility and waveforms are\n demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep vein thrombosis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-11 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 839029,
"text": " 2:46 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Please assess for abscess.\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma, s/p ex-lap/splenectomy/trach now with fever, ^WBC,\n ileus.\n REASON FOR THIS EXAMINATION:\n Please assess for abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 53-year-old man with history of trauma, status post\n splenectomy, now presenting with fever . Assessment for an abscess.\n\n TECHNIQUE: Axial slices of the abdomen and pelvis were obtained from the\n diaphragm to the pubic symphysis with IV contrast. Comparison is made with\n the prior CT of . Additional reformatted imaging in the\n coronal and sagittal planes was obtained.\n\n CT OF THE ABDOMEN WITH CONTRAST: Bilateral pleural effusions are seen, left\n more than right. A left-sided basal atelectasis is noted which is decreased\n compared to the prior study. Mild ascites is seen. A single calcified\n gallstone is present within the gallbladder. The patient is status post\n splenectomy. Low-attenuation fluid is seen within the splenectomy bed which\n appears unchanged. The liver, pancreas, adrenals, and kidneys appear normal\n except for a small left renal cyst.\n\n CT OF THE PELVIS WITH CONTRAST: There is free fluid within the pelvis. A\n foleys catheter is seen within the bladder. Calcification is seen within the\n prostate.\n\n Bone windows are unremarkable.\n\n IMPRESSION:\n 1. Mild Ascites.\n\n 2. Bilateral pleural effusions, left more than right, and left basilar\n atelectasis.\n\n 3. Single calcified gallbladder stone.\n\n\n\n\n\n (Over)\n\n 2:46 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: Please assess for abscess.\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT; EXPLORATORY LAPAROTOMY\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2101-08-29 00:00:00.000",
"description": "Report",
"row_id": 181974,
"text": "Sinus rhythm\nGeneralized low QRS voltages\nNo previous tracing for comparison\n\n"
}
] |
25,779 | 155,168 | The patient was initially treated with steroids, Benadryl, and ranitidine. Upon transfer to the floor ranitidine was continued, the other treatments were not. The patient was ambulatory, eating comfortably, moving her bowels without difficulty, speaking without difficulty, and had no subjective complaints. She remained in the hospital overnight (, to ), and on , she was transferred directly from the hospital to Dialysis Center () in , for her scheduled hemodialysis. From there she was to return home. | Abnormal left axis deviation. Sinus rhythm. | 1 | [
{
"category": "ECG",
"chartdate": "2183-04-07 00:00:00.000",
"description": "Report",
"row_id": 245360,
"text": "Sinus rhythm. Abnormal left axis deviation. Since the previous tracing\nof T wave inversions of evolving inferolateral myocardial infarction\nare no longer seen.\n\n"
}
] |
18,360 | 151,179 | 63 M with mantle cell lymphoma, recently XRT to abdominal mass, admitted with abdominal symptoms, fever, and hypotension. . The patient had a brief stay in the MICU where an NGT was placed and he was fluid resucistated. His BP responded well and he defervesed. He was then transfered to the BMT service for further work-up. GI was consulted and it was decided that an endoscopy would not be performed here in , as he gets his primary oncology care in . The obstruction was likely intermitent to non-compliance with a lwo residue diet. It appeared to have resolved and he was able to take fluids and soft solids without emesis. He had some diarrhea which was likely radiation colitis. He was discharged tolerating POs to continue oncologic care in . | Marked gastric distention for which virtually no contrast has entered the small bowel loops. There is marked gastric distention with contrast and contents, and very little contrast present in distal small bowel loops. Prominent retroperitoneal and mesenteric lymph nodes measuring up to 1 cm are unchanged. Right nare NGT to LCWS, putting out scant amounts of bilious drainage. Hypotensive at baseline. Non-specific shallow T waveinversions in leads II, aVF and V4-V6. Marked gastric distension that is not diagnostic, but suggestive of gastroparesis or outlet obstruction. PA AND LATERAL CHEST RADIOGRAPHS: There are low lung volumes. Partially blind Right eye.CV: NSR. TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and pelvis with coronal and sagittal reformatted images was performed after the uneventful administration of 130 cc Optiray contrast. Right eye partially blind.CV: BP stable, 95-110s systolically (baseline sbp lower mid 90s-100s). Minimal degenerative changes are seen within the thoracic spine. The gallbladder is distended with IV contrast or sludge layering within it. Hypodensity within the left kidney measures simple fluid density and is likely a simple cyst. CT PELVIS WITH CONTRAST: The rectum, sigmoid, large bowel, bladder are all unremarkable, and note is made of a small bowel containing left inguinal hernia. Foley patent draining adequate CYU.SKIN: Intact, no breakdown noted.ID: Afebrile. Noprevious tracing available for comparison. Diffuse degenerative changes are noted. Central venous catheter terminates in the proximal right atrium. Small bilateral atelectasis and punctate granuloma at the left lung base are unchanged. Rare ventricular premature beat. Sinus tachycardia. CT ABDOMEN WITH CONTRAST: The small bibasilar atelectasis is present in the visualized lung bases. Field of view: 36 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) otherwise remarkable for diffuse degenerative changes. Few subcutaneous collateral vessels are noted. A tiny left pleural effusion is new since . 8:36 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: abscess? Although this is not diagnostic, it is suggestive of gastric outlet obstruction. Soft tissue and osseous structures are within normal limits. Exam no abd ttp. REASON FOR THIS EXAMINATION: abscess? The pancreas is unremarkable. BP 100/50's.Resp: LSCTA, slightly diminished at bases. Tip of the central venous catheter terminates in the upper right atrium. LCTAB. The intraabdominal vessels cannot be well evaluated on this study, however it is clear that the SMA and SMV are encased by this mass. A small amount of contrast is seen layering within a nondistended stomach, and contrast passes through the small bowel into the descending colon with no evidence of obstruction. Transfer to medical/oncology floor in am if pt remains stable. COMPARISON: CT abdomen . There is a right subclavian catheter, with the tip in the SVC. colitis? colitis? colitis? Antibiotics started in ED. TECHNIQUE: Multidetector helical scanning of the abdomen was performed with oral contrast only. The SMA and branches course through this mass are narrowed, but patent. The terminal ileum is collapsed. The pancreas, spleen, and small bowel loops are unremarkable. Low normal voltage in the limb leads. Coronal and sagittal reformats were displayed. Bibasilar atelectasis is noted. The SMA and its major branches that course through this mass are narrowed, but patent. CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Heart size is normal and there is no pericardial effusion. NGT placed. IMPRESSION: No acute cardiopulmonary abnormalities identified. +BS. + BS. Abdomen protuberant, soft. On this non-IV contrast scan, the liver, spleen and adrenal glands are normal. Transferred to SICU in the event of surgical intervention.Neuro: AOx3. The large mesenteric mass is not entirely included on the study, however measures 8 x 11.5 cm and is likely unchanged in size when accounting for the shifted axis of the lesion. IMPRESSION: 1. IMPRESSION: 1. Continue w/percutaneous management w/NGT. Continue percutaneous management with NGT. Continues w/loose green/brown stool. Continue to monitor hemodynamics & resp effort. There is a newly identified 4.8 x 3.8 cm soft tissue mass in the cecum, at the ileocecal valve, likely a focus of lymphoma given patient's history. Multiple prominent retroperitoneal and mesenteric lymph nodes are also noted measuring up to 1 cm. NURSING NOTEPLEASE SEE CAREVUE FOR SPECIFICSNEURO: A&Ox3. An NG tube descends below the diaphragm terminating in the antrum of the stomach. NSR HR 60-80s, PVCs noted on occassion. No suspicious lesions are identified in the liver, and the gallbladder is contracted. Nursing Admit NoteSee Carevue for specificsPt admitted from ED with N/V, diarrhea, fever, hypotension ?gastric outlet obstruction. No contraindications for IV contrast WET READ: AHPb SUN 9:58 AM 1. Currently on Levaquin, flagyl, vanco IV.Plan: No surgical intervention at this time per surgical team. COMPARISON: None. COMPARISON: None. (Over) 11:40 AM CT ABDOMEN W/O CONTRAST Clip # Reason: Eval for debris/ patency of gastric outlet - perform with PO Admitting Diagnosis: COUGH, FEVER, GASTRIC OUTLET OBSTRUCTION FINAL REPORT (Cont) 2. No evidence for small bowel obstruction or coliitis. Continues to have small amounts liquid greenish-brown stool guaic negative.GU: Foley draining large amounts clear yellow urine.ID: Afebrile. FINAL REPORT INDICATION: Mantle cell lymphoma on steroids with nausea, vomiting and diarrhea. Prior distention of the stomach was likely due to gastroparesis. | 6 | [
{
"category": "Radiology",
"chartdate": "2201-05-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 958873,
"text": " 6:31 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with fevers and cough\n REASON FOR THIS EXAMINATION:\n r/o infectious process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with fevers and cough, evaluate for infectious\n process.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: There are low lung volumes. Bibasilar\n atelectasis is noted. The lungs are otherwise clear. No pleural effusions or\n pneumothorax is seen. Soft tissue and osseous structures are within normal\n limits. There is a right subclavian catheter, with the tip in the SVC.\n Minimal degenerative changes are seen within the thoracic spine.\n\n IMPRESSION: No acute cardiopulmonary abnormalities identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-05-20 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 959341,
"text": " 11:40 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Eval for debris/ patency of gastric outlet - perform with PO\n Admitting Diagnosis: COUGH, FEVER, GASTRIC OUTLET OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with mantle cell lymphoma of the abdomen with gastric outlet\n obstruction\n REASON FOR THIS EXAMINATION:\n Eval for debris/ patency of gastric outlet - perform with PO contrast only\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mantle cell lymphoma with possible gastric outlet obstruction on\n prior CT.\n\n COMPARISON: CT abdomen .\n\n TECHNIQUE: Multidetector helical scanning of the abdomen was performed with\n oral contrast only. Coronal and sagittal reformats were displayed.\n\n CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Heart size is normal and there is\n no pericardial effusion. Small bilateral atelectasis and punctate granuloma\n at the left lung base are unchanged. A tiny left pleural effusion is new\n since . Central venous catheter terminates in the proximal right\n atrium. An NG tube descends below the diaphragm terminating in the antrum of\n the stomach.\n\n On this non-IV contrast scan, the liver, spleen and adrenal glands are normal.\n Hypodensity within the left kidney measures simple fluid density and is likely\n a simple cyst. The gallbladder is distended with IV contrast or\n sludge layering within it. The pancreas is unremarkable.\n\n A small amount of contrast is seen layering within a nondistended stomach, and\n contrast passes through the small bowel into the descending colon with no\n evidence of obstruction. The large mesenteric mass is not entirely included\n on the study, however measures 8 x 11.5 cm and is likely unchanged in size\n when accounting for the shifted axis of the lesion. The intraabdominal\n vessels cannot be well evaluated on this study, however it is clear that the\n SMA and SMV are encased by this mass. Prominent retroperitoneal and\n mesenteric lymph nodes measuring up to 1 cm are unchanged. There is no free\n air or ascites. The terminal ileum is collapsed. There is a newly identified\n 4.8 x 3.8 cm soft tissue mass in the cecum, at the ileocecal valve, likely a\n focus of lymphoma given patient's history. This lesion was not well seen on\n the prior exam due to lack of oral contrast within the cecum.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions. Diffuse degenerative\n changes are noted.\n\n IMPRESSION:\n\n 1. No evidence of gastric outlet obstruction. Prior distention of the\n stomach was likely due to gastroparesis.\n (Over)\n\n 11:40 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Eval for debris/ patency of gastric outlet - perform with PO\n Admitting Diagnosis: COUGH, FEVER, GASTRIC OUTLET OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Persistent large abdominal mass encasing the SMA and SMV. Additional 4.8\n cm soft tissue mass at the ileocecal valve is also likely a focus of lymphoma,\n not previously identified due to lack of oral contrast in the cecum on the\n prior scan.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-05-17 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 958881,
"text": " 8:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? colitis?\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with mantle cell lymphoma of the abdomen on steroids with\n n/v/d, with guiac negative, s/p xrt and chem last week, nearly neutropenic.\n Exam no abd ttp.\n REASON FOR THIS EXAMINATION:\n abscess? colitis?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb SUN 9:58 AM\n 1. Massive abdominal mass (20 x 14 x 10 cm) has small areas of necrosis\n inferiorly. The SMA and branches course through this mass are narrowed, but\n patent.\n 2. Marked gastric distention for which virtually no contrast has entered the\n small bowel loops. Although this is not diagnostic, it is suggestive of\n gastric outlet obstruction.\n 3. No evidence for small bowel obstruction or coliitis.\n\n Comparison to outside CTs would be helpful for this patient.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mantle cell lymphoma on steroids with nausea, vomiting and\n diarrhea.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and pelvis with\n coronal and sagittal reformatted images was performed after the uneventful\n administration of 130 cc Optiray contrast.\n\n CT ABDOMEN WITH CONTRAST: The small bibasilar atelectasis is present in the\n visualized lung bases. Tip of the central venous catheter terminates in the\n upper right atrium. There is marked gastric distention with contrast and\n contents, and very little contrast present in distal small bowel loops. No\n suspicious lesions are identified in the liver, and the gallbladder is\n contracted. The pancreas, spleen, and small bowel loops are unremarkable.\n\n There is a very large abdominal mass measuring 20 x 14 x 10 cm (CC x AP x TV)\n with areas hypodense foci inferiorly. The SMA and its major branches that\n course through this mass are narrowed, but patent. SMV also courses through\n the mass but is not as well evaluated. Few subcutaneous collateral vessels\n are noted. Multiple prominent retroperitoneal and mesenteric lymph nodes are\n also noted measuring up to 1 cm. There is no free air or ascites.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, large bowel, bladder are all\n unremarkable, and note is made of a small bowel containing left inguinal\n hernia.\n\n BONE WINDOWS: No suspicious lesions are identified in the bones that are\n (Over)\n\n 8:36 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? colitis?\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n otherwise remarkable for diffuse degenerative changes.\n\n IMPRESSION:\n 1. Very large 20 cm abdominal mass encasing SMA and SMV and major branches.\n SMA and branches appears patent, but dedicated arterial and venous phase\n imaging would be necessary for more sensitive exam if necessary.\n\n 2. Marked gastric distension that is not diagnostic, but suggestive of\n gastroparesis or outlet obstruction.\n\n Outside comparison CTs would be helpful for this patient.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-05-17 00:00:00.000",
"description": "Report",
"row_id": 1504038,
"text": "Nursing Admit Note\nSee Carevue for specifics\n\nPt admitted from ED with N/V, diarrhea, fever, hypotension ?gastric outlet obstruction. Antibiotics started in ED. NGT placed. Transferred to SICU in the event of surgical intervention.\n\nNeuro: AOx3. Pleasant and cooperative. Partially blind Right eye.\n\nCV: NSR. HR 70's. Hypotensive at baseline. BP 100/50's.\n\nResp: LSCTA, slightly diminished at bases. Sats 99% 3 L NC.\n\nGI: NGT right nare to CLWS draining bilious drainage. +BS. Abdomen protuberant, soft. Continues to have small amounts liquid greenish-brown stool guaic negative.\n\nGU: Foley draining large amounts clear yellow urine.\n\nID: Afebrile. Currently on Levaquin, flagyl, vanco IV.\n\nPlan: No surgical intervention at this time per surgical team. Continue percutaneous management with NGT. Transfer to medical/oncology floor in am if pt remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2201-05-18 00:00:00.000",
"description": "Report",
"row_id": 1504039,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nNEURO: A&Ox3. Pleasant & cooperative. MAE. Right eye partially blind.\n\nCV: BP stable, 95-110s systolically (baseline sbp lower mid 90s-100s). NSR HR 60-80s, PVCs noted on occassion. K of 3.5 repleted w/40meq KCL.\n\nRESP: Sat'ing 99% on 3L NC. LCTAB. Pt w/productive cough (has had sinus infection for over a week now).\n\nGI/GU: Abdomen soft, slightly distended. + BS. Continues w/loose green/brown stool. Right nare NGT to LCWS, putting out scant amounts of bilious drainage. Foley patent draining adequate CYU.\n\nSKIN: Intact, no breakdown noted.\n\nID: Afebrile. Continues on abx.\n\nSOCIAL: Son & girlfriend in to visit pt. Will be back in am.\n\nPLAN OF CARE: Continue to check & replace labs as needed. Continue w/percutaneous management w/NGT. Continue to monitor hemodynamics & resp effort. ? Transfer to Medical/Oncology floor in am.\n"
},
{
"category": "ECG",
"chartdate": "2201-05-17 00:00:00.000",
"description": "Report",
"row_id": 228237,
"text": "Sinus tachycardia. Rare ventricular premature beat. Non-specific shallow T wave\ninversions in leads II, aVF and V4-V6. Low normal voltage in the limb leads. No\nprevious tracing available for comparison.\n\n"
}
] |
8,109 | 163,080 | Patient is a 68 year old female with history of stage V chronic kidney disease, coronary artery disease, and diabetes mellitus who presented to an outside hospital with diarrhea, with complicated course including hypoxia, hypotension, and NSTEMI, transferred for further management. | Minorintraventricular conduction delay. A-V conduction delay. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Sinus rhythm with first degree A-V delay. Possibleleft ventricular hypertrophy. Lateraland anterolateral ST segment abnormality consistent with possible ischemia orleft ventricular hypertrophy. P-R interval prolongation. Sinus rhythm. Sinus rhythm. Clinicalcorrelation is suggested. Compared to the previous tracing of thelateral and anterolateral ST segment abnormality is more prominent. Compared to the previous tracing of multiple describedabnormalities persist. Clinical correlation is suggested. No significant change compared to theprevious tracing of . | 3 | [
{
"category": "ECG",
"chartdate": "2156-09-08 00:00:00.000",
"description": "Report",
"row_id": 302444,
"text": "Sinus rhythm. P-R interval prolongation. Left atrial abnormality. Possible\nleft ventricular hypertrophy. Diffuse ST-T wave abnormalities may be related\nto left ventricular hypertrophy but cannot rule out underlying myocardial\nischemia. Compared to the previous tracing of multiple described\nabnormalities persist. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-09-06 00:00:00.000",
"description": "Report",
"row_id": 302445,
"text": "Sinus rhythm. A-V conduction delay. Left atrial abnormality. Lateral\nand anterolateral ST segment abnormality consistent with possible ischemia or\nleft ventricular hypertrophy. Compared to the previous tracing of the\nlateral and anterolateral ST segment abnormality is more prominent. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-08-31 00:00:00.000",
"description": "Report",
"row_id": 302446,
"text": "Sinus rhythm with first degree A-V delay. Left atrial abnormality. Minor\nintraventricular conduction delay. No significant change compared to the\nprevious tracing of .\n\n\n"
}
] |
17,933 | 177,268 | HD1: Admitted to ICU for observation, made NPO, Foley placed, started on Vancomycin, Levaquin, Flagyl. Placed on IV Lopressor for blood pressure control. ERCP Findings: The CBD was not dilated and there was one questionable filling defect within. After filling the CBD with contrast a leak from the duct of luschka was identified. | The position was confirmed under CT fluoroscopy. Pt updated, voicing understanding of plan/treatment.A: hemodynamically stable; resp. Position was confirmed using CT fluoroscopy and then the wire was removed. PB's and sc heparin for DVT prophylaxis. 3:07 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Please evaluate for possible drainage of biloma. Remains hypophosemic.Skin: grossly intact.ID: WBC up to 15.5 from 14. Protonix for GI prophylaxis.GU: foley patent draining adequate amts. COMPARISON: CT from on . CT showed fluid collection in GB fossa. Lytes repleted as ordered.ID: tmax 101.9po; peripheral BC x2 and urine spec sent. Now hypoxic REASON FOR THIS EXAMINATION: eval for lung dz FINAL REPORT CHEST SINGLE VIEW ON . An optimal entry site at right upper abdomen was identified with ultrasound. **DO NOT DRAIN WITHOUT PAGING DR. OR DR. . IMPRESSION: Unchanged, small fluid collection within the gallbladder fossa. **Please send fluid for culture and gram stain** No contraindications for IV contrast FINAL REPORT CT-GUIDED ABSCESS DRAINAGE DATED COMPARISON: CT of the abdomen dated . TECHNIQUE: Multidetector contiguous axial images of the abdomen and pelvis were obtained following the administration of oral contrast, 130 cc of Optiray. There is diverticulosis of the sigmoid colon without diverticulitis. adequate analgesia. Adequate analgesia. FINDINGS: Within the gallbladder fossa, a 2.7 x 3.1 x 2.5 cm, ovoid, anechoic fluid collection is present. ** FINAL REPORT HISTORY: Biloma following cholecystectomy. The patient is status post cholecystectomy. 1% lidocaine was administered locally. CT PELVIS WITH IV CONTRAST: There are calcifications seen in a normal sized prostate. The cardiac and mediastinal silhouettes are normal. Admitted to TSICU for potential sepsis and resp. (Over) 1:24 PM PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # Reason: aspiration and/or drainage of collection Admitting Diagnosis: SEPSIS FINAL REPORT (Cont) The heart is normal size and the mediastinum is midline. Heme: hct 32.2Resp: LS diminished throughout, denies shortness of breath or any difficulty breathing. status improved; temp. NON-CONTRAST CT OF THE ABDOMEN: After the procedure was explained to the patient along with risks and benefits, written informed consent was obtained. There is a tiny amount of residual fluid in the gallbladder fossa, measuring approximately 1.5 x 1.5 cm. IMPRESSION: Successful aspiration of fluid collection in gallbladder fossa. (Over) 10:58 AM CT PERIRENAL DRIANAGE; CT GUIDANCE DRAINAGE Clip # Reason: abscess in anterior abdomen between left lateral segment of Admitting Diagnosis: SEPSIS FINAL REPORT (Cont) IMPRESSION: Successful CT-guided placement of a drain in a fluid collection adjacent to the left hepatic lobe. The CT of the abdomen demonstrates a 7 cm x 6.7 cm low-density collection lateral to the lateral segment of the left hepatic lobe and anterior to the stomach displacing the stomach posteriorly. Comparison made to prior ultrasound dated . Monito resp status, encourage CDB, IS. (Over) 12:48 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: s/p cholangitis, ercp, rising wbc Admitting Diagnosis: SEPSIS Field of view: 38 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) Larger collection inferior to the left lobe of the liver as described above, amenable to percutaneous image guided drainage. The caliber of the loops of small and large bowel are normal in appearance. 50mcg fentanyl prn with +effect per pt report.CV: HR 100-110's, BP 120-140's/50-80's. CT ABDOMEN WITH IV CONTRAST: Few images through the lung bases demonstrate small bilateral pleural effusions, left greater than right. SBP 120-140's Pulses palpable throughout; no edema.Pulm: NP 3l sats > 95%; RA sats to 90%. Then under CT fluoroscopy guidance, an 18-gauge access needle was advanced into the collection. Through the needle, a 0.035 wire was placed. CT-GUIDED NEEDLE INSERTION: The skin was anesthetized using 1% lidocaine in the area that was previously marked. The rectum is normal in appearance. Small 1.5 cm collection of fluid in the gallbladder fossa. The patient's skin was then marked and prepped and draped in usual sterile fashion. Utilizing realtime ultrasound guidance, an 18-gauge needle was inserted into the collection via a lower right intercostal space, traversing a portion of the right hepatic lobe. Pain: c/o mid/upper abd pain at 1 on scale 0-10 at rest; up to with palpation, C+DB. | 8 | [
{
"category": "Radiology",
"chartdate": "2140-01-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 944332,
"text": " 3:07 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for possible drainage of biloma. **DO NOT D\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with biloma following cholecystectomy\n REASON FOR THIS EXAMINATION:\n Please evaluate for possible drainage of biloma. **DO NOT DRAIN WITHOUT PAGING\n DR. OR DR. . Thanks!**\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Biloma following cholecystectomy.\n\n COMPARISON: CT from on .\n\n FINDINGS: Within the gallbladder fossa, a 2.7 x 3.1 x 2.5 cm, ovoid, anechoic\n fluid collection is present. This collection is unchanged in size from the\n previous CT examination from four days previously.\n\n IMPRESSION: Unchanged, small fluid collection within the gallbladder fossa.\n Findings were discussed with Dr. at 3:50 p.m., .\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943946,
"text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for lung dz\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p lap ccy now w/ likely biloma. Now hypoxic\n REASON FOR THIS EXAMINATION:\n eval for lung dz\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Status post lap cholecystectomy, now with likely biloma and hypoxic,\n evaluate for lung disease.\n\n FINDINGS: There are no old films available for comparison. The cardiac and\n mediastinal silhouettes are normal. The lungs are clear without infiltrate or\n effusion. There is a patchy area of volume loss in the left lower lobe\n laterally. There is no focal infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-21 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 944608,
"text": " 12:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: s/p cholangitis, ercp, rising wbc\n Admitting Diagnosis: SEPSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man hx cholecystectomy, rising wbc, please assess for undrained\n collections of infection\n REASON FOR THIS EXAMINATION:\n s/p cholangitis, ercp, rising wbc\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old man with history of cholecystectomy and elevated WB cell\n count, evaluate for undrained collections.\n\n TECHNIQUE: Multidetector contiguous axial images of the abdomen and pelvis\n were obtained following the administration of oral contrast, 130 cc of\n Optiray. Reformatted images in coronal and sagittal planes were obtained.\n\n CT ABDOMEN WITH IV CONTRAST: Few images through the lung bases demonstrate\n small bilateral pleural effusions, left greater than right. There is a small\n amount of atelectasis in the dependent portion of the left lower lobe.\n\n The patient is status post cholecystectomy. There is a tiny amount of\n residual fluid in the gallbladder fossa, measuring approximately 1.5 x 1.5 cm.\n There is a separate fluid collection extending inferior to the left lobe of\n the liver and extending to the anterior aspect of the stomach measuring\n approximately 7.1 cm AP x 6.3 cm transverse x 5.4 cm craniocaudad. No other\n fluid collections are present in the abdomen. There is no free air in the\n abdomen. The liver, pancreas, spleen, adrenal glands, and both kidneys are\n normal in appearance. No enlarged mesenteric or retroperitoneal lymph nodes\n are present. The caliber of the loops of small and large bowel are normal in\n appearance.\n\n CT PELVIS WITH IV CONTRAST: There are calcifications seen in a normal sized\n prostate. The bladder is normal in appearance. The rectum is normal in\n appearance. There is diverticulosis of the sigmoid colon without\n diverticulitis. There is a small amount of free fluid seen in the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions. Degenerative changes\n consisting of endplate sclerosis and disc space narrowing at L5-S1.\n\n Reformatted images confirm these findings.\n\n Findings were discussed with Dr. on .\n\n IMPRESSION:\n 1. Small 1.5 cm collection of fluid in the gallbladder fossa.\n 2. Larger collection inferior to the left lobe of the liver as described\n above, amenable to percutaneous image guided drainage.\n\n (Over)\n\n 12:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: s/p cholangitis, ercp, rising wbc\n Admitting Diagnosis: SEPSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944613,
"text": " 1:24 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pulmonary source of infection/white count elevation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with biloma s/p aspiration now w/ rising white count\n REASON FOR THIS EXAMINATION:\n r/o pulmonary source of infection/white count elevation\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Bile collection. Aspiration. Fever.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small bilateral pleural effusions have increased since . Aside from\n minimal plate-like atelectasis at the right lung base, lungs are clear. The\n heart is normal size and the mediastinum is midline.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-22 00:00:00.000",
"description": "CT PERIRENAL DRIANAGE",
"row_id": 944747,
"text": " 10:58 AM\n CT PERIRENAL DRIANAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: abscess in anterior abdomen between left lateral segment of\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with abscess/collection in abdomen with rising wbc. No PO\n contrast\n REASON FOR THIS EXAMINATION:\n abscess in anterior abdomen between left lateral segment of liver an stomach,\n needs drainage. **Please send fluid for culture and gram stain**\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED ABSCESS DRAINAGE DATED \n\n COMPARISON: CT of the abdomen dated .\n\n INDICATION: 51-year-old male with abscess/collection in the abdomen with\n rising WBC count.\n\n NON-CONTRAST CT OF THE ABDOMEN: After the procedure was explained to the\n patient along with risks and benefits, written informed consent was obtained.\n The patient was placed on the CT table in the supine position. A\n preprocedural timeout was performed to document the patient's identity, type\n of procedure, and site of procedure using two patient identifiers. The CT of\n the abdomen demonstrates a 7 cm x 6.7 cm low-density collection lateral to the\n lateral segment of the left hepatic lobe and anterior to the stomach\n displacing the stomach posteriorly.\n\n CT-GUIDED LOCALIZATION: CT fluoroscopy was used to find an appropriate spot\n for entry into this collection. The patient's skin was then marked and\n prepped and draped in usual sterile fashion.\n\n CT-GUIDED NEEDLE INSERTION: The skin was anesthetized using 1% lidocaine in\n the area that was previously marked. Then under CT fluoroscopy guidance, an\n 18-gauge access needle was advanced into the collection. Through the needle,\n a 0.035 wire was placed. The position was confirmed under CT fluoroscopy.\n The access needle was then removed and over a wire an 8 French pigtail\n catheter was placed. Position was confirmed using CT fluoroscopy and then the\n wire was removed. The pigtail catheter was deployed and secured to the\n patient's skin. Approximately 15 cc of clear dark yellow fluid was aspirated,\n portion of which was sent for microbiology and bilirubin levels. The patient\n tolerated the procedure well and there were no immediate post-procedure\n complications.\n\n MEDICATIONS: Moderate sedation was provided by administering divided doses of\n 2 mg of Versed and 125 mcg of fentanyl throughout the total intraservice time\n of 50 minutes during which the patient's hemodynamic parameters were\n continuously monitored.\n\n Dr. , attending radiologist, was present throughout the entire\n procedure.\n (Over)\n\n 10:58 AM\n CT PERIRENAL DRIANAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: abscess in anterior abdomen between left lateral segment of\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Successful CT-guided placement of a drain in a fluid collection\n adjacent to the left hepatic lobe. 15 cc of clear bright yellow fluid was\n aspirated and a portion of which was sent to the lab for bilirubin and\n microbiology. The catheter was placed to gravity drainage. There were no\n immediate post-procedure complications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-20 00:00:00.000",
"description": "PERITONEAL ABSCESS DRAINAGE US",
"row_id": 944448,
"text": " 1:24 PM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n Reason: aspiration and/or drainage of collection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with biloma following cholecystectomy possibly infected\n\n REASON FOR THIS EXAMINATION:\n aspiration and/or drainage of collection\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Ultrasound-guided drainage of gallbladder fossa collection.\n\n CLINICAL HISTORY: 51-year-old man with biloma following cholecystectomy.\n Possibly infected. Aspiration of collection.\n\n Comparison made to prior ultrasound dated .\n\n PROCEDURE: After the procedure was explained to the patient, including risks\n and potential complications, informed consent was obtained. A timeout was\n performed to ensure accuracy.\n\n Pre-procedure scanning again demonstrated a fluid collection in the\n gallbladder fossa measuring approximately 2.6 x 3.0 x 2.6 cm, in this patient\n post cholecystectomy.\n\n An optimal entry site at right upper abdomen was identified with ultrasound.\n The area was cleansed and draped in the usual sterile fashion. 1% lidocaine\n was administered locally. Utilizing realtime ultrasound guidance, an 18-gauge\n needle was inserted into the collection via a lower right intercostal\n space, traversing a portion of the right hepatic lobe. A total of slightly\n more than 10 cc of brownish, cloudy fluid was removed and sent to the\n laboratory for analysis, as requested by the referring physician. \n of the collection was demonstrated on ultrasound.\n\n The patient tolerated the procedure well. No immediate complications.\n\n Staff radiologist, Dr. , was present during the procedure.\n\n Moderate sedation was provided by administering divided doses of 100 mcg of\n fentanyl and 1.5 mg of Versed throughout the total intra-service time of 14\n minutes, during which time the patient's hemodynamic parameters were\n continuously monitored.\n\n IMPRESSION: Successful aspiration of fluid collection in gallbladder fossa.\n\n\n\n (Over)\n\n 1:24 PM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n Reason: aspiration and/or drainage of collection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-01-16 00:00:00.000",
"description": "Report",
"row_id": 1498326,
"text": "T-SICU NPN/admission note\n\nNKDA Universal precautions\n\nPMH: no significant history until lap. ccy .\n\n51yo s/p lap ccy . Pt re-admitted to campus with abd pain x3 days. CT showed fluid collection in GB fossa. Tx to for ERCP w/sphincterotomy which showed contrast extravasation c/w duct leak. Medicated with 4.5mg versed, 200mcg fentanyl and phenergan. Post ERCP O2sats 89% on NRB, awake and interacting. Admitted to TSICU for potential sepsis and resp. distress. Plan for percutaneous drain placement, ? tomorrow.\n\nROS:\nNeuro: A+OX3, MAE's, follows commands consistently. Pain: c/o mid/upper abd pain at 1 on scale 0-10 at rest; up to with palpation, C+DB. 50mcg fentanyl prn with +effect per pt report.\nCV: HR 100-110's, BP 120-140's/50-80's. Skin warm, dry. Pedal pulses palpable. PB's and sc heparin for DVT prophylaxis. Heme: hct 32.2\nResp: LS diminished throughout, denies shortness of breath or any difficulty breathing. Enc. C+DB, using IS appropriately reaching 1000ml. RR teens-20's. Cool face mask weaned from 100% to 50% with O2sats 94-98%.\nGI: abd softly distended, BS hypoactive, no n/v. No stool, last BM per pt . NPO. Protonix for GI prophylaxis.\nGU: foley patent draining adequate amts. clear, amber urine. Lytes repleted as ordered.\nID: tmax 101.9po; peripheral BC x2 and urine spec sent. 650mg tylenol given, temp. down to 99.8po.\nSkin: intact throughout\nPsych/social: pt's wife in this afternoon, affect/questions appropriate. Pt updated, voicing understanding of plan/treatment.\nA: hemodynamically stable; resp. status improved; temp. down to 99.8\nP: Monitor VS, I/O, labs. Cont. aggressive pulmonary hygiene. Assess pain, med. prn. ? perc. drain placement tomorrow. Cont. ongoing open communication, comfort, and support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-01-17 00:00:00.000",
"description": "Report",
"row_id": 1498327,
"text": "NPN, 1900-0700\nneuro: completely intact. Calm and cooperative. Stoic pain tolerance. Med w/ fentanyl 50 mcg q 3-4 w/ ? adequate analgesia. Pt absolutely declines dilaudid.\n\nCV: NSR, variable MFVEA. SBP 120-140's Pulses palpable throughout; no edema.\n\nPulm: NP 3l sats > 95%; RA sats to 90%. BS diminished throughout. Non-productive splinted cough. IS to 500-700cc.\n\nGI: abd softly distended; BS hypoactive. Denies nausea but admits to intermittent \"queeziness\". No stool. Very tender abdomen diffusely, pain specifically over epigastrum.\n\nRenal: F/C urine dark amber, clear; OP marginal 20-60cc/hr; LR at 150cc/hr. Lytes repleted last . Remains hypophosemic.\n\nSkin: grossly intact.\n\nID: WBC up to 15.5 from 14. Tmax 100.2po. Cont on vanco and meropenum\n\nEndo; RISS\n\nPsychosocial: pt spoke at length to wife last and felt less stressed.\n\nP: US this abd, followed by ? perc drain. Adequate analgesia. Miantain NPO. Monito resp status, encourage CDB, IS.\n\n\n"
}
] |
11,270 | 149,592 | The patient is a gentleman who was transferred from an OSH with a slowly progressive illness over the last few days in which he has had neck stiffness. His CT scans document a retropharyngeal fluid collection and examination documents a palpable fluctuance of the posterior oropharyngeal wall. The patient was taken to the operating room that night for incision and drainage of the abscess. CUltures were sent and patient was started on IV Unasyn. There were no complications. Patient was extubated in the operating room and was taken to recovery in stable condition. AFter meeting PACU criteria, patient was transferred to the floor Unfortunately, he continued to worsen and repeat CAT scan 48 hours later revealed extension of the abscess into the parapharyngeal space. This correlated clinically with his spiking fevers and worsening symptoms. The decision was made to proceed to the operating room for transcervical drainage of the abscess. At this time, 3 penrose drains were placed intra-op, cultures semt, and it was decided to keep the patient intubated because of the edema. He was transferred to the recovery room and then surgical ICU intubated in stable condition. Patient remained intubated for 4 days because of edema. Packing was pulled back 3 inches a day. neck swelling slowly decreased over time. On post-op day 3, NGT was placed , ID consult was obtained, tube feeds started. Patient was then started on vancomycin. Patient was successfully extubated on -op day #4. Range of motion markedly improved, no stridor apparent, Patient was then transferred to the floor. post-op day 5, patient was started on clear liquids and tube feeds were at goal. Thsat night packing was removed without bleeding. post-op day 6, superior penrose drain was removed. Post-op day 7, diet was advanced, and MRI obtained which was negative for osteomyelitis. Post-op day 8, The other penroses were removed. Patient was discharged in good condition with VNA care. | + CSM + PP to extremities. lungs clear to diminished at bases bilat.Gi/GU: Abd soft NT. Left radial aline placed by H>O. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT LIGHTLY SEDATED ON PROPOFOL GTT. This same low signal intensity appears to extend along the tract of the right transcervical drainage. K REPLTED.GI: NPO. Sputum Cx sent. FINAL REPORT HISTORY: Known retropharyngeal abscess. SCANT DRG VIA PENROSE DRAINS.PLAN: CONT TO MONITOR. Abnormal retropharyngeal fluid is now clearly seen extending into the - and oropharyngeal compartments. Status post transcervical drainage. 10:18 AM MR W& W/O CONTRAST; MR CONTRAST GADOLIN Clip # Reason: H/O RETROPHARYNGEAL ABSCESS S/P TRANNSCERVICAL DRAINAGE. 1cc air in cuff to maintain low cuff pressres. Abg's within normal limits with PaO2 188. Sinus tachycardiaNonspecific T wave flattening in leads lll, aVL, aVF, V6No previous tracing FINDINGS: Comparison to the prior neck CT scan of redemonstrates the large presumed retropharyngeal inflammatory collection which exhibits exuberant enhancement except in a central region, with where a linear area of low signal intensity could represent either gas, nonenhancing fluid, or a combination of the two. SCANT TAN SECRETIONS VIA ET SUCTION. CONCLUSION: Redemonstration of large retropharyngeal inflammatory collection. Sxd mod amt. No contraindications for IV contrast FINAL REPORT HISTORY: Status post drainage of retropharyngeal abscess on , now with increasing neck pain and stiffness. IV MSO4 FOR PAIN WITH STATED RELIEF.RESP: LS RHONCHOROUS THROUGHOUT. COMMENT: There is moderate mucosal thickening within the visualized portion of the sphenoid sinus. NORMOTENSIVE. AFEBRILE. + HTN. MRI per ID request. This was discussed with Dr. who stated that the patient had already been extubated. Rule out osteomyelitis. Resp CarePt placed on CPAP at start of shift-parameters noted. Will continue mech vent and wean as tol. CUFF LEAK.CV: TMAX 100.8. No weaning this shift as pt has edema. Tolerating well. Diminished breath sounds bilat. PT PLACED ON A/C FROM PSV FOR SCOPING THIS A.M. RE-TAPED TUBE. u/a and c&s sent.Neck dsg old drg noted sanguinous (3 penroses beneath dsg so expect drg. IMPRESSION: High position of the endotracheal tube. , spontaneously, opened eys spontaneously to noxious stimuli.Pulm:Pt vented. CONCLUSION: Progression of what is presumed to be an extensive retropharyngeal infection, despite attempts to drain the infected material. Foley patent drng adequate urine.ID: Cont of vanco and unasynEndo: RISSskin: Right lateral neck dsg w/ penrose drain and new guaze intact.Plan: Cont to monitor resp status. There is a prominent left jugulodigastric lymph node, also seen on the prior study. FINDINGS: Comparison with the prior neck CT scan of discloses substantial expansion of low density, which again appears to be within the retropharyngeal space and whose greatest thickness (23 mm) anteroposteriorly is at the level of the superior margin of the thyroid cartilage. In our conversation today with Dr. , he indicated that a drain is present in this latter locale. Resp CarePt remains on mech vent-parameters noted. Adv diet as tolerated. PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH: Comparison is made to a CT of . REASON FOR THIS EXAMINATION: r/o osteomylitis. ABGs acceptable. SEROSANGUINES DRAINAGE FROM NECK INCISION. RESP CARE: Pt remains intubated/on vent on PS 10/5/.40. TECHNIQUE: Bolus intravenous-enhanced imaging of the neck was obtained. An endotracheal tube terminates just above the thoracic inlet. Plan: Keep intubated until swelling goes down. Awaiting extubation if pt has positive air leak. Wean Fio2 as tolerated. trnf to floor. SOFT ABD.GU: CLEAR TELLOW U/O VIA FOLEY.SKIN: NECK DSG INTACT, ABLE TO PLACE 3 FINGERS BETWEEN DSG AND PT'S NECK. Nursing Progress NotePlease see carvue for specifics:Neuro: Intact no deficitsCV: HR NSR w/ no noted ectopy. WIll postpone extubation until pt has less swelling. NG tube within the stomach. Increased temp. Breath sounds are diminished bilat. CONTINUE TO MONITER. FINDINGS: Lung volumes are reduced. A minimal amount of atelectasis is seen at the right lung base. IVF at 80cc/hrResp: Extubated . WEAN TO EXTUBATE TODAY. Please evaluate for undrained deep neck space infection. Please evaluate for undrained deep neck space infection. Please evaluate for undrained deep neck space infection. Pts lungs coarse bilat. Pt still swollen from surgery-minimal cuff leak present. FOLLOWS COMMANDS. However, the low density now extends laterally, partially enveloping the right common carotid artery as well as the common carotid bifurcation and extends to the medial aspect of the left common carotid artery near its bifurcation as well. Bs clear bilaterally. D:Pt sedated on propofol 80mcg/kg/min. ABLE TO COMMNICATE EFFECTIVELY VIA WRITING. PT IS VERY SECRETIONAL. VSS. Allowing for this, cardiac and mediastinal contours are normal. Lungs coarse bilat. please use contrast. focus updatesee carevue for details:neuro: mae's, follows commands, propofol gtt, medicated q3h with morphine for incisional painresp: cedrvical edema continues, remains intubated for airway protection, cpap 5peep, 5ps,cv: tmax 99.4, hr nsr, no ectopy, hererin and pneumo boots on, a-line patent, ivf d51/2 ns with 20meq kcl,gi: npo, bs +,gu: adequate hourly urine outputint: neck dsg changed for mod amt purulent drga/p: continue emotional and educational support NSR. nursing note SEE CARE VUE FOR SPECIFICS. NURSING NOTE SEE CARE VUE FOR SPECIFICS. RSBI 60 this am. OPENS EYES TO VOICE. EVEN ON THAT AMOUNT OF SEDATION AND MEDICATION AWAKENS EASILY, ORIENTED, RESPONDS APPROPRIATELY. Within this retropharyngeal pathology are streaks of gas. + strong cought able to clear secretions. DRESSING CHANGED. PO@ tolerated change.ENT service plan for pt is to leave intubated until swelling dissipates-may be several days.CV:SR to ST no ectopics, skin warm,dry, no pressors. | 17 | [
{
"category": "Radiology",
"chartdate": "2157-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 864349,
"text": " 10:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: for dohhoff placement\n Admitting Diagnosis: ABSCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n for dohhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old with retropharyngeal abscess, assess NG tube\n position.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH: Comparison is made to a CT of\n .\n\n FINDINGS:\n Lung volumes are reduced. Allowing for this, cardiac and mediastinal contours\n are normal. A minimal amount of atelectasis is seen at the right lung base.\n The right upper lobe infiltrate seen on the prior CT is not seen on this\n study. No definite effusions are seen. There is no pneumothorax. Pulmonary\n vasculature is normal. An endotracheal tube terminates just above the\n thoracic inlet. Dobbhoff-type feeding tube is seen within the stomach.\n\n IMPRESSION:\n High position of the endotracheal tube. This was discussed with Dr. who\n stated that the patient had already been extubated. NG tube within the\n stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-05-30 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 864727,
"text": " 10:18 AM\n MR W& W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: H/O RETROPHARYNGEAL ABSCESS S/P TRANNSCERVICAL DRAINAGE. R/O OSTEOMYLITIS\n Admitting Diagnosis: ABSCESS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with h/o retropharyngeal abscess s/p transcervical drainage.\n please use contrast. MRI per ID request.\n REASON FOR THIS EXAMINATION:\n r/o osteomylitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known retropharyngeal abscess. Status post transcervical drainage.\n Rule out osteomyelitis.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted gadolinium-enhanced imaging of the\n cervical spine was obtained.\n\n FINDINGS: Comparison to the prior neck CT scan of redemonstrates\n the large presumed retropharyngeal inflammatory collection which exhibits\n exuberant enhancement except in a central region, with where a linear area of\n low signal intensity could represent either gas, nonenhancing fluid, or a\n combination of the two. This same low signal intensity appears to extend\n along the tract of the right transcervical drainage. In our conversation\n today with Dr. , he indicated that a drain is present in this latter\n locale. Within the limits of MR scanning, no overt evidence for discitis or\n osteomyelitis is seen. There is no subluxation of the component vertebrae.\n There is relatively poor delineation of the cord versus subarachnoid space due\n to extensive pulsation artifacts on the sagittal T2-weighted images. However,\n definition of this margin is better on the axial scans. There is no gross\n evidence for the presence of cord compression or pathological enhancement to\n suggest that there is an epidural abscess.\n\n CONCLUSION: Redemonstration of large retropharyngeal inflammatory collection.\n No definite evidence for osteomyelitis or discitis. No overt sign for an\n epidural abscess.\n\n COMMENT: There is moderate mucosal thickening within the visualized portion\n of the sphenoid sinus. This finding could represent an allergic or some other\n type of inflammatory process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-05-23 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 863900,
"text": " 9:07 AM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: 41 year old man with retropharyngeal abscess drained , n\n Admitting Diagnosis: ABSCESS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with retropharyngeal abscess drained , no with increasing\n neck pain and stiffness. Please evaluate for undrained deep neck space\n infection.\n REASON FOR THIS EXAMINATION:\n 41 year old man with retropharyngeal abscess drained , no with increasing\n neck pain and stiffness. Please evaluate for undrained deep neck space\n infection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post drainage of retropharyngeal abscess on , now with\n increasing neck pain and stiffness. Please evaluate for undrained deep neck\n space infection.\n\n TECHNIQUE: Bolus intravenous-enhanced imaging of the neck was obtained.\n\n FINDINGS: Comparison with the prior neck CT scan of discloses\n substantial expansion of low density, which again appears to be within the\n retropharyngeal space and whose greatest thickness (23 mm) anteroposteriorly\n is at the level of the superior margin of the thyroid cartilage. However, the\n low density now extends laterally, partially enveloping the right common\n carotid artery as well as the common carotid bifurcation and extends to the\n medial aspect of the left common carotid artery near its bifurcation as well.\n There has also been longitudinal progression of this abnormality. Abnormal\n retropharyngeal fluid is now clearly seen extending into the - and\n oropharyngeal compartments. Within this retropharyngeal pathology are streaks\n of gas. It is difficult to be certain whether these are simply the result of\n recent drainage procedure or possibly represent a gas-forming organism. There\n is a prominent left jugulodigastric lymph node, also seen on the prior study.\n\n The present study also shows partial imaging of what appears to be an\n infiltrate within the right upper lobe posteriorly. There may also be pleural\n fluid seen bilaterally. In light of this finding, more comprehensive imaging\n of the chest is warranted.\n\n CONCLUSION: Progression of what is presumed to be an extensive\n retropharyngeal infection, despite attempts to drain the infected material.\n Dr. , attending physician, well as the ENT resident staff were\n informed immediately of these findings.\n\n The right upper lobe infiltrate and possible pleural fluid is new since the\n prior study, as well.\n\n\n (Over)\n\n 9:07 AM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: 41 year old man with retropharyngeal abscess drained , n\n Admitting Diagnosis: ABSCESS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2157-05-21 00:00:00.000",
"description": "Report",
"row_id": 291028,
"text": "Sinus tachycardia\nNonspecific T wave flattening in leads lll, aVL, aVF, V6\nNo previous tracing\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-25 00:00:00.000",
"description": "Report",
"row_id": 1410420,
"text": "focus update\nsee carevue for details:\n\nneuro: mae's, follows commands, propofol gtt, medicated q3h with morphine for incisional pain\n\nresp: cedrvical edema continues, remains intubated for airway protection, cpap 5peep, 5ps,\n\ncv: tmax 99.4, hr nsr, no ectopy, hererin and pneumo boots on, a-line patent, ivf d51/2 ns with 20meq kcl,\n\ngi: npo, bs +,\n\ngu: adequate hourly urine output\n\nint: neck dsg changed for mod amt purulent drg\n\na/p: continue emotional and educational support\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 1410421,
"text": "RESP CARE: Pt remains intubated/on vent on PS 10/5/.40. Pts lungs coarse bilat. Sxd mod amt. thick tan sputum. 1cc air in cuff to maintain low cuff pressres. Awaiting extubation if pt has positive air leak.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 1410422,
"text": "nursing note\n SEE CARE VUE FOR SPECIFICS. VSS OVERNIGHT. AFEBRILE. SEROSANGUINES DRAINAGE FROM NECK INCISION. DRESSING CHANGED. NO AIR LEAK PRESENT THIS AM, WITH NO AIR IN ET TUBE CUFF TIDAL VOLUMES REMAINED IN THE 500-600 RANGE.\n CONTINUES ON PROPOFOL AT 80 MCG AND MORPHINE Q 3-4/HRS AROUND THE CLOCK. EVEN ON THAT AMOUNT OF SEDATION AND MEDICATION AWAKENS EASILY, ORIENTED, RESPONDS APPROPRIATELY.\n CONTINUE TO MONITER SWELLING, MEDICATE FOR PAIN. ? NGT TODAY FOR FEEDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 1410423,
"text": "\n PT MAINTAINED ON A/C VENTILATION AT 40%. VITALS STABLE WITH LOW GRADE OF 100 THIS AFTERNOON. PT PLACED ON A/C FROM PSV FOR SCOPING THIS A.M. RE-TAPED TUBE. PT IS VERY SECRETIONAL. LAST ABG SHOWED GOOD GAS EXCHANGE. PT DOES HAVE CUFF LEAK BUT SMALL. PLAN IS TO MAKE DECISION THIS AFTERNOON ABOUT EXTUBATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-26 00:00:00.000",
"description": "Report",
"row_id": 1410424,
"text": "see carevue for details\nfocus data update:\n\nmedicated with morphine for pain, larygescope done @ bedside,\nparalyzed with cistacarium, fentanyl, and propofol, tol procedure well, dobhof feeding tube placed, tube feeds started @ 1700, extubated this pm, post extubation gases good, sat 96-100%, orally suctioning self, both patient and family given emotional and educational support\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-27 00:00:00.000",
"description": "Report",
"row_id": 1410425,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Intact no deficits\nCV: HR NSR w/ no noted ectopy. + HTN. Cuff pressures and aline pressures with average 20 pt difference. + CSM + PP to extremities. Some noted neck and jaw edema noted per pt's wife has decreased. Otherwise heme stable. IVF at 80cc/hr\nResp: Extubated . Tolerating well. Sats>95% over noc. + strong cought able to clear secretions. lungs clear to diminished at bases bilat.\nGi/GU: Abd soft NT. + BS no flatus per pt. Tube feedings continue adv as tol to goal of 90 currently @ 30cc/hr. Able to tolerate clear liquids well. Foley patent drng adequate urine.\nID: Cont of vanco and unasyn\nEndo: RISS\nskin: Right lateral neck dsg w/ penrose drain and new guaze intact.\nPlan: Cont to monitor resp status. Adv diet as tolerated. ? trnf to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-24 00:00:00.000",
"description": "Report",
"row_id": 1410413,
"text": "D:Pt sedated on propofol 80mcg/kg/min. , spontaneously, opened eys spontaneously to noxious stimuli.\nPulm:Pt vented. FIO2 decreased from 50% to 40%. PO@ tolerated change.\nENT service plan for pt is to leave intubated until swelling dissipates-may be several days.\nCV:SR to ST no ectopics, skin warm,dry, no pressors. Left radial aline placed by H>O. Tmax 102, pt pan cultured.\nGI:NGT was not placed in OR and should not be attempted per ENT due to pharyngeal swelling. Abd soft no bowel sounds heard, no stool.\nGU:foley to BSD drg adequate urine. u/a and c&s sent.\nNeck dsg old drg noted sanguinous (3 penroses beneath dsg so expect drg. First dsg to be changed by surgeons today.\n wife in to visit at 2200. ICU information given to wife as well as pt condition and what to expect over next 24-48 hours.\nPlan:Continue to provide information to pt and his wife.\n pt sedate with prop and pain free using morphine as ordered.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-24 00:00:00.000",
"description": "Report",
"row_id": 1410414,
"text": "Respiratory Care:\n\nPatient transferred from Pacu intubated on mechanical support. Vent settings Vt 500, A/c 16, Fio2 50%, and Peep 5. Fio2 weaned to 50%. Abg's within normal limits with PaO2 188. Bs clear bilaterally. Sx'd for sm amount of thick blood tinged/tan secretions. Increased temp. Sputum Cx sent. RSBI 60 this am. No further changes made. Plan: Keep intubated until swelling goes down. Wean Fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-24 00:00:00.000",
"description": "Report",
"row_id": 1410415,
"text": "Resp Care\nPt remains on mech vent-parameters noted. No weaning this shift as pt has edema. Breath sounds are diminished bilat. Suction for thick tan secretions. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-24 00:00:00.000",
"description": "Report",
"row_id": 1410416,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT LIGHTLY SEDATED ON PROPOFOL GTT. OPENS EYES TO VOICE. FOLLOWS COMMANDS. ABLE TO COMMNICATE EFFECTIVELY VIA WRITING. IV MSO4 FOR PAIN WITH STATED RELIEF.\nRESP: LS RHONCHOROUS THROUGHOUT. SCANT TAN SECRETIONS VIA ET SUCTION. NO VENT CHANGES. CUFF LEAK.\nCV: TMAX 100.8. NSR. NORMOTENSIVE. K REPLTED.\nGI: NPO. SOFT ABD.\nGU: CLEAR TELLOW U/O VIA FOLEY.\nSKIN: NECK DSG INTACT, ABLE TO PLACE 3 FINGERS BETWEEN DSG AND PT'S NECK. SCANT DRG VIA PENROSE DRAINS.\nPLAN: CONT TO MONITOR. ? WEAN TO EXTUBATE TOMORROW IF SWELLING DECREASED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-25 00:00:00.000",
"description": "Report",
"row_id": 1410417,
"text": "NURSING NOTE\n SEE CARE VUE FOR SPECIFICS. TMAX 101.1, CULTERED YESTERDAY. CULTURES PENDING. VSS. MEDICATED FOR PAIN WITH 4 MG MORPHINE Q 3-4 WITH GOOD EFFECT. PROPOFOL INCREASED TO 90 MCG AS HE WAS STILL UNCOMFORTABLE DESPITE MORPHINE FREQUENCY.ABG'S WNL THIS AM. ? WEAN TO EXTUBATE TODAY. CONTINUE TO MONITER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-25 00:00:00.000",
"description": "Report",
"row_id": 1410418,
"text": "RESP CARE: Pt remained intubated/on vent overnight on AC 500/16/.50/5 PEEP. ABGs acceptable. Lungs coarse bilat. Sxd thick white sputum. RSBI-23.4 Plan is to place pt on SBT whem more awake and then extubate\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-05-25 00:00:00.000",
"description": "Report",
"row_id": 1410419,
"text": "Resp Care\nPt placed on CPAP at start of shift-parameters noted. Has tol all shift. Pt still swollen from surgery-minimal cuff leak present. WIll postpone extubation until pt has less swelling. Diminished breath sounds bilat.\n"
}
] |
51,257 | 145,513 | Pt was admitted to the hospital through the emergency department for SAH and left temporal contusion. She had a seizure in the ED and was intubated. She was loaded with dilantin and subsequently extubated the next am. She did have a slight increase in her troponin's and was seen by cardiology. The cardiology team recommended asa and an echo. These recs were followed. Results of the echo are in the reports section of this summary. She was also seen and cleared by the trauma team. She was moved to step down and diet and activity were advanced. Repeat images were obtained and were stable. An MRI of the brain was done and ruled out underlying mass. She was seen by PT and OT and deemed to be a candidate for rehab. | Intubated post seizure in ED. Received hydralazine prn. Received hydralazine prn. Pneumococcal Vac Polyvalent 17. Pneumococcal Vac Polyvalent 17. Moderate [2+] tricuspid regurgitation is seen. False LV tendon (normal variant). Action: PRN miazolam while intubated. Pt uncooperative with bedside swallow eval. Pt uncooperative with bedside swallow eval. Levothyroxine Sodium 11. Levothyroxine Sodium 11. WET READ VERSION #1 CXWc FRI 7:32 PM 11x7mm hyperdense focus left inferior temporal lobe likely hemorrhagic contusion. Small, hyperdynamic leftventricle with probable diastoilc dysfunction. Transfer to where pt seized in ED and was intubated. Transfer to where pt seized in ED and was intubated. Transfer to where pt seized in ED and was intubated. Subarachnoid hemorrhage (SAH) Assessment: s/p left SAH and seizure activity. Subarachnoid hemorrhage (SAH) Assessment: s/p left SAH and seizure activity. Docusate Sodium 7. Docusate Sodium 7. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. S/P left temporal SAH. Focal calcifications inaortic root. Chlorhexidine Gluconate 0.12% Oral Rinse 6. Chlorhexidine Gluconate 0.12% Oral Rinse 6. Elevated trops, ntd per cardiology. Elevated trops, ntd per cardiology. Elevated trops, ntd per cardiology. Subarachnoid hemorrhage (SAH) Assessment: Action: Response: Plan: There is borderlinepulmonary artery systolic hypertension. Cont PSV;? Action: Q1 hr neuro checks, extubated this am, on dilantin. Action: Q1 hr neuro checks, extubated this am, on dilantin. Study of limited diagnostic quality but: 11x7mm hyperdense focus left inferior temporal lobe likely hemorrhagic contusion. Emphysema. Emphysema. Emphysema. Eval by cardiology for elevated trops. At OSH, with L temporal lobe contusion/hemorrhage. At OSH, with L temporal lobe contusion/hemorrhage. At OSH, with L temporal lobe contusion/hemorrhage. Chief complaint: Fall PMHx: HTN, MVP, Hypothyroid, NHL s/p radiation and chemo Current medications: 1. Chief complaint: Fall PMHx: HTN, MVP, Hypothyroid, NHL s/p radiation and chemo Current medications: 1. extub today/RSBI good. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Pt transferred to . Pt transferred to . Wean to extubate. Eval by trauma service - cleared. Midazolam 13. Midazolam 13. Degenerative changes mid c-spine. Degenerative changes mid c- spine. Degenerative changes mid c- spine. Recommended asprin and echo. Pain: Sedate with versed/fentanyl. Pain: Sedate with versed/fentanyl. Pain: Sedate with versed/ fentanyl. The tricuspid valve leaflets are mildlythickened. Response: NGT placed for oral contrast to be given Plan: CT abd. Senna 19. Senna 19. (BP does not tolerate propofol) CVS: Keep BP < 160; prn hydral. (BP does not tolerate propofol) CVS: Keep BP < 160; prn hydral. Multilevel compression deformities of the vertebral bodies are again noted, acuity unknown. Probable right femoral hernia containing a small bowel loop, nonobstructed. FINDINGS: In the left mid temporal lobe, there is a 12 x 7 mm ovoid hyperdense lesion, without surrounding edema or mass effect. Marked tortuosity of the thoracic aorta is unchanged. There is some vicarious excretion of contrast into the gallbladder, which is not distended. In the right parietal convexity (4:24), there is a small focus of hyperintensity signal, possibly representing hemorrhagic change, measuring approximately 3.1 x 4.6 mm in size. Prevertebral soft tissues are within normal limits given the presence of an endotracheal tube. COMPARISON: Non-contrast CT of the abdomen and pelvis of . Normal flow void signal is identified in the major vascular structures. CT CHEST WITHOUT IV CONTRAST: An endotracheal tube and nasogastric tube are in place. Limited evaluation of solid organs and bowel in the absence of intravenous and oral contrast. CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Evaluation of solid organs is limited in the absence of intravenous contrast. Compared to the previoustracing of there is absence of septal R waves which may be secondaryto lead placement. There is right convex scoliosis of the thoracolumbar spine, and multiple vertebral body compression fractures which are not significantly changed from , including: T11, L4 and L5 as seen on this study. Unchanged focus of hemorrhage identified on the left temporal lobe measuring approximately 6.6 x 10.0 mm in the transverse dimensions. Unchanged focus of hemorrhage identified on the left temporal lobe measuring approximately 6.6 x 10.0 mm in the transverse dimensions. Final Attending Comment: Above mentioned hyperdensity could represent hemorhhage versus mass. Unchanged area of hemorrhage on the left temporal lobe. There is marked aortic tortuosity. Punctate area of hyperintensity signal demonstrated on the right parietal convexity possibly consistent with focal hemorrhagic change. Heart is normal in size, but demonstrates left ventricular configuration. Marked tortuosity of the thoracic aorta. FINDINGS: An endotracheal tube is present with the distal tip in satisfactory position approximately 4.8 cm from the carina. FINDINGS: A 12 x 7 mm ovoid focus of hyperdensity in the left temporal lobe is unchanged since . sternal/rib fx FINAL REPORT (Cont) OSSEOUS STRUCTURES: There are compression deformities of the vertebral bodies at multiple levels, including T8, T10, T11, L4 and L5, of unknown acuity. Punctate areas of restricted diffusion as described in detail above, possibly consistent with subacute ischemic changes, these areas are not visualized in the corresponding ADC maps. COMPARISON: Prior CT of the head without contrast dated . Extensive periventricular white matter hypodensity is unchanged since and likely represents chronic microvascular infarct. There is a Foley catheter within the bladder, which is decompressed. | 24 | [
{
"category": "Respiratory ",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 449491,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received from ER intub with OETT and placed on mech vent\n as per Metavision. Lung sounds ess clear. Pt in NARD once switched to\n PSV. Cont PSV;? extub today/RSBI good.\n"
},
{
"category": "Nursing",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 449564,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 449565,
"text": "Pt found down in bathroom by daughter lapse time 1-3 hours. Pt alert\n when found. Unknown reason for fall. Pt taken to OSH, when she had\n seizure activity, become unresponsive and was intubated. Ct showed\n small left temporal SAH. Pt transferred to .\n Subarachnoid hemorrhage (SAH)\n Assessment:\n s/p left SAH and seizure activity.\n Action:\n Q1 hr neuro checks, extubated this am, on dilantin. CE cycled\n Response:\n Pt opens eyes to voice, speech garbled, knows name but not place or\n date, does recognize family. Extremities weak but purposeful. ? left\n side weaker than right. Follows commands inconsistently, PERL 3mm\n brisk. b/p parameters 120-140. Received hydralazine prn. LS coarse\n and ronchorus weak cough sat mid 90\ns on 50% FT. dilantin level 20\n this am. CE- tropi .14 tranding down from OSH, last set sent 10am.\n Plan:\n Cont neuro checks, repeate head CT\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pt cachexic with significant bruising to all extremities. Family\n states poor appetite and pt c/o chest/abd pain at home.\n Action:\n Due to hx of lymphoma and exam, CT abd with contrast ordered. Pt\n uncooperative with bedside swallow eval.\n Response:\n NGT placed for oral contrast to be given\n Plan:\n CT abd.\n"
},
{
"category": "Physician ",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 449482,
"text": "Chief Complaint: Fall\n HPI:\n Daughters found pt fallen in bathroom (? for 2 hours). Pt 2 with\n increasing confusion throught day. Pt initially complaining of chest\n pain, and with increased trops at OSH and . At OSH, with L\n temporal lobe contusion/hemorrhage. Transfer to where pt seized in\n ED and was intubated. Eval by cardiology for elevated trops.\n Recommended asprin and echo. Eval by trauma service - cleared.\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, MVP, Hypothyroid, NHL s/p radiation and chemo\n Lives with husband - currently at for AMS/dementia. 3 daughters\n (2 local) and 1 son.\n Flowsheet Data as of 01:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 78 (78 - 93) bpm\n BP: 125/80(91) {125/80(91) - 150/99(111)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 55 mL\n PO:\n TF:\n IVF:\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -445 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 8.1 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 75 yo F with L temporal lobe contusion\n NEURO: Continue dilantin, neuro checks q1 hr.\n Pain: Sedate with versed/fentanyl. (BP does not tolerate propofol)\n CVS: Keep BP < 160; prn hydral. Elevated trops, ntd per cardiology.\n Consider Echo, follow enzymes\n PULM: Ween to extubate\n GI: NPO, PPI\n RENAL: Follow renal function\n HEME: Follow hct\n ENDO: RISS, levothyroxine\n ID: No indication of infection\n TLD: Foley, piv, ETT\n IVF: 70 ml/hr NS + 20 KCl\n CONSULTS: cardiology, neurosurgery, trauma\n BILLING DIAGNOSIS: ICH\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 449529,
"text": "TSICU\n HPI:\n Daughters found pt fallen in bathroom (? for 2 hours). Pt initially\n complaining of chest pain, and with increased trops. At OSH, with L\n temporal lobe contusion/hemorrhage. Transfer to where pt seized in\n ED and was intubated.\n Chief complaint:\n Fall\n PMHx:\n HTN, MVP, Hypothyroid, NHL s/p radiation and chemo\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Calcium Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Docusate Sodium 7. HydrALAzine 8. Influenza Virus Vaccine 9. Insulin\n 10. Levothyroxine Sodium\n 11. Magnesium Sulfate 12. Midazolam 13. Ondansetron 14. Pantoprazole\n 15. Phenytoin 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Senna 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 01:01 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.1\nC (97\n HR: 94 (74 - 94) bpm\n BP: 129/89(99) {104/68(77) - 150/99(111)} mmHg\n RR: 16 (13 - 16) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 39.5 kg (admission): 39 kg\n Total In:\n 295 mL\n PO:\n Tube feeding:\n IV Fluid:\n 295 mL\n Blood products:\n Total out:\n 0 mL\n 1,160 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -865 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 426 (426 - 426) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 21\n PIP: 13 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 5.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: No(t) Rash:\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 172 K/uL\n 12.4 g/dL\n 34.2 %\n 10.0 K/uL\n [image002.jpg]\n 04:17 AM\n WBC\n 10.0\n Hct\n 34.2\n Plt\n 172\n Assessment and Plan\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 75 yo F with L temporal lobe contusion\n NEURO: Continue dilantin, neuro checks q1 hr.\n Pain: Sedate with versed/ fentanyl. (BP does not tolerate propofol)\n CVS: Keep BP < 160; prn hydralazine. Elevated trops, ntd per\n cardiology. Hold ASA. Consider Echo, follow enzymes\n PULM: Extubate today\n GI: NPO, PPI\n RENAL: Follow renal function\n HEME: Follow hct\n ENDO: RISS, levothyroxine\n ID: No indication of infection\n TLD: Foley, piv, ETT\n IVF: 70 ml/hr NS + 20 KCl\n CONSULTS: cardiology, neurosurgery, trauma\n BILLING DIAGNOSIS: Hemorrhage NOS\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:52 AM\n 20 Gauge - 02:53 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 449508,
"text": "S/P left temporal SAH. Intubated post seizure in ED.\n DNR\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Pt becoming more alert this am. Inconsistently follows commands. Moves\n all extremities. Pupils equal and reactive. Agitated at times, responds\n well to bolus midazolam. Pt remains intubated on CPAP 5/5/50%.\n Action:\n PRN miazolam while intubated. Dilantin for seizure prevention.\n Response:\n Neuro exam unchanged\n Plan:\n Q 1 hour neuro exam. Wean to extubate.\n"
},
{
"category": "Nursing",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 449599,
"text": "Pt found down in bathroom by daughter lapse time 1-3 hours. Pt alert\n when found. Unknown reason for fall. Pt taken to OSH, when she had\n seizure activity, become unresponsive and was intubated. Ct showed\n small left temporal SAH. Pt transferred to .\n Subarachnoid hemorrhage (SAH)\n Assessment:\n s/p left SAH and seizure activity.\n Action:\n Q1 hr neuro checks, extubated this am, on dilantin. CE cycled\n Response:\n Pt opens eyes to voice, speech garbled, knows name but not place or\n date, does recognize family. Extremities weak but purposeful. ? left\n side weaker than right. Follows commands inconsistently, PERL 3mm\n brisk. b/p parameters 120-140. Received hydralazine prn. LS coarse\n and ronchorus weak cough sat mid 90\ns on 50% FT. dilantin level 20\n this am. CE- tropi .14 tranding down from OSH, last set sent 10am.\n Plan:\n Cont neuro checks, repeate head CT\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pt cachexic with significant bruising and skin trars to all\n extremities. Family states poor appetite and pt c/o chest/abd pain at\n home.\n Action:\n Due to hx of lymphoma and exam, CT abd with contrast ordered. Pt\n uncooperative with bedside swallow eval.\n Response:\n NGT placed for oral contrast to be given\n Plan:\n CT abd done 1700. awaiting results.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n DNR (do not resuscitate)\n Height:\n Admission weight:\n 39 kg\n Daily weight:\n 39.5 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Precautions:\n PMH: Smoker\n CV-PMH: Hypertension\n Additional history: hypothyroidism, non hodg lymphoma\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:91\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,275 mL\n 24h total out:\n 3,845 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 04:17 AM\n Potassium:\n 3.2 mEq/L\n 04:17 AM\n Chloride:\n 100 mEq/L\n 04:17 AM\n CO2:\n 28 mEq/L\n 04:17 AM\n BUN:\n 9 mg/dL\n 04:17 AM\n Creatinine:\n 0.7 mg/dL\n 04:17 AM\n Glucose:\n 101 mg/dL\n 04:17 AM\n Hematocrit:\n 34.2 %\n 04:17 AM\n Finger Stick Glucose:\n 97\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: T/\n Transferred to: 1118\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2187-04-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 449506,
"text": "TSICU\n HPI:\n Daughters found pt fallen in bathroom (? for 2 hours). Pt initially\n complaining of chest pain, and with increased trops. At OSH, with L\n temporal lobe contusion/hemorrhage. Transfer to where pt seized in\n ED and was intubated.\n Chief complaint:\n Fall\n PMHx:\n HTN, MVP, Hypothyroid, NHL s/p radiation and chemo\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.\n Calcium Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Docusate Sodium 7. HydrALAzine 8. Influenza Virus Vaccine 9. Insulin\n 10. Levothyroxine Sodium\n 11. Magnesium Sulfate 12. Midazolam 13. Ondansetron 14. Pantoprazole\n 15. Phenytoin 16. Pneumococcal Vac Polyvalent\n 17. Potassium Chloride 18. Senna 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 01:01 AM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 04:00 AM\n Other medications:\n Flowsheet Data as of 05:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.1\nC (97\n HR: 94 (74 - 94) bpm\n BP: 129/89(99) {104/68(77) - 150/99(111)} mmHg\n RR: 16 (13 - 16) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 39.5 kg (admission): 39 kg\n Total In:\n 295 mL\n PO:\n Tube feeding:\n IV Fluid:\n 295 mL\n Blood products:\n Total out:\n 0 mL\n 1,160 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -865 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 426 (426 - 426) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 21\n PIP: 13 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 5.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: No(t) Rash:\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 172 K/uL\n 12.4 g/dL\n 34.2 %\n 10.0 K/uL\n [image002.jpg]\n 04:17 AM\n WBC\n 10.0\n Hct\n 34.2\n Plt\n 172\n Assessment and Plan\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 75 yo F with L temporal lobe contusion\n NEURO: Continue dilantin, neuro checks q1 hr.\n Pain: Sedate with versed/fentanyl. (BP does not tolerate propofol)\n CVS: Keep BP < 160; prn hydral. Elevated trops, ntd per cardiology.\n Consider Echo, follow enzymes\n PULM: Ween to extubate\n GI: NPO, PPI\n RENAL: Follow renal function\n HEME: Follow hct\n ENDO: RISS, levothyroxine\n ID: No indication of infection\n TLD: Foley, piv, ETT\n IVF: 70 ml/hr NS + 20 KCl\n CONSULTS: cardiology, neurosurgery, trauma\n BILLING DIAGNOSIS: Hemorrhage NOS\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:52 AM\n 20 Gauge - 02:53 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Echo",
"chartdate": "2187-04-30 00:00:00.000",
"description": "Report",
"row_id": 89101,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Elevated troponin. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 86\nBSA (m2): 1.38 m2\nBP (mm Hg): 99/71\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal regional LV\nsystolic function. False LV tendon (normal variant). Hyperdynamic LVEF >75%.\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nBorderline PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Regional left\nventricular wall motion is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: No cardiac source of embolism identified. Small, hyperdynamic left\nventricle with probable diastoilc dysfunction. Moderate tricuspid\nregurgitation.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070097,
"text": " 6:08 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval for chest injury, ICH, cspine fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 7:58 PM\n Study of limited diagnostic quality but: 11x7mm hyperdense focus left inferior\n temporal lobe likely hemorrhagic contusion. No other acute abnormality.\n WET READ VERSION #1 CXWc FRI 7:32 PM\n 11x7mm hyperdense focus left inferior temporal lobe likely hemorrhagic\n contusion. No other acute abnormality.\n ______________________________________________________________________________\n PRELIMINARY REPORT\n !! WET READ !!\n Study of limited diagnostic quality but: 11x7mm hyperdense focus left inferior\n temporal lobe likely hemorrhagic contusion. No other acute abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1070098,
"text": " 6:08 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval for ICH, traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 7:59 PM\n Study of limited diagnostic quality but No fracture or acute malalignment.\n Degenerative changes mid c- spine.\n WET READ VERSION #1 CXWc FRI 7:18 PM\n No fracture or acute malalignment. Degenerative changes mid c-spine.\n ______________________________________________________________________________\n PRELIMINARY REPORT\n !! WET READ !!\n Study of limited diagnostic quality but No fracture or acute malalignment.\n Degenerative changes mid c- spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1070099,
"text": " 6:09 PM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval for ICH, traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 7:59 PM\n Study of limited diagnostic quality but: No acute abnormalities: no fractures,\n no PE or acute aortic abnormality. Emphysema.\n WET READ VERSION #1 CXWc FRI 7:34 PM\n No acute abnormalities: no fractures, no PE or acute aortic abnormality.\n Emphysema.\n ______________________________________________________________________________\n PRELIMINARY REPORT\n !! WET READ !!\n Study of limited diagnostic quality but: No acute abnormalities: no fractures,\n no PE or acute aortic abnormality. Emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070108,
"text": " 8:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with head injury s/p intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placment\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT HOURS.\n\n HISTORY: Head injury, post-intubation.\n\n COMPARISON: None.\n\n FINDINGS: An endotracheal tube is present with the distal tip in satisfactory\n position approximately 4.8 cm from the carina. A nasogastric tube is noted\n extending into the left upper quadrant off the inferior edge of the\n radiograph. The lungs are grossly clear with linear lines noted at the right\n lung base, likely atelectasis versus scarring. There is marked aortic\n tortuosity. The cardiac silhouette is within normal limits for size. No\n effusion or pneumothorax is noted. Overall, there is marked hyperexpansion of\n the lungs.\n\n IMPRESSION: Marked hyperexpansion. Marked tortuosity of the thoracic aorta.\n Endotracheal tube in satisfactory position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070109,
"text": " 8:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change in ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with temporal hemorrhage now sz\n REASON FOR THIS EXAMINATION:\n eval for interval change in ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 10:23 PM\n 11x6mm hyperdensity left temporal lobe could be small hemorrhagic contusion,\n but lack of associated traumatic findings makes this less likely. Cannot rule\n out metastasis from occult primary. Recommend f/u imaging to assess for\n evolution.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with seizure and suspected temporal hemorrhage.\n\n COMPARISON: Head CT obtained at Hospital approximately six hours\n earlier.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. Multiplanar reformatted images were generated.\n\n FINDINGS: In the left mid temporal lobe, there is a 12 x 7 mm ovoid\n hyperdense lesion, without surrounding edema or mass effect.\n\n There is no other hyperdensity to suggest other acute intracranial hemorrhage.\n There is no edema, shift of normally midline structures, or evidence of major\n vascular territorial infarct. Extensive periventricular white matter\n hypodensities are consistent with chronic small vessel ischemia. The\n ventricles and sulci are normal in size and configuration. The basilar\n cisterns are patent. The -white differentiation is preserved. There is\n no fracture. There is a small amount of soft tissue density material within\n the left maxillary sinus, consistent with mucous retention cyst. Paranasal\n sinuses and mastoid air cells are otherwise well aerated. Soft tissues are\n unremarkable.\n\n IMPRESSION: 12 x 7 mm hyperdensity within the left temporal lobe. In the\n setting of trauma, a small hemorrhagic contusion is possible, although less\n likely in the absence of other sequela of trauma. Alternatively, a metastatic\n lesion from an occult primary cannot be excluded. Recommend followup imaging\n to assess for interval change as a traumatic lesion should evolve on short\n order.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1070110,
"text": " 8:04 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o abnl\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fall, ip bleed\n REASON FOR THIS EXAMINATION:\n r/o abnl\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 8:49 PM\n No fracture or malalignment. DJD mid cervical spine with minimal canal\n narrowing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman status post fall.\n\n COMPARISON: CT C-spine obtained at Hospital approximately six hours\n earlier.\n\n TECHNIQUE: Contiguous axial images were obtained through the cervical spine.\n Multiplanar reformatted images were generated. No contrast was administered.\n\n FINDINGS: There has been interval endotracheal intubation and nasogastric\n tube placement. There is no fracture or acute malalignment of the cervical\n spine. Moderate degenerative changes are present in the upper and mid\n cervical spine, with mild, grade 1 anterolisthesis of the C3 on C4. There is\n pronounced loss of intervertebral disc height between C4 and C7, with\n posterior disc osteophyte complexes at these levels, slightly narrowing the\n spinal canal, and contacting the thecal sac. Prevertebral soft tissues are\n within normal limits given the presence of an endotracheal tube. Vertebral\n body heights are preserved.\n\n Lung apices demonstrate marked emphysema. Multifocal hypodensities within the\n thyroid gland are present. There is no lymphadenopathy within the neck, by\n size criteria. Vascular calcifications are present.\n\n IMPRESSION:\n 1. No fracture or acute malalignment of the cervical spine.\n 2. Moderate degenerative changes result in posterior disc osteophyte\n complexes in the mid cervical spine that contacts the thecal sac. MRI is more\n sensitive for evaluation of the thecal sac and its contents.\n 3. Emphysema.\n 4. Thyroid hypodensities. Recommend clinical correlation and ultrasound\n evaluation if not previously performed, on a non-emergent basis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-27 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1070111,
"text": " 8:06 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval bone ? sternal/rib fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fall, ip bleed\n REASON FOR THIS EXAMINATION:\n eval bone ? sternal/rib fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 10:18 PM\n Multiple vertebral compression deformities: T8,10,11, L4,5, acuity unknown. No\n other fractures. No evidence of other traumatic injury to chest, abd, pelvis\n although right hip arthroplasty obscures eval.\n WET READ VERSION #1 CXWc FRI 8:55 PM\n Multiple vertebral compression deformities: T8,10,11, L4,5, acuity unknown. No\n other fractures. No evidence of other traumatic injury to chest, abd, pelvis\n although b/l hip arthroplasty obscures eval.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman status post fall.\n\n COMPARISON: CT chest obtained at Hospital approximately six hours\n earlier.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the torso. No\n contrast was administered, because the patient had previously received\n intravenous contrast. Multiplanar reformatted images were generated.\n\n CT CHEST WITHOUT IV CONTRAST: An endotracheal tube and nasogastric tube are\n in place. Coronary and aortic atherosclerotic calcifications are noted. The\n heart is not enlarged and there is no pericardial effusion. Great vessels are\n grossly unremarkable.\n\n Lungs demonstrate diffuse, moderate emphysematous changes, worse at the lung\n apices. There is no consolidation or pleural effusion. There is no\n pneumothorax. The tracheobronchial tree is patent up to subsegmental level.\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Evaluation of solid organs is\n limited in the absence of intravenous contrast. However, a nasogastric tube\n terminates in the stomach. The liver, spleen, and adrenal glands are\n unremarkable. There are no gross abnormalities in the region of the pancreas.\n The gallbladder contains high-density material consistent with prior contrast\n administration. The kidneys also contain high-density materials in the\n collecting systems consistent with prior contrast administration. There is no\n free air in the abdomen.\n\n CT PELVIS WITHOUT IV CONTRAST: The absence of intravenous or oral contrast\n and the presence of a right hip prosthesis severely limit evaluation of pelvic\n contents, including evaluation of bowel. The urinary bladder contains a Foley\n catheter and excreted contrast material.\n\n (Over)\n\n 8:06 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval bone ? sternal/rib fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n OSSEOUS STRUCTURES: There are compression deformities of the vertebral bodies\n at multiple levels, including T8, T10, T11, L4 and L5, of unknown acuity.\n Multilevel degenerative changes are also present. There is no malalignment.\n The lower sternal body demonstrate a mild deformity, but without adjacent\n hematoma or swelling, this is unlikely acute. Severe osteopenia is noted.\n Soft tissues are unremarkable.\n\n IMPRESSION:\n 1. Multilevel compression deformities of vertebral bodies in the thoracic and\n lumbar spine. Acuity unknown. Multilevel degenerative change.\n 2. Limited evaluation of solid organs and bowel in the absence of intravenous\n and oral contrast. Further, large portions of the pelvis are obscured by\n streak artifact from indwelling right hip prosthesis.\n 3. Emphysema.\n 4. Minimal deformity of the lower sternal body with no adjacent hematoma or\n swelling, unlikely to represent acute injury. Correlate with point\n tenderness.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-05-01 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1070686,
"text": " 1:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for underlying mass / as described on CT \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 9\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left temporal contusion and sah after fall in bathroom.\n REASON FOR THIS EXAMINATION:\n eval for underlying mass / as described on CT \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa TUE 6:26 PM\n STUDY: MRI of the head with and without contrast. On the susceptibility\n sequences, multiple punctate foci are identified, possibly representing\n amyloid deposits, other considerations include micro-hemorrhages. Significant\n areas of hyperintensity signal are demonstrated in the subcortical white\n matter on T2 and FLAIR, likely consistent with severe chronic microvascular\n ischemic disease. Unchanged focus of hemorrhage identified on the left\n temporal lobe measuring approximately 6.6 x 10.0 mm in the transverse\n dimensions. Mucosal thickening is noted on the left maxillary sinus.\n Prominence of the sulci and ventricles for the patient's age indicating\n atrophy. A second focus of hemorrhage is identified on the right parietal\n lobe on the convexity (4:24) measuring approximately 3 x 4 mm in size.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the head with and without contrast.\n\n CLINICAL INDICATION: 75-year-old woman with left temporal contusion and\n subarachnoid hemorrhage after fall in the bathroom. Evaluate for underlying\n mass as described on the prior CT of the head.\n\n COMPARISON: Prior CT of the head without contrast dated .\n\n TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,\n axial FLAIR, axial magnetic susceptibility, axial T2, diffusion-weighted\n sequences. After the administration of intravenous gadolinium contrast\n material, the T1-weighted images were repeated in axial T1, sagittal MP-RAGE\n and multiplanar reconstructions.\n\n In comparison with the prior CT dated , again a focus of\n hemorrhage is identified on the left temporal lobe, measuring approximately\n 6.6 x 10.0 mm in size (4:11), the T2 and FLAIR images demonstrate multiple\n scattered areas of hyperintensity signal in the subcortical white matter,\n likely consistent with chronic microvascular ischemic changes, the sulci and\n ventricles are prominent, likely indicating atrophy and possibly involutional\n in nature. On the magnetic susceptibility sequences, multiple foci of\n magnetic susceptibility are demonstrated, more obvious in the occipital and\n parietal regions. A few of these lesions are identified in the left\n cerebellar hemisphere. Given the size and distribution, amyloid deposit is a\n strong consideration, however, other entities like micro-bleeds cannot be\n completely excluded. On the diffusion-weighted sequences, there are punctate\n areas of moderate restricted diffusion raising the possibility of subacute\n (Over)\n\n 1:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for underlying mass / as described on CT \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 9\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n embolic events (602:17 and 602:13). After the administration of gadolinium\n contrast material, there is no evidence of abnormal enhancement. In the right\n parietal convexity (4:24), there is a small focus of hyperintensity signal,\n possibly representing hemorrhagic change, measuring approximately 3.1 x 4.6 mm\n in size. Normal flow void signal is identified in the major vascular\n structures. Mucosal thickening is observed on the left maxillary sinus with\n small fluid level.\n\n IMPRESSION:\n\n 1. Unchanged area of hemorrhage on the left temporal lobe.\n\n 2. Multiple foci of magnetic susceptibility signal demonstrated mainly in the\n parietal and occipital lobes, possibly consistent with amyloid deposits, other\n entities cannot be completely excluded such as micro- bleedings.\n\n 3. There is no evidence of abnormal enhancement.\n\n 4. Punctate area of hyperintensity signal demonstrated on the right parietal\n convexity possibly consistent with focal hemorrhagic change.\n\n 5. Punctate areas of restricted diffusion as described in detail above,\n possibly consistent with subacute ischemic changes, these areas are not\n visualized in the corresponding ADC maps.\n\n 6. Multiple areas of hyperintensity signal demonstrated in the subcortical\n white matter as described above, likely consistent with chronic microvascular\n ischemic changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-05-01 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1070687,
"text": ", NSURG FA11 1:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for underlying mass / as described on CT \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 9\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left temporal contusion and sah after fall in bathroom.\n REASON FOR THIS EXAMINATION:\n eval for underlying mass / as described on CT \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n STUDY: MRI of the head with and without contrast. On the susceptibility\n sequences, multiple punctate foci are identified, possibly representing\n amyloid deposits, other considerations include micro-hemorrhages. Significant\n areas of hyperintensity signal are demonstrated in the subcortical white\n matter on T2 and FLAIR, likely consistent with severe chronic microvascular\n ischemic disease. Unchanged focus of hemorrhage identified on the left\n temporal lobe measuring approximately 6.6 x 10.0 mm in the transverse\n dimensions. Mucosal thickening is noted on the left maxillary sinus.\n Prominence of the sulci and ventricles for the patient's age indicating\n atrophy. A second focus of hemorrhage is identified on the right parietal\n lobe on the convexity (4:24) measuring approximately 3 x 4 mm in size.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070226,
"text": " 2:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: follow up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left temp lobe contusion\n REASON FOR THIS EXAMINATION:\n follow up\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DXAe SAT 8:58 PM\n No change since .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup of left temporal lobe lesion.\n\n COMPARISON: Multiple prior exams, the most recent dated .\n\n TECHNIQUE: Non-contrast axial imaging was obtained through the skull vertex\n to the skull base. Repeat imaging was obtained due to patient motion.\n\n FINDINGS: A 12 x 7 mm ovoid focus of hyperdensity in the left temporal lobe\n is unchanged since . There is no evidence of adjacent edema or mass\n effect. Extensive periventricular white matter hypodensity is unchanged since\n and likely represents chronic microvascular infarct. The -white\n matter differentiation is preserved. The paranasal sinuses are grossly clear\n except to note small soft tissue density within the left maxillary sinus. The\n mastoid air cells are clear. The soft tissues are unremarkable.\n\n IMPRESSION: 12 x 7 mm hyperdensity in the left temple lobe is more concerning\n for neoplastic lesion given the lack of change since . Continued\n followup or MRI is recommended for further evaluation.\n\n\n Final Attending Comment:\n Above mentioned hyperdensity could represent hemorhhage versus mass. Recommend\n MRI for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1070227,
"text": ", NSURG SICU-B 2:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: follow up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left temp lobe contusion\n REASON FOR THIS EXAMINATION:\n follow up\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-28 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1070228,
"text": " 2:15 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: per trauma \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n per trauma \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with trauma.\n\n COMPARISON: Non-contrast CT of the abdomen and pelvis of .\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of 100 mL of Optiray contrast IV, and\n oral contrast via the nasogastric tube. Coronal and sagittal reformatted\n images were generated.\n\n CT OF THE ABDOMEN WITH CONTRAST: Extensive emphysema is noted at the lung\n bases. There are a few scattered hypodensities in the liver which are too\n small to characterize, as they measure under 1 cm (3:26, 3:30, 3:34 and 35).\n The portal vein remains patent. There is some vicarious excretion of contrast\n into the gallbladder, which is not distended. The spleen is unremarkable. No\n pancreatic abnormalities are identified. There is a suggestion of a vague 5-\n mm lesion of the left adrenal, rounded and hypodense (3:18), but this not\n fully characterized on this study. The kidneys enhance symmetrically and\n excrete normally, without hydronephrosis.\n\n A nasogastric tube tip is located in the body of the stomach. The stomach and\n bowel loops are unremarkable. Bowel loops are nondilated, and no wall\n thickening is seen. Oral contrast passes to the level of the proximal\n transverse colon, and stool and air are seen within the remaining colon. There\n is no free air in the abdomen. No free fluid is clearly seen in the abdomen,\n though there is a paucity of intra-abdominal fat for the assessment. There is\n a minimal amount of stranding posterior to the right lobe of the liver (3:30)\n and anterior to the spleen and lateral to the left colon (3:20), which is\n entirely nonspecific. Slight asymmetry in the psoas muscles is thought to be\n related to scoliosis.\n\n The abdominal aorta is normal in caliber, with ectasia and moderately severe\n atherosclerotic calcification. No mesenteric or retroperitoneal adenopathy is\n seen.\n\n CT OF THE PELVIS WITH CONTRAST: There is a moderate-to-severe amount of\n artifact related to the patient's right total hip replacement. There is a\n Foley catheter within the bladder, which is decompressed. The rectum and\n uterus are unremarkable. There is likely sigmoid diverticulosis. There is no\n definite pelvic free fluid. No pelvic or inguinal adenopathy.\n\n (Over)\n\n 2:15 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: per trauma \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Small bowel loops are seen adjacent to the medial aspect of the right common\n femoral artery and vein, possibly a nonobstructed femoral hernia. As bowel\n loops are normal, there is no obstruction.\n\n BONE WINDOWS: The bones are markedly osteopenic. There is right convex\n scoliosis of the thoracolumbar spine, and multiple vertebral body compression\n fractures which are not significantly changed from , including: T11,\n L4 and L5 as seen on this study.\n\n IMPRESSION:\n\n 1. No new findings in the abdomen/pelvis today. Multilevel compression\n deformities of the vertebral bodies are again noted, acuity unknown. No clear\n evidence of solid organ injury.\n\n 2. Subcentimeter hepatic hypodensities, rounded and too small to\n characterize.\n\n 3. Moderately severe atherosclerotic disease.\n\n 4. Emphysema.\n\n 5. Probable right femoral hernia containing a small bowel loop,\n nonobstructed.\n\n 6. 5 mm left adrenal nodule, not characterized on this exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-04-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070198,
"text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT position\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left temp contusion\n REASON FOR THIS EXAMINATION:\n NGT position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Nasogastric tube assessment.\n\n Nasogastric tube courses below the diaphragm. Heart is normal in size, but\n demonstrates left ventricular configuration. Marked tortuosity of the\n thoracic aorta is unchanged. Lungs are hyperexpanded consistent with CT\n demonstrated emphysema. Minimal linear atelectasis at left base with\n otherwise grossly clear lungs. Multiple compression deformities in the spine\n of indeterminate age.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-04-29 00:00:00.000",
"description": "Report",
"row_id": 243424,
"text": "Sinus rhythm. Possible septal myocardial infarction. Compared to the previous\ntracing of there is absence of septal R waves which may be secondary\nto lead placement.\n\n"
},
{
"category": "ECG",
"chartdate": "2187-04-27 00:00:00.000",
"description": "Report",
"row_id": 243425,
"text": "Possible ectopic atrial rhythm. Diffuse T wave changes which are non-specific.\nNo previous tracing available for comparison.\n\n"
}
] |
31,136 | 148,910 | 65 year old female with hx of CLL who presented to the ED with fever x 2 days up to 101.9 day 23 s/p second cycle of FCR (Fludarabine, Cytoxan and Rituxan). In the ED, she was not neutropenic but did have an episode of hypotension that responded to IVF. Currently looks well and remains hemodynamically stable. Patient admitted to the BMT service for management. . #Febrile Neutropenia/ID: Patient was continued on broad neutropenic coverage with cefepime and vancomycin on admission given hypotension in ED and counts < 1000 and decreasing on admission. CT torso was performed for evaluation for a source for fever. A small RLL infiltate was identified concerning for pneumonia. In patient with history of TB there was concern for reactivation of prior infection in setting of neutropenia and patient was placed in respiratory isolation. On Hospital day 2 patient complained of headache, neck pain and nausea. Concern for infectious process in CNS and patient had stat head CT to r/o bleed. LP was deferred given thrombocytopenia. Abx broadened to include fungal coverage and anaerobes at that time. On morning of Hospital day 3 patient became hypotensive w/ SBP in upper 70's, low 80's requiring IV fluid boluses, mild tachycardia, and increasing tachypnea. With IVF's patient's pressures normalized, but she became hypoxic. Started on azithromycin for atypical coverage. Impression was for sepsis and she was transferred to the ICU for monitoring. In ICU LP was performed that showed no evidence of significant CNS infection. Bronchoscopy exluced TB or other fungal processes. Patient's pressures stabilized but she required intermittent IVF boluses for support. After day ICU stay she was called out to the floor. On floor she was monitored while counts recovered. Repeat CT scan of the chest demonstrated a new pleural effusion concerning for a para-pneumonic effusion. However, patient remained afebrile and so decision was made to monitor her and to perform thoracentesis only if patient's fevers returned. Antibiotics were peeled off as possible and patient completed full course of azithromycin for atypicals and cefepime 2mg IV q8 days for regular pneumonia coverage. She remained afebrile and she autodiuresed on arrival to the floor much of the fluid she had retained earlier. Ultrasound of her R-uppper extremity was negative for any DVT. Patient discharged to home with plan for outpatient follow-up with Dr. early the following week and further discussion of her plan for chemotherapy at that time. . #Cardiac: Echo demonstrated no new wall motion abnormalities, depressed EF of infectious lesions. Small pericardial effusion noted on CT scan not reported on Echo. Patient without pulsus on exam, but with low voltage on EKG not noted previously. . #Leukemia: counts recovered with recovery from infection. Further treatment to be discussed as an outpatien with Dr. . Patient to remain on acyclovir, fluconazole, and bactrim PPx on discharge. . #Hypertension: Not-hypertensive during this stay. HCTZ held and advised not to restart until seen as an outpatient. #Gout: stable. Continue on allopurinol #Hypothyroidism: Stable. Continued on levothyroxine. | No contraindications for IV contrast FINAL REPORT INDICATION: CLL now with febrile neutropenia. # Hypotension: Resolved after fluid rescusitation. MildPA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. A pelvic lymphadenopathy is essentially unchanged with bilateral inguinal nodes and pelvic sidewall nodes again demonstrated. Mild (1+) mitral regurgitation is seen. There is extensive gastrohepatic ligament, hepatoduodenal ligament, retroperitoneal, retrocrural and root of mesentery lymphadenopathy again seen, with side to side comparison suggesting no significant change. Since the previous tracingof sinus tachycardia is now present. Infection pericardial effusion.Height: (in) 63Weight (lb): 168BSA (m2): 1.80 m2BP (mm Hg): 117/69HR (bpm): 99Status: InpatientDate/Time: at 15:19Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. There is no pericardial effusion.Compared with the prior study (images reviewed) of , the findings aresimilar with limited views except for mild mitral regurgitation and mildpulmonary artery systolic hypertension. CT OF CHEST WITH IV CONTRAST: The soft tissue windows demonstrate multiple pathologically enlarged mediastinal and hilar nodes which appear unchanged compared to the prior study. CT OF THE ABDOMEN WITH IV CONTRAST: The massive splenomegaly and hepatomegaly are unchanged. # Febrile neutropenia. CHEST, PA AND LATERAL: Prominence of the hilar and mediastinal contours consistent with underlying lymphadenopathy is again identified and appears stable. Febrile neutropenia. The uterus contains a large calcified fibroid which appears unchanged. Diffuse mesenteric lymphadenopathy is unchanged. Unchanged size and appearance of multiple mesenteric and retroperitoneal nodes. There are simple atheroma in the aortic root. There has been interval development of mild pericardial effusion and moderate right and small left pleural effusion. - supportive O2 for now - plan for NIPPV if needed Hypotension: fluid responsive, seems likely due to sepsis and hypovolemia at this point. - supportive O2 for now - plan for NIPPV if needed Hypotension: seems likely due to sepsis at this point (cortisol of note normal at 21 this AM) from an unclear source. If she continues to evolve a volume overloaded (or potentially picture) then she would be a good candidate for NIPPV - supportive O2 for now - plan for NIPPV if needed Hypotension: seems likely sepsis at this point (cortisol of note normal at 21 this AM) from an unclear source. If she continues to evolve a volume overloaded (or potentially picture) then she would be a good candidate for NIPPV - supportive O2 for now - plan for NIPPV if needed Hypotension: seems likely sepsis at this point (cortisol of note normal at 21 this AM) from an unclear source. If she continues to evolve a volume overloaded (or potentially picture) then she would be a good candidate for NIPPV - supportive O2 for now - plan for NIPPV if needed Hypotension: seems likely sepsis at this point (cortisol of note normal at 21 this AM) from an unclear source. - TTE to eval for effusion given hx of TB - bolus IVF for decreased UOP . - consider TTE to eval for effusion given hx of TB - bolus IVF for decreased UOP . She was placed on isolation precautions b/o c/o stiff neck and frontal headache. She was placed on isolation precautions b/o c/o stiff neck and frontal headache. - supportive O2 for now - plan for NIPPV if needed Hypotension: fluid responsive, seems likely due to sepsis and hypovolemia at this point. - TTE as above - bolus IVF for decreased UOP, tachycardia or hypotension. Resolved - Bolus IVF for decreased UOP, tachycardia or hypotension as has responded well, though would be careful given hypoxia and pulmonary edema. - consider TTE to eval for effusion given hx of TB - bolus IVF for decreased UOP . - Bolus IVF for decreased UOP, tachycardia or hypotension as has responded well, though would be careful given hypoxia and pulmonary edema. - Bolus IVF for decreased UOP, tachycardia or hypotension as has responded well, though would be careful given hypoxia and pulmonary edema. - Bolus IVF for decreased UOP, tachycardia or hypotension as has responded well, though would be careful given hypoxia and pulmonary edema. - Caution with IVF, may bolus as needed but should go first to NIPPV if develops further hypoxia. - Caution with IVF, may bolus as needed but should go first to NIPPV if develops further hypoxia. - Caution with IVF, may bolus as needed but should go first to NIPPV if develops further hypoxia. - Caution with IVF, may bolus as needed but should go first to NIPPV if develops further hypoxia. # Hypotension: likely related to sepsis from unclear source. 2) Hypotension: likely related to sepsis from unclear source. No c/o sob resp rate in 30s even when sleeping lungs clear crackles bases dyspneic wheezing with exertion, o2 sat >96%, cxr pulmonary edema, rll pna Action: Vanco/cefedime/voriconazole Response: Afebrile o2 sats improved Plan: Cont antibx, await cx results, sputum for afb results, maintain droplet precautions until r/o, monitor temp, cxr, ?lasix, using Albuterol neb Hypotension (not Shock) Assessment: Bp mean >56 when asleep Action: Continue to monitor Response: Plan: .H/O tuberculosis Assessment: Action: Response: Plan: Await results of afb, maintain droplet precautions | 59 | [
{
"category": "Nutrition",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 322479,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322473,
"text": "Chief Complaint: resp distress\n 24 Hour Events:\n BLOOD CULTURED - At 01:40 AM\n FEVER - 102.0\nF - 11:00 PM\n Tachycardia with fevers, resolved with defervesence\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: fevers\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.8\nC (98.2\n HR: 104 (87 - 121) bpm\n BP: 102/60(68) {88/46(59) - 118/68(80)} mmHg\n RR: 17 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,388 mL\n PO:\n 830 mL\n 450 mL\n TF:\n IVF:\n 3,320 mL\n 938 mL\n Blood products:\n Total out:\n 1,525 mL\n 300 mL\n Urine:\n 1,325 mL\n 300 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,088 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n Gen: lying in bed, diaphoretic, complaining of fatigue\n HEENT: dry oropharynx\n CV: tachy RR\n Chest: decreased BS in RLL\n Abd: distended +BS\n Ext: 1+\n Neuro:\n Labs / Radiology\n 10.6 g/dL\n 51 K/uL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic host\n though PNA is leading candidate.\n All cx have thus far been negative\n RLL PNA: BAL pending\n Hx of TB adenitis, Bal pending (prelim smear neg)\n Meningitis: LP unrevealing\n - Bronch done to eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n pending LP culture results info as well as vori, azithro, and flagyl\n (given poor dentition and location of infiltrate)\n Hypoxemia PNA in the RLL, with volume overload and weaning O2 as\n tolerated\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension:resolved. Was fluid responsive due to sepsis and\n hypovolemia at this point\n Widened mediastinum\n stable by PA/lat- likely swollen nodes due to\n volume resucitation.\n H/O TB lymphadenitis. \nt suspect reactivation now.\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition: poor po intake, encourage\n Glycemic Control: SSRI\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-17 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1009187,
"text": " 10:08 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Please evaluate for interval change and source for fever\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL a/w febrile neutropenia w/ ongoing fevers in setting\n of broad spectrum Abx and resolution of neutropenia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change and source for fever\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old woman with CLL and febrile neutropenia, please\n evaluate for interval change and source of fever.\n\n Comparison is made to the prior CT of the torso of .\n\n TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to the pubic\n symphysis after administration of 130 cc of Optiray intravenously. Oral\n contrast was also used. Sagittal and coronal reformatted images region were\n then obtained.\n\n CT OF CHEST WITH IV CONTRAST: The soft tissue windows demonstrate multiple\n pathologically enlarged mediastinal and hilar nodes which appear unchanged\n compared to the prior study. Bilateral pathologically enlarged axillary nodes\n are also unchanged. The heart and great vessels have normal appearance. There\n has been interval development of mild pericardial effusion and moderate right\n and small left pleural effusion.\n\n The lung windows do not demonstrate any pulmonary nodule, parenchymal\n opacification. Diffuse vascular engorgement is visualized.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The massive splenomegaly and hepatomegaly\n are unchanged. Cholelithiasis with no evidence of cholecystitis is\n visualized. The adrenal glands, kidneys, pancreas, stomach, duodenum and\n loops of small bowel and large bowel have normal appearance. Diffuse\n mesenteric lymphadenopathy is unchanged. The periportal nodes and the\n aortocaval node appear unchanged. The largest node is located between the\n portal vein anteriorly and the vena cava posteriorly measuring 32 x 16 mm.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, distal small\n bowel loops are normal. A small amount of ascitic fluid is noted within the\n pelvis. The uterus contains a large calcified fibroid which appears\n unchanged. Multiple enlarged inguinal nodes are unchanged.\n\n BONE WINDOWS: Degenerative changes of the lumbosacral spine are noted. No\n concerning lytic or sclerotic lesion.\n\n IMPRESSION:\n\n (Over)\n\n 10:08 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Please evaluate for interval change and source for fever\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No pathology is identified to explain the patient's source of fever.\n\n 2. Unchanged size and appearance of multiple mesenteric and retroperitoneal\n nodes. Unchanged massive splenomegaly.\n\n 3. Interval development of moderate right and small left pleural effusion and\n interval development of ascites.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-11 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1008404,
"text": " 1:45 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Staging and source of infection, patient with cough, fever a\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL a/w febrile neutropenia. Please perform CT scan for\n diagostic as well as staging purposes.\n REASON FOR THIS EXAMINATION:\n Staging and source of infection, patient with cough, fever and neutropenia.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL now with febrile neutropenia.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple MDCT axial images were obtained from the base of the neck\n through the proximal thighs after administration of 130 mL of Optiray. Enteric\n contrast was administered. Coronal and sagittal reformations were obtained.\n\n CT CHEST WITH IV CONTRAST: There is persistent asymmetric enlargement of the\n left lobe of the thyroid. Extensive are essentially unchanged upper\n paratracheal, bilateral axillary, prevascular, and mediastinal nodes are seen.\n Side to side comparison to suggest no significant change. Some hilar or\n mediastinal lymph nodes are calcified, suggesting either response to treatment\n or prior granulomatous disease. There is no pneumothorax or pleural effusion.\n The heart and great vessels appear essentially normal.\n\n CT ABDOMEN WITH IV CONTRAST: The liver, kidneys, adrenals, and pancreas\n appear unremarkable. There is unchanged massive splenomegaly. There is\n extensive gastrohepatic ligament, hepatoduodenal ligament, retroperitoneal,\n retrocrural and root of mesentery lymphadenopathy again seen, with side to\n side comparison suggesting no significant change. Abdominal loops of bowel\n are unremarkable and there is no abdominal free air or free fluid.\n\n CT OF THE PELVIS: Calcified fibroid uterus. A pelvic lymphadenopathy is\n essentially unchanged with bilateral inguinal nodes and pelvic sidewall nodes\n again demonstrated. Bladder, distal ureters, and pelvic loops of bowel appear\n normal and there is no significant pelvic free fluid and no free air.\n\n MUSCULOSKELETAL: Mild degenerative disc disease is again seen, but there is\n no suspicious lytic or blastic lesion.\n\n IMPRESSION:\n\n 1. No significant interval change in nodal size and massive splenomegaly.\n\n 2. Increasing opacification in the right lower lobe may have an infectious\n etiology.\n\n (Over)\n\n 1:45 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Staging and source of infection, patient with cough, fever a\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n COMMENT: Drs & Abigan contact regarding findings at 3p by Dr\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-17 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1009283,
"text": " 9:02 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ? DVT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL, here w/ fevers of unknown origin. Has swollen R\n forearm, tender, red. ? DVT\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old female with CLL presenting with swollen right\n forearm.\n\n COMPARISONS: None.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of\n the right internal jugular, subclavian, axillary, brachial and basilic veins\n were performed. The cephalic vein was diminutive and poorly assessed. These\n images demonstrate normal compressibility, augmentation, color flow and\n waveforms. No intraluminal echogenic thrombus is identified. Focused scanning\n of the area of erythema in the right proximal forearm demonstrates moderate\n subcutaneous edema. No drainable fluid collections are seen.\n\n IMPRESSION:\n 1. No evidence of right upper extremity DVT.\n 2. Subcutaneous edema in the area of swelling in the right forearm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1008721,
"text": " 1:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval worsening\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with pneumonia now with new hypotension and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for interval worsening\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old woman with new hypotension and hypoxia, being treated\n for pneumonia, history of CLL.\n\n COMPARISON: at 21:00 hours.\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 1:15 P.M.: Lung volumes are low. The\n heart has undergone interval enlargement. Peripheral linear opacities\n indicate the development of interstitial pulmonary edema. Pulmonary\n vasculature is engorged. There is no pleural effusion.\n\n The superior mediastinum appears acutely widened, with tracheal narrowing and\n slight deviation. This could be explained by the increased pulmonary vascular\n congestion, but could alternatively be concerning for the development of\n hematoma if the patient has undergone a recent procedure.\n\n Airspace opacity in the right lower lobe appears largely unchanged, and there\n are no new foci of parenchymal consolidation. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Acute interstitial pulmonary edema.\n\n 2. Interval increased widening of the superior mediastinum accompanied by\n tracheal deviation and slight narrowing, possibly explained by vascular\n distention and known underlying lymph node enlargement but hematoma should be\n considered if there was a recent intervention.\n\n 3. Right lower lobe pneumonia.\n\n Findings discussed with Dr. , the covering physician.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1008850,
"text": " 3:08 PM\n CHEST (PA & LAT) Clip # \n Reason: eval mediastinum\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL admitted with pneumonia c/b hypotension with\n mediastinal widening on AP CXR\n REASON FOR THIS EXAMINATION:\n eval mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, .\n\n HISTORY: CLL. Pneumonia and hypotension.\n\n IMPRESSION: AP chest compared to through :\n\n Heterogeneous consolidation in the right lower lung has increased since and could be due to pneumonia or worsening atelectasis. Small right\n pleural effusion has also increased. Mediastinal widening, which progressed\n after is slightly more pronounced and could be due to vascular\n congestion, thrombosis, or even acute increase in preexisting severe central\n adenopathy. Heart is normal size. Left lung is clear and there is little if\n any left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1008630,
"text": " 9:14 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with w/ h/o CLL a/w febrile neutropenia. RLL infiltrate on\n CT scan.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CLL with febrile neutropenia and right lower lobe infiltrate on CT\n scan.\n\n FINDINGS: In comparison with the study of , there is some increased\n opacification at the right base that is consistent with the area of\n consolidation seen on the CT scan of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1008628,
"text": " 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for acute bleed other intracranial pathology\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL a/w febrile neutropenia. Now w/ headache and\n nausea. Please evaluate for acute bleed.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute bleed other intracranial pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL. Febrile neutropenia. Headaches and nausea.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect,\n hydrocephalus, or infarction. The visualized paranasal sinuses and mastoid\n air cells are clear. The soft tissues are unremarkable. As described in more\n detail on prior CT of the neck, several small and borderline posterior\n cervical lymph nodes are noted; however, incompletely assessed.\n\n IMPRESSION: No hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1008886,
"text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with neutropenic fever, RLL infiltrate\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Neutropenic fever, right lower lobe infiltrate, evaluate change.\n\n CHEST, SINGLE AP VIEW.\n\n The lower left chest wall and left costophrenic angle are excluded from the\n film. Again seen is cardiomegaly as well as a widened mediastinum and\n prominent aortic arch. There is patchy increased density at both bases and\n upper zone redistribution -- ? due to asymmetric distribution of CHF.\n Possibility of an infectious infiltrate or aspiration cannot be excluded. No\n gross effusion is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1008313,
"text": " 6:23 PM\n CHEST (PA & LAT) Clip # \n Reason: eval lung fields, r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with CLL, on chemo, presents with fever, no cough, SOB, or\n CP. neutropenia w/u\n REASON FOR THIS EXAMINATION:\n eval lung fields, r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL, fever, neutropenia.\n\n COMPARISONS: .\n\n CHEST, PA AND LATERAL: Prominence of the hilar and mediastinal contours\n consistent with underlying lymphadenopathy is again identified and appears\n stable. No focal pulmonary opacities are identified to indicate pneumonia.\n Linear scarring within the right perihilar region is unchanged.\n\n IMPRESSION: No acute cardiopulmonary disease.\n\n"
},
{
"category": "Echo",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Report",
"row_id": 68085,
"text": "PATIENT/TEST INFORMATION:\nIndication: Febrile neutropenia with ? Increased cardiac silhouette on CXR ? Infection pericardial effusion.\nHeight: (in) 63\nWeight (lb): 168\nBSA (m2): 1.80 m2\nBP (mm Hg): 117/69\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 15:19\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting\ntachycardia (HR>100bpm). Emergency study performed by the cardiology fellow on\ncall.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar with limited views except for mild mitral regurgitation and mild\npulmonary artery systolic hypertension. No pericardial effusion. Normal\nbiventricular systolic function.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-04-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1008813,
"text": " 8:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with neutropenic fever, RLL infiltrate.\n REASON FOR THIS EXAMINATION:\n Please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Neutropenic fever, right lower lobe infiltrate, assess interval\n change.\n\n CHEST, SINGLE AP VIEW\n\n Again seen is an alveolar opacity at the right base, presumably in the lower\n lobe, minimally improved compared with one day earlier. Also again seen is\n marked enlargement of the superior mediastinum. Retrocardiac density is\n stable. No CHF or effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Report",
"row_id": 162481,
"text": "Sinus tachycardia. There is a late transition which is probably normal.\nLow voltage. Compared to the previous tracing low voltage is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-04-10 00:00:00.000",
"description": "Report",
"row_id": 162482,
"text": "Sinus tachycardia. Otherwise, normal tracing. Since the previous tracing\nof sinus tachycardia is now present.\n\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322343,
"text": ".H/O nausea / vomiting\n Assessment:\n c/o of nausea unsure if related to her headache or medication\n Action:\n Given zofran 4mg po and percocet for headache\n Response:\n Nausea and pain controlled\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o of headache as above\n Action:\n Tx with percocet\n Response:\n No pain\n Plan:\n Medicate prn for pain\n Assessment:\n On 3l np . No c/o sob resp rate in 30\ns even when sleeping lungs clear\n crackles bases\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322325,
"text": "65 year old woman admitted from ED : history of CLL s/p 6 cycles of\n R-CVP for bulky LAD and splenomegaly and most recently 2 cycles of\n fludarabine, rituxan and cytoxan (last dose 23 days prior to admission)\n who developed fever at home to 101.9 x 2 days. She took motrin for the\n fever. She denied any cough, headache, abdominal pain, diarrhea or\n dysuria at the time. She was mildly hypotensive in the ED and responded\n to fluid boluses. She was initiated on Vanco/Cefe and admitted to BMT.\n She did well there but conituned to have fevers, yesterday she noted\n the development of HA and neck stiffness and there was a concern for\n meningitis however she was unable to be safely LP'd low Plts. Her\n antibiotic coverage was expanded to meningitis doses. She currently\n says the HA has abated and there is no neck stiffness. Noted by nurse\n to be hypotensive this AM, responded to 2L NS and 2 bags platelets.\n Developed hypoxemia and dyspnea. Transferred to .\n Hypoxemia\n Assessment:\n O2sat >95% on 3L NC, rr 20\ns, LS coarse upper/crackles lower, most\n recent CXR results pending, appears that fluid to increase BP and\n 2units platelets may have caused resp distress.\n Action:\n ECHO ordered for Pericardial Effusion, abx for ? PNA/flu, remains on 3L\n NC\n Response:\n Pt states resp status improved, Unable to get ECHO d/t need for bronch\n (now no staff over weekend to perform procedure, MD\ns were made aware\n prior).\n Plan:\n Remain on NC, awaiting CXR results, nebs PRN, no foley (monitor urine\n output)\n Hypotension (not Shock)\n Assessment:\n SBP remains >95\n Action:\n ABX for ? infections (sepsis), LP for ? meningitis (multiple other labs\n as well)\n Response:\n Tolerating abx, tolerated LP well, Urine cx\ns from yesterday neg.\n Plan:\n Bld cx and Influenza a/b sent yesterday pending, LP results pending,\n cont abx, monitor BP, remains on droplet precautions.\n .H/O tuberculosis\n Assessment:\n Pt stopped 4drug TB regimen after 6months, no cough noted prior to\n Bronch\n Action:\n Bronch for AFB and other tests, required 25mcg fent and 1mg versed for\n procedure,\n Response:\n Tolerated bronch well, MD l malasia (R side worse\n than L)\n Plan:\n Awaiting test results for TB, remains on airborne precautions (TB mask\n and negative pressure room).\n Daughter visited, updated on condition and POC, remains in room w/ pt @\n this time.\n Currently allowed for sips, MD\ns may restart diet when pt more awake.\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322590,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n BLOOD CULTURED - At 01:08 AM\n FEVER - 101.2\nF - 10:00 PM, cultured, tachy with fever\n TTE done yesterday, no pericardial effusion\n ID recs: continue current mgmt\n Micro: AFB prelim smear negative, awaiting concentrated smear results\n to dc respiratory precautions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Voriconazole - 10:00 PM\n Metronidazole - 02:00 AM\n Cefipime - 02:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Docusate\n Percocet\n Azithromycin 250PO daily\n Ipratropium\n Acetaminophen\n Prochlorperazine\n Ondansetron\n Bactrim\n Lorazepam\n Levothyroxine\n Allopurinol\n Senna\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies pain, occasional HA, is sensitive to light.\n No nausea but appetitite is poor. No SOB. No\n fevers/chills/diaphoresis since last night.\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.6\nC (97.8\n HR: 90 (90 - 111) bpm\n BP: 94/53(63) {90/42(55) - 117/72(77)} mmHg\n RR: 11 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 2,307 mL\n 450 mL\n PO:\n 720 mL\n 250 mL\n TF:\n IVF:\n 1,587 mL\n 200 mL\n Blood products:\n Total out:\n 850 mL\n 150 mL\n Urine:\n 850 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,457 mL\n 300 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% 1-2L\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished, No acute distress. Pleasant\n Head, Ears, Nose, Throat: Normocephalic, MMM, no meningismus\n Respiratory / Chest: (Expansion: Symmetric), crackles 1/3 up lung\n fieldsclear anteriorly\n Cor: RRR, no MRG\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No edema\n Neurologic: Alert and oriented x 3, moving all extremities, no focal\n deficits noted.\n Labs / Radiology\n 61 K/uL\n 10.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 135 mEq/L\n 31.3 %\n 2.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n 11:04 PM\n WBC\n 1.8\n 1.6\n 1.5\n 2.6\n Hct\n 27.0\n 28.7\n 30.1\n 31.3\n Plt\n 67\n 52\n 51\n 61\n Cr\n 0.7\n 0.7\n 0.8\n Glucose\n 94\n 106\n 95\n Other labs: PT / PTT / INR:14.3/29.7/1.2, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:1.4 mg/dL\n TTE : PRELIM READ -- Right ventricular chamber size and free wall\n motion are normal. There are simple atheroma in the aortic root. The\n mitral valve appears structurally normal with trivial mitral\n regurgitation. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion. There are no\n echocardiographic signs of tamponade.\n IMPRESSION: No pericardial effusion and no echo signs of tamponade. If\n clinically indicated should obtain full study by son.\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia and\n continued fevers.\n # Febrile neutropenia. Most likely source PNA given RLL lobar\n infiltrate. So far no informative culture or gram stain data. Pt has\n history of partially treated extrapulmonary TB, lobar appearance of CXR\n not really suggestive of reactivated TB. Patient with continued fevers\n (102 axillary) overnight.\n -Covering broadly for neutropenic CAP with vanc/cefepime/azithromycin\n with flagyl for anaerobes, voriconazole for fungal coverage. Could\n consider peeling back coverage pending culture results, though would\n continue for now given persistent fevers and relative neutropenia.\n -Follow up all cultures, AFB smears negative, but awaiting concentrated\n smear, due back this afternoon\n -Tylenol prn fevers, cooling blanket prn\n -Continue neutropenic and negative pressure respiratory isolation for\n r/o TB\n - DFA for influenza negative, will dc droplet isolation, though still\n requires resp isolation as above\n # Hypoxia: Occurred in setting of aggressive fluid rescusitation for\n hypotension, has resolved and has not recurred. Pt sating well on\n minimal supplemental 02. If she were to become hypoxic again in\n setting of possible infection with concurrent pulmonary edema would try\n NIPPV.\n # Hypotension: Resolved after fluid rescusitation. BP has been stable.\n Continue to monitor.\n # Hx of Extra-pulmonary TB: Found on supraclavicular LN biopsy for ?\n CLL, + caseating granuloma without any culture + TB found. Patient\n completed only 6 months of therapy so would be at risk for relapse.\n Prolonged fevers raise suspicion for reactivated TB.\n - Prelim AFB smear from bronch negative, concentrated smear will be\n complete at 1pm today, if negative can d/c respiratory precautions and\n call out to floor.\n - ID recs\n -Azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n # Neck pain: Resolved. Patient developed pain and soreness after being\n in the hospital w/o other sign of meningitis except for fever. LP\n without evidence of meningitis. Likely benign muscle ache/spasm.\n - No growth on CSF culture\n - Serum and CSF crp ag negative, AFB smear from CSF pending.\n - Reduced cefepime from meningitis to PNA doses.\n - Tylenol, percocet prn pain.\n # CLL: ANC >1000, continues to improve. No longer neutropenic.\n - BMT recs\n - Continue prophy: bactrim and acyclovir\n # Hypothyroidism: Continue current dose levothyroxine\n # FEN: Bowel regimen, Nutrition consult appreciated, will receive\n supplements for poor PO intake. Repleted K and Phos today. Corrected\n Ca WNL. IVF boluses as above PRN.\n ICU Care\n Nutrition: Taking PO\n Glycemic Control: ISS PRN\n Lines:\n 22 Gauge - 11:30 PM\n Prophylaxis:\n DVT: no SC heparin for low platelets, didn\nt tolerate pneumoboots\n Stress ulcer: taking PO, not needed\n VAP: Not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Call out to BMT once off respiratory isolation\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322592,
"text": "Chief Complaint: Fever in immunocompromised host.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n HPI:\n 65 yo woman with CLL, 1 month s/p chemo adm with febrile neutropenia,\n RLL infiltrate, hypotension, hypoxemia. Bronched on arrival to MICU.\n Continued fevers.\n 24 Hour Events:\n BLOOD CULTURED - At 01:08 AM\n FEVER - 101.2\nF - 10:00 PM\n No pericardial effusion.\n neg smear.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Voriconazole - 10:00 PM\n Metronidazole - 02:00 AM\n Cefipime - 02:00 AM\n Acyclovir - 06:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.8\nC (98.3\n HR: 89 (88 - 111) bpm\n BP: 115/73(82) {86/42(55) - 117/73(82)} mmHg\n RR: 9 (9 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 2,307 mL\n 801 mL\n PO:\n 720 mL\n 370 mL\n TF:\n IVF:\n 1,587 mL\n 431 mL\n Blood products:\n Total out:\n 850 mL\n 350 mL\n Urine:\n 850 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,457 mL\n 451 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilat bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, eating\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): all, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 10.8 g/dL\n 61 K/uL\n 95 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 135 mEq/L\n 31.3 %\n 2.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n 11:04 PM\n WBC\n 1.8\n 1.6\n 1.5\n 2.6\n Hct\n 27.0\n 28.7\n 30.1\n 31.3\n Plt\n 67\n 52\n 51\n 61\n Cr\n 0.7\n 0.7\n 0.8\n Glucose\n 94\n 106\n 95\n Other labs: PT / PTT / INR:14.3/29.7/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:2.9 g/dL, Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:1.4 mg/dL\n Imaging: Echo: normal EF, mild PAH.\n Microbiology: Cx NGTD blood, CSF, resp viral cx\n Bronch: neg cx, no microorgs.\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic host\n though PNA is leading candidate.\n All cx have thus far been negative\n RLL PNA: BAL pending\n Hx of TB adenitis, Bal pending (prelim smear neg)\n Meningitis: LP unrevealing\n - Bronch done to eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage Vanco and Cefepime vori, azithro, and flagyl\n (given poor dentition and location of infiltrate concern for aspiration\n Hypoxemia PNA in the RLL, with volume overload and weaning O2 as\n tolerated\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension:resolved.\n Tachycardia: in setting of fevers, now improved. Echo in AM pre BMT -\n can look for veg, no evidence of increased cardiac siloutte by plain\n films or on recent CT but can also look for small pericard eff.\n Widened mediastinum\n stable by PA/lat- likely swollen nodes due to\n volume resucitation. Hol doff on repeat CT as just had on .\n H/O TB lymphadenitis: if remains febrile without a source for many more\n days, may need repeat node bx to r/o TB or lymphoma\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Note\n ICU Care\n Nutrition:\n Comments: PO diet but poor intake.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322593,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, LS clear and dim.\n At RL base. RR easy at 10-20\ns. on RA. Bronch done to R/O for TB and\n flu therefore on resp. isolation.\n Action:\n Broad IV and PO abx coverage.\n Response:\n RA O2 sat 95-98%, denies dyspnea. Flu neg and prelim. neg.\n Concentrated smear due to come back today. Tolerating OOB to chair\n without dyspnea.\n Plan:\n f/u concentrated smear results and if Negative d/c resp. isolation.\n Afebrile since midnight. WBC 2.5 today.\n .H/O pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tobacco use, prior\n Assessment:\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n No further nausea or vomiting over the weekend.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache\n Action:\n Given percocet\n Response:\n Tolerates meds, able to sleep after percocet without pain\n Plan:\n Continue to assess and treat\n .\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 80.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: CLL dx , diffuse LAD, - 2 cycles R-CVP -\n 2 cycles ludarabine, cytoxan and rituxan; Hypothyroidism,\n Osteoarthritis, Presumed TB adenitis(caseating granulomas on bx, + PPD,\n cx neg) stopped tx at 6 mos, Granuloma annulare\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:60\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,165 mL\n 24h total out:\n 350 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 11:04 PM\n Potassium:\n 3.7 mEq/L\n 11:04 PM\n Chloride:\n 107 mEq/L\n 11:04 PM\n CO2:\n 19 mEq/L\n 11:04 PM\n BUN:\n 15 mg/dL\n 11:04 PM\n Creatinine:\n 0.8 mg/dL\n 11:04 PM\n Glucose:\n 95 mg/dL\n 11:04 PM\n Hematocrit:\n 31.3 %\n 11:04 PM\n Finger Stick Glucose:\n 117\n 06:00 PM\n Additional pertinent labs:\n Kphos 30 mmol in 500cc hung at 1200 for phos 1.4 today\n Lines / Tubes / Drains:\n PIV\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Fimard 411\n Transferred to:\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322596,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, LS clear and dim.\n At RL base. RR easy at 10-20\ns. on RA. Bronch done to R/O for TB and\n flu therefore on resp. isolation.\n Action:\n Broad IV and PO abx coverage.\n Response:\n RA O2 sat 95-98%, denies dyspnea. Flu neg and prelim. AFB neg.\n Tolerating OOB to chair without dyspnea.\n Plan:\n AFB concentrated smear results negative. Resp. isolation d/c\n Afebrile since midnight. WBC 2.5 today.\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n No further nausea or vomiting over the weekend.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache. LP done and neg.\n Action:\n Medicated with Percocet 1 tab at 0800.\n Response:\n Resting after recived Percodet. No head ache at this time.\n Plan:\n Continue to assess and treat.\n .\n Demographics\n Attending MD:\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 80.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: CLL dx , diffuse LAD, - 2 cycles R-CVP -\n 2 cycles ludarabine, cytoxan and rituxan; Hypothyroidism,\n Osteoarthritis, Presumed TB adenitis(caseating granulomas on bx, + PPD,\n cx neg) stopped tx at 6 mos, Granuloma annulare\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:71\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,165 mL\n 24h total out:\n 350 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 11:04 PM\n Potassium:\n 3.7 mEq/L\n 11:04 PM\n Chloride:\n 107 mEq/L\n 11:04 PM\n CO2:\n 19 mEq/L\n 11:04 PM\n BUN:\n 15 mg/dL\n 11:04 PM\n Creatinine:\n 0.8 mg/dL\n 11:04 PM\n Glucose:\n 95 mg/dL\n 11:04 PM\n Hematocrit:\n 31.3 %\n 11:04 PM\n Finger Stick Glucose:\n 117\n 06:00 PM\n Additional pertinent labs:\n Kphos 30 mmol in 500cc hung at 1200 for phos 1.4 today\n Lines / Tubes / Drains:\n 2 PIVs. Pt. is a difficult stick.\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 411\n Transferred to: 782\n Date & time of Transfer: 1400\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322389,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n BRONCHOSCOPY - At 04:00 PM\n CSF CULTURE - At 04:30 PM\n FEVER - 101.9\nF - 06:00 AM\n -got for ? reactivation TB\n -got LP for ? PNA, no WBC, cefepime decreased to non-meningitis doses.\n -Febrile to 101.2 this am, re-cultured blood and urine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 PM\n Metronidazole - 02:10 AM\n Cefipime - 03:10 AM\n Voriconazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:07 PM\n Midazolam (Versed) - 04:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.8\nC (101.9\n HR: 129 (98 - 129) bpm\n BP: 117/53(66) {78/41(52) - 127/76(84)} mmHg\n RR: 27 (17 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 540 mL\n 1,183 mL\n PO:\n 50 mL\n 480 mL\n TF:\n IVF:\n 490 mL\n 703 mL\n Blood products:\n Total out:\n 200 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 340 mL\n 583 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: pleasant, sweat soaked, NAD\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), LLSB, tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : , Wheezes : )\n Abdominal: Soft, Non-tender\n Extremities: No edema.\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, CN II-XII intact. upper and lower extremity\n strength intact\n Labs / Radiology\n 52 K/uL\n 9.9 g/dL\n 94\n 0.7\n 18\n 4.1\n 11\n 111\n 138\n 28.7 %\n 1.6 K/uL\n [image002.jpg] Ca 7.4 Mg 1.9 P 1.8\n PT 14.7 PTT 30.5 INR 1.3 ANC 560\n BAL fluid:\n WBC 0\n RBC 0 PMNs 0, Lymphs 44, Monos 23 Other 33\n Source: LP; 2\n CSF\n Chemistry\n Protein\n 22\n Glucose\n 57\n SOURCE: LP 4\n CSF\n WBC\n 0\n RBC\n 8\n Poly\n 0\n Lymph\n 84\n Mono\n 16\n EOs\n Legionella urinary ag negative\n Cryptococcal serum and CSF antigen negative\n UA negative\n Urine and blood cultures pending\n No microorganisms on BAL sample\n AFP and viral pending.\n 03:24 PM\n 05:11 AM\n WBC\n 1.8\n 1.6\n Hct\n 27.0\n 28.7\n Plt\n 67\n 52\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia.\n #Febrile neutropenia. Most likely source PNA given absence of other\n localizing findings besides new RLL lobar infiltrate. So far no\n informative culture or gram stain data. Pt has history of partially\n treated extrapulmonary TB, lobar appearance of CXR not really\n suggestive of reactivated TB.\n -cover broadly for neutropenic CAP with vanc/cefepime/azithromycin with\n flagyl for anaerobes, voriconazole for funal coverage. Peel back\n coverage if no GPCs on sputum from BAL.\n -follow up all cultures, call micro lab to ensure AFB smear for r/o TB\n being processed.\n -Tylenol prn fevers\n -continue neutropenic and negative pressure respiratory isolation for\n r/o TB.\n .\n #Hypoxia: likely related to underlying CAP now acutely exacerbated by\n fluid resusitation. Has resolved overnight, satting well on 2L NC. CXR\n appears less fluid overloaded today. Pulmonary edema likely from\n aggressive fluid rescusitation. No history of heart failure.\n -TTE on Monday\n -Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: likely related to sepsis from unclear source. no\n evidence of blood loss or ischemic cause. pericardial effusion with\n tamponade is possible given hx of TB but would be unlikely. currently\n lactate normal and normal mentation to perfusion adequate.\n - TTE as above\n - bolus IVF for decreased UOP, tachycardia or hypotension. Responded\n very well to 1L NS this am. Would use LR in future as is becoming\n hyperchloremic.\n .\n 3) Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. currently without other significant\n constitutional symptoms that had featured prominently before. would\n expect low probability for pulmonary TB.\n - continue airborne precautions for now pending AFB from bronch\n - ID recs\n -azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n .\n 4) Neck pain: patient developed pain and soreness after being in the\n hospital w/o other sign of meningitis except for fever. would have low\n probability for meningitis but given immune suppressed status it would\n be difficult to entirely exclude. alternatively could be benign muscle\n ache. LP yesterday, normal, no evidence of meningitis.\n - Reduce cevepime from meningitis to PNA doses.\n - tylenol, percocet prn pain.\n .\n 5) CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - follow\n - continue prophy: bactrim and acyclovir\n .\n 6) Hypothyroidism: continue current dose\n ICU Care\n Nutrition: neutropenic diet\n Glycemic Control: adqeuate\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: pneumaboots\n Stress ulcer: eating\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:call out to bmt later today if bp remains stable.\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322311,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 year old woman admitted from ED : history of CLL s/p 6 cycles of\n R-CVP for bulky LAD and splenomegaly and most recently 2 cycles of\n fludarabine, rituxan and cytoxan (last dose 23 days prior to admission)\n who developed fever at home to 101.9 x 2 days. She took motrin for the\n fever. She denied any cough, headache, abdominal pain, diarrhea or\n dysuria at the time. She was mildly hypotensive in the ED and responded\n to fluid boluses. She was initiated on Vanco/Cefe and admitted to BMT.\n She did well there but conituned to have fevers, yesterday she noted\n the development of HA and neck stiffness and there was a concern for\n meningitis however she was unable to be safely LP'd low Plts. Her\n antibiotic coverage was expanded to meningitis doses. She currently\n says the HA has abated and there is no neck stiffness. Noted by nurse\n to be hypotensive this AM, responded to 2L NS and 2 bags platelets.\n Developed hypoxemia and dyspnea. Transferred to .\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Vanco and Cefepime\n (Home meds acyclovir, diflucan, bactrim SS qd, levothyroxine,\n allopurinol, ativan, HCTZ.)\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n Presumed TB adenitis(caseating granulomas on bx, + PPD, cx neg) \n stopped tx at 6 mos\n Granuloma annulare\n non contrib\n Occupation: former cashier in , now home health aide\n Drugs: no\n Tobacco: 40 pack year, quit \n Alcohol: no\n Other: lives with husband, frequent travel to \n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, dry\n Gastrointestinal: No(t) Abdominal pain, Nausea\n Musculoskeletal: Myalgias\n Heme / Lymph: Lymphadenopathy\n Neurologic: Headache, mild\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 112 (112 - 114) bpm\n RR: 30 (30 - 31) insp/min\n SpO2: 96% on 3LNC\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1 mL\n Respiratory\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress. Nonproductive\n cough.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness :\n bases), (Breath Sounds: Crackles : at the bases b/l, Diminished: bases\n bilateral). Diffuse wheezing now- since fluid resuscitation.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51\n 27\n 0.7\n 12\n 19\n 107\n 4\n 134\n 1.9\n [image002.jpg] AG 8\n Other labs: PT / PTT / INR://1.3, Differential-Neuts:38.4, Band:0,\n LDH:281\n Fluid analysis / Other labs: Cortisol 21\n ANC 600 on arrival\n ABG: 61* 30* 7.42\n Imaging: CXR : increasing RLL and RML process with some component\n of increasing interstitial volume present as well over the series of\n films from to the film.\n CT: (): interval development of RLL lesion when compared to\n previous findings on . Diffuse mediastinal LAD, hilar LAD, RLL post\n seg gg inf and consolidation.\n Head CT done for headache: no blood, no masses, no sinus consolidation.\n Microbiology: Blood, legionella, urine Clx: neg\n Cryptococcal Ag: neg, nasal viral asp neg\n UA: no bacteria, 1 WBC\n B glucan and GM: pending\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All clx have thus far been negative. There was a suggestion of a\n RLL process on the initial CT scan as well as continued diffuse\n lymphadenopathy. In addition to covering for bacterial and atypical\n pathogens from a respiratory standpoint it seems reasonable to at least\n consider the possibility of recurrent TB in the setting of her\n neutropenia. The RLL location would seem atypical for TB, however we\n need to further eval to rule it out. She seems clinically stable at\n this point to be able to tolerate a bronch with BAL. Also,\n consideration must be given to the possibility of meningitis given her\n fevers and symptoms (whether it be bacterial, viral or TB). It seems\n unlikely that TB is the source of her hypotension ( I would favor a\n super infection of some sort). Finally, it may be reasonable to\n consider a bx of one the axillary nodes if the above work up is\n unrevealing.\n - Plan for LP pending safe plts and INR\n - Bronch now to further eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n pending LP info as well as vori, azithro, and flagyl (given poor\n dentition and location of infiltrate)\n - Pan cx\n - Appreciate ID recs\n Hypoxemia: there may be an element of PNA in the RLL, however the\n recent evolution of changes seems more consistent with volume\n challenge. We will continue to closely monitor for now. If she\n continues to evolve a volume overloaded (or potentially picture)\n then she would be a good candidate for NIPPV. Note- 40PY former smoker.\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: seems likely due to sepsis at this point (cortisol of note\n normal at 21 this AM) from an unclear source. We will continue to\n volume resus with boluses as needed. Goal UOP 0.5 cc/kg/hr. Will\n alternate b/w NS and LR to prevent hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n - Consider echo if hypotension persists despite fluid resuscitation.\n H/O TB lymphadenitis. \nt suspect reactivation now.\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition:\n Comments: NPO pending LP. Reg diet following.\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 75 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322399,
"text": "Chief Complaint: febrile neutropenia, sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 04:00 PM\n CSF CULTURE - At 04:30 PM\n FEVER - 101.9\nF - 06:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 PM\n Metronidazole - 02:10 AM\n Cefipime - 03:10 AM\n Voriconazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:07 PM\n Midazolam (Versed) - 04:07 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: Tachycardia\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Flowsheet Data as of 09:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 36.3\nC (97.4\n HR: 119 (98 - 129) bpm\n BP: 102/58(67) {78/41(52) - 127/76(84)} mmHg\n RR: 14 (14 - 36) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 540 mL\n 1,871 mL\n PO:\n 50 mL\n 530 mL\n TF:\n IVF:\n 490 mL\n 1,341 mL\n Blood products:\n Total out:\n 200 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 340 mL\n 1,271 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Gen: lying in bed, diaphoretic\n HEENT: dry oropharynx\n CV: tachy RRR\n Chest: coarse BS in right base, no wheezes\n Abd: soft nt\n Ext: 1+ edema\n Labs / Radiology\n 9.9 g/dL\n 52 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 18 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.7 %\n 1.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n WBC\n 1.8\n 1.6\n Hct\n 27.0\n 28.7\n Plt\n 67\n 52\n Cr\n 0.7\n Glucose\n 94\n Other labs: PT / PTT / INR:14.7/30.5/1.3, Ca++:7.4 mg/dL, Mg++:1.9\n mg/dL, PO4:1.8 mg/dL\n Fluid analysis / Other labs: ANC 560\n Microbiology: CSF: no org no PMN\n BAL no org no PMN\n Cultures pending\n Crypto Ag neg (serum and CSF)\n Flu pending\n Legionella neg\n CXR with RLL infiltrate interstitial\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All cx have thus far been negative\n RLL PNA: BAL pending\n Hx of TB adenitis, Bal pending\n Meningitis: LP unrevealing\n - Bronch done to eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n pending LP culture results info as well as vori, azithro, and flagyl\n (given poor dentition and location of infiltrate)\n Hypoxemia PNA in the RLL, with volume overload.\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: fluid responsive, seems likely due to sepsis and\n hypovolemia at this point. Will alternate b/w NS and LR to prevent\n hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n - Consider echo if hypotension persists despite fluid resuscitation.\n H/O TB lymphadenitis. \nt suspect reactivation now.\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition: neutropenic diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: boots\n Code status: Full code\n Disposition : ICU\n Total time spent: 40\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322510,
"text": ".H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n RLL consolidation on CXR. LS clear and dim at RL base. On O2 at 1L NC.\n RR easy and regural. Denies cough or sputum production. Possible flu.\n Action:\n Cont. on multiple IV and PO abx.\n Response:\n O2 sat 96-98% on 1L NC. Afebrile all shift. Denies SOB.\n Plan:\n Cont. current abx. Coverage and f/u cx. data. F/U cxr daily.\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322573,
"text": "Chief Complaint: Fever in immunocompromised host.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 yo woman with CLL, 1 month s/p chemo adm with febrile neutropenia,\n RLL infiltrate, hypotension, hypoxemia. Bronched on arrival to MICU.\n Continued fevers.\n 24 Hour Events:\n BLOOD CULTURED - At 01:08 AM\n FEVER - 101.2\nF - 10:00 PM\n No pericardial effusion.\n AFB neg smear.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Voriconazole - 10:00 PM\n Metronidazole - 02:00 AM\n Cefipime - 02:00 AM\n Acyclovir - 06:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.8\nC (98.3\n HR: 89 (88 - 111) bpm\n BP: 115/73(82) {86/42(55) - 117/73(82)} mmHg\n RR: 9 (9 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 2,307 mL\n 801 mL\n PO:\n 720 mL\n 370 mL\n TF:\n IVF:\n 1,587 mL\n 431 mL\n Blood products:\n Total out:\n 850 mL\n 350 mL\n Urine:\n 850 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,457 mL\n 451 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilat bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, eating\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): all, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 10.8 g/dL\n 61 K/uL\n 95 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 135 mEq/L\n 31.3 %\n 2.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n 11:04 PM\n WBC\n 1.8\n 1.6\n 1.5\n 2.6\n Hct\n 27.0\n 28.7\n 30.1\n 31.3\n Plt\n 67\n 52\n 51\n 61\n Cr\n 0.7\n 0.7\n 0.8\n Glucose\n 94\n 106\n 95\n Other labs: PT / PTT / INR:14.3/29.7/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:2.9 g/dL, Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:1.4 mg/dL\n Imaging: Echo: normal EF, mild PAH.\n Microbiology: Cx NGTD blood, CSF, resp viral cx\n Bronch: neg cx, no microorgs.\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n ICU Care\n Nutrition:\n Comments: PO diet but poor intake.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322299,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 year old woman history of CLL s/p 6 cycles of R-CVP for bulky LAD\n and splenomegaly and most recently 2 cycles of fludarabine, ritoxan and\n cytoxan (last dose 23 days prior to admission) who developed fever at\n home to 101.9 x 2 days. She took motrin for the fever. She denied any\n cough, headache, abdominal pain, diarrhea or dysuria at the time. She\n was hypotensive in the ED and responded to fluid boluses. She was\n initiated on Vanco/Cefe and admitted to BMT. She did well there but\n conituned to have fevers, yesterday she noted the development of HA and\n neck stiffness and there was a concern for meningitis however she was\n unable to be safely LP'd low Plts. Her coverage was expanded to\n meningitis doses. She currently says the HA has abated and there is no\n neck stiffness.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Vanco and Cefepime\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n ? TB adenitis (caseating granulomas on bx, + PPD, clx neg)\n Granuloma annulare\n non contrib\n Occupation: former cashier in , now home health aide\n Drugs: no\n Tobacco: 40 pack year, quit \n Alcohol: no\n Other: lives with husband, frequent travel to \n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, dry\n Gastrointestinal: No(t) Abdominal pain, Nausea\n Musculoskeletal: Myalgias\n Heme / Lymph: Lymphadenopathy\n Neurologic: Headache, mild\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 112 (112 - 114) bpm\n RR: 30 (30 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1 mL\n Respiratory\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness :\n bases), (Breath Sounds: Crackles : at the bases b/l, Diminished: bases\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51\n 27\n 0.7\n 12\n 19\n 107\n 4\n 134\n 1.9\n [image002.jpg]\n Other labs: PT / PTT / INR://1.3, Differential-Neuts:38.4, Band:0,\n LDH:281\n Fluid analysis / Other labs: Cortisol 21\n ABG: 61* 30* 7.42\n Imaging: CXR\n CT: (): interval development of RLL lesion when compared to\n previous findings on .\n Microbiology: Blood, legionella, urine Clx: neg\n Cryptococcal Ag: neg, NP asp neg\n UA: no bacteria, 1 WBC\n B glucan and GM: pending\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All clx have thus far been negative. There was a suggestion of a\n RLL process on the initial CT scan as well as continued diffuse\n lymphadenopathy. In addition to covering for bacterial and atypical\n pathogens from a respiratory standpoint it seems reasonable to at least\n consider the possibility of recurrent TB in the setting of her\n neutropenia. The RLL location would seem atypical for TB, however we\n need to further eval to rule it out. She seems clinically stable at\n this point to be able to tolerate a bronch with BAL. Also,\n consideration must be given to the possibility of meningitis given her\n fevers and symptoms (whther it be bacterial, viral or TB). It seems\n unlikely that TB is the\n - Plan for LP pending safe plts and INR\n - Plan for bronch to further eval RLL lesion: (PCP, , ,\n viral, bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n - Pan clx\n - Appreciate ID recs\n Hypoxemia: there may be an element of PNA in the RLL, however the\n recent evolution of changes seems more consistent with volume\n challenge. We will continue to closely monitor for now. If she\n continues to evolve a volume overloaded (or potentially picture)\n then she would be a good candidate for NIPPV\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: seems likely sepsis at this point (cortisol of note\n normal at 21 this AM) from an unclear source. We will continue to\n volume resus with boluses as needed. Goal UOP 0.5 cc/kg/hr. Will\n alternate b/w NS and LR to prevent hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n CLL: s/p recent treatment. Appreciate BMT recs.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition:\n Comments: NPO pending LP\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 95 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322300,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 year old woman history of CLL s/p 6 cycles of R-CVP for bulky LAD\n and splenomegaly and most recently 2 cycles of fludarabine, ritoxan and\n cytoxan (last dose 23 days prior to admission) who developed fever at\n home to 101.9 x 2 days. She took motrin for the fever. She denied any\n cough, headache, abdominal pain, diarrhea or dysuria at the time. She\n was hypotensive in the ED and responded to fluid boluses. She was\n initiated on Vanco/Cefe and admitted to BMT. She did well there but\n conituned to have fevers, yesterday she noted the development of HA and\n neck stiffness and there was a concern for meningitis however she was\n unable to be safely LP'd low Plts. Her coverage was expanded to\n meningitis doses. She currently says the HA has abated and there is no\n neck stiffness.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Vanco and Cefepime\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n ? TB adenitis (caseating granulomas on bx, + PPD, clx neg)\n Granuloma annulare\n non contrib\n Occupation: former cashier in , now home health aide\n Drugs: no\n Tobacco: 40 pack year, quit \n Alcohol: no\n Other: lives with husband, frequent travel to \n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, dry\n Gastrointestinal: No(t) Abdominal pain, Nausea\n Musculoskeletal: Myalgias\n Heme / Lymph: Lymphadenopathy\n Neurologic: Headache, mild\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 112 (112 - 114) bpm\n RR: 30 (30 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1 mL\n Respiratory\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness :\n bases), (Breath Sounds: Crackles : at the bases b/l, Diminished: bases\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51\n 27\n 0.7\n 12\n 19\n 107\n 4\n 134\n 1.9\n [image002.jpg]\n Other labs: PT / PTT / INR://1.3, Differential-Neuts:38.4, Band:0,\n LDH:281\n Fluid analysis / Other labs: Cortisol 21\n ABG: 61* 30* 7.42\n Imaging: CXR\n CT: (): interval development of RLL lesion when compared to\n previous findings on .\n Microbiology: Blood, legionella, urine Clx: neg\n Cryptococcal Ag: neg, NP asp neg\n UA: no bacteria, 1 WBC\n B glucan and GM: pending\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All clx have thus far been negative. There was a suggestion of a\n RLL process on the initial CT scan as well as continued diffuse\n lymphadenopathy. In addition to covering for bacterial and atypical\n pathogens from a respiratory standpoint it seems reasonable to at least\n consider the possibility of recurrent TB in the setting of her\n neutropenia. The RLL location would seem atypical for TB, however we\n need to further eval to rule it out. She seems clinically stable at\n this point to be able to tolerate a bronch with BAL. Also,\n consideration must be given to the possibility of meningitis given her\n fevers and symptoms (whether it be bacterial, viral or TB). It seems\n unlikely that TB is the source of her hypotension ( I would favor a\n super infection of some sort). Finally, it may be reasonable to\n consider a bx of one the axillary nodes if the above work up is\n unrevealing.\n - Plan for LP pending safe plts and INR\n - Plan for bronch to further eval RLL lesion: (PCP, , ,\n viral, bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n - Pan clx\n - Appreciate ID recs\n Hypoxemia: there may be an element of PNA in the RLL, however the\n recent evolution of changes seems more consistent with volume\n challenge. We will continue to closely monitor for now. If she\n continues to evolve a volume overloaded (or potentially picture)\n then she would be a good candidate for NIPPV\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: seems likely sepsis at this point (cortisol of note\n normal at 21 this AM) from an unclear source. We will continue to\n volume resus with boluses as needed. Goal UOP 0.5 cc/kg/hr. Will\n alternate b/w NS and LR to prevent hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n CLL: s/p recent treatment. Appreciate BMT recs.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition:\n Comments: NPO pending LP\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 95 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322301,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65 year old woman history of CLL s/p 6 cycles of R-CVP for bulky LAD\n and splenomegaly and most recently 2 cycles of fludarabine, ritoxan and\n cytoxan (last dose 23 days prior to admission) who developed fever at\n home to 101.9 x 2 days. She took motrin for the fever. She denied any\n cough, headache, abdominal pain, diarrhea or dysuria at the time. She\n was hypotensive in the ED and responded to fluid boluses. She was\n initiated on Vanco/Cefe and admitted to BMT. She did well there but\n conituned to have fevers, yesterday she noted the development of HA and\n neck stiffness and there was a concern for meningitis however she was\n unable to be safely LP'd low Plts. Her coverage was expanded to\n meningitis doses. She currently says the HA has abated and there is no\n neck stiffness.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Vanco and Cefepime\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n ? TB adenitis (caseating granulomas on bx, + PPD, clx neg)\n Granuloma annulare\n non contrib\n Occupation: former cashier in , now home health aide\n Drugs: no\n Tobacco: 40 pack year, quit \n Alcohol: no\n Other: lives with husband, frequent travel to \n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, dry\n Gastrointestinal: No(t) Abdominal pain, Nausea\n Musculoskeletal: Myalgias\n Heme / Lymph: Lymphadenopathy\n Neurologic: Headache, mild\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 112 (112 - 114) bpm\n RR: 30 (30 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1 mL\n Respiratory\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness :\n bases), (Breath Sounds: Crackles : at the bases b/l, Diminished: bases\n bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51\n 27\n 0.7\n 12\n 19\n 107\n 4\n 134\n 1.9\n [image002.jpg]\n Other labs: PT / PTT / INR://1.3, Differential-Neuts:38.4, Band:0,\n LDH:281\n Fluid analysis / Other labs: Cortisol 21\n ABG: 61* 30* 7.42\n Imaging: CXR : increasing RLL and RML process with some component\n of increasing interstitial volume present as well over the series of\n films from to the film.\n CT: (): interval development of RLL lesion when compared to\n previous findings on .\n Microbiology: Blood, legionella, urine Clx: neg\n Cryptococcal Ag: neg, NP asp neg\n UA: no bacteria, 1 WBC\n B glucan and GM: pending\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All clx have thus far been negative. There was a suggestion of a\n RLL process on the initial CT scan as well as continued diffuse\n lymphadenopathy. In addition to covering for bacterial and atypical\n pathogens from a respiratory standpoint it seems reasonable to at least\n consider the possibility of recurrent TB in the setting of her\n neutropenia. The RLL location would seem atypical for TB, however we\n need to further eval to rule it out. She seems clinically stable at\n this point to be able to tolerate a bronch with BAL. Also,\n consideration must be given to the possibility of meningitis given her\n fevers and symptoms (whether it be bacterial, viral or TB). It seems\n unlikely that TB is the source of her hypotension ( I would favor a\n super infection of some sort). Finally, it may be reasonable to\n consider a bx of one the axillary nodes if the above work up is\n unrevealing.\n - Plan for LP pending safe plts and INR\n - Plan for bronch to further eval RLL lesion: (PCP, , ,\n viral, bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n - Pan clx\n - Appreciate ID recs\n Hypoxemia: there may be an element of PNA in the RLL, however the\n recent evolution of changes seems more consistent with volume\n challenge. We will continue to closely monitor for now. If she\n continues to evolve a volume overloaded (or potentially picture)\n then she would be a good candidate for NIPPV\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: seems likely sepsis at this point (cortisol of note\n normal at 21 this AM) from an unclear source. We will continue to\n volume resus with boluses as needed. Goal UOP 0.5 cc/kg/hr. Will\n alternate b/w NS and LR to prevent hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n CLL: s/p recent treatment. Appreciate BMT recs.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition:\n Comments: NPO pending LP\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 95 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322304,
"text": "TITLE: PGY2 Admission Note\n Chief Complaint: fever, hypotension, hypoxia\n HPI:\n Mrs. is a 65 year old woman well history of CLL s/p 6 cycles\n of R-CVP for bulky LAD and splenomegaly and most recently 2 cycles of\n fludarabine, ritoxan and cytoxan (last dose 23 days prior to admission\n ) who developed fever at home to 101.9 x 2 days. She took motrin\n for the fever. She denied any cough, headache, abdominal pain, diarrhea\n or dysuria at the time. She was referred to the ED for further work up.\n .\n She presented on . In the ED she had a temp to 100.1, was\n slightly hypotensive to 89/47 HR 98 and received 1L NS, Cefepime and\n Vancomycin. She improved hemodynamically and was admitted to the floor.\n She underwent CT C/A/P which revealed unchanged lymphadenopathy and\n splenomegaly, as well as a possible RLL pneumonia. She was placed in\n respiratory isolation. Since admission she has developed a frontal\n headache which radiates to her neck. She endorses neck pain and\n stiffness but denies photophobia. The neck pain fluctuated over the\n hospital course. She attributes the neck pain to laying in the hospital\n bed. She has had a fever every day during the hospital course. Her\n presenting ANC was 600 which has increased to 760. ID was consulted\n for assistance in diagnosis. Pan-culture was recommended (blood,\n urine, sputum, for bacteria. An LP was planned for after\n transfusing her platelets.\n .\n On the morning of the ICU transfer her blood pressure on routine check\n prior to planned platelet transfusion was found to be 80/60. The\n platelets were then started. She was bolused fluid (2L and 2 bags of\n platelets) with improvement in her blood pressure to 105/70. An ABG\n was 7.42/30/61 on RA. Following that her respiratory rate was gradually\n rising during the IVF. Her O2sats were ~87-94% on 2L which improved to\n >97% on 8L facemask.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Meds:\n Bactrim SS daily\n allopurinol 300 mg daily\n ativan 0.5-1mg q4-6prn\n Hydrochlorothiazide 12.5 mg daily\n levothyroxine 150 mcg (8 pills per week)\n diflucan 200 mg daily\n acyclovir 400 mg TID\n .\n Meds prior to Transfer:\n Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing\n Levothyroxine Sodium 150 mcg PO DAILY\n Lorazepam 0.5-1 mg PO Q6H:PRN\n Magnesium Sulfate Replacement (Oncology) IV Sliding Scale Order\n MetRONIDAZOLE (FLagyl) 500 mg PO TID\n Acyclovir 400 mg PO Q8H\n Ondansetron 4 mg IV Q8H:PRN nausea\n Potassium Chloride Replacement (Oncology) PO Sliding Scale Order\n Prochlorperazine 10 mg PO Q6H:PRN nausea\n Allopurinol 300 mg PO DAILY\n Azithromycin 500 mg PO Q24H Duration: 1 Doses\n Sulfameth/Trimethoprim SS 1 TAB PO DAILY\n Calcium Replacement (Oncology) IV Sliding Scale\n Vancomycin 1000 mg IV Q 12H\n CefePIME 2 g IV Q8H\n Voriconazole 400 mg IV Q12H\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n ? TB adenitis - necrotizing R supra-clav LN , +PPD s/p 6 months\n of 4 drug therapy but stopped prior to completing recommended 9months\n Granuloma annulare on skin biopsy\n NC\n Occupation: retired physician from \n Drugs: none\n Tobacco: quit after 35 years\n Alcohol: none\n Other: Lives with husband and daughter and 20 year old grandson.\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:00 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 110 () bpm\n BP: 125/60\n SpO2: 97\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Venti mask\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), LLSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : , Wheezes : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, CN II-XII intact. upper and lower extremity\n strength intact\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na 134 K 107 BUN 12 Gluc 121 AGap=12\n K 4.0 Cl 19 Cr 0.7\n Ca: 7.6 Mg: 2.1 P: 2.4\n ALT: 13 AP: 83 Tbili: 0.5 Alb: 2.9\n AST: 27 LDH: 281 UricA:3.6\n Cortsol: 21.0\n WBC 1.9 Hb 9.6 Hct 26.8 Plt 51 MCV 89\n N:38.4 Band:0 L:57.9 M:2.6 E:0.7 Bas:0.4\n Hypochr: 1+ Anisocy: 3+ Poiklo: 1+ Ovalocy: 1+ Schisto: 1+\n ANC: 740\n PT: 14.4 PTT: 30.8 INR: 1.3\n .\n UA <1red 1 WBC 0 epi\n Imaging: CXR - Prominence of the hilar and mediastinal contours\n consistent with underlying lymphadenopathy is again identified and\n appears stable. No focal pulmonary opacities are identified to indicate\n pneumonia. Linear scarring within the right perihilar region is\n unchanged.\n .\n / CT c/a/p - 1. No significant interval change in nodal size and\n massive splenomegaly.\n 2. Increasing opacification in the right lower lobe may have an\n infectious etiology.\n .\n CT head - There is no evidence of hemorrhage, edema, mass effect,\n hydrocephalus, or infarction. The visualized paranasal sinuses and\n mastoid air cells are clear. The soft tissues are unremarkable. As\n described in more detail on prior CT of the neck, several small and\n borderline posterior cervical lymph nodes are noted; however,\n incompletely assessed.\n .\n CXR - In comparison with the study of , there is some increased\n opacification at the right base that is consistent with the area of\n consolidation seen on the CT scan of .\n .\n CXR - pending\n Microbiology: Micro:\n Bld Cx - NGTD\n Urine: legionella Ag neg, crytpococcal Ag neg\n CMV viral load < assay\n Respiratory viruses: not done\n ECG: sinus tach. otherwise unchanged from priors\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia.\n .\n 1) Hypoxia: likely related to underlying CAP now acutely exacerbated by\n fluid resusitation. pathogen differential still broad given immune\n status. more likely typical pathogen given focality to infiltrate.\n however atypical, viral possible as well. less likely fungal.\n - repeat viral screen\n - check BNP\n - sputum culture\n - f/u glucan/galactomannan\n - f/u BAL results\n - ID recs\n - abx: vanc/cefepime/vori (empiric CAP in febrile neutropenic),\n azithromycin, flagyl (oral anaerobes)\n .\n 2) Hypotension: likely related to sepsis from unclear source. no\n evidence of blood loss or ischemic cause. pericardial effusion with\n tamponade is possible given hx of TB but would be unlikely. currently\n lactate normal and normal mentation to perfusion adequate.\n - consider TTE to eval for effusion given hx of TB\n - bolus IVF for decreased UOP\n .\n 3) Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. currently without other significant\n constitutional symptoms that had featured prominently before. would\n expect low probability for pulmonary TB.\n - continue airborne precautions for now pending AFB from bronch\n - ID recs\n .\n 4) Neck pain: patient developed pain and soreness after being in the\n hospital w/o other sign of meningitis except for fever. would have low\n probability for meningitis but given immune suppressed status it would\n be difficult to entirely exclude. alternatively could be benign muscle\n ache.\n - LP as already had platelet prep\n - cefepime adequated for empiric coverage for now\n .\n 5) CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - follow\n - continue prophy: bactrim and acyclovir\n .\n 6) Hypothyroidism: continue current dose\n .\n ICU Care\n Nutrition: neutropenic diet\n Glycemic Control: adequate\n Lines: 2PIV\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: eating\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322292,
"text": "TITLE:\n Chief Complaint: fever, hypotension, hypoxia\n HPI:\n Mrs. is a 65 year old woman well history of CLL s/p 6 cycles\n of R-CVP for bulky LAD and splenomegaly and most recently 2 cycles of\n fludarabine, ritoxan and cytoxan (last dose 23 days prior to admission\n ) who developed fever at home to 101.9 x 2 days. She took motrin\n for the fever. She denied any cough, headache, abdominal pain, diarrhea\n or dysuria at the time. She was referred to the ED for further work up.\n .\n She presented on . In the ED she had a temp to 100.1, was\n slightly hypotensive to 89/47 HR 98 and received 1L NS, Cefepime and\n Vancomycin. She improved hemodynamically and was admitted to the floor.\n She underwent CT C/A/P which revealed unchanged lymphadenopathy and\n splenomegaly, as well as a possible RLL pneumonia. She was placed in\n respiratory isolation. Since admission she has developed a frontal\n headache which radiates to her neck. She endorses neck pain and\n stiffness but denies photophobia. The neck pain fluctuated over the\n hospital course. She attributes the neck pain to laying in the hospital\n bed. She has had a fever every day during the hospital course. Her\n presenting ANC was 600 which has increased to 760. ID was consulted\n for assistance in diagnosis. Pan-culture was recommended (blood,\n urine, sputum, for bacteria. An LP was planned for after\n transfusing her platelets.\n .\n On the morning of the ICU transfer her blood pressure on routine check\n prior to planned platelet transfusion was found to be 80/60. The\n platelets were then started. She was bolused fluid (2L and 2 bags of\n platelets) with improvement in her blood pressure to 105/70. An ABG\n was 7.42/30/61 on RA. Following that her respiratory rate was gradually\n rising during the IVF. Her O2sats were ~87-94% on 2L which improved to\n >97% on 8L facemask.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n CLL dx , diffuse LAD,\n - 2 cycles R-CVP\n - 2 cycles fludarabine, cytoxan and rituxan\n Hypothyroidism\n Osteoarthritis\n ? TB adenitis - necrotizing R supra-clav LN , +PPD s/p 6 months\n of 4 drug therapy but stopped prior to completing recommended 9months\n Granuloma annulare on skin biopsy\n NC\n Occupation: retired physician from \n Drugs: none\n Tobacco: quit after 35 years\n Alcohol: none\n Other: Lives with husband and daughter and 20 year old grandson.\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:00 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 110 () bpm\n BP: 125/60\n SpO2: 97\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Venti mask\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), LLSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : , Wheezes : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, CN II-XII intact. upper and lower extremity\n strength intact\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na 134 K 107 BUN 12 Gluc 121 AGap=12\n K 4.0 Cl 19 Cr 0.7\n Ca: 7.6 Mg: 2.1 P: 2.4\n ALT: 13 AP: 83 Tbili: 0.5 Alb: 2.9\n AST: 27 LDH: 281 UricA:3.6\n Cortsol: 21.0\n WBC 1.9 Hb 9.6 Hct 26.8 Plt 51 MCV 89\n N:38.4 Band:0 L:57.9 M:2.6 E:0.7 Bas:0.4\n Hypochr: 1+ Anisocy: 3+ Poiklo: 1+ Ovalocy: 1+ Schisto: 1+\n ANC: 740\n PT: 14.4 PTT: 30.8 INR: 1.3\n .\n UA <1red 1 WBC 0 epi\n Imaging: CXR - Prominence of the hilar and mediastinal contours\n consistent with underlying lymphadenopathy is again identified and\n appears stable. No focal pulmonary opacities are identified to indicate\n pneumonia. Linear scarring within the right perihilar region is\n unchanged.\n .\n / CT c/a/p - 1. No significant interval change in nodal size and\n massive splenomegaly.\n 2. Increasing opacification in the right lower lobe may have an\n infectious etiology.\n .\n CT head - There is no evidence of hemorrhage, edema, mass effect,\n hydrocephalus, or infarction. The visualized paranasal sinuses and\n mastoid air cells are clear. The soft tissues are unremarkable. As\n described in more detail on prior CT of the neck, several small and\n borderline posterior cervical lymph nodes are noted; however,\n incompletely assessed.\n .\n CXR - In comparison with the study of , there is some increased\n opacification at the right base that is consistent with the area of\n consolidation seen on the CT scan of .\n .\n CXR - pending\n Microbiology: Micro:\n Bld Cx - NGTD\n Urine: legionella Ag neg, crytpococcal Ag neg\n CMV viral load < assay\n Respiratory viruses: not done\n ECG: sinus tach. otherwise unchanged from priors\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia.\n .\n 1) Hypoxia: likely related to underlying CAP now acutely exacerbated by\n fluid resusitation. pathogen differential still broad given immune\n status. more likely typical pathogen given focality to infiltrate.\n however atypical, viral possible as well. less likely fungal.\n - repeat viral screen\n - check BNP\n - sputum culture\n - f/u glucan/galactomannan\n - could consider bronch later\n - ID recs\n - abx: vanc/cefepime/vori (empiric CAP in febrile neutropenic),\n azithromycin, flagyl (oral anaerobes)\n .\n 2) Hypotension: likely related to sepsis from unclear source. no\n evidence of blood loss or ischemic cause. pericardial effusion with\n tamponade is possible given hx of TB but would be unlikely. currently\n lactate normal and normal mentation to perfusion adequate.\n - TTE to eval for effusion given hx of TB\n - bolus IVF for decreased UOP\n .\n 3) Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. currently without other significant\n constitutional symptoms that had featured prominently before. would\n expect low probability for pulmonary TB.\n - continue airborne precautions for now\n - ID recs\n .\n 4) Neck pain: patient developed pain and soreness after being in the\n hospital w/o other sign of meningitis except for fever. would have low\n probability for meningitis but given immune suppressed status it would\n be difficult to entirely exclude. alternatively could be benign muscle\n ache.\n - LP as already had platelet prep\n - cefepime adequated for empiric coverage for now\n .\n 5) CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - follow\n - continue prophy: bactrim and acyclovir\n .\n 6) Hypothyroidism: continue current dose\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322421,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, lungs cont dyspnea\n with tachypneic and wheezing o2 sats remain >96% resp rate ?28, she is\n neutrapenic wbc 1.6 \n Action:\n Awaiting cx results, tx with antibx broad spectrum\n Response:\n Pt denies sob\n Plan:\n Monitor closely, check wbc, temp, cont antibx await cx results\n .H/O pulmonary edema\n Assessment:\n Stable cxr shows no pulm edema\n Action:\n Given fluid slowly and monitored closely\n Response:\n stable\n Plan:\n Continue to monitor closely, follow o2 sats\n .H/O tobacco use, prior\n Assessment:\n Wheezing unclear if copd vs cardiac\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n Continue to monitor and treat\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache\n Action:\n Given percocet\n Response:\n Tolerates meds, able to sleep after percocet without pain\n Plan:\n Continue to assess and treat\n .\n .H/O tuberculosis\n Assessment:\n On droplet precautions, tests pnding\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322422,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, lungs cont dyspnea\n with tachypneic and wheezing o2 sats remain >96% resp rate ?28, she is\n neutrapenic wbc 1.6 \n Action:\n Awaiting cx results, tx with antibx broad spectrum\n Response:\n Pt denies sob\n Plan:\n Monitor closely, check wbc, temp, cont antibx await cx results\n .H/O pulmonary edema\n Assessment:\n Stable cxr shows no pulm edema\n Action:\n Given fluid slowly and monitored closely\n Response:\n stable\n Plan:\n Continue to monitor closely, follow o2 sats\n .H/O tobacco use, prior\n Assessment:\n Wheezing unclear if copd vs cardiac\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n Continue to monitor and treat\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache\n Action:\n Given percocet\n Response:\n Tolerates meds, able to sleep after percocet without pain\n Plan:\n Continue to assess and treat\n .\n .H/O tuberculosis\n Assessment:\n On droplet precautions, tests pnding\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322423,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, lungs cont dyspnea\n with tachypneic and wheezing o2 sats remain >96% resp rate ?28, she is\n neutrapenic wbc 1.6 \n Action:\n Awaiting cx results, tx with antibx broad spectrum\n Response:\n Pt denies sob\n Plan:\n Monitor closely, check wbc, temp, cont antibx await cx results\n .H/O pulmonary edema\n Assessment:\n Stable cxr shows no pulm edema\n Action:\n Given fluid slowly and monitored closely\n Response:\n stable\n Plan:\n Continue to monitor closely, follow o2 sats\n .H/O tobacco use, prior\n Assessment:\n Wheezing unclear if copd vs cardiac\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n Continue to monitor and treat\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache\n Action:\n Given percocet\n Response:\n Tolerates meds, able to sleep after percocet without pain\n Plan:\n Continue to assess and treat\n .\n .H/O tuberculosis\n Assessment:\n On droplet precautions, tests pnding\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322424,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema.\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Temp high of 101.9 on pan cx results pnding, lungs cont dyspnea\n with tachypneic and wheezing o2 sats remain >96% resp rate ?28, she is\n neutrapenic wbc 1.6 \n Action:\n Awaiting cx results, tx with antibx broad spectrum\n Response:\n Pt denies sob\n Plan:\n Monitor closely, check wbc, temp, cont antibx await cx results\n .H/O pulmonary edema\n Assessment:\n Stable cxr shows no pulm edema\n Action:\n Given fluid slowly and monitored closely\n Response:\n stable\n Plan:\n Continue to monitor closely, follow o2 sats\n .H/O tobacco use, prior\n Assessment:\n Wheezing unclear if copd vs cardiac\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n c/o nausea off and on, tx include zofran and lorazapam with good effect\n Action:\n Zofran and lorazapan\n Response:\n Plan:\n Continue to monitor and treat\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o headache\n Action:\n Given percocet\n Response:\n Tolerates meds, able to sleep after percocet without pain\n Plan:\n Continue to assess and treat\n .\n .H/O tuberculosis\n Assessment:\n On droplet precautions, tests pnding\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322430,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked temp to 102 at 2300\n Action:\n Received 650 mg Tylenol and 325 mg one hour later per HO, pt is also\n receiving percocets PRN for persistant headache, blood cultures sent,\n ordered for urine culture pt voids, placed on cooling blanket\n Response:\n Pt\ns temp 99.5 at 0230, cooling blanket off\n Plan:\n Continue to monitor temps, f/u blood cultures, obtain urine culture\n when available\n Tachycardia, Other\n Assessment:\n obtained pt with HR in the 120s, reporting RN pt becomes\n tachycardic with activity and when\nabout to spike a fever,\n checked\n temp 102 as noted above\n Action:\n In addition to treating temp pt received 2 250 cc fluid boluses,\n obtained EKG per HO pt in ST\n Response:\n HR low 100s\n Plan:\n Continue to monitor HR, pt consistently in the high 90s low 100s\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322419,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with fever\n and hypotension was admitted to the floor and placed on IV antibiotics.\n CT of chest showed RLL pna. She was placed on isolation precautions b/o\n c/o stiff neck and frontal headache. She had LP done which was neg. She\n remained on droplet precautions because she she had a + PPD in past\n but only took 6months vs 9months of therapy. She was admitted to ICU\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tobacco use, prior\n Assessment:\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322420,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with fever\n and hypotension was admitted to the floor and placed on IV antibiotics.\n CT of chest showed RLL pna. She was placed on isolation precautions b/o\n c/o stiff neck and frontal headache. She had LP done which was neg. She\n remained on droplet precautions because she she had a + PPD in past\n but only took 6months vs 9months of therapy. She was admitted to ICU\n after a routine check bp 80/60 she was given 2liters NS and sob po2 61\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tobacco use, prior\n Assessment:\n Action:\n Response:\n Plan:\n .H/O nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322413,
"text": " MD notes/orders, metavision data\n Neuro: Alert and oriented x 3, mae, follows commands consistently,\n communicates appropriately.\n CV: Initially ST/no ectopy with sbp 83-88 with good response to IVF\n bolus 1000cc. Currently SR 95, bp 98/59.\n Pulm: Lungs clear with resolved rales at right base, tubular breath\n sounds rul. CXR consistent with RLL pneumonia.\n AP/ films this afternoon for concern over widened\n mediastinum. 02 sat 95-98%, respiratory effort unlabored.\n GU: Voiding on bed pan, 200cc this shift, clear amber\n GI: Abd obese, bs present. Pt states last bm yesterday. PO intake poor,\n pt states she has no appetite, treated x2 for nausea and one episode\n emesis. Per daughter appetite is fair/poor at baseline and she has\n taken in very little since hospitalization Tuesday. Several bites\n cereal and\n bottle ensure taken this shift with 200cc emesis. Pt\n appears dehydrated, lips/mm dry. 1L ns infusing at present.\n Endo: finger stick glucose <200\n Skin: Pale, frequently moist, surfaces grossly intact with strong\n peripheral pulses and no edema. IV sites wnl with some tenderness with\n abx infusion. Afebrile this shift, culture data pending, continues on\n abx coverage per .\n Soc: Daughter at bedside.\n P: Follow hemodynamics, continue fluid resuscitation for hypotension,\n observe for dyspnea, adventitious breath sounds or drop in 02 sats.\n Prn zofran, notify team of unresolved n/v, consider nutrition consult /\n calorie count. Echo Monday,. Possible transfer out of ICU in am. Keep\n family up to date on poc, validate feelings/concerns.\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322530,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt with temp spike 101.2 ax at 22\n Action:\n Received 650 mg Tylenol, blood cultures sent\n Response:\n Temp trending down following Tylenol adm, 98.6 at 02\n Plan:\n Continue to monitor temp prn Tylenol, f/u blood cultures\n Hypoxemia\n Assessment:\n pt on NC 1-2L, breath sounds clear/dim in , pt has pneumonia,\n being r/o for TB and flu\n Action:\n Maintaining droplet and airborn precautions\n Response:\n Prelim TB results negative, awaiting final smear, ruled out for flu\n from bronch results\n Plan:\n Continue to monitor resp status, continue to maintain airborn\n precautions pending smear results\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322358,
"text": ".H/O nausea / vomiting\n Assessment:\n c/o of nausea unsure if related to her headache or medication, +/-lack\n of sleep\n Action:\n Given zofran 4mg po and percocet for headache, LP done on days\n Response:\n Nausea and pain controlled\n Plan:\n Allow uninterrupted sleep time, medicate with ativan /zofran/compazine\n prn, await LP results\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o of headache as above\n Action:\n Tx with percocet\n Response:\n No pain\n Plan:\n Medicate prn for pain\n hypoxia\n Assessment:\n On 3l np . No c/o sob resp rate in 30\ns even when sleeping lungs clear\n crackles bases dyspneic wheezing with exertion, o2 sat >96%, cxr \n pulmonary edema, rll pna\n Action:\n Vanco/cefedime/voriconazole\n Response:\n Febrile 101.9, o2 sats improved, resp rate still >30\n Plan:\n Cont antibx, await cx results, obtain new cx bld and urine,\n sputum for afb results, maintain droplet precautions until r/o,\n monitor temp, cxr, ?lasix, using Albuterol neb, when able get patient\n oob to chair\n Hypotension (not Shock)\n Assessment:\n Bp mean >56 when asleep\n Action:\n Continue to monitor, pt has been npo drank ice water o/n, IVF 10cc q hr\n Response:\n Patient appears dry continues with crackles in RLL possibly related to\n PN vs PULM EDEMA\n Plan:\n ? cxr this am, ? starting diet +/or increasing ivf slightly\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n Await results of afb, maintain droplet precautions\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322457,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked temp to 102 at 2300\n Action:\n Received 650 mg Tylenol and 325 mg one hour later per HO, pt is also\n receiving percocets PRN for persistent headache, blood cultures sent,\n ordered for urine culture pt voids, placed on cooling blanket\n Response:\n Current temp 97.2, cooling blanket off since 0230\n Plan:\n Continue to monitor temps, f/u blood cultures, obtain urine culture\n when available\n Tachycardia, Other\n Assessment:\n obtained pt with HR in the 120s, reporting RN pt becomes\n tachycardic with activity and when\nabout to spike a fever,\n checked\n temp 102 as noted above\n Action:\n In addition to treating temp pt received 2 250 cc fluid boluses,\n obtained EKG per HO pt in ST\n Response:\n HR low 100s\n Plan:\n Continue to monitor HR, pt consistently in the high 90s low 100s\n Headache\n Assessment:\n Pt with persistent h/a, rated at times\n Action:\n Able to sleep through the night with Tylenol received, reporting pain\n high at 0630, received percocet\n Response:\n unknown\n Plan:\n Continue to monitor pain control, pt was being r/o for meningitis\n appears to be negative from preliminary results of LP, percocets with\n good effect, monitor acetaminophen intake closely\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322461,
"text": "Chief Complaint:\n 24 Hour Events:\n - Repeat PA/Lat ordered as per radiology to best assess increase in\n size of mediastinum showed no change in widening as from prior PA/Lat\n - ID rec adding on cytology to LP and continuing broad coverage with\n vanc/flagyl/vori, and acyclovir/bactrim ppx\n - Micro: AFB prelim smear neg, but per micro lab, cannot dc precautions\n until concentrated smear completed on Monday\n - T 102 axillary at MN, given 1gm tylenol, bcx and ucx sent, cooled\n with icepacks/cooling blanket, 250cc NS bolus x3, ECG unchanged (sinus\n tach), lactate 1.0\n - Influenza DFA reordered as priors had been cancelled (x2)\n - T 102 axillary at MN with tachycardia to 120s, given 1gm tylenol, bcx\n and ucx sent, cooled with cooling blanket, 250cc NS bolus x2, ECG\n unchanged (sinus tach), lactate 1.0, tachycardia resolved with\n defervescence\n - Influenza DFA reordered as priors had been cancelled (x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:39 PM\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.2\n HR: 104 (87 - 126) bpm\n BP: 111/58(70) {83/46(59) - 118/68(80)} mmHg\n RR: 15 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,015 mL\n PO:\n 830 mL\n 300 mL\n TF:\n IVF:\n 3,320 mL\n 715 mL\n Blood products:\n Total out:\n 1,525 mL\n 0 mL\n Urine:\n 1,325 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51 K/uL\n 10.6 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Imaging: Prelim read on PA/Lat: no increased mediastinal widening\n Microbiology: Bcx x2 and : NGTD\n BAL : No AFB on prelim smear, AF cx pending, no legionella isolated\n on prelim, PCP pending, viral cx cancelled, DFA for influenza cancelled\n RSV screen cancelled due to lack of cells\n CSF cx: NGTD, gram stain neg\n Bcx x4 : NGTD\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia.\n #Febrile neutropenia. Most likely source PNA given absence of other\n localizing findings besides new RLL lobar infiltrate. So far no\n informative culture or gram stain data. Pt has history of partially\n treated extrapulmonary TB, lobar appearance of CXR not really\n suggestive of reactivated TB.\n -cover broadly for neutropenic CAP with vanc/cefepime/azithromycin with\n flagyl for anaerobes, voriconazole for funal coverage. Peel back\n coverage if no GPCs on sputum from BAL.\n -follow up all cultures, call micro lab to ensure AFB smear for r/o TB\n being processed.\n -Tylenol prn fevers\n -continue neutropenic and negative pressure respiratory isolation for\n r/o TB.\n #Hypoxia: likely related to underlying CAP now acutely exacerbated by\n fluid resusitation. Has resolved overnight, satting well on 2L NC. CXR\n appears less fluid overloaded today. Pulmonary edema likely from\n aggressive fluid rescusitation. No history of heart failure.\n -TTE on Monday\n -Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: likely related to sepsis from unclear source. no\n evidence of blood loss or ischemic cause. pericardial effusion with\n tamponade is possible given hx of TB but would be unlikely. currently\n lactate normal and normal mentation to perfusion adequate.\n - TTE as above\n - bolus IVF for decreased UOP, tachycardia or hypotension. Responded\n very well to 1L NS this am. Would use LR in future as is becoming\n hyperchloremic.\n 3) Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. currently without other significant\n constitutional symptoms that had featured prominently before. would\n expect low probability for pulmonary TB.\n - continue airborne precautions for now pending AFB from bronch\n - ID recs\n -azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n 4) Neck pain: patient developed pain and soreness after being in the\n hospital w/o other sign of meningitis except for fever. would have low\n probability for meningitis but given immune suppressed status it would\n be difficult to entirely exclude. alternatively could be benign muscle\n ache. LP yesterday, normal, no evidence of meningitis.\n - Reduce cevepime from meningitis to PNA doses.\n - tylenol, percocet prn pain.\n 5) CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - follow\n - continue prophy: bactrim and acyclovir\n 6) Hypothyroidism: continue current dose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322463,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n - Repeat PA/Lat ordered as per radiology to best assess increase in\n size of mediastinum showed no change in widening as from prior PA/Lat\n - ID rec adding on cytology to LP and continuing broad coverage with\n vanc/flagyl/vori, and acyclovir/bactrim ppx\n - Micro: AFB prelim smear neg, but per micro lab, cannot dc precautions\n until concentrated smear completed on Monday\n - T 102 axillary at MN, given 1gm tylenol, bcx and ucx sent, cooled\n with icepacks/cooling blanket, 250cc NS bolus x3, ECG unchanged (sinus\n tach), lactate 1.0\n - Influenza DFA reordered as priors had been cancelled (x2)\n - T 102 axillary at MN with tachycardia to 120s, given 1gm tylenol, bcx\n and ucx sent, cooled with cooling blanket, 250cc NS bolus x2, ECG\n unchanged (sinus tach), lactate 1.0, tachycardia resolved with\n defervescence\n - Influenza DFA reordered as priors had been cancelled (x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:39 PM\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.2\n HR: 104 (87 - 126) bpm\n BP: 111/58(70) {83/46(59) - 118/68(80)} mmHg\n RR: 15 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,015 mL\n PO:\n 830 mL\n 300 mL\n TF:\n IVF:\n 3,320 mL\n 715 mL\n Blood products:\n Total out:\n 1,525 mL\n 0 mL\n Urine:\n 1,325 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases), clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: WWP\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51 K/uL\n 10.6 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Imaging: Prelim read on PA/Lat: no increased mediastinal widening\n Microbiology: Bcx x2 and : NGTD\n BAL : No AFB on prelim smear, AF cx pending, no legionella isolated\n on prelim, PCP pending, viral cx cancelled, DFA for influenza cancelled\n RSV screen cancelled due to lack of cells\n CSF cx: NGTD, gram stain neg\n Bcx x4 : NGTD\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia and\n continued fevers.\n # Febrile neutropenia. Most likely source PNA given absence of other\n localizing findings besides new RLL lobar infiltrate. So far no\n informative culture or gram stain data. Pt has history of partially\n treated extrapulmonary TB, lobar appearance of CXR not really\n suggestive of reactivated TB. Patient with continued fevers (102\n axillary) overnight.\n -Covering broadly for neutropenic CAP with vanc/cefepime/azithromycin\n with flagyl for anaerobes, voriconazole for funal coverage. Could\n consider peeling back coverage pending culture results, though would\n continue for now given persistent fevers and relative neutropenia\n -Follow up all cultures, AFB smears negative, but awaiting concentrated\n smear and cultures likely on Monday\n -Tylenol prn fevers, cooling blanket prn\n -Continue neutropenic and negative pressure respiratory isolation for\n r/o TB.\n - Re-ordered DFA for influenza as high on differential given broad abx\n coverage with continued fevers. Sample from BAL and prior nasal\n aspirate had been cancelled.\n # Hypoxia: Stable and resolving. Likely related to underlying CAP and\n acutely exacerbated by fluid resusitation. Has resolved. Patient was\n able to tolerate small fluid boluses during fevers with continued sats\n in the mid-high 90s on 2L NC.\n - Continue to follow CXR, has appeared less fluid overloaded.\n Pulmonary edema likely from aggressive fluid rescusitation. No history\n of heart failure.\n - Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: Stable. Likely related to sepsis from unclear source. No\n evidence of blood loss or ischemic cause. Patient also with some\n question of mediastinal widening on AP film as compared to PA/Lat. Per\n radiology, recommended repeat PA/Lat which showed no further widening\n and was not concerning for hematoma as no recent\n intervention/procedure. Pericardial effusion with tamponade is\n possible given hx of TB but not clinically likely. Lactate continues\n to be normal (1.0 this am) and normal mentation so perfusion adequate.\n - Can consider TTE on Monday as not able to get one on the weekend.\n - Bolus IVF for decreased UOP, tachycardia or hypotension as has\n responded well, though would be careful given hypoxia and pulmonary\n edema. Would alternate NS and LR given hyperchloremia.\n # Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. Currently without other significant\n constitutional symptoms that had featured prominently before. Would\n expect low probability for pulmonary TB.\n - Continue airborne precautions for now pending AFB concentrated smear\n from bronch on Monday\n - ID recs\n -Azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n # Neck pain: Resolved. Patient developed pain and soreness after being\n in the hospital w/o other sign of meningitis except for fever. LP\n without evidence of meningitis. Likely benign muscle ache/spasm.\n - Reduced cevepime from meningitis to PNA doses.\n - Tylenol, percocet prn pain.\n # CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - Continue prophy: bactrim and acyclovir\n # Hypothyroidism: Continue current dose levothyroxine\n ICU Care\n Nutrition:\n Glycemic Control: adequate\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: eating\n VAP: on abx/not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: can consider call out to BMT if stable\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322370,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 04:00 PM\n CSF CULTURE - At 04:30 PM\n FEVER - 101.9\nF - 06:00 AM\n -got for ? reactivation TB\n -got LP for ? PNA, no WBC, cefepime decreased to non-meningitis doses.\n -Febrile to 101.2 this am, re-cultured blood and urine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 PM\n Metronidazole - 02:10 AM\n Cefipime - 03:10 AM\n Voriconazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:07 PM\n Midazolam (Versed) - 04:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.8\nC (101.9\n HR: 129 (98 - 129) bpm\n BP: 117/53(66) {78/41(52) - 127/76(84)} mmHg\n RR: 27 (17 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 540 mL\n 1,183 mL\n PO:\n 50 mL\n 480 mL\n TF:\n IVF:\n 490 mL\n 703 mL\n Blood products:\n Total out:\n 200 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 340 mL\n 583 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 52 K/uL\n 9.9 g/dL\n 28.7 %\n 1.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n WBC\n 1.8\n 1.6\n Hct\n 27.0\n 28.7\n Plt\n 67\n 52\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322371,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n BRONCHOSCOPY - At 04:00 PM\n CSF CULTURE - At 04:30 PM\n FEVER - 101.9\nF - 06:00 AM\n -got for ? reactivation TB\n -got LP for ? PNA, no WBC, cefepime decreased to non-meningitis doses.\n -Febrile to 101.2 this am, re-cultured blood and urine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 PM\n Metronidazole - 02:10 AM\n Cefipime - 03:10 AM\n Voriconazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:07 PM\n Midazolam (Versed) - 04:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.8\nC (101.9\n HR: 129 (98 - 129) bpm\n BP: 117/53(66) {78/41(52) - 127/76(84)} mmHg\n RR: 27 (17 - 36) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 540 mL\n 1,183 mL\n PO:\n 50 mL\n 480 mL\n TF:\n IVF:\n 490 mL\n 703 mL\n Blood products:\n Total out:\n 200 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 340 mL\n 583 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Sclera edema\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), LLSB\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : , Wheezes : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, CN II-XII intact. upper and lower extremity\n strength intact\n Labs / Radiology\n 52 K/uL\n 9.9 g/dL\n 28.7 %\n 1.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n WBC\n 1.8\n 1.6\n Hct\n 27.0\n 28.7\n Plt\n 67\n 52\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia.\n .\n 1) Hypoxia: likely related to underlying CAP now acutely exacerbated by\n fluid resusitation. pathogen differential still broad given immune\n status. more likely typical pathogen given focality to infiltrate.\n however atypical, viral possible as well. less likely fungal.\n - repeat viral screen\n - check BNP\n - sputum culture\n - f/u glucan/galactomannan\n - f/u BAL results\n - ID recs\n - abx: vanc/cefepime/vori (empiric CAP in febrile neutropenic),\n azithromycin, flagyl (oral anaerobes)\n .\n 2) Hypotension: likely related to sepsis from unclear source. no\n evidence of blood loss or ischemic cause. pericardial effusion with\n tamponade is possible given hx of TB but would be unlikely. currently\n lactate normal and normal mentation to perfusion adequate.\n - consider TTE to eval for effusion given hx of TB\n - bolus IVF for decreased UOP\n .\n 3) Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. currently without other significant\n constitutional symptoms that had featured prominently before. would\n expect low probability for pulmonary TB.\n - continue airborne precautions for now pending AFB from bronch\n - ID recs\n .\n 4) Neck pain: patient developed pain and soreness after being in the\n hospital w/o other sign of meningitis except for fever. would have low\n probability for meningitis but given immune suppressed status it would\n be difficult to entirely exclude. alternatively could be benign muscle\n ache.\n - LP as already had platelet prep\n - cefepime adequated for empiric coverage for now\n .\n 5) CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - follow\n - continue prophy: bactrim and acyclovir\n .\n 6) Hypothyroidism: continue current dose\n ICU Care\n Nutrition: neutropenic diet\n Glycemic Control: adqeuate\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: pneumaboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322373,
"text": "Chief Complaint: febrile neutropenia, sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 04:00 PM\n CSF CULTURE - At 04:30 PM\n FEVER - 101.9\nF - 06:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:45 PM\n Metronidazole - 02:10 AM\n Cefipime - 03:10 AM\n Voriconazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:07 PM\n Midazolam (Versed) - 04:07 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: Tachycardia\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Flowsheet Data as of 09:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 36.3\nC (97.4\n HR: 119 (98 - 129) bpm\n BP: 102/58(67) {78/41(52) - 127/76(84)} mmHg\n RR: 14 (14 - 36) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 540 mL\n 1,871 mL\n PO:\n 50 mL\n 530 mL\n TF:\n IVF:\n 490 mL\n 1,341 mL\n Blood products:\n Total out:\n 200 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 340 mL\n 1,271 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Gen: lying in bed, diaphoretic\n HEENT: dry oropharynx\n CV: tachy RRR\n Chest: coarse BS in right base, no wheezes\n Abd: soft nt\n Ext: 1+ edema\n Labs / Radiology\n 9.9 g/dL\n 52 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 18 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.7 %\n 1.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n WBC\n 1.8\n 1.6\n Hct\n 27.0\n 28.7\n Plt\n 67\n 52\n Cr\n 0.7\n Glucose\n 94\n Other labs: PT / PTT / INR:14.7/30.5/1.3, Ca++:7.4 mg/dL, Mg++:1.9\n mg/dL, PO4:1.8 mg/dL\n Fluid analysis / Other labs: ANC 560\n Microbiology: CSF: no org no PMN\n BAL no org no PMN\n Cultures pending\n Crypto Ag neg (serum and CSF)\n Flu pending\n Legionella neg\n CXR with RLL infiltrate interstitial\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic\n host. All cx have thus far been negative\n RLL PNA: BAL pending\n Hx of TB adenitis, Bal pending\n Meningitis: LP unrevealing\n - Bronch now to further eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage at meningitic doses (Vanco and Cefepime)\n pending LP info as well as vori, azithro, and flagyl (given poor\n dentition and location of infiltrate)\n Hypoxemia PNA in the RLL, with volume overload.\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension: fluid responsive, seems likely due to sepsis and\n hypovolemia at this point. Will alternate b/w NS and LR to prevent\n hyperchloremic met acidosis\n - Volume bolus to maintain MAP > 65 mmHg\n - Monitor renal function\n - Consider echo if hypotension persists despite fluid resuscitation.\n H/O TB lymphadenitis. \nt suspect reactivation now.\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition: neutropenic diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: boots\n Communication:\n Code status: Full code\n Disposition : ICU\n Total time spent:\n"
},
{
"category": "Nutrition",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 322484,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Nutrition consult: Poor intake greater than 7 days\n Diet order: Regular; Neutropenic\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Given patient\ns current clinical presentation of spiking fever and PNA\n in setting of CLL, it is not unique that her po intake is poor. Will\n provide po nutritional supplements at this point with the assumption\n her intake will improve as her clinical picture improves. However, we\n recommend enteral nutrition support if po intake remains poor given her\n compromised status. Please consult again if nutrition support\n indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322472,
"text": "Chief Complaint: resp distress\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 01:40 AM\n FEVER - 102.0\nF - 11:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.8\nC (98.2\n HR: 104 (87 - 121) bpm\n BP: 102/60(68) {88/46(59) - 118/68(80)} mmHg\n RR: 17 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,388 mL\n PO:\n 830 mL\n 450 mL\n TF:\n IVF:\n 3,320 mL\n 938 mL\n Blood products:\n Total out:\n 1,525 mL\n 300 mL\n Urine:\n 1,325 mL\n 300 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,088 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 51 K/uL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nutrition",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 322480,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Nutrition consult: Poor intake greater than 7 days\n Diet order: Regular; Neutropenic\n"
},
{
"category": "Nutrition",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 322481,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Nutrition consult: Poor intake greater than 7 days\n Diet order: Regular; Neutropenic\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322489,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n - Repeat PA/Lat ordered as per radiology to best assess increase in\n size of mediastinum showed no change in widening as from prior PA/Lat\n - ID rec adding on cytology to LP and continuing broad coverage with\n vanc/flagyl/vori, and acyclovir/bactrim ppx\n - Micro: AFB prelim smear neg, but per micro lab, cannot dc precautions\n until concentrated smear completed on Monday\n - T 102 axillary at MN, given 1gm tylenol, bcx and ucx sent, cooled\n with icepacks/cooling blanket, 250cc NS bolus x3, ECG unchanged (sinus\n tach), lactate 1.0\n - Influenza DFA reordered as priors had been cancelled (x2)\n - T 102 axillary at MN with tachycardia to 120s, given 1gm tylenol, bcx\n and ucx sent, cooled with cooling blanket, 250cc NS bolus x2, ECG\n unchanged (sinus tach), lactate 1.0, tachycardia resolved with\n defervescence\n - Influenza DFA reordered as priors had been cancelled (x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:39 PM\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.2\n HR: 104 (87 - 126) bpm\n BP: 111/58(70) {83/46(59) - 118/68(80)} mmHg\n RR: 15 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,015 mL\n PO:\n 830 mL\n 300 mL\n TF:\n IVF:\n 3,320 mL\n 715 mL\n Blood products:\n Total out:\n 1,525 mL\n 0 mL\n Urine:\n 1,325 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases), clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: WWP\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51 K/uL\n 10.6 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Imaging: Prelim read on PA/Lat: no increased mediastinal widening\n Microbiology: Bcx x2 and : NGTD\n BAL : No AFB on prelim smear, AF cx pending, no legionella isolated\n on prelim, PCP pending, viral cx cancelled, DFA for influenza cancelled\n RSV screen cancelled due to lack of cells\n CSF cx: NGTD, gram stain neg\n Bcx x4 : NGTD\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia and\n continued fevers.\n # Febrile neutropenia. Most likely source PNA given RLL lobar\n infiltrate. So far no informative culture or gram stain data. Pt has\n history of partially treated extrapulmonary TB, lobar appearance of CXR\n not really suggestive of reactivated TB. Patient with continued fevers\n (102 axillary) overnight.\n -Covering broadly for neutropenic CAP with vanc/cefepime/azithromycin\n with flagyl for anaerobes, voriconazole for funal coverage. Could\n consider peeling back coverage pending culture results, though would\n continue for now given persistent fevers and relative neutropenia\n -Follow up all cultures, AFB smears negative, but awaiting concentrated\n smear and cultures likely on Monday\n -Tylenol prn fevers, cooling blanket prn\n -Continue neutropenic and negative pressure respiratory isolation for\n r/o TB.\n - Re-ordered DFA for influenza as high on differential given broad abx\n coverage with continued fevers. Sample from BAL and prior nasal\n aspirate had been cancelled.\n # Hypoxia: Stable and resolving. Likely related to underlying CAP and\n acutely exacerbated by fluid resusitation. Has resolved. Patient was\n able to tolerate small fluid boluses during fevers with continued sats\n in the mid-high 90s on 2L NC.\n - Continue to follow CXR, has appeared less fluid overloaded.\n Pulmonary edema likely from aggressive fluid rescusitation. No history\n of heart failure.\n - Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: Stable. Likely related to sepsis from unclear source. No\n evidence of blood loss or ischemic cause. Patient also with some\n question of mediastinal widening on AP film as compared to PA/Lat. Per\n radiology, recommended repeat PA/Lat which showed no further widening\n and was not concerning for hematoma as no recent\n intervention/procedure. Pericardial effusion with tamponade is\n possible given hx of TB but not clinically likely. Lactate continues\n to be normal (1.0 this am) and normal mentation so perfusion adequate.\n - Can consider TTE on Monday as not able to get one on the weekend.\n - Bolus IVF for decreased UOP, tachycardia or hypotension as has\n responded well, though would be careful given hypoxia and pulmonary\n edema. Would alternate NS and LR given hyperchloremia.\n # Hx of Extra-pulmonary TB: patient completed only 6 months of therapy\n so would be at risk for relapse. Currently without other significant\n constitutional symptoms that had featured prominently before. Would\n expect low probability for pulmonary TB.\n - Continue airborne precautions for now pending AFB concentrated smear\n from bronch on Monday\n - ID recs\n -Azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n # Neck pain: Resolved. Patient developed pain and soreness after being\n in the hospital w/o other sign of meningitis except for fever. LP\n without evidence of meningitis. Likely benign muscle ache/spasm.\n - Reduced cevepime from meningitis to PNA doses.\n - Tylenol, percocet prn pain.\n # CLL: ANC >500 so perhaps could be start of trend. would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - Continue prophy: bactrim and acyclovir\n # Hypothyroidism: Continue current dose levothyroxine\n ICU Care\n Nutrition:\n Glycemic Control: adequate\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: eating\n VAP: on abx/not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: can consider call out to BMT if stable\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322491,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n - Repeat PA/Lat ordered as per radiology to best assess increase in\n size of mediastinum showed no change in widening as from prior PA/Lat\n - ID rec adding on cytology to LP and continuing broad coverage with\n vanc/flagyl/vori, and acyclovir/bactrim ppx\n - Micro: AFB prelim smear neg, but per micro lab, cannot dc precautions\n until concentrated smear completed on Monday\n - T 102 axillary at MN, given 1gm tylenol, bcx and ucx sent, cooled\n with icepacks/cooling blanket, 250cc NS bolus x3, ECG unchanged (sinus\n tach), lactate 1.0\n - Influenza DFA reordered as priors had been cancelled (x2)\n - T 102 axillary at MN with tachycardia to 120s, given 1gm tylenol, bcx\n and ucx sent, cooled with cooling blanket, 250cc NS bolus x2, ECG\n unchanged (sinus tach), lactate 1.0, tachycardia resolved with\n defervescence\n - Influenza DFA reordered as priors had been cancelled (x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:39 PM\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.2\n HR: 104 (87 - 126) bpm\n BP: 111/58(70) {83/46(59) - 118/68(80)} mmHg\n RR: 15 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,015 mL\n PO:\n 830 mL\n 300 mL\n TF:\n IVF:\n 3,320 mL\n 715 mL\n Blood products:\n Total out:\n 1,525 mL\n 0 mL\n Urine:\n 1,325 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases), clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: WWP\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 51 K/uL\n 10.6 g/dL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n ANC 580\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Imaging: Prelim read on PA/Lat: no increased mediastinal widening\n Microbiology: Bcx x2 and : NGTD\n BAL : No AFB on prelim smear, AF cx pending, no legionella isolated\n on prelim, PCP pending, viral cx cancelled, DFA for influenza cancelled\n RSV screen cancelled due to lack of cells\n CSF cx: NGTD, gram stain neg\n Bcx x4 : NGTD\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia and\n continued fevers.\n # Febrile neutropenia. Most likely source PNA given RLL lobar\n infiltrate. So far no informative culture or gram stain data. Pt has\n history of partially treated extrapulmonary TB, lobar appearance of CXR\n not really suggestive of reactivated TB. Patient with continued fevers\n (102 axillary) overnight.\n -Covering broadly for neutropenic CAP with vanc/cefepime/azithromycin\n with flagyl for anaerobes, voriconazole for fungal coverage. Could\n consider peeling back coverage pending culture results, though would\n continue for now given persistent fevers and relative neutropenia\n -Follow up all cultures, AFB smears negative, but awaiting concentrated\n smear and cultures likely on Monday\n -Tylenol prn fevers, cooling blanket prn\n -Continue neutropenic and negative pressure respiratory isolation for\n r/o TB\n - DFA for influenza negative, will dc droplet isolation, though still\n requires resp isolation as above\n # Hypoxia: Stable and resolving. Likely related to underlying CAP and\n acutely exacerbated by fluid resusitation. Has resolved. Patient was\n able to tolerate small fluid boluses during fevers with continued sats\n in the mid-high 90s on 2L NC.\n - Continue to follow CXR, has appeared less fluid overloaded, though\n e/o edema on CXR this am. Pulmonary edema likely from aggressive fluid\n rescusitation. No history of heart failure.\n - Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: Stable. Likely related to sepsis from unclear source. No\n evidence of blood loss or ischemic cause. Patient also with some\n question of mediastinal widening on AP film as compared to PA/Lat. Per\n radiology, recommended repeat PA/Lat which showed no further widening\n and was not concerning for hematoma as no recent\n intervention/procedure. Pericardial effusion with tamponade is\n possible given hx of TB but not clinically likely. Lactate continues\n to be normal (1.0 this am) and normal mentation so perfusion adequate.\n - Follow up final read on PA/Lat\n - Can consider TTE on Monday as not able to get one on the weekend.\n - Bolus IVF for decreased UOP, tachycardia or hypotension as has\n responded well, though would be careful given hypoxia and pulmonary\n edema. Would alternate NS and LR given concern for hyperchloremia.\n # Hx of Extra-pulmonary TB: Patient completed only 6 months of therapy\n so would be at risk for relapse. Currently without other significant\n constitutional symptoms that had featured prominently before. Would\n expect low probability for pulmonary TB.\n - Continue airborne precautions for now pending AFB concentrated smear\n from bronch on Monday\n - ID recs\n -Azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n # Neck pain: Resolved. Patient developed pain and soreness after being\n in the hospital w/o other sign of meningitis except for fever. LP\n without evidence of meningitis. Likely benign muscle ache/spasm.\n - Reduced cevepime from meningitis to PNA doses.\n - Tylenol, percocet prn pain.\n # CLL: ANC >500 so perhaps could be start of trend. Would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - Continue prophy: bactrim and acyclovir\n # Hypothyroidism: Continue current dose levothyroxine\n # FEN: Bowel regimen, Nutrition consult\n ICU Care\n Nutrition: consult for low PO, neutropenic diet\n Glycemic Control: adequate\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: eating\n VAP: on abx/not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: can consider call out to BMT if stable\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322502,
"text": "Chief Complaint: resp distress\n 24 Hour Events:\n BLOOD CULTURED - At 01:40 AM\n FEVER - 102.0\nF - 11:00 PM\n Tachycardia with fevers, resolved with defervesence\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Voriconazole - 10:00 PM\n Cefipime - 02:00 AM\n Metronidazole - 02:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: fevers, tachycardia, fatigue\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.8\nC (98.2\n HR: 104 (87 - 121) bpm\n BP: 102/60(68) {88/46(59) - 118/68(80)} mmHg\n RR: 17 (10 - 28) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 4,150 mL\n 1,388 mL\n PO:\n 830 mL\n 450 mL\n TF:\n IVF:\n 3,320 mL\n 938 mL\n Blood products:\n Total out:\n 1,525 mL\n 300 mL\n Urine:\n 1,325 mL\n 300 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,625 mL\n 1,088 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n Gen: lying in bed, diaphoretic, complaining of fatigue\n HEENT: dry oropharynx\n CV: tachy RR\n Chest: decreased BS in RLL\n Abd: distended +BS\n Ext: 1+\n Neuro:\n Labs / Radiology\n 10.6 g/dL\n 51 K/uL\n 106 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 109 mEq/L\n 136 mEq/L\n 30.1 %\n 1.5 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n WBC\n 1.8\n 1.6\n 1.5\n Hct\n 27.0\n 28.7\n 30.1\n Plt\n 67\n 52\n 51\n Cr\n 0.7\n 0.7\n Glucose\n 94\n 106\n Other labs: PT / PTT / INR:15.0/28.7/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 65 year old woman with CLL s/p recent treatment, now neutropenic with\n fevers of unclear etiology and history notable for probable TB\n lymphadenitis which was treated for 6 months.\n Neutropenic Fever: multiple sources of concern in this neutropenic host\n though PNA is leading candidate.\n All cx have thus far been negative\n RLL PNA: BAL pending\n Hx of TB adenitis, Bal pending (prelim smear neg)\n Meningitis: LP unrevealing\n - Bronch done to eval RLL lesion: (PCP, , , viral,\n bacterial clx)\n - Continue broad coverage Vanco and Cefepime vori, azithro, and flagyl\n (given poor dentition and location of infiltrate concern for aspiration\n Hypoxemia PNA in the RLL, with volume overload and weaning O2 as\n tolerated\n - supportive O2 for now\n - plan for NIPPV if needed\n Hypotension:resolved.\n Tachycardia: in setting of fevers, now improved. Echo in AM pre BMT -\n can look for veg, no evidence of increased cardiac siloutte by plain\n films or on recent CT but can also look for small pericard eff.\n Widened mediastinum\n stable by PA/lat- likely swollen nodes due to\n volume resucitation. Hol doff on repeat CT as just had on .\n H/O TB lymphadenitis: if remians febrile without a source for many more\n days, ? role of repeat node bx\n CLL: s/p recent treatment. Manage per BMT.\n Other issues per ICU Resident Admission Note\n ICU Care\n Nutrition: poor po intake, encourage\n Glycemic Control: SSRI\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition : possibly to BMT if stable\n Total time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322346,
"text": ".H/O nausea / vomiting\n Assessment:\n c/o of nausea unsure if related to her headache or medication, lack of\n sleep\n Action:\n Given zofran 4mg po and percocet for headache\n Response:\n Nausea and pain controlled\n Plan:\n Allow uninterrupted sleep time, medicate with ativan /zofran/compazine\n prn\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o of headache as above\n Action:\n Tx with percocet\n Response:\n No pain\n Plan:\n Medicate prn for pain\n hypoxia\n Assessment:\n On 3l np . No c/o sob resp rate in 30\ns even when sleeping lungs clear\n crackles bases dyspneic wheezing with exertion, o2 sat >96%, cxr \n pulmonary edema, rll pna\n Action:\n Vanco/cefedime/voriconazole\n Response:\n Afebrile o2 sats improved\n Plan:\n Cont antibx, await cx results, sputum for afb results, maintain droplet\n precautions until r/o, monitor temp, cxr, ?lasix, using Albuterol neb\n Hypotension (not Shock)\n Assessment:\n Bp mean >56 when asleep\n Action:\n Continue to monitor\n Response:\n Plan:\n .H/O tuberculosis\n Assessment:\n Action:\n Response:\n Plan:\n Await results of afb, maintain droplet precautions\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322561,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n BLOOD CULTURED - At 01:08 AM\n FEVER - 101.2\nF - 10:00 PM, cultured, tachy with fever\n TTE done yesterday, no pericardial effusion\n ID recs: continue current mgmt\n Micro: AFB prelim smear negative, awaiting concentrated smear results\n to dc respiratory precautions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Voriconazole - 10:00 PM\n Metronidazole - 02:00 AM\n Cefipime - 02:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Docusate\n Percocet\n Azithromycin 250PO daily\n Ipratropium\n Acetaminophen\n Prochlorperazine\n Ondansetron\n Bactrim\n Lorazepam\n Levothyroxine\n Allopurinol\n Senna\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.6\nC (97.8\n HR: 90 (90 - 111) bpm\n BP: 94/53(63) {90/42(55) - 117/72(77)} mmHg\n RR: 11 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 2,307 mL\n 450 mL\n PO:\n 720 mL\n 250 mL\n TF:\n IVF:\n 1,587 mL\n 200 mL\n Blood products:\n Total out:\n 850 mL\n 150 mL\n Urine:\n 850 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,457 mL\n 300 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% 1-2L\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases), clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: WWP\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 61 K/uL\n 10.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 135 mEq/L\n 31.3 %\n 2.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n 11:04 PM\n WBC\n 1.8\n 1.6\n 1.5\n 2.6\n Hct\n 27.0\n 28.7\n 30.1\n 31.3\n Plt\n 67\n 52\n 51\n 61\n Cr\n 0.7\n 0.7\n 0.8\n Glucose\n 94\n 106\n 95\n Other labs: PT / PTT / INR:14.3/29.7/1.2, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:1.4 mg/dL\n TTE : PRELIM READ -- Right ventricular chamber size and free wall\n motion are normal. There are simple atheroma in the aortic root. The\n mitral valve appears structurally normal with trivial mitral\n regurgitation. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion. There are no\n echocardiographic signs of tamponade.\n IMPRESSION: No pericardial effusion and no echo signs of tamponade. If\n clinically indicated should obtain full study by son.\n Assessment and Plan\n 65 year old woman with history of CLL now ~25 days s/p FCR intially\n presenting with febrile neutropenia found to have RLL infiltrate and\n neck pain now complicated by hypotension followed by hypoxia and\n continued fevers.\n # Febrile neutropenia. Most likely source PNA given RLL lobar\n infiltrate. So far no informative culture or gram stain data. Pt has\n history of partially treated extrapulmonary TB, lobar appearance of CXR\n not really suggestive of reactivated TB. Patient with continued fevers\n (102 axillary) overnight.\n -Covering broadly for neutropenic CAP with vanc/cefepime/azithromycin\n with flagyl for anaerobes, voriconazole for fungal coverage. Could\n consider peeling back coverage pending culture results, though would\n continue for now given persistent fevers and relative neutropenia. ?\n d/c vancomycin given culture data\n -Follow up all cultures, AFB smears negative, but awaiting concentrated\n smear and cultures likely on Monday\n -Tylenol prn fevers, cooling blanket prn\n -Continue neutropenic and negative pressure respiratory isolation for\n r/o TB\n - DFA for influenza negative, will dc droplet isolation, though still\n requires resp isolation as above\n # Hypoxia: Stable and resolving. Likely related to underlying CAP and\n acutely exacerbated by fluid resusitation. Has resolved. Patient was\n able to tolerate small fluid boluses during fevers with continued sats\n in the mid-high 90s on 2L NC.\n - Continue to follow CXR, has appeared less fluid overloaded, though\n e/o edema on CXR this am. Pulmonary edema likely from aggressive fluid\n rescusitation. No history of heart failure.\n - Caution with IVF, may bolus as needed but should go first to NIPPV if\n develops further hypoxia.\n # Hypotension: Stable. Likely related to sepsis from unclear source. No\n evidence of blood loss or ischemic cause. Patient also with some\n question of mediastinal widening on AP film as compared to PA/Lat. Per\n radiology, recommended repeat PA/Lat which showed no further widening\n and was not concerning for hematoma as no recent\n intervention/procedure. Pericardial effusion with tamponade is\n possible given hx of TB but not clinically likely. Lactate continues\n to be normal (1.0 this am) and normal mentation so perfusion adequate.\n Resolved\n - Bolus IVF for decreased UOP, tachycardia or hypotension as has\n responded well, though would be careful given hypoxia and pulmonary\n edema. Would alternate NS and LR given concern for hyperchloremia.\n # Hx of Extra-pulmonary TB: Patient completed only 6 months of therapy\n so would be at risk for relapse. Currently without other significant\n constitutional symptoms that had featured prominently before. Would\n expect low probability for pulmonary TB.\n - Continue airborne precautions for now pending AFB concentrated smear\n from bronch, should be done on today\n - ID recs\n -Azithromycin instead of levo for atypical PNA coverage to avoid TB\n partial treatment.\n # Neck pain: Resolved. Patient developed pain and soreness after being\n in the hospital w/o other sign of meningitis except for fever. LP\n without evidence of meningitis. Likely benign muscle ache/spasm.\n - Reduced cefepime from meningitis to PNA doses.\n - Tylenol, percocet prn pain.\n # CLL: ANC >500 so perhaps could be start of trend. Would still be\n immune suppressed due to lymphocyte dysfunction.\n - BMT recs\n - Continue prophy: bactrim and acyclovir\n # Hypothyroidism: Continue current dose levothyroxine\n # FEN: Bowel regimen, Nutrition consult appreciated, will receive\n supplements for poor PO intake. Repleted K and Phos today. Corrected\n Ca WNL. IVF boluses as above PRN.\n ICU Care\n Nutrition: Taking PO, neutropenic diet\n Glycemic Control: ISS PRN\n Lines:\n 22 Gauge - 11:30 PM\n Prophylaxis:\n DVT: no SC heparin for low platelets, didn\nt tolerate pneumoboots\n Stress ulcer: taking PO, not needed\n VAP: Not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ? Call out to BMT once off respiratory isolation\n"
},
{
"category": "Physician ",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322556,
"text": "Chief Complaint: 65 year old woman with history of CLL now ~25 days s/p\n FCR intially presenting with febrile neutropenia found to have RLL\n infiltrate and neck pain now complicated by hypotension followed by\n hypoxia.\n 24 Hour Events:\n BLOOD CULTURED - At 01:08 AM\n FEVER - 101.2\nF - 10:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Voriconazole - 10:00 PM\n Metronidazole - 02:00 AM\n Cefipime - 02:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 36.6\nC (97.8\n HR: 90 (90 - 111) bpm\n BP: 94/53(63) {90/42(55) - 117/72(77)} mmHg\n RR: 11 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 2,307 mL\n 450 mL\n PO:\n 720 mL\n 250 mL\n TF:\n IVF:\n 1,587 mL\n 200 mL\n Blood products:\n Total out:\n 850 mL\n 150 mL\n Urine:\n 850 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,457 mL\n 300 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 61 K/uL\n 10.8 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 135 mEq/L\n 31.3 %\n 2.6 K/uL\n [image002.jpg]\n 03:24 PM\n 05:11 AM\n 12:37 AM\n 11:04 PM\n WBC\n 1.8\n 1.6\n 1.5\n 2.6\n Hct\n 27.0\n 28.7\n 30.1\n 31.3\n Plt\n 67\n 52\n 51\n 61\n Cr\n 0.7\n 0.7\n 0.8\n Glucose\n 94\n 106\n 95\n Other labs: PT / PTT / INR:14.3/29.7/1.2, Lactic Acid:1.0 mmol/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322440,
"text": "65 yo woman h/o CLL that has been poorly responsive to chemotherapy,\n last dose 23 days ago of 2 cycles of fludarabine, ritoxan, and cytoxan.\n She developed fever at home for two days and presented to EW with\n fever and hypotension was admitted to the floor and placed on IV\n antibiotics. CT of chest showed RLL pna. She was placed on isolation\n precautions b/o c/o stiff neck and frontal headache. She had LP done\n r/o meningitis. She remained on droplet precautions because she had a\n + PPD in past but only took 6months vs 9months of therapy. She was\n admitted to ICU after a routine check bp 80/60 she was given 2liters\n NS and became sob, po2 61 cxr pulm edema\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked temp to 102 at 2300\n Action:\n Received 650 mg Tylenol and 325 mg one hour later per HO, pt is also\n receiving percocets PRN for persistant headache, blood cultures sent,\n ordered for urine culture pt voids, placed on cooling blanket\n Response:\n Current temp 97.2, cooling blanket off since 0230\n Plan:\n Continue to monitor temps, f/u blood cultures, obtain urine culture\n when available\n Tachycardia, Other\n Assessment:\n obtained pt with HR in the 120s, reporting RN pt becomes\n tachycardic with activity and when\nabout to spike a fever,\n checked\n temp 102 as noted above\n Action:\n In addition to treating temp pt received 2 250 cc fluid boluses,\n obtained EKG per HO pt in ST\n Response:\n HR low 100s\n Plan:\n Continue to monitor HR, pt consistently in the high 90s low 100s\n"
},
{
"category": "Nursing",
"chartdate": "2131-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322549,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt with temp spike 101.2 ax at 22\n Action:\n Received 650 mg Tylenol, blood cultures sent\n Response:\n Temp trending down following Tylenol adm, 98.6 at 02\n Plan:\n Continue to monitor temp prn Tylenol, f/u blood cultures\n Hypoxemia\n Assessment:\n pt on NC 1-2L, breath sounds clear/dim in , pt has pneumonia,\n being r/o for TB and flu\n Action:\n Maintaining droplet and airborn precautions\n Response:\n Prelim TB results negative, awaiting final smear, ruled out for flu\n from bronch results\n Plan:\n Continue to monitor resp status, continue to maintain airborn\n precautions pending smear results\n"
}
] |
28,671 | 157,438 | 59 yo male with pmh of recurrent squamous cell lung carcinoma s/p left pneumonectomy in now s/p cycle one of gemcitabine (last on ) who presented on with fevers and hypotension possibly be secondary to Gemcitabine-related inflammatory lung disease. | He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Agree with MICU team plan of care and empahsize: HoTN -gemcitabine vs. sepsis vs. cardiac vs. PE -weaned off pressor - empiric vanco/cefpime/levaquin pending cx data. Hypoxemia interstitial process -gemcitabine vs. sepsis -weaned off pressor - empiric vanco/cefpime/levaquin pending cx data. Hypoxemia interstitial process -gemcitabine vs. sepsis -weaned off pressor - empiric vanco/cefpime/levaquin pending cx data. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Response: Pt resp status/ low sats and tachypnea responsive to MDI, increased 02 NC and Face tent. Flu test came back neg. Flu test came back neg. Flu test came back neg. base,non productive cough+,h/o PE in the past,HR 90-120,sinus,CTA neg for PE Action: Contd nebs,abx ,steroid,02 weaned to 3L NC Response: Sats mostly in 92-95%,but does desats to high 80s at times,but quckly reverts back,also asymptamatic with desats,does gets sob at times with exertion which may require high amount of 02 for a brief period of time..CT chest more like pneumonotis picture ?gemcitabine toxicity Plan: Will cont to assess the respiratory status,wean 02 as needed,cont nebs and solumedrol. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. d/c abx and continue levaquin -requiring supp FiO2 via NC - wean as tolerated - Atrovent q6 -Will decrease solumedol 60mg Q6 Hypotension -Continue antiarrythmic therapy -Give fluid if hypotensive Pancytopenia -Will follow, chemo related Afib -Continue home meds holding dilt until BP improves H/o Pulmonary embolism- CTA negative, per patient had problem from chest wound from anticoagulation chart reports hemoptysis. Agree with MICU team plan of care and empahsize: HoTN -gemcitabine vs. sepsis vs. cardiac vs. PE -weaned off pressor - empiric vanco/cefpime/levaquin pending cx data. Agree with MICU team plan of care and empahsize: HoTN -gemcitabine vs. sepsis vs. cardiac vs. PE -weaned off pressor - empiric vanco/cefpime/levaquin pending cx data. If worsens, will try BiPAP ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 04:48 AM 18 Gauge - 04:49 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition : Total time spent: Stable post left pneumonectomy changes. , MED MICU-7 10:24 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for interval change as remains hypoxic. He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p ablasion, PEs , he is not on anti-ocag for this, multiple bouts of pna, +ppd in past, full course of INH given. 10:24 AM CHEST (PORTABLE AP) Clip # Reason: Please evaluate for interval change as remains hypoxic. Left pneumonectomy is again seen. Compared to the previous tracing of atrial fibrillation hasnow converted to sinus rhythm. Left pneumonectomy. Left pneumonectomy. Stable post- pneumectomy appearance. # Atrial fibrillation: In sinus rhythm. # Atrial fibrillation: In sinus rhythm. # Atrial fibrillation: In sinus rhythm. | 76 | [
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 374934,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 374936,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Spiked to 101\n Weaned off Neo\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g\n atrovent\n cefepime\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100% 50%FM\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS BS on left, no crackles/wheezes\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology:\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n BNP-Pending\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n -Will Check CTPA to rule out PE and eval for PNA\n -Check BNP\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n -Give fluid if hypotensive\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- will check CTA.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen\n ICU Care\n Nutrition: regluar diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375211,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\n ?infection.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n Taper steroids solumedrol 60q6\n Follow CXR\n Continue home levo, would stop vanc and cefepime today\n Follow up cultures and reculture if febrile.\n Obtain sputum if making any.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 375212,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\n ?infection.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n Taper steroids solumedrol 60q6\n Follow CXR\n Continue home levo, would stop vanc and cefepime today\n Follow up cultures and reculture if febrile.\n Obtain sputum if making any.\n Called out to floor Hem Onc.\n Transferred via ambulance\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n Admission weight:\n 78.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD\n CV-PMH: Arrhythmias\n Additional history: nsmlca, sq cell ca, l pneumonectomy, afib/flutter\n s/p ablasion, hx of pe NOT on anticoagulation, +ppd in past\n treated\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:59\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 223 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 10:23 AM\n Potassium:\n 3.6 mEq/L\n 10:23 AM\n Chloride:\n 108 mEq/L\n 10:23 AM\n CO2:\n 26 mEq/L\n 10:23 AM\n BUN:\n 21 mg/dL\n 10:23 AM\n Creatinine:\n 0.7 mg/dL\n 10:23 AM\n Glucose:\n 150 mg/dL\n 10:23 AM\n Hematocrit:\n 31.6 %\n 10:23 AM\n Finger Stick Glucose:\n 164\n 12:00 PM\n Valuables / Signature\n Patient valuables: clothes, sneakers,\n Other valuables:\n Clothes: Sent with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU7\n Transferred to: 1184\n Date & time of Transfer: 1830\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375213,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\n ?infection.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n Taper steroids solumedrol 60q6\n Follow CXR\n Continue home levo, would stop vanc and cefepime today\n Follow up cultures and reculture if febrile.\n Obtain sputum if making any.\n Called out to . Reis1184 transport via transfer note faxed\n report to RN.\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374863,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\n gemcitibine three days PTA. He presented with three days of\n intermittent fever to 102 , weakness and anorexia. He reports mild\n dyspnea and cough at baseline which is not worse. He was referred to\n the ED for evaluation and while there developed SBP to 70s and sinus\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\n was placed and neosynephrine started. CVP=10. He received vanco and\n cefipime and was previously on levaquin\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\n .\n In addition, lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n History obtained from Medical Records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Cefepime\n levaquin\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Asa 325\n Neurontin\n Advair\n Flecanide\n Levaquin 500 q24\n Vanco 1 q2 (#2)\n Atrovent nebs\n Morphine\n Heparin SC\n At Home Meds:\n Flecanide\n Cardizem\n Levaquin\n Advair\n Albuterol\n Neurontin\n Dilaudid\n Compazine\n atrovent\n Past medical history:\n Family history:\n Social History:\n Squamous cell Ca lung\no dx , T3N2 (L mainstem bronchus)\no tumor debridement, stent placement, \no chemotherapy, XRT /30/08: Cisplatin etoposide\no L pneumonectomy, mediastinal LN dissection, \no bronchial washings + (brushings -) \no PET : uptake at pneumonectomy suture line, around cavity,\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\n home. S/P ablation in \n COPD\n Pulmonary embolism \n L frozen shoulder\n Per RAN\n Quit cigs 1 year ago.\n Review of systems: Reviewed in Detail . Please see RAN of .\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS BS on left, no crackles/wheezes\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology\n CBC, Chem 7 wnl\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\n possibility but so far no infectious source. His oxygen requirement\n appear to be declining slowly and may reflect SIRS, PNA, and poor pulm\n reserve. There may be a component of underlying pulm HTN given the\n pneumoectomy and the prior PE. Agree with MICU team plan of care and\n empahsize:\n Will wean off pressors as tolerated. Continue antiarrythmic\n therapy, not on anticoagulation due to bleeding risk.\n On 4-3L NC presently and will wean as tolerated. Atrovent q6\n Full diet\n Empiric vanco/cefpime/levaquin with plan to discontinue if\n w/u negative.\n PPX- heparin SC\n DISPO- FULL code. MICU today for montioring. Possible\n transfer to floor if stable.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT: Heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: MICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374873,
"text": "Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\n pain. Lchest pain @ 1530 received Morphine 15 PO\n Action:\n Received Morphine 15mg PO x2. Received Neutrotin per routine.\n Response:\n Pain relief w/meds\n Plan:\n Pain assessment\n Pain med PRN\n Sepsis without organ dysfunction\n Assessment:\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\n R, Dypneic with activity. Dry cough 02 sats 90-95% O2 3L/min increased\n to 4L/min desats to 88 when off 02. @ 1530 ^ dypneia RR>30 anxious dry\n cough Sats 90% on 4l/min stat EKG demand ischemia. Feeling cold Temp\n 07.9 rigor received Tylenol 650.\n Action:\n Cont Pressor slow to wean, afebrile received Tylenol for Rigors. Triple\n Abx vanco/cefepine/Levofloxicin.\n Response:\n BP cont labile off neo Goal Map>55 and SBP>90\n Plan:\n wean off neo resume for hypotension.\n keep MAP 55 or SPB>85\n monitor CXR for infiltrate has developed post-hydration\n f/u blood and urine Cx\n obtain sputum cx\n Continue flecainide, aspirin. hold diltiazem temporarily\n Followup EKG and cardiac enzymes.\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374861,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\n gemcitibine three days PTA. He presented with three days of\n intermittent fever to 102 , weakness and anorexia. He reports mild\n dyspnea and cough at baseline which is not worse. He was referred to\n the ED for evaluation and while there developed SBP to 70s and sinus\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\n was placed and neosynephrine started. CVP=10. He received vanco and\n cefipime and was previously on levaquin\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\n .\n In addition, lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n History obtained from Medical Records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Cefepime\n levaquin\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Asa 325\n Neurontin\n Advair\n Flecanide\n Levaquin 500 q24\n Vanco 1 q2 (#2)\n Atrovent nebs\n Morphine\n Heparin SC\n At Home Meds:\n Flecanide\n Cardizem\n Levaquin\n Advair\n Albuterol\n Neurontin\n Dilaudid\n Compazine\n atrovent\n Past medical history:\n Family history:\n Social History:\n T3N2 SCC s/p left pneumonectomy with recurrence in\n hilar stump and left pleura. Had taxotere x 2. gemcitibine x 1.\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\n home. S/P ablation in \n COPD\n Pulmonary embolism \n L frozen shoulder\n Per RAN\n Quit cigs 1 year ago.\n Review of systems: Reviewed in Detail . Please see RAN of .\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS BS on left, no crackles/wheezes\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\n possibility but so far no infectious source. His respiratory status\n appears intact and is responding to resuscitation. Agree with MICU\n team plan of care and empahsize.\n CV\n 1. wean off pressors. Continue antiarrythmic therapy, not on\n anticoagulation due to bleeding risk.\n PULM\n On 3L NC presently but may not need this. Will wean off. Atrovent q6\n GI\n Full diet\n ID\n Micro w/u. Empiric vanco/cefpime with plan to discontinue if w/u\n negative.\n PPX- heparin SC\n DISPO- FULL code. MICU today for montioring. Possible transfer to\n floor if stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374864,
"text": "Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\n pain\n Action:\n Received Morphine 15mg PO. Received Neutrotin per routine.\n Response:\n Pain relief w/meds\n Plan:\n Pain assessment\n Pain med PRN\n Sepsis without organ dysfunction\n Assessment:\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\n R, Dypneic with activity. 02 sats 90-95% O2 3L/min increased to 4L/min\n desats to 88 when off 02.\n Action:\n Cont Pressor slow to wean, afebrile. Ripple Abx vanco/cefepine/azythro\n Response:\n BP cont labile off neo Goal Map>55 and SBP>90\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374968,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Rceievd the pt on 0.4mcg on neo,sbp in 100\ns,map 70\ns,uop\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\n Action:\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\n Response:\n Sbp mostly in 90-100\ns,but does drops to 80\ns at times,but mentaing\n fine with map>60,currently autodiuresing\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,?if no evolving\n PNA on CT,plan to dc abx.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 70% face tent with 6L\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\n 100-120 sinus tachy\n Action:\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n tent.(50%)\n Plan:\n Follow up on CTA,cont nebs,solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374865,
"text": "Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\n pain\n Action:\n Received Morphine 15mg PO. Received Neutrotin per routine.\n Response:\n Pain relief w/meds\n Plan:\n Pain assessment\n Pain med PRN\n Sepsis without organ dysfunction\n Assessment:\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\n R, Dypneic with activity. 02 sats 90-95% O2 3L/min increased to 4L/min\n desats to 88 when off 02.\n Action:\n Cont Pressor slow to wean, afebrile. Ripple Abx vanco/cefepine/azythro\n Response:\n BP cont labile off neo Goal Map>55 and SBP>90\n Plan:\n wean off neo\n keep MAP 60 or SPB>85\n monitor CVP and urine output\n recheck CXR to see if infiltrate has developed post-hydration\n f/u blood and urine Cx\n obtain sputum cx\n obtain legionella UA.\n Continue flecainide, aspirin. hold diltiazem temporarily\n neo rather than levo\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374862,
"text": "Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\n pain\n Action:\n Received Morphine 15mg PO. Received Neutrotin per routine.\n Response:\n Pain relief w/meds\n Plan:\n Pain assessment\n Pain med PRN\n Sepsis without organ dysfunction\n Assessment:\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\n Neo .5mcg/kg/min Pt on sm amt of neo on arrival from ed. Vss. Denies\n lightheadedness.\n Action:\n Continues on neo. Although apparently documented previous bp are\n 90-105/\n Response:\n Will titrate neo to off\n Plan:\n Titrate neo. Fluid as needed\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374969,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Rceievd the pt on 0.4mcg on neo,sbp in 100\ns,map 70\ns,uop\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\n Action:\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\n Response:\n Sbp mostly in 90-100\ns,but does drops to 80\ns at times,but mentaing\n fine with map>60,currently autodiuresing\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 70% face tent with 6L\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\n 100-120 sinus tachy\n Action:\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE,received morphine\n for pain and compazine for nausea\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n tent.(50%),CTA prelim without any PE,but s/o diffuse parenchymal\n disease.\n Plan:\n Follow up on final read of CTA,cont nebs,solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375053,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,02 weaned to 3L NC\n Response:\n Sats mostly in 92-95%,but does desats to high 80\ns at times,but quckly\n reverts back,also asymptamatic with desats,does gets sob at times with\n exertion which may require high amount of 02 for a brief period of\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374962,
"text": "HPI:59 yr old male with recurrent squmal cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose received was on .At the\n time of presentation to ED BP was 116/76 but subsequently HR went up to\n 120\ns and dropped BP to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Rceievd the pt on 04mcg on neo,sbp in 100\ns,map 70\ns,uop\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\n Action:\n Neo weaned off,started on solumedrol\n Response:\n Sbp mostly in 90-100\ns,but does drops to 80\ns at times,but mentaing\n fine with map>60,currently autodiuresing\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375019,
"text": "Chief Complaint: Hypoxia\n Hypotension\n Fever\n 24 Hour Events:\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.1\nC (97\n HR: 96 (92 - 113) bpm\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\n RR: 26 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1,349 mL\n 277 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 277 mL\n Blood products:\n Total out:\n 4,270 mL\n 395 mL\n Urine:\n 4,270 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine.\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - on levoquin chronically\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375020,
"text": "Chief Complaint: Hypoxia\n Hypotension\n Fever\n 24 Hour Events:\n - weaned off Neo\n - BNP 1000\n - started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\n inflammatory lung disease\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\n diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right\n middle lobe nodule slightly increased, likely infectious. Persistent\n worrisome thickening of the left hilar stump and pleural nodules. Signs\n of anemia.\n - continued Antibiotics overnight\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.1\nC (97\n HR: 96 (92 - 113) bpm\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\n RR: 26 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1,349 mL\n 277 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 277 mL\n Blood products:\n Total out:\n 4,270 mL\n 395 mL\n Urine:\n 4,270 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine.\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - on levoquin chronically\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375024,
"text": "Chief Complaint: Hypoxia\n Hypotension\n Fever\n 24 Hour Events:\n - weaned off Neo\n - BNP 1000\n - started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\n inflammatory lung disease\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\n diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right\n middle lobe nodule slightly increased, likely infectious. Persistent\n worrisome thickening of the left hilar stump and pleural nodules. Signs\n of anemia.\n - continued Antibiotics overnight\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.1\nC (97\n HR: 96 (92 - 113) bpm\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\n RR: 26 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1,349 mL\n 277 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 277 mL\n Blood products:\n Total out:\n 4,270 mL\n 395 mL\n Urine:\n 4,270 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n GEN: A&O, mildly tachypneic when speaking\n HEENT: mmm, no op lesions\n CV: reg, no g/m/r, nl s1, s2\n Pulm: coarse breath sounds over R lung\n Abd: Soft, nt, nd, nabs, no hsm\n Ext: no edema\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine.\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - on levoquin chronically\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375027,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.6\nC (96\n HR: 98 (91 - 113) bpm\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\n RR: 20 (16 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,349 mL\n 295 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 295 mL\n Blood products:\n Total out:\n 4,270 mL\n 635 mL\n Urine:\n 4,270 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375028,
"text": "Chief Complaint:\n 1. Hypoxia\n 2. Hypotension\n 3. Fever\n 24 Hour Events:\n - Weaned off Neo ( at 8am)\n - BNP 1000\n - Started Solu-Medrol 125mg Q6hrs for possible Gemcitabine-related\n inflammatory lung disease\n - Chest CTA showed no PE, s/p left pneumonectomy; also with increased\n diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right\n middle lobe nodule slightly increased, likely infectious. Persistent\n worrisome thickening of the left hilar stump and pleural nodules. Signs\n of anemia.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.1\nC (97\n HR: 96 (92 - 113) bpm\n BP: 128/79(90) {82/54(61) - 128/83(91)} mmHg\n RR: 26 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1,349 mL\n 277 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 277 mL\n Blood products:\n Total out:\n 4,270 mL\n 395 mL\n Urine:\n 4,270 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n GEN: A&O, mildly tachypneic when speaking\n HEENT: mmm, no op lesions\n CV: reg, no g/m/r, nl s1, s2\n Pulm: coarse breath sounds over R lung\n Abd: Soft, nt, nd, nabs, no hsm\n Ext: no edema\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n # Sepsis: Presents with recent immunosupression but no neutropenia. Pt\n has fever and hypotension refractory to fluids. However, his CVP is 10,\n he has good urine output and lactate has improved which indicates that\n he is likely volume rescucitated. In addition, his mixed venous O2 is\n c/w sepsi at 94s. He has no localizing source at this time with\n baseline CXR and neg UA. His shock is most likely a distrubtive shock\n picture and is most likely c/w reaction to gemcitabine.\n - Continue steroids for Gemcitabine-related inflammatory lung disease\n - Keep MAP 60 or SPB>85\n - Monitor CVP and urine output\n - Continue Vanc/Cefepime/Levofloxacin (Day 1: ) for broad coverage;\n on levaquin chronically\n - If Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - F/U blood culture data\n - Obtain sputum cx if possible\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - Will follow\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem once 24 hrs off pressors\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - Trend for now\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n ICU Care\n Nutrition: cardiac/heart healthy diet, replete lytes prn\n Glycemic Control: Check finger sticks while on steroids; if\n elevated, HISS\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer: PPI given steroids\n VAP: n/a\n Communication: Daughter (; HCP is son\n , Phone number: \n Code status: Full code\n Disposition: ICU care for now ; possible call-out afternoon \n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375029,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Off neo\n started on solumedol\n CTA neg PE see report\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.6\nC (96\n HR: 98 (91 - 113) bpm\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\n RR: 20 (16 - 29) insp/min\n SpO2: 93% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,349 mL\n 295 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 295 mL\n Blood products:\n Total out:\n 4,270 mL\n 635 mL\n Urine:\n 4,270 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\n Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: fine interstitial pattern\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n BNP 1000\n Micro-urine negative\n -Blood pending\n -Legionella negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation.\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: NPO will discuss bronch.\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Will trend vitals if stable will call out.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374964,
"text": "HPI:59 yr old male with recurrent squmal cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose received was on .At the\n time of presentation to ED BP was 116/76 but subsequently HR went up to\n 120\ns and dropped BP to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Rceievd the pt on 04mcg on neo,sbp in 100\ns,map 70\ns,uop\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\n Action:\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\n Response:\n Sbp mostly in 90-100\ns,but does drops to 80\ns at times,but mentaing\n fine with map>60,currently autodiuresing\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus,?if no evolving\n PNA on CT,plan to dc abx.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd,received the pt this am with 70% face tent with 6L\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\n left,exp wheeze on rt on exam,non productive cough++,h/o PE in the\n past,HR 100-120 sinus tachy\n Action:\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n mask\n Plan:\n Follow up on CTA,cont nebs,solumedrol,\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375107,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt cont to desat to mid to high 80\ns when wearing only nasal canula.\n Upset about having to wear face mask and about having the door closed\n for droplet precautions.\n Action:\n Pt encouraged many times to wear face tent to keep o2 sat\ns elevated.\n Flu test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375083,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,and o2 supplementation\n Response:\n Sats mostly 91-95%,but does desats to mid to high 80\ns with minimal\n exertion,also does get sob at times,which was managed with 50% face\n tent. Pt didn\nt tolerate 3l NC,currently running at 4L,A rapid test for\n flu is pending.\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375087,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,and o2 supplementation\n Response:\n Sats mostly 91-95%,but does desats to mid to high 80\ns with minimal\n exertion,also does get sob at times,which was managed with 50% face\n tent. Pt didn\nt tolerate 3l NC,currently running at 4L,A rapid test for\n flu is pending.\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375079,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,and o2 supplementation\n Response:\n Sats mostly 91-95%,but does desats to mid to high 80\ns with minimal\n exertion,also does get sob at times,which was managed with 50% face\n tent. Pt didn\nt tolerate 3l NC,currently running at 4L\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375197,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\n and may reflect SIRS, PNA, and poor pulm reserve. SOB probably\n multifactorial with COPD, s/p pneumonectomy, gemcitabine effect and\n ?infection.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n Taper steroids solumedrol 60q6\n Follow CXR\n Continue home levo, would stop vanc and cefepime today\n Follow up cultures and reculture if febrile.\n Obtain sputum if making any.\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375201,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n breathing better.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n asa 325\n neurontin 600mg Q 8hr\n advair\n flecinide\n levofloxacin 500Q 24\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n protonix\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 91% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 81 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 81 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -569 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: no film Pending\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Labs pending:\n Micro-DFA negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. Low WBC on high dose steroids may be\n secondary to possible viral etiology if this is not chemo related\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will decrease solumedol 60mg Q6 and transition to prednisone with\n rapid taper over next 5-7 days\n Hypotension ahs resolved\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow, chemo related\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM Will d\nc central line\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer: PPI steroids\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Floor and will need to assess o2 needs pre discharge\n Total time spent: 25 mins\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374902,
"text": "Chief Complaint: fever\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed\n Sepsis without organ dysfunction/ Nursing Diagnosis: Impaired Tissue\n Perfusion\n Assessment:\n Pt\ns sbp approx 80 at beginning of this 12 hours;\n Pt afebrile at beginning of shift, there was direct a direct\n correlation between pt temp and O2 sat, when pt\ns T elevated, pts O2\n sat decreased, w/ pt requiring increase in nasal cannula O2 delivery;\n Action:\n b/p cuff re-cycled a few times at beginning of shift to confirm sbp\n 80/low 80s, confirmed; therefore neo gtt restarted at low dose;\n T max 101 at 02:00, not cx\nd covering MD at that time d/t cx <24\n hrs;\n Pt continues to receive IV abx of cefepime and vancomycin;\n Response:\n At neo gtt dose level .1 mck/kg/min, pt remained hypotensive below\n accepted range, sbp adequate w/ neo at .5 mcg/k/min; heart rate also\n decreased from low 100\ns down to hi 80\ns after b/p adequate;\n Pt\ns O2 sat successfully increased to acceptable range of mid 90\ns w/\n increase of n.c O2 delivery;\n Plan:\n Titrate neo gtt to keep MAP >60, sbp >85;\n Titrate n.c. O2 to keep O2 sat >92;\n ****next time pt spikes T, pt is to be cultured;\n Hygiene cares if pt diaphoretic after elevated T\n Also this noc pt received magnesium and potassium repletion for low\n serum levels drawn yesterday afternoon; a.m. labs to be drawn at\n approx. 05:00\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375196,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent. Pt oxygen requirement appear to be declining slowly\n and may reflect SIRS, PNA, and poor pulm reserve.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375195,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu. Off\n precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25 now on O2 to NC 5l/min . cont solumedrol . Abx\n Vanco/cepfapine/levoflxicin. Started on spiriva.\n Response:\n Pt resp status/ low sats and tachypnea responsive to MDI, increased 02\n NC and Face tent.\n Plan:\n Cont to monitor o2 sat\ns and resp function.\n Cont with Abx anf MDI per routine.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375192,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB and anxious about oxygen status watching Sat\n value on monitor. Enc DB&C with dry cough. Lungs RUL clear few exp\n wheezes L lung DIM BS. Pt sitting high fowlers/sitting Side of bed/OOB\n chair with improved 02 requirement. O2 tapered to NC 5l/min with sats\n low 90\n Action:\n Resp status remains tenuous. Sats low 90\ns, desats to 80\ns with\n activity and RR>25. wean O2 to NC 5l/min . cont to taper steroids. Pt\n encouraged many times to wear face tent to keep o2 sat\ns elevated. Flu\n test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374884,
"text": "Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Awake alert oriented x3 , MAE random. @ 0800 c/o Lsided chest rib pain\n , nonradiating. Pt states has this pain since s/p L pneumonectomy\n pain. Lchest pain @ 1530 received Morphine 15 PO\n Action:\n Received Morphine 15mg PO x2. Received Neutrotin per routine.\n Response:\n Pain relief w/meds\n Plan:\n Pain assessment\n Pain med PRN\n Sepsis without organ dysfunction\n Assessment:\n T-max 98.2 WBC . HR 85-102 NSR-ST no ectopy BP labile Reciecved on\n Neo 0.5mcg/kg/min off @ 0900 BP cont labile hypotensive SBP 80 MAPS 55,\n @1030 Resumed Neo 0.5mcg/g/min titrated to off @ 1300. Cont\n hypotensive. Denies lightheadedness. RR 20-24 Lungs DIM lL, crackles\n R, Dypneic with activity. Dry cough 02 sats 90-95% O2 3L/min increased\n to 4L/min desats to 88 when off 02. @ 1530 ^ dypneia RR>30 anxious dry\n cough Sats 90% on 4l/min stat EKG demand ischemia. Feeling cold Temp\n 07.9 rigor received Tylenol 650.\n Action:\n Cont Pressor slow to wean, afebrile received Tylenol for Rigors. Triple\n Abx vanco/cefepine/Levofloxicin.\n Response:\n BP cont labile off neo Goal Map>55 and SBP>90\n Plan:\n wean off neo resume for hypotension.\n keep MAP 55 or SPB>85\n monitor CXR for infiltrate has developed post-hydration\n f/u blood and urine Cx\n obtain sputum cx\n Continue flecainide, aspirin. hold diltiazem temporarily\n Followup EKG and cardiac enzymes.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 375071,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol,02\n wened to 3L NC,ruled out PE with CTA.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,02 weaned to 3L NC\n Response:\n Sats mostly in 92-95%,but does desats to high 80\ns at times,but quckly\n reverts back,also asymptamatic with desats,does gets sob at times with\n exertion which may require high amount of 02 for a brief period of\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Respiratory ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 375068,
"text": "Respiratory Care Shift Procedures\n Bedside Procedures:\n Nasopharyngeal swab (1600)\n Comments: No nasal bleed noted. Pt with deviated septum difficult to\n get into right nare,? If enough cells were obtained for that swab.\n Pt also seen fro neb treatments, Lung sounds clear with diminished\n bases, pt tolerated treatments well.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375175,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Received pt tachypneic @ rest RR 30-35, sats 90% on 70% open FT and NC\n 4L/min. pt feeling SOB anxious about oxygen status. DB&C dry cough.\n Lungs RUL clear few exp wheezes L lung DIM BS. Pt placerd high fowlers\n and sitting Side of bed with improved 02 requirement. Desat mid to\n high 80\ns with activity. Pt cont to desat to mid to high 80\ns when\n wearing only nasal canula. Upset about having to wear face mask and\n about having the door closed for droplet precautions.\n Action:\n Pt encouraged many times to wear face tent to keep o2 sat\ns elevated.\n Flu test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374878,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\n gemcitibine three days PTA. He presented with three days of\n intermittent fever to 102 , weakness and anorexia. He reports mild\n dyspnea and cough at baseline which is not worse. He was referred to\n the ED for evaluation and while there developed SBP to 70s and sinus\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\n was placed and neosynephrine started. CVP=10. He received vanco and\n cefipime and was previously on levaquin\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\n .\n In addition, lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n History obtained from Medical Records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Cefepime\n levaquin\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Asa 325\n Neurontin\n Advair\n Flecanide\n Levaquin 500 q24\n Vanco 1 q2 (#2)\n Atrovent nebs\n Morphine\n Heparin SC\n At Home Meds:\n Flecanide\n Cardizem\n Levaquin\n Advair\n Albuterol\n Neurontin\n Dilaudid\n Compazine\n atrovent\n Past medical history:\n Family history:\n Social History:\n Squamous cell Ca lung\no dx , T3N2 (L mainstem bronchus)\no tumor debridement, stent placement, \no chemotherapy, XRT /30/08: Cisplatin etoposide\no L pneumonectomy, mediastinal LN dissection, \no bronchial washings + (brushings -) \no PET : uptake at pneumonectomy suture line, around cavity,\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\n home. S/P ablation in \n COPD\n Pulmonary embolism \n L frozen shoulder\n Per RAN\n Quit cigs 1 year ago.\n Review of systems: Reviewed in Detail . Please see RAN of .\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS BS on left, no crackles/wheezes\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology\n CBC, Chem 7 wnl\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -wean off pressors as tolerated\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n Cardiac\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n H/o Pulmonary embolism\n - not on anticoag due to risk factors and has cancer predisposing\n - however improving so results of scan not likely to change management\n at present\n - consider further w/u for PE once stabilized. Not likely to anticoag\n given risk though might warrant filter placement if sig clot burden\n given single lung and already had PE in past\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -MDI\n For remainder of plan see resident note.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT: Heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: MICU\n Patient is critically ill.\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375059,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Off neo\n started on solumedol\n CTA neg PE see report\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.6\nC (96\n HR: 98 (91 - 113) bpm\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\n RR: 20 (16 - 29) insp/min\n SpO2: 93% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,349 mL\n 295 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 295 mL\n Blood products:\n Total out:\n 4,270 mL\n 635 mL\n Urine:\n 4,270 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: fine interstitial pattern\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n BNP 1000\n Micro-urine negative\n -Blood pending\n -Legionella negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation.\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: NPO will discuss bronch.\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Will trend vitals if stable will call out.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375064,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Off neo\n started on solumedol\n CTA neg PE see report\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Cefipime - 10:00 PM\n Vancomycin - 02:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 PM\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.6\nC (96\n HR: 98 (91 - 113) bpm\n BP: 118/75(86) {82/54(64) - 128/93(99)} mmHg\n RR: 20 (16 - 29) insp/min\n SpO2: 93% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,349 mL\n 295 mL\n PO:\n 500 mL\n TF:\n IVF:\n 849 mL\n 295 mL\n Blood products:\n Total out:\n 4,270 mL\n 635 mL\n Urine:\n 4,270 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,921 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: fine interstitial pattern\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n BNP 1000\n Micro-urine negative\n -Blood pending\n -Legionella negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. Low WBC on high dose steroids may be\n secondary to possible viral etiology if this is not chemo related\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow, chemo related\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : transition to floor today, taper steroids over next week.\n Total time spent: 25 mins\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375066,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,02 weaned to 3L NC\n Response:\n Sats mostly in 92-95%,but does desats to high 80\ns at times,but quckly\n reverts back,also asymptamatic with desats,does gets sob at times with\n exertion which may require high amount of 02 for a brief period of\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375174,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt cont to desat to mid to high 80\ns when wearing only nasal canula.\n Upset about having to wear face mask and about having the door closed\n for droplet precautions.\n Action:\n Pt encouraged many times to wear face tent to keep o2 sat\ns elevated.\n Flu test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374978,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Rceievd the pt on 0.4mcg on neo,sbp in 100\ns,map 70\ns,uop\n 120-160cc/hr,CVP 6.no chest pain.warm extremities,\n Action:\n Neo weaned off,started on solumedrol,contd cefipime,vanco and levoquin.\n Response:\n Sbp mostly in 90-100\ns,but does drops to 80\ns at times,but mentaing\n fine with map>60,currently autodiuresing\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 70% face tent with 6L\n NC,sats in 92-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. ,non productive cough++,h/o PE in the past,HR\n 100-120 sinus tachy\n Action:\n Contd nebs,abx ,steroid,also Undergone CTA to r/o PE,received morphine\n for pain and compazine for nausea\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n tent.(50%),CTA chest prelim without any PE,but s/o diffuse parenchymal\n disease.\n Plan:\n Follow up on final read of CTA,cont nebs,solumedrol.Assess and manage\n pain.\n Others:PO intake better today.no episode of vomiting\n.daughter called\n ,updated by this RN..family member visited.\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375151,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 81 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 81 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -569 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375152,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 81 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 81 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -569 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. Low WBC on high dose steroids may be\n secondary to possible viral etiology if this is not chemo related\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow, chemo related\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375156,
"text": "Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), LUNG\n HYPOTENSION (NOT SHOCK)\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375158,
"text": "Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\n SpO2: 94%\n ABG: ////\n Physical Examination\n Pleasant appears comfortable today\n HEENT no oral ulcers\n Regular S1 S2 no m/r/g\n Lungs clear bilaterally, no wheezing or rales, decreased L base\n Abd soft nontender +bowel sounds\n Extrem warm no edema palpable distal pulses\n Neuro alert and interactive\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, admitted\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\n and tachycardia.\n # Sepsis: Clinically much improved. Thought likely a reaction to\n gemcitabine. No organisms identified.\n - Continue steroids for Gemcitabine-related inflammatory lung disease\n - Continue home levo, would stop vanc and zosyn today\n - Follow up cultures and reculture if febrile\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem once 24 hrs off pressors\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - follow daily, maintain active t+S, transfuse hct>25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375159,
"text": "Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\n SpO2: 94%\n ABG: ////\n Physical Examination\n Pleasant appears comfortable today\n HEENT no oral ulcers\n Regular S1 S2 no m/r/g\n Lungs clear bilaterally, no wheezing or rales, decreased L base\n Abd soft nontender +bowel sounds\n Extrem warm no edema palpable distal pulses\n Neuro alert and interactive\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n CXR \n 1. Stable post- pneumectomy appearance.\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n 3. Unchanged nodular opacities in the right peripheral lung base.\n Micro urine legionella negative, viral DFA negative, blood cx\n NGTD\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, admitted\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\n and tachycardia.\n # Sepsis: Clinically much improved. Thought likely a reaction to\n gemcitabine. No organisms identified.\n - Continue steroids for Gemcitabine-related inflammatory lung disease\n - Continue home levo, would stop vanc and zosyn today\n - Follow up cultures and reculture if febrile\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem today\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - follow daily, maintain active t+S, transfuse hct>25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 375168,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n No events breathing better.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n asa 325\n neurontin 600mg Q 8hr\n advair\n flecinide\n levofloxacin 500Q 24\n vanc 1g 12\n atrovent\n cefepime 2GQ12\n Solumedol 125Q6\n hep TID\n protonix\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 91% 5L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 81 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 81 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -569 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 1/3 up\n improved. Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology: no film Pending\n 9.4 g/dL\n 151 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n Labs pending:\n Micro-DFA negative\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. Low WBC on high dose steroids may be\n secondary to possible viral etiology if this is not chemo related\n Hypoxemia interstitial process\n -gemcitabine vs. sepsis\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will decrease solumedol 60mg Q6\n Hypotension\n -Continue antiarrythmic therapy\n -Give fluid if hypotensive\n Pancytopenia\n -Will follow, chemo related\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- CTA negative, per patient had \n problem from chest wound from anticoagulation chart reports hemoptysis.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM Will d\nc central line\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer: PPI steroids\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 375169,
"text": "Chief Complaint: fever\n 24 Hour Events:\n - flu sent and was negative\n - couldn't call out as was still requiring face tent intermittently\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:17 AM\n Vancomycin - 02:20 PM\n Cefipime - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:30 PM\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Breathing better today no pain.\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 91 (91 - 110) bpm\n BP: 109/69(79) {93/35(50) - 128/97(101)} mmHg\n RR: 25 (20 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,240 mL\n 83 mL\n PO:\n 500 mL\n TF:\n IVF:\n 740 mL\n 83 mL\n Blood products:\n Total out:\n 1,555 mL\n 650 mL\n Urine:\n 1,555 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -567 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula @4L, 50% face tent\n SpO2: 94%\n ABG: ////\n Physical Examination\n Pleasant appears comfortable today\n HEENT no oral ulcers\n Regular S1 S2 no m/r/g\n Lungs clear bilaterally, no wheezing or rales, decreased L base\n Abd soft nontender +bowel sounds\n Extrem warm no edema palpable distal pulses\n Neuro alert and interactive\n Labs / Radiology\n 151 K/uL\n 9.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 105 mEq/L\n 140 mEq/L\n 28.5 %\n 3.4 K/uL\n [image002.jpg]\n Labs above are from \n 04:06 PM\n 05:09 AM\n 04:11 AM\n WBC\n 5.6\n 6.1\n 3.4\n Hct\n 29.2\n 27.5\n 28.5\n Plt\n 147\n 161\n 151\n Cr\n 0.6\n 0.7\n 0.6\n Glucose\n 108\n 103\n 160\n Other labs: PT / PTT / INR:14.1/27.8/1.2, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.7\n mg/dL\n CXR \n 1. Stable post- pneumectomy appearance.\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n 3. Unchanged nodular opacities in the right peripheral lung base.\n Micro urine legionella negative, viral DFA negative, blood cx\n NGTD\n Assessment and Plan\n 59 year old male with recurrent squamous cell lung cancer, admitted\n C1D10 of gemcitabine, last dose on who p/w fever, hypotension\n and tachycardia.\n # Sepsis: Clinically much improved. Thought likely a reaction to\n gemcitabine. No organisms identified. SOB probably multifactorial with\n COPD, s/p pneumonectomy, gemcitabine effect and ?infection.\n - Continue steroids for Gemcitabine-related inflammatory lung disease.\n Will change to solumedrol 60q6 and plan to taper.\n - Repeat CXR today\n - Continue home levo, would stop vanc and cefepime today\n - Follow up cultures and reculture if febrile. Check sputum if making\n any.\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - Restart home diltiazem today\n # COPD: continue advair, prn albuterol, spiriva\n # Anemia: Likely from bone marrow supression from chemotherapy\n - follow daily, maintain active t+S, transfuse hct>25\n - Guiac stools\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - Treatment per Onc when infection resolves\n - Add on ANC today. WBC declining, likely due to recent chemotherapy.\n Needs CBC with diff today.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Dc central line\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: continue PPI\n VAP: OOB as tolerated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 375134,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol, ct\n scan r/o PE. Pt placed on droplet precautions, pt is neg for flu.\n Currently off precautions.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt cont to desat to mid to high 80\ns when wearing only nasal canula.\n Upset about having to wear face mask and about having the door closed\n for droplet precautions.\n Action:\n Pt encouraged many times to wear face tent to keep o2 sat\ns elevated.\n Flu test came back neg.\n Response:\n Pt refuses to keep face mask on and becoming agitated about being\n encouraged to wear it. Pt given serax to help sleep. Pt pleased that\n the test was neg and now off precautions.\n Plan:\n Cont to monitor o2 sat\ns and resp function. Cont to encourage wearing\n mask till o2 sat\ns stable. Cont with antbx and nebs.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374827,
"text": "Nursing Admission Note\n Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n No pain presently\n Action:\n Prn pain meds available for chronic back and s/p L pneumonectomy pain\n Response:\n As needed\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Pt on sm amt of neo on arrival from ed. Vss. Denies lightheadedness.\n Action:\n Continues on neo. Although apparently documented previous bp are\n 90-105/\n Response:\n Will titrate neo to off\n Plan:\n Titrate neo. Fluid as needed\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 374831,
"text": "Chief Complaint: fever\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS:\n ================\n Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H Aspirin 325 mg\n Tablet Sig: One (1) Tablet PO DAILY (Daily).\n Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H\n Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\n One (1) Disk with Device Inhalation (2 times a day).\n Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff\n Inhalation Q6H (every 6 hours) as needed.\n Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3\n times a day).\n Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6\n hours) as needed.\n Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at\n bedtime) as needed.\n Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO\n Q6H (every 6 hours) as needed.\n Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:\n One (1) Cap Inhalation DAILY (Daily).\n Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr\n Past medical history:\n Family history:\n Social History:\n PAST ONCOLOGIC HISTORY:\n ======================\n ONC: squamous cell lung cancer T3, N2 s/p L pneumonectomy after\n chemo and XRT; bronchoscopy on revealed erythema and abnormal\n appearance in the L bronchial stump suggesting recurrent disease.\n Recent PET shows some FDG avidity along the pneumonectomy suture line\n with a comment about a foci of avidity in the AP window area. There is\n also circumferential uptake around the pneumonectomy cavity. There is\n also a note of poor anatomic delineation without a contrast CT. There\n was also FDG avidity between the right atrial appendage and the left\n ventricular outflow track without anatomic correlate. No definite bony\n lesions, no subdiaphragmatic lesions. He is being considered for\n radiation therapy\n - He started weekly Taxotere on , and completed two\n cycles.\n - C1D10 of gemcitabine, last dose on \n .\n PAST MEDICAL HISTORY:\n ====================\n - a-flutter s/p ablation in ; not anticoagulated bleeding\n problems while on coumadin for PE in the past\n - PE \n - multiple PNAs, most recently in (as above)\n - + PPD, treated with INH x8 months (completed in )\n - COPD: FEV1 of 1.55 liters or 48% of predicted, an FVC of 2.38\n liters or 53% of predicted, and an FEV1/FVC ratio of 55%\n - Pulmonary embolism \n - L frozen shoulder\n Father died of laryngeal cancer. Does not know what his mother\n died from.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient is divorced and lives with his two daughters. son as\n well. Only rare alcohol use and prior tobacco use (roughly 70 pack\n years); he quit smoking approximately a year ago just prior to be\n diagnosed with lung cancer. He was born in and came to the U.S.\n roughly forty years ago.\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,231 mL\n PO:\n TF:\n IVF:\n 231 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,661 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n Physical Examination\n GENERAL: NAD\n SKIN: warm and well perfused, no excoriations or lesions, no rashes\n HEENT: no JVD, no LAD, no oral ulcers or lesions\n CARDIAC: RRR, S1/S2, no mrg\n LUNG: bilateral high pitched end expiratory wheeze\n ABDOMEN: nondistended, +BS, nontender in all quadrants, no\n rebound/guarding, no hepatosplenomegaly\n M/S: moving all extremities well, no cyanosis, clubbing or edema, no\n obvious deformities\n PULSES: 2+ DP pulses bilaterally\n NEURO: CN II-XII intact\n Labs / Radiology\n 181\n 134\n 0.9\n 14\n 21\n 104\n 4.2\n 136\n 32.7\n 7.2\n [image002.jpg]\n Other labs: Differential-Neuts:98.7, Band:0, Lymph:7.9, Mono:0.6,\n Eos:1.5\n Fluid analysis / Other labs: UA: neg\n lactate 2.9-> 0.6\n pH7.33/ 38/72 HCO3\n Mixed venous O2Sat: 94\n .\n PT: 15.1 PTT: 31.2 INR: 1.3\n .\n Trop< 0.01\n CK 31\n Imaging: CXR: white-out of left side c/w prior pneumonectomy, right\n side with unchanged streaking infiltrates\n Microbiology: UA: neg\n ECG: NSR, no ischemia\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia c/s sepsis.\n .\n # Sepsis: Presents with recent immunosupression but no neutropenia. Pt\n has fever and hypotension refractory to fluids c/w septic shock.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA.\n - wean off neo\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin\n - f/u LFT's\n - recheck CXR to see if infiltrate has developed post-hydration\n - f/u blood and urine Cx\n - obtain sputum cx\n - obtain legionella UA\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - hold diltiazem temporarily\n - neo rather than levo\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n .\n # Disposition: pending resolution of above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: not needed\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374836,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient, Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374837,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever and dizziness. He called\n the oncology fellow tonight w/ temp to 102.3. Onc fellow recommended he\n come to ER for counts to r/o febrile neutropenia. He reports that he\n had fever and rigors with chemotherapy 3 days ago, was told to take\n tylenol. The following day hie was afebrile. The day of admission, he\n felt weak, went to sleepi nthe afternoon and t hen awoke with fever\n 102.3., no chills or rigors. He states that he has been pushing fluids\n and has had nl urine output, btu has had appetitie. He denies any\n change in cough or sputum production\n only basein occaisonal thin\n white sputum- Sob at baseline, no V/D, no abd pain, no dysuria, no\n rashes, no oral ulcers, no myalgias, no HA. He states that he has been\n on levofloxacin as ppx for a long time.\n .\n In the ED: He was initially stable with SBP 116/76 but then developed\n tachycardiac to 120's and eventually hypotension to SBP 70's. He was\n given a central line -which had to be replaced 3 times due to curling\n of the line. He also was given 6liters NS with improvement of HR to\n 100's but SBP remained 85/40. Neo was started. CVP was 10 and UOP 1870.\n He was mentating well. He was also given Vancomycin and Cefepime. In\n addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51\n Vitals on transfer:\n .\n Of Note, he was discharged from the CCU one month ago after being\n admitted for aflutter with RVR. The resolved spontaneously and his\n medications were not changed.\n History obtained from Patient, Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 374840,
"text": "Chief Complaint: Fever, tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 59M with recurrent SCLC s/p left pneumonectomy, and s/p first round\n gemcitibine three days PTA. He presented with three days of\n intermittent fever to 102 , weakness and anorexia. He reports mild\n dyspnea and cough at baseline which is not worse. He was referred to\n the ED for evaluation and while there developed SBP to 70s and sinus\n tachycardia to 120 bpm. He received 6L NS without improvement so a CVL\n was placed and neosynephrine started. CVP=10. He received vanco and\n cefipime and was previously on levaquin\n On arrival his initial VS 116/76 88 76 22 100%2L . He was urinating\n and on 0.5 neosynephrine gtt. He did not develop hypoxemia.\n .\n In addition, no lateral ST depressions were noted in V4-V6; cardiac\n enzymes negative in the ED.\n History obtained from Medical Records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:08 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Asa 325\n Neurontin\n Advair\n Flecanide\n Levaquin 500 q24\n Vanco 1 q2 (#2)\n Atrovent nebs\n Morphine\n Heparin SC\n At Home Meds:\n Flecanide\n Cardizem\n Levaquin\n Advair\n Albuterol\n Neurontin\n Dilaudid\n Compazine\n atrovent\n Past medical history:\n Family history:\n Social History:\n T3N2 SCC s/p left pneumonectomy with recurrence in\n hilar stump and left pleura. Had taxotere x 2. gemcitibine x 1.\n Paroxysimal aflutter with RVR- on flecainide and cardizem at\n home. S/P ablation in \n Per RAN\n Quit cigs 1 year ago.\n Review of systems: Reviewed in Detail . Please see RAN of .\n Flowsheet Data as of 08:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 85 (85 - 85) bpm\n BP: 109/70(80) {109/70(80) - 109/70(80)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,243 mL\n PO:\n TF:\n IVF:\n 243 mL\n Blood products:\n Total out:\n 0 mL\n 2,570 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,673 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of gemcitibine. Sepsis a\n possibility but so far no infectious source. His respiratory status\n appears intact and is responding to resuscitation. Agree with MICU\n team plan of care and empahsize.\n CV\n 1. wean off pressors. Continue antiarrythmic therapy, not on\n anticoagulation due to bleeding risk.\n PULM\n On 3L NC presently but may not need this. Will wean off. Atrovent q6\n GI\n Full diet\n ID\n Micro w/u. Empiric vanco/cefpime with plan to discontinue if w/u\n negative.\n PPX- heparin SC\n DISPO- FULL code. MICU today for montioring. Possible transfer to\n floor if stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 374946,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Spiked to 101\n Weaned off Neo\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g\n atrovent\n cefepime\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100% 50%FM\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\n Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology:\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n BNP-Pending\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -Will Check CTPA to rule out PE and eval for PNA\n -Check BNP\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n -Give fluid if hypotensive\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- will check CTA, per patient had \n problem from chest wound from anticoagulation.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen\n ICU Care\n Nutrition: regluar diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 374953,
"text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note bellow.\n Chief complaint: Fever/hypotension\n HPI:\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. RA O2 requirement prior to admission.\n 24 Hour Events:\n Spiked to 101\n Weaned off Neo\n EKG - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:33 AM\n Cefipime - 10:17 AM\n Levofloxacin - 10:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n asa 325\n neurontin\n advair\n flecinide\n levofloxacin\n vanc 1g\n atrovent\n cefepime\n hep TID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.7\n HR: 109 (82 - 113) bpm\n BP: 83/60(65) {75/49(57) - 118/75(83)} mmHg\n RR: 27 (17 - 27) insp/min\n SpO2: 100% 50%FM\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 7 (7 - 7)mmHg\n Total In:\n 7,234 mL\n 672 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n 834 mL\n 472 mL\n Blood products:\n Total out:\n 4,930 mL\n 2,880 mL\n Urine:\n 3,060 mL\n 2,880 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -2,208 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n GEN NAD\n CV regular s1 s2 no m/r/g\n LUNGS No BS left, Fine dry end inspiratory rales right lung 2/3 up.\n Prolonged exp phase apex\n ABD Soft, NT/ND\n EXT Trace edema\n SKIN No rashes\n NEURO Non-focal\n Labs / Radiology:\n 9.2 g/dL\n 161 K/uL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n BNP-Pending\n Assessment and Plan\n 59M with severe SIRS likely as a consequence of recent gemcitabine\n therapy. Sepsis a possibility but so far no infectious source\n identified on evaluation. His oxygen requirement appear to be\n declining slowly and may reflect SIRS, PNA, and poor pulm reserve.\n There may be a component of underlying pulm HTN given the pneumoectomy\n and the prior PE. Agree with MICU team plan of care and empahsize:\n HoTN\n -gemcitabine vs. sepsis vs. cardiac vs. PE\n -weaned off pressor\n - empiric vanco/cefpime/levaquin pending cx data. If negative cx. d/c\n abx and continue levaquin\n -Will Check CTPA to rule out PE and eval for PNA\n -Check BNP\n -Continue antiarrythmic therapy\n -not on anticoagulation due to bleeding risk.\n -Give fluid if hypotensive\n Hypoxemia\n -requiring supp FiO2 via NC - wean as tolerated\n - Atrovent q6\n -Will start emperic solumedol 125Q6\n Afib\n -Continue home meds holding dilt until BP improves\n H/o Pulmonary embolism- will check CTA, per patient had \n problem from chest wound from anticoagulation.\n Recurrent NSCLCA\n -s/p gemcitabine\n COPD\n -home regimen, may need anxiolytics for dyspnea. If worsens, will try\n BiPAP\n ICU Care\n Nutrition: regluar diet\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ heprin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 mins\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374815,
"text": "Nursing Admission Note\n Pt is a 59 yo male, comes to the ED last eve after having fever,\n weakness and nausea at home.\n He has a hx of recurrant NSMLCA, L pneumonectomy , afib/flutter s/p\n ablasion, PE\ns , he is not on anti-ocag for this, multiple bouts\n of pna, +ppd in past, full course of INH given.\n In the , pt\ns bp upon arrival was in the 70\ns, hr in the 120\ns. He\n received 6L of ns, and started on neo. Hr 70\ns bp 116\ns now. Initially\n sepsis catheter placed, unable to position well and was replaced with a\n tlc. Initial lactate 2.9, now 0.6.\n Sent to the micu for further care\n Pt is divorced and lives at home with his two supportive daughters\n Acute \n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 374933,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\n - on levoquin chronically\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 374935,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n - spiked temp to 101, rigors\n resolved with Tylenol, not cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - had been on Vanc/Cefepime/Levofloxacin for broad coverage\n - on levoquin chronically\n - if Blood cx neg after 49 hrs would stop Vanc/Cefepime as well\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2152-04-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 374937,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 04:00 PM\n \n - continued abx for emprici covergae in setting of fever, hypotension,\n although still most likely gemcitabine related\n - needed intermittant pressors during the day\n - spiked temp to 101, rigors\n resolved with Tylenol, not cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 AM\n Cefipime - 10:20 PM\n Vancomycin - 02:33 AM\n Infusions:\n Phenylephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.6\nC (97.8\n HR: 101 (78 - 110) bpm\n BP: 109/75(83) {74/28(46) - 118/77(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,234 mL\n 386 mL\n PO:\n 400 mL\n TF:\n IVF:\n 834 mL\n 386 mL\n Blood products:\n Total out:\n 4,930 mL\n 1,980 mL\n Urine:\n 3,060 mL\n 1,980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n -1,594 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 108 mEq/L\n 140 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 04:06 PM\n 05:09 AM\n WBC\n 5.6\n 6.1\n Hct\n 29.2\n 27.5\n Plt\n 147\n 161\n Cr\n 0.6\n 0.7\n Glucose\n 108\n 103\n Other labs: PT / PTT / INR:14.7/36.6/1.3, ALT / AST:20/29, Alk Phos / T\n Bili:84/0.5, Differential-Neuts:89.6 %, Lymph:7.9 %, Mono:0.6 %,\n Eos:1.8 %, Albumin:2.9 g/dL, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ACUTE PAIN\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n 59 year old male with recurrent squamous cell lung cancer, now C1D10 of\n gemcitabine, last dose on who p/w fever, hypotension and\n tachycardia.\n .\n # Hypotension/Fever: Presents with recent immunosupression but no\n neutropenia. Pt has fever and hypotension refractory to fluids.\n However, his CVP is 10, he has good urine output and lactate has\n improved which indicates that he is likely volume rescucitated. In\n addition, his mixed venous O2 is c/w sepsi at 94s. He has no\n localizing source at this time with baseline CXR and neg UA. His shock\n is most likely a distrubtive shock picture and is most likely c/w\n reaction to gemcitabine.\n - wean off neo as tolerated\n - keep MAP 60 or SPB>85\n - monitor CVP and urine output\n - cont Vanc/Cefepime/Levofloxacin for broad coverage\n - check CTA of chest, d/c Vanc / Cefepime if no infiltrate\n - if Blood cx neg after 48 hrs would stop Vanc/Cefepime as well\n - on levoquin chronically\n - f/u blood and urine Cx\n - obtain sputum cx if possible\n .\n # Non-gap metabolic acidosis: pH 7.33/38, bicarb 21, AG 11. Appropriate\n respiratory compensation. Last albumin 3.3 in 2/009. Pt is not having\n diarrhea and has nl creatinine.\n - check albumin\n - will follow\n .\n # Atrial fibrillation: In sinus rhythm.\n - Continue flecainide, aspirin.\n - restart home diltiazem once 24 hrs off pressors\n .\n # COPD: continue advair, prn albuterol, spiriva\n .\n # Anemia: Likely from bone marrow supression from chemotherapy\n - trend for now\n - guiac stools\n .\n # Squamous cell carcinoma: s/p neoadjuvant cisplatin and etoposide with\n concomitant radiation completed for squamous cell lung cancer\n s/p left pneumonectomy on and s/p first dose of palliative\n Taxotere on .\n - treatment per Onc when infection resolves\n .\n # FEN: cardiac/heart healthy diet, replete lytes prn\n .\n # Prophylaxis: sc heparin, bowel regimen prn\n .\n # Code: presumed full\n .\n # Communication: Daughter (; HCP is son\n , Phone number: \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:48 AM\n 18 Gauge - 04:49 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 374998,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n Hypotension (not Shock)\n Assessment:\n Pt alert and oriented. No episodes of dizziness. Bp normotensive. O2\n sat\ns dropping occ to high 80\ns. hr in 90\ns to low 100\ns with occ\n pvc\n Action:\n ,contd cefipime,vanco and levoquin, solumedrol had been given Q8hr\n and has now been inc to q 6/hrs.\n Response:\n No drop in blood pressure, mentaing fine with map>60, urine output\n slowing down.\n Plan:\n Goal sbp>85,map>60,If hypotensive may need fluid bolus.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Pt with 5lnc on all shift and will occ drop o2 sat\ns to the high 80\n resp rate in the 20\ns, lung sounds witih insp/exp wheezes. Vss.\n Action:\n Pt receiving nebs and using inhalers. Also receiving steroids which\n have been inc to q 6/hrs. occ will put on face tent to help with\n desaturation.\n Response:\n Pt does get sob intermittently,o2 requirement varies greatly,pt seems\n comfortable on 5L nc mostly and intermittent sob is manged with face\n tent.(50%), final read of cta neg for pe.\n Plan:\n cont nebs,solumedrol.\n"
},
{
"category": "Nursing",
"chartdate": "2152-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 375086,
"text": "HPI:59 yr old male with recurrent squamous cell carcinoma,s/p left\n pneumonectomy in presented with fever and dizziness post\n chemotherapy with gemcitabine,last dose was on .At the time of\n presentation to ED BP was 116/76 but subsequently HR went up to 120\n and BP dropped to 80\ns,A central line was placed and received 6L\n NS,,HR improved to 100\ns post fluid but BP was 85/40.Started on low\n dose of Neo,also received Vancomycin and cefipime for ?PNA.Transferred\n to MICU for further care.\n ICU course:Neo was successfully weaned off,started on solumedrol,02\n wened to 3L NC,ruled out PE with CTA.\n Cancer (Malignant Neoplasm), Lung\n Assessment:\n Known Ca lung,s/p left pneumonectomy in ,pt doesn\nt uses O2 at\n home,known copd also,received the pt this am with 5L NC,sats in\n 91-95%,resting comfortably,diminished breath sounds on the\n left,crackles on the Rt. base,non productive cough+,h/o PE in the\n past,HR 90-120,sinus,CTA neg for PE\n Action:\n Contd nebs,abx ,steroid,02 weaned to 3L NC\n Response:\n Sats mostly in 92-95%,but does desats to high 80\ns at times,but quckly\n reverts back,also asymptamatic with desats,does gets sob at times with\n exertion which may require high amount of 02 for a brief period of\n time..CT chest more like pneumonotis picture ?gemcitabine toxicity\n Plan:\n Will cont to assess the respiratory status,wean 02 as needed,cont nebs\n and solumedrol.\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1078223,
"text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change as remains hypoxic.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with gemcitabine related inflammatory lung disease\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change as remains hypoxic.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DDBc WED 12:19 PM\n PFI: No change from prior day. Nonspecific but progressive right-sided\n process.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with lung cancer on gemcitabine. To further assess.\n\n TECHNIQUE: radiograph was obtained.\n\n COMPARISON: .\n\n REPORT:\n\n Patient is status post pneumonectomy on the left side. A left-sided central\n line is identified in situ. There is evidence of widespread patchy change in\n the right lung, which is nonspecific, but as mentioned before could reflect\n toxic drug damage ,edema or infection. The appearances are certainly not\n changed from prior day, but when compared to multiple prior radiographs have\n demonstrated probable progressive change. The nodular pattern may be\n misleading given the widespread emphysematous change present. Osseous\n structures are grossly unremarkable.\n\n CONCLUSION:\n\n No change from previous day.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077654,
"text": " 12:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new L IJ\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with new left IJ. Evaluate line placement.\n\n COMPARISON: at 10:37 p.m.\n\n SINGLE AP VIEW OF THE CHEST: There is a new left internal jugular central\n line, with tip crossing midline and likely extending into the right\n brachiocephalic vein.\n\n Again noted are left pneumonectomy changes, with shift of midline structures\n to the left. Within the right lung are emphysematous changes, with patchy\n nodular and airspace opacities within the right lower lung, as previously\n seen, likely reflecting residual infection. Of note, the right costophrenic\n sulcus is excluded.\n\n IMPRESSION: Left IJ central line tip crossing midline, and crossing over to\n the right brachiocephalic vein.\n\n Dr. was paged at the time of this interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1077880,
"text": " 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, PEs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 9:31 PM\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\n Increased diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right middle\n lobe nodule slightly increased, likely infectious. Persistent worrisome\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\n ______________________________________________________________________________\n FINAL REPORT\n CTPA INPATIENT\n\n REASON FOR EXAM: 59-year-old men with history of PE, rule out pneumonia, now\n with hypoxia.\n\n TECHNIQUE: Chest MDCT was performed without and following 100 cc of\n intravenous Optiray using 5 mm and 2.5 mm axial slice thickness. Coronal,\n sagittal and oblique reformations were also obtained.\n\n COMPARISON: and priors back to .\n\n FINDINGS: There is no pulmonary embolism to the subsegmental level on the\n right. Left pneumonectomy is again seen. Soft tissue in the left hilar\n region and lateral to the hilar stump is unchanged, worrisome for local\n recurrence, up to 12 mm in thickness lateral to the surgical sutures. Basilar\n pleural nodules are also unchanged, corresponding to areas of FDG avidity on\n the most recent PET/CT. Emphysema is unchanged.\n\n Peribronchial and diffuse opacities in the right lung have increased. Right\n middle lobe peribronchial opacity also slightly increased (3:63). Scattered\n coronary artery calcifications are unchanged. Tiny small right pleural\n effusion is new. Signs of anemia persist. There is no pericardial effusion.\n\n This study was not tailored for subdiaphragmatic evaluation but the upper\n abdomen is unremarkable. There is no bone lesion suspicious for malignancy.\n Left humeral bone infarct or enchondroma is unchanged. Left thoracotomy\n changes are stable.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. Increased peribronchial and diffuse right lung opacities, superimposed\n upon emphysema. The diffuse abnormalities may be due to pulmonary edema,\n especially given a new small right pleural effusion, but diffuse infection is\n (Over)\n\n 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n also possible. Right middle lobe and other peribronchial opacities slightly\n increased, likely infectious, but attention to this region should be paid on\n subsequent followups.\n\n 3. Persistent soft tissue lateral to the hilar pneumonectomy stump, very\n worrisome for local recurrence. Unchanged left basilar pleural nodules,\n suggestive of pleural metastases.\n\n 4. Signs of anemia.\n\n 5. Stable old left humeral bone infarct or enchondroma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1077881,
"text": ", MED MICU-7 1:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pneumonia, PEs.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with h/o PEs, ? pneumonia, now w/ hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, PEs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No pulmonary embolism to the subsegmental level. Left pneumonectomy.\n Increased diffuse right lung opacities and new small right pleural effusion,\n could be due to superimposed edema on infection and emphysema. Right middle\n lobe nodule slightly increased, likely infectious. Persistent worrisome\n thickening of the left hilar stump and pleural nodules. Signs of anemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1078224,
"text": ", MED MICU-7 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change as remains hypoxic.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with gemcitabine related inflammatory lung disease\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change as remains hypoxic.\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change from prior day. Nonspecific but progressive right-sided\n process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077661,
"text": " 2:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new position of L IJ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with repositioned L IJ\n REASON FOR THIS EXAMINATION:\n ? new position of L IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with repositioned left IJ.\n\n COMPARISON: .\n\n SINGLE AP VIEW OF THE CHEST: The left internal jugular central venous\n catheter tip appears in same position, likely within the right brachiocephalic\n vein. There has been no other interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077662,
"text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new L IJ\n REASON FOR THIS EXAMINATION:\n ? placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with new left IJ. Evaluate placement.\n\n COMPARISON: at 2:22 a.m.\n\n SINGLE AP VIEW OF THE CHEST: There is a left internal jugular venous\n catheter, which has been retracted, and tip likely lies within the left\n brachiocephalic vein. There have been no other interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077967,
"text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 3:13 PM\n Interval increase in reticular nodular opacities in the right mid lung and\n lower lobe concerning for volume overload, infection or, less likely\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male with hypoxia. Evaluate for change.\n\n COMPARISON: Multiple studies including most recent of and CT of\n .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: As before, there is complete opacification\n of the left hemithorax consistent with prior pneumonectomy. Nodular opacities\n in the right peripheral lung base are not significantly changed from prior.\n However, there is increased reticulonodular opacities in the right lung base\n concerning for volume overload, infection or, less likely, post- pneumectomy\n syndrome resulting in impaired lymphatic or venous drainage. The remainder of\n the exam including the left IJ catheter is unchanged.\n\n IMPRESSION:\n 1. Stable post- pneumectomy appearance.\n\n 2. Increased reticular nodular opacity in the right mid- and lower lung\n concerning for volume overload, infection or post-pneumectomy syndrome\n resulting in impairment of lymphatic or venous drainage.\n\n 3. Unchanged nodular opacities in the right peripheral lung base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077968,
"text": ", MED MICU-7 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in reticular nodular opacities in the right mid lung and\n lower lobe concerning for volume overload, infection or, less likely\n post-pneumectomy syndrome with impaired lymphatic or venous drainage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077647,
"text": " 10:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with squamous cell lung CA, Hypotensive, tachycardic, febrile.\n I s/p L lubectomy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with squamous cell carcinoma, hypotensive,\n tachycardia, status post left pneumonectomy. Evaluate for infiltrate.\n\n COMPARISON: .\n\n SINGLE SUPINE AP VIEW OF THE CHEST: The patient is status post left\n pneumonectomy, with fluid within the left pneumonectomy space. There is\n unchanged leftward shift of mediastinal structures. The right lung contains\n ill-defined patchy and nodular densities, particularly within the right lower\n lung, which may reflect residual areas of consolidation, likely infectious, as\n seen on prior chest CT . Emphysema is also noted. There is no\n pleural effusion or pneumothorax within the right lung.\n\n IMPRESSION:\n 1. Stable post left pneumonectomy changes.\n 2. Patchy nodular densities within the right lower lung, likely reflect\n residual infection, as seen on chest CT .\n 3. Emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077729,
"text": " 1:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls eval for infiltrate, interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with lung ca, s/p pneumonectomy, now s/p hydration\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: , 3:59 a.m.\n\n FINDINGS: As compared to the previous examination, there is little overall\n change. The left-sided central venous access line is in constant position,\n with its tip projecting over the slightly displaced trachea. The total\n opacification of the left hemithorax is constant (status post pneumonectomy).\n In the right lung, there is a minimal decrease of the diffuse parenchymal\n opacities that remain, however, clearly visible, notably in the periphery of\n the lung.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-04-22 00:00:00.000",
"description": "Report",
"row_id": 217629,
"text": "Sinus tachycardia. Lateral ST-T wave changes. Cannot rule out myocardial\nischemia. Compared to the previous tracing of atrial fibrillation has\nnow converted to sinus rhythm. Ventricular premature beats have resolved.\nLateral ST-T wave changes are new. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-04-23 00:00:00.000",
"description": "Report",
"row_id": 217628,
"text": "Sinus tachycardia\nAnterolateral ST-T changes are nonspecific\nSince previous tracing of , the heart rate has decreased, ST-T wave\nabnormalities are less\n\n"
}
] |
96,643 | 152,852 | 60yo female with history of MS, neurogenic bladder and disorder who presents from rehab with altered mental status, found to have E. coli UTI, bacteremia and sepsis, resolved with antibiotics. 1. E. coli UTI, bacteremia, and sepsis- Patient presented with altered mental status, elevated WBC, elevated lactate and positive UA. Imaging concerning for pyelonephritis. She received ceftriaxone in the ED but developed possible anaphylaxis. Initially treated in the MICU given sepsis with temperature of 101 and tachycardic to the 130s. Meropenem and Vancomycin started in the MICU. The urology service was consulted and they determined that the only indication for drainage would be if there is an obstruction; she has chronic hydronephrosis due to neurogenic bladder and reflux. An arterial line and a central venous access line were placed and patient given fluids. Her urine and blood cultures both resulted E.coli sensitive to fluoroquinolones. Her vancomycin and meropenem were discontinued and switched to cipro to complete a 14-day treatment course (last day ). UTI appears related to sexual intercourse and neurogenic bladder. Consider post-coital prophylaxis. 2. Altered mental status- Pt was initially lethargic upon her admission to the MICU. She was extremely agitated on the night of and she was given seroquel and haldol which eventually calmed her down. Her mental status waxed and waned during her stay in the MICU and she was re-started on her home wellbutrin and divalproex. Pt had a negative head CT. After transfer to the floor, patient continues to have waxing and mental status, but slowly improved over time. AAOx3 on discharge. Trazodone held in the setting of altered mental status, consider restarting as outpatient when stable. 3. Possible Anaphylaxis- Patient became hypotensive to the high 70s while undergoing CT scan in the ED after receiving ceftriaxone. She received benadryl, steroid, famotidine and epinephrine with reponse in BP. Rash resolved by the time of her admission to the MICU. Unclear if this is secondary to contrast vs ceftriaxone the patient received in the ED as she has a known penicillin allergy. 4. Multiple sclerosis- patient takes Glatiramer for relapsing MS. She is not on any other chronic medications (interferon beta 1a, natalizumab). She is taking baclofen and detrol for history of neurogenic bladder. Copoxone was initially held in the setting of sepsis. Restarted on discharge. Her baclofen and detrol were continued at her home dose. 5. Neurogenic bladder- Patient has incontinence at baseline without urinary retention. Detrol held in the setting of UTI and sepsis. Consider restarting as outpatient. 6. Depression, disorder - Pt was periodically with altered mental status and agitation during her stay in the MICU. Her home buproprion and divalproex were continued. 7. Hyperlipidemia- continued on her home statin # Transitional issues- Pending HIV screening results, blood culture, urine culture (will communicate to Dr. Restart Detrol after UTI treatment Restart Trazodone once mental status completely back to baseline Consider starting Bactrim DS for postcoital prophylaxis | There is left retrocardiac opacification, likely atelectasis. EXAMINATION: NON-CONTRAST HEAD CT. There is delayed excretion of contrast of the left as compared to the right kidney. (Over) 1:03 AM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for intraabdominal process Contrast: OPTIRAY Amt: FINAL REPORT (Cont) CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and uterus are unremarkable. This examination is motion limited with repeat axial series attempted through the region of greatest motion in the mid abdomen. There is mild left hydroureteronephrosis demonstrated to the level of the distal ureter (300B:33) where there is an apparent intraluminal filling defect involving the left distal ureter, of indeterminate significance. Mild left hydroureteronephrosis demonstrated to the level of distal ureter where there is an apparent filling defect which non-specific and may represent a stone, debris, or even possibly soft tissue. Contrast is demonstrated within the right renal collecting system. FINDINGS: CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal bibasilar atelectasis, left slightly greater than right. FINDINGS: A frontal view was performed only with a lateral deferred secondary to patient's request. Delayed excretion of contrast involving the left kidney. Also, a left-sided retrocardiac density remains and raises question of atelectasis versus infiltrate. Whit ematter hypodense foci- likely non-specific. Ectasia of the left renal pelvis is seen. There is extensive periventricular and subcortical hypodense foci which are non-specific in appearance. Non-specific ST-T wave changes in the anterior precordial leads.Compared to the previous tracing of the anterior precordial T wavechanges are slightly less prominent. The patient is noted to have a cervical fusion, incompletely assessed on this examination. During the interval, a left-sided central venous line has been placed using the subclavian approach. These findings may benon-specific although cannot exclude the possibility of myocardial ischemia.Clinical correlation is suggested. Clip # Reason: Is there evidence of outflow obstruction (renal calculi)? EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH. Mild left hydroureteronephrosis with an apparent intraluminal filling defect in the distal ureter which is non-specific and may represent debris, a non-calcified, stone, and soft tissue also remains a possibility. Lead V6 is absent. Lead V6 is absent. Loss of the normal corticomedullary differentiation of the left kidney which raises concern for possible pyelonephritis. There is suggestion of loss of the normal corticomedullary differentiation, particularly on the repeat sequences (2B:104 and 2B:110) that raises concern for infection. Evaluate for intracranial process. REASON FOR THIS EXAMINATION: Is there evidence of outflow obstruction (renal calculi)? The urinary bladder appears within normal limits. Thick-walled enhancing bladder compatible with clinically known cystitis. Thick-walled bladder compatible with clinically known cystitis. Recent abdominal CT showing left hydroureteronephrosis. TECHNIQUE: Helically acquired axial images were obtained from the lung bases to the pubic symphysis after the uneventful administration of 130 cc of Optiray intravenous contrast. There is hyperostosis frontalis. FINDINGS: AP single view of the chest has been obtained with patient in supine position. Sinus rhythm with borderline lowQRS voltage. Right ocular lens is not seen. There is grade 1 anterolisthesis of the L3 on L4 vertebral body. FINAL REPORT STUDY: Renal ultrasound. IMPRESSION: Left retrocardiac opacification, likely atelectasis, though infection remains a less likely possibility. The ureteral jets are seen bilaterally. The line terminates overlying the SVC at the level 3 cm below the carina and still above the expected entrance into the right atrium. Borderline low QRS voltage. (Over) 1:03 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for intracranial process FINAL REPORT (Cont) The liver, gallbladder, spleen, both adrenal glands, right kidney and right ureter, pancreas, and visualized loops of intra-abdominal small and large bowel are unremarkable. The bladder is relatively thick-walled with enhancement in keeping with known diagnosis of cystitis. Evaluate for acute intra-abdominal process. Sphenoid sinus septation inserts on the right carotid groove. There is normal corticomedullary echotexture. Sinus rhythm. T wave inversion in leads V1-V3 withnon-specific T wave flattening in leads I, aVL and V4-V5. EXAMINATION: CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST. General vascular appearance in the lung is that of congestion; however, this might be simulated by patient's poor inspirational effort and motion blur. 1:03 AM CT ABD & PELVIS WITH CONTRAST Clip # Reason: evaluate for intraabdominal process Contrast: OPTIRAY Amt: MEDICAL CONDITION: 60 year old woman with altered mental status, abdominal pain and tenderness, RLQ pain REASON FOR THIS EXAMINATION: evaluate for intraabdominal process No contraindications for IV contrast WET READ: 3:19 AM Subtle loss of the corticomedullary differentiation of the left kidney with delayed excretion raises concern for pyelonephritis. The cardiomediastinal and hilar contours are normal. Motion-limited examination demonstrating no acute intracranial hemorrhage or mass effect. In addition, there is diffuse prominence of the extra-axial spaces and sulci in the parietal and occipital lobes and posterior fosssa. | 7 | [
{
"category": "Radiology",
"chartdate": "2181-09-13 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1213254,
"text": " 1:31 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: EVALUATE FOR CARDIOPULMONARY PROCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with altered mental status.\n\n EXAMINATION: SINGLE FRONTAL CHEST RADIOGRAPH.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n A frontal view was performed only with a lateral deferred secondary to\n patient's request. There is left retrocardiac opacification, likely\n atelectasis. The remainder of the lungs are clear with no other focal\n opacification. There are no pleural effusions or pneumothorax. The\n cardiomediastinal and hilar contours are normal. There may be pulmonary\n vascular congestion, though the vasculature is in part enlarged by supine\n technique. Contrast is demonstrated within the right renal collecting system.\n The patient is noted to have a cervical fusion, incompletely assessed on this\n examination.\n\n IMPRESSION: Left retrocardiac opacification, likely atelectasis, though\n infection remains a less likely possibility.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-09-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1213249,
"text": " 1:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:28 AM\n Motion limited. Diffuse global atrophy. No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with altered mental status. Evaluate for\n intracranial process.\n\n EXAMINATION: NON-CONTRAST HEAD CT.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. Initial\n attempts were motion limited. Subsequent attempts still demonstrated\n limitations from motion.\n\n FINDINGS:\n\n Motion-limited images through the brain are grossly unremarkable with no\n evidence of hemorrhage, edema, mass effect, or obvious acute infarction. The\n -white matter differentiation is preserved. There is extensive\n periventricular and subcortical hypodense foci which are non-specific in\n appearance. The ventricles and sulci are prominent, most compatible with a\n component of involutional change. In addition, there is diffuse prominence of\n the extra-axial spaces and sulci in the parietal and occipital lobes and\n posterior fosssa. There is hyperostosis frontalis. The visualized portions\n of the paranasal sinuses and mastoid air cells are well aerated. Sphenoid\n sinus septation inserts on the right carotid groove.\n Right ocular lens is not seen.\n\n IMPRESSION:\n\n 1. Motion-limited examination demonstrating no acute intracranial hemorrhage\n or mass effect.\n 2. Whit ematter hypodense foci- likely non-specific. However, correlate\n clinically to decide on the need for further workup with MRI if not\n contra-indicated.\n (Over)\n\n 1:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-09-13 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1213250,
"text": " 1:03 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intraabdominal process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with altered mental status, abdominal pain and tenderness,\n RLQ pain\n REASON FOR THIS EXAMINATION:\n evaluate for intraabdominal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:19 AM\n Subtle loss of the corticomedullary differentiation of the left kidney with\n delayed excretion raises concern for pyelonephritis. Mild left\n hydroureteronephrosis with an apparent intraluminal filling defect in the\n distal ureter which is non-specific and may represent debris, a non-calcified,\n stone, and soft tissue also remains a possibility.\n Thick-walled bladder compatible with clinically known cystitis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with altered mental status and abdominal pain\n and tenderness. Evaluate for acute intra-abdominal process.\n\n EXAMINATION: CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the uneventful administration of 130 cc of\n Optiray intravenous contrast. This examination is motion limited with repeat\n axial series attempted through the region of greatest motion in the mid\n abdomen. Coronal and sagittal reformations are provided for review.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n There is minimal bibasilar atelectasis, left slightly greater than right. The\n lung bases are otherwise clear with no focal parenchymal opacification.\n\n The liver, gallbladder, spleen, both adrenal glands, right kidney and right\n ureter, pancreas, and visualized loops of intra-abdominal small and large\n bowel are unremarkable.\n\n There is delayed excretion of contrast of the left as compared to the right\n kidney. There is suggestion of loss of the normal corticomedullary\n differentiation, particularly on the repeat sequences (2B:104 and 2B:110) that\n raises concern for infection. There is mild left hydroureteronephrosis\n demonstrated to the level of the distal ureter (300B:33) where there is an\n apparent intraluminal filling defect involving the left distal ureter, of\n indeterminate significance.\n (Over)\n\n 1:03 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for intraabdominal process\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n uterus are unremarkable. The bladder is relatively thick-walled with\n enhancement in keeping with known diagnosis of cystitis. There is no pelvic\n free fluid. There is no pelvic or inguinal lymphadenopathy. The appendix is\n normal in appearance. This can best be appreciated with tip at the level of\n 300B:28.\n\n BONE WINDOWS: There are multilevel degenerative changes with dextroconvex\n scoliosis of the thoracolumbar spine. There is grade 1 anterolisthesis of the\n L3 on L4 vertebral body.\n\n IMPRESSION:\n\n 1. Loss of the normal corticomedullary differentiation of the left kidney\n which raises concern for possible pyelonephritis.\n 2. Delayed excretion of contrast involving the left kidney. Mild left\n hydroureteronephrosis demonstrated to the level of distal ureter where there\n is an apparent filling defect which non-specific and may represent a stone,\n debris, or even possibly soft tissue.\n 3. Thick-walled enhancing bladder compatible with clinically known cystitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-09-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1213343,
"text": " 3:41 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate placement of left subclavian line\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with presumed urosepsis\n REASON FOR THIS EXAMINATION:\n Evaluate placement of left subclavian line\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 60-year-old female patient with presumed urosepsis, evaluate\n placement of left subclavian line.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. Analysis is performed in direct comparison with the next\n preceding similar study obtained 13 hours earlier during the same day. During\n the interval, a left-sided central venous line has been placed using the\n subclavian approach. The line terminates overlying the SVC at the level 3 cm\n below the carina and still above the expected entrance into the right atrium.\n No pneumothorax or any other placement-related complication is identified.\n General vascular appearance in the lung is that of congestion; however, this\n might be simulated by patient's poor inspirational effort and motion blur.\n Also, a left-sided retrocardiac density remains and raises question of\n atelectasis versus infiltrate. No pneumothorax is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-09-18 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1213895,
"text": " 8:49 AM\n RENAL U.S. Clip # \n Reason: Is there evidence of outflow obstruction (renal calculi)?\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with multiple sclerosis and neurogenic bladder, with\n abdominal CT findings of L hydroureteronephrosis with filling defect concerning\n for possible stone or soft tissue, as well as pyelonephritis and cystitis. Pt\n has E. coli UTI and was in the ICU for urosepsis.\n REASON FOR THIS EXAMINATION:\n Is there evidence of outflow obstruction (renal calculi)?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound.\n\n INDICATION: 60-year-old female with multiple sclerosis and neurogenic\n bladder. E. coli urinary tract infection. Recent abdominal CT showing left\n hydroureteronephrosis.\n\n TECHNIQUE: Realtime Grayscale and color Doppler imaging of the kidneys\n bilaterally and urinary bladder was performed and reviewed.\n\n Correlation is made to previous CT of the abdomen and pelvis dated .\n\n FINDINGS: The right kidney measures 12 cm in size and the left kidney\n measures 12 cm in size. There is normal corticomedullary echotexture.\n Ectasia of the left renal pelvis is seen. There is no evidence of\n hydronephrosis or nephrolithiasis.\n\n The urinary bladder appears within normal limits. The ureteral jets are seen\n bilaterally.\n\n IMPRESSION: No evidence of hydronephrosis or nephrolithiasis.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-09-13 00:00:00.000",
"description": "Report",
"row_id": 236021,
"text": "Baseline artifact. Lead V6 is absent. Sinus rhythm with borderline low\nQRS voltage. Non-specific ST-T wave changes in the anterior precordial leads.\nCompared to the previous tracing of the anterior precordial T wave\nchanges are slightly less prominent. Lead V6 is absent. Suggest repeat tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2181-09-12 00:00:00.000",
"description": "Report",
"row_id": 236022,
"text": "Sinus rhythm. Borderline low QRS voltage. T wave inversion in leads V1-V3 with\nnon-specific T wave flattening in leads I, aVL and V4-V5. These findings may be\nnon-specific although cannot exclude the possibility of myocardial ischemia.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
23,483 | 108,568 | 59 year old female with dilated CM (EF 15%) s/p BiV ICD, s/p CABG ' SVG-LAD, Severe MR & TR, PAF, presenting with SOB & fevers. 1. CV: A) Pump: The patient presented with a history of CHF/CMP and hx, sx and exam consistent with failure (SOB, orthopnea, JVD, mild crackles, non-pitting edema). On admission, she was started on milrinone and her lasix was increased as her BP tolerated. She did not diurese well on this regimen and was transferred to the CCU on where a a Swan Ganz catheter was placed for tailored CHF therapy. In the CCU, she was continued on milrinone gtt and a nipride gtt was titirated up to achieve a CI of >2.2 and a decreased SVR and PAP. On this therapy she achieved good diuresis with average 24 hours fluid balance negative 1-2L. After the initial success with diuresis, the patient was started on valsartan and imdur in an attempt to wean off drips and convert to oral medication. With steadily increasing doses of valsartan and imdur, she did wean off the nipride and the milrinone but developed an episode of sustained hypotension and decreased urine output when the milrinone was stopped. From this it was presumed that the patient required the additional inotropic support of the milrinone, and after re-starting milrinone her CO and CI increased sufficiently to maintain MAP >60. On HD#10 (), the patient was on a stable dose of aldactone 25mg once daily (decreased from 50mg po daily as an outpatient), bisoprolol 5mg once daily, milrinone 0.385mcg/kg/min gtt and was loaded on digoxin. Her isordil, nipride, valsartan, and lasix were discontinued. Once on a stable heart failure regimen, the patient was transferred out of the CCU and sent to the step down unit. There her ins and outs were not well recorded and secondary to a foley that was re-inserted on the floor, she developed a UTI/pyelonephritis confirmed by CT scan which required re-admission to the CCU for further management. On her second admission to the CCU, her heart failure regimen was again altered due to her inability to tolerate milrinone secondary to development of persistent HA. She was empirically taken off milrinone with subsequent decompensation and was then started on low dose dopamine instead. She tolerated the dopamine well with good urine output and maintenance of pressures. She was able to regain forward flow and returned to compensated heart failure. At this point her regimen consisted of Dopamine 2.5mcg/kg/min, bisoprolol 5mg once daily, and digoxin 0.125mg once daily. She was taken off the aldactone for persistent hyponatremia. Initially the plan was to discharge her on home dopamine, but without right heart catheterization, approval was not granted for home dopamine infusion. The patient refused another right heart cath. Upon the patient's insistence, dopamine was discontinued. She maintained her blood pressures and remained in compensated CHF during the following day. She also decided to pursue cardiac transplantation prior to discharge. The PFT's, carotid studies and panel of serologies were sent prior to discharge. | felt to be r/t dc'ing of milrinone am. k- 3.6, re'd 40meq (started on nocts) kcl iv and then 40meq kcl po, repeat lytes pnd this pm.resp- on 3l sats 96-100. l/s clear with cxs/coarse sounds lower, esp. isordil, lasix, bisoprolol held in am d/t low bp. RECEIVING LASIX 80 MG IV BID.GI: ABD SL DISTENDED, + BOWEL SOUNDS. digoxin level added on and pnd. LOWER EXTREMITIES 3+ PITTING EDEMA.RESP: O2 3L VIA NC. off milrinone gtt since d/t headaches.heparin at 1000uhr. (describing headache)o: pls see carevue flowsheet for complete vs/data/eventsid: temp is low. Vanco and Imipenem dc'd. Off Milrinone CO was 3.6 from 4.7, CI 1.93 from 2.51, SVR 1044 from 851, cvp 7 from 10. abg: 7.40/31/73/20/-3. No bm.GU: UO has picked up since milrinone restarted.ID: afebrile, cont on ceftriaxone.A/P: treating pyelonephritis, BP stable on Milrinone, UO improving. Family called.A: Off Lasix gtt/restarted valsartin and coumadin/slightly decreased niprideP: Cont to keep careful I & O. bp 90-105/60 via nbp.coags sent off pic line this am. RLL crackles, RUL, LLL, LUL all clear.GI/GU: +bs, + med. (first dose 4/11)HR 80 Vpaced. BP became more stable & Milrinone restarted at 0.385mcg/kg/min at 16:00. She was replaced with 60 meq KCL, nuerta phos and Mag oxide. "O: Please see careview for VS and additional data.CV: Pt HR 80-81 AV paced, NBP 95-107/36-72, pt continues on dopamine gtt 2.5 mcg/kg/min. Diuretics held today.ID: TM 99.4. pads 36 to 28, cvp 23 to 14, co 4.4, up to 5.3 this pm ci 2.73, svr 863. hct 35.2, ptt 78.9, inr 1.6. cont. COUMADIN RESTARTED ON . milrinone resumed at prior dose without a bolus.hr 80s vpaced w pvcs. CO/CI STABLE ON PRESENT REGIME OF MEDS; NIPRIDE 2 MCG/KG/MIN, MILRINONE 0.385 MCG/KG/MIN. Full code.CV: Upon start of shift, am meds were held r/t hypotension. D/C FLAGYL FOR R/O S DIFF. BP 94/49-102/64. on same doses nipride, heparin, milrinone, lasix. "O: For complete VS see CCU flow sheet.ID: T-max 99.8po.CV: Some changes made in taylored therapy today. supplements.OOB QD as tol. cont on vanco(needs trough before mdnoc dose), po flagyl and imipenum.had abd ct which noted l pylonephritis.cv: hr 80-100, mostly vpaced. lasix held d/t hypotension. also cont on tid clonipin.a: afib, hypotension, poor uop.p: cont to follow hemodynamics, volume status. K 3.4, will replete w/ 60mEq sliding scale when Mg is complete. BP 97/62- 109/69.contin. WBC 15.BC/urine pnd from .HR 80's vpaced. apnea noted. abx, recent c+s pnd.cv- hr 80s vpaced with occ to freq pvc, occ. holding lasix in setting of bacterimia.k 5.0, mg 2.1.resp: labored w min exertion. lfts elevated, down for liver us.p- cont. MILRINONE DOWN TO 0.18MCG/KG/MIN. contact precautions dc'd.cv: hr 80-90s paced, occ pvc. po4 1.3, re'd neutraphos. inr 1.6, ptt 78.dig level 3.4 this am and dose was held.na 124(128). Mg 1.6 repleted.Resp: Pt conts to have dyspniec with exertion. Diuretics held today. HR 73-85 A-fib, occ. supprort to pt. refused- able to fall asleep again.A: improved u/o on dopa. She was started on milronone and diuresed, but remains profoundly anasarcic.CV: HR has been in 70s, afib, multiple PVCs and occasional paced beats. She initially had hematuria, but it has since resolved.GI: Pt conts to have excellent apetite. ccu npno- id-afebrile. a peripheral line was placed by the iv team.resp: basilar cxs. Labs (18:00) Mg 1.7, repleting w/ 4gm Mag Sulfate IV. "O: For complete VS see CCU flow sheet.ID: Pt afebrile.CV: Nipride being weaned. rec'd dose of fiorocet w some effect. IV Heparin dc'd at 12n d/t elevated INR. f/u liver us results. ptt 92. inr 1.8.resp: rr 20s. (1 of which was drawn peripherally this am). EKG DONE, MD NOTIFIED. u/o improved on milrinone. one run of VT 8bts, rate 150. asympt. on ceftriax q24hr. SEE CAREVUE FOR VS/OBJECTIVE DATACV: HR 80 V-PACED W/PVC'S/OCCS COUPLETS, BP 99-106/50-60'S ON DOPAMINE @ 2.5MCGS; HEPARIN REMAINS AT 800U/HR W/PTT W/I RANGE 83RESP: SATS 98-99% ON 2L NC, SATS 89-92% ON ROOM AIR, LUNGS - FEW CRACKLES AT BASESALT COMFORT: PT CONTINUES C/O HA - 2MG IV MSO4 GIVEN X1 W/SOME RELIEF - SLEEPING OFF/ONGI: LIVER US REVEALED INFLAMMATION OF COMMON BILE DUCT PER TECHNO STOOLGU: FOLEY DRAINING YELLOW URINE I/O'S EVEN FOR DAYSOCIAL: - WILL CALL IN AMA: VS UNCHANGED AFTER CHANGE FROM MILRINONE TO DOPAMINE CONTINUED HA - UNKNOWN ETIOLOGYP: MONITOR VS, CONT DOPA/HEPARIN, ASSESS HEADACHE - MEDS FOR COMFORT AND ASSESS EFFECTIVENESS - CONT FOLLOW LFT'S, ASSESS MENTAL STATUS,CONT SUPPORTIVE CARE. Atrial sensed ventricular pacedSince previous tracing of , ventricular ectopy absent Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , sinus rhythm now absent Atrial sensed ventricular pacedVentricular premature complexesSince previous tracing of , atrial fibrillation now absent Atrial sensed ventricular pacedVentricular premature complexesSince previous tracing of , atrial fibrillation now absent Since the previous tracing of there is a runof ventricular paced rhythm. Ventricular paced rhythmAtrial mechanism is probably atrial fibrillationSince previous tracing of , no significant change Compared to the previous tracingof atrial fibrillation is no longer recorded and the rhythm is sinuswith atrial sensing and ventricular pacing. Ventricular couplets. There is atrial and ventricular pacing. fibrillationSince previous tracing of , sinus rhythm now absent Intermittentventricular paced rhythm. Pacemaker rhyth. CONTINUED DIURESES UNTIL MINNOC. Atrial fibrillation and demand ventricular pacingIntraventricular conduction delay - left axis deviationSince previous tracing, atrial fibrillation is new Ventricular paced rhythmAtrial mechanism appears to be flutter/? Compared to the previous tracingthe atria are now paced. Paced rhythmSince previous tracing, no significant change Atrial sensed and ventricular paced rhythm. Compared tothe previous tracing no significant change.TRACING #1 +MUR. Compared tothe previous tracing of no significant change.TRACING #2 DP PALP. Regular ventricular pacing. Regular ventricular pacing. MHR 80S SR, NO VEA. Atrial fibrillation. Marked left axis deviation.Intraventricular conduction defect. PT TO ASSIST W/ RECONDITIONING. Pacemaker rhythm. Left ventricular hypertrophy. A-V sequential pacing*** complex QRS morphology - no further analysis ***Since previous tracing, the heart rate is faster PCWP OF 24. CONTINUE DIURESIS AS TOLERATED. IMPROVED MV 72% AND CI >3. MAGNESIUM AND POTASSIUM REPLACED. C/O SORENESS AT SWAN INSERTION SITE. 10L. No further analysis. No further analysis. NEG >1L AT 2300 LAST EVENING. PT MED W/ OXYCODONE AND TYLENOL W/ GOOD EFFECTS.RESP:LUNGS W/ CRACKLES AT BASES OTHERWISE CLR. CCU NURSING NOTESS:I'M FEELING BETTER THIS EVENING.O:59YR OLD FEMALE W/ DILATED CM, CHF MANAGEMENT CCU DAY 4, REMAINS ON MILRINONE, HEPARIN, LASIX . SNP WEANED OFF AND VALSARTAN INCREASED TO 80MG. | 47 | [
{
"category": "Nursing/other",
"chartdate": "2166-04-08 00:00:00.000",
"description": "Report",
"row_id": 1569270,
"text": "ccu nursing progress note\ns: out of 10. (describing headache)\no: pls see carevue flowsheet for complete vs/data/events\nid: temp is low. 95-97 orally. wbc 15. cont on ceftriaxone for ecoli pyelonephritis/bacteremia. bld and urine recultured.\ncv: no cp. ^'d sob at rest, lethargic and poor uop. felt to be r/t dc'ing of milrinone am. milrinone resumed at prior dose without a bolus.\nhr 80s vpaced w pvcs. bp 90-105/60 via nbp.\ncoags sent off pic line this am. inr 8.1, ptt >150. repeat sent from peripheral draw, awaiting results.\nheparin off at noon for poss lp in w/u of persistent ha.\nresp: sats 94-98% on ra, 95-100% on 2l nc. has periods of sob at rest, ^'d w exertion. also noted someirreg patterns similar to cheynne . abg: 7.40/31/73/20/-3. lactate 5.6.\ngi: poor appetite. no nv. no stool. taking only juice. abd benign.\ngu: had not voided since 11pm last noc, up to void at 10am without result. foley placed at 12n. urine is drk brn to red. cr 1.4 stable from yesterday. na 126(129, 124, 121). hco3 18(25).\nms: lethargic, groggy. c/o ha, describes as severe, sl relief w fioricet. neuro consulted to eval. oob w assist x1.\nsocial: pt spoke w brother by phone, no other visits.\na: further decompensated heart failure off milrinone w evidence of hypoperfusion and metabolic acidosis. cont headache of unknown etiology.\np: reeval labs this eve w restart of milrinone. follow resp exam, volume status. med for comfort. check results of repeat coags. med for comfort. support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-08 00:00:00.000",
"description": "Report",
"row_id": 1569271,
"text": "CCU NPN 3-11pm\nCV: cont on milrinone .38mcg/kg/min, restarted at 12N, HR 80 v-paced, BP high90's-low100/60's, UO picked up to 50-100cc/hr. States she is SOB, does not appear is distress. Sat 93-94% on RA. PTT >150 earlier today, repeat at 2130 was 63.4. Restarting Hep at 100U/hr without a bolus at 2300. Follow PTT in 6hrs.\n\nResp: crackles at bases bilaterally, with scattered rhonchi, intermittently coughing, nonproductive.\n\nNeuro: cont to c/o HA, given oxycontin at 1630 and Clonazepam. Has been sleepy but states that she does not sleep. Neruo evaluated. No focal findings, recommended MSO4 for pain, dc'ed Oxycontin and Fioricet(can get rebound HA's), recommended good night sleep.\nPt has been sleeping since ~ after nieces left.\n\nGI: ate custard at dinner, drinking sips of juice. No bm.\n\nGU: UO has picked up since milrinone restarted.\n\nID: afebrile, cont on ceftriaxone.\n\nA/P: treating pyelonephritis, BP stable on Milrinone, UO improving. Lethargic, now sleeping. Reevaluate HA after she awakens, MSO4 for pain prn(has not gotten yet).\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-29 00:00:00.000",
"description": "Report",
"row_id": 1569251,
"text": "CCU NSG NOTE: ALT IN CV/HEART FAILURE\nS: \"I always have chest pain, this is just worse.\"\nO: For complete VS see CCU flow sheet.\nID: T-max 99.8po.\nCV: Some changes made in taylored therapy today. Her lasix gtt was d/c and she is now receiving lasix 80mg iv bid. She has received her second dose. Her nipride was decreased from 2.2 mic/kilo to 2mic/kilo with increase in SVR to 1191 and with an increase in filling pressures. She was put back on her valsartin 40mg and last c.o 2 hours after that were 5.7/ 3.05/ 758. Nipride remains a 2.0. Heparin remains at 1000 with a theraputic PTT, and coumadin 5mg po was started. She was replaced with 60 meq KCL, nuerta phos and Mag oxide. Afternoon lyted contd low and she will receive 4 amp of mag and KPhos. Hr has been in 80s to mid 80, going between v-paced and NSR. BP has been 89-101/60-70s. PAP has been 45-50/22-28 with wedge of 20 and RA .\nRESP: Pt has faint rales at bases. Early she had exp wheezes, but is clear now.\nRENAL: With lasix off at 9a and IV lasix given at 9:30 pt was 3700cc neg for the day and 8 liters neg LOS.\nGI: Pt OOB to comode and had Lg G- stool. She is eating very well with no c/o of nausea. She needs dietary consult to help with her diet when she returns home.\nSKIN: Despite excellent diuresis she conts to have 3+ pitting edema in extremities. No areas of breakdown.\nMS: Pt oriented X 3. She conts to become very fatigued with minmal exertion. She declined getting OOB this afternoon. Spirits seem good. Family called.\nA: Off Lasix gtt/restarted valsartin and coumadin/slightly decreased nipride\nP: Cont to keep careful I & O. Monitor for change in hemodynamics. REcheck lytes later tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 1569257,
"text": "CCU Nurse Progress Note 3p-11p\n59 yo female patient w/ decompensated heart failure admitted to CCU for diuresis and tailored therapy. Full code.\n\nCV: Upon start of shift, am meds were held r/t hypotension. Milrinone was dc'ed at 10:00a also r/t hypotension. Off Milrinone CO was 3.6 from 4.7, CI 1.93 from 2.51, SVR 1044 from 851, cvp 7 from 10. BP became more stable & Milrinone restarted at 0.385mcg/kg/min at 16:00. Numbers got better, CO 4.5, CI 2.41, SVR 996, cvp 14, maps 60's. HR 80-82 Vpaced, occ. PVC's. BP 85-93/46-77. Dig, Nipride(off yesterday), Valsartan & Coumadin all dc'ed today. Hep gtt cont at 1000 units/hr, PTT remains therapeutic at 82.3. Mixed venous sat (18:00) = 60. Will not resume coumadin until swan dc'd.\n\nNeuro: A&Ox3, calm & cooperative. C/O swan site pain given Oxycodone 5mg PO.\n\nResp: becomes SOB, tired w/ activity, such as getting up to commode. Will rest a few secs, then is ok. RR 14-20. Sats 90-97 room air. RLL crackles, RUL, LLL, LUL all clear.\n\nGI/GU: +bs, + med. formed bm. Foley draining amber, cloudy urine. Given 80mg IV Lasix 20:30, responding well. Output 390cc so far since Lasix dose. 24h balance +181. Bun/Crea 17/0.7.\n\nID: afebrile, no abx.\n\nSkin: Intact. Multiple ecchymoses right arm r/t bp cuff, which was switched from left arm r/t pain.\n\nSocial: No family members visited this shift, however patient did speak to someone (not sure of who) on the phone. Pt spoke w/ us about her decision not to have the heart transplant. She said she does not know what, but something does not make her feel comfortable about it. She is also concerned about the rehab period post-op. Pt verbalized that she made & is comfortable w/ her decision, and is ready to deal with any consequences of it.\n\nA/P: 59 yo w/ CHF, volume overloaded, admitted to CCU for Milrinone, diuresis, and tailored therapy. Monitor hemodynamics, & fluid balance. Monitor PTT. Electrolytes needed at 01:00 due to Lasix dose. Support patient and family.\n\nNote entered by: , Student Nurse \n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-01 00:00:00.000",
"description": "Report",
"row_id": 1569258,
"text": "CCU NPN 11p-7a\nS: \"I feel okay...I have ankles.\"\n\nO: Please see careview for VS and additional data.\n\nCV: PT V paced with underlying rhythm afib, HR 80-83, NBP 84-94/46-53, MAPs 56-67, Intern , MD aware and will tol MAPs> 55 while pt sleeping. PAP 42-50/20-25, CVP 9-11. This am CO 5.3 (was 4.5) CI 2.83 (was 2.41) SVR 740 (was 996), pt continues on milrinone 0.385 mcg/kg/min, Heparin gtt 1000 units/hr. Pt given 400 mg PO amiodarone for rhythm control. AM labs pending. Pt palp pulses + edema in lower extremities.\n\nResp: Pt LS CTA to crackles RLL, O2 sats 92-95 on room air, RR 16-19, pt + dry sounding, nonproductive cough. Pt denies SOB, resting comfortably/sleeping in bed.\n\nGI/GU: pt abd soft, + BS x 4, no stool this shift. Pt with foley cath draining dark yellow urine, approx 15-210 cc/hr, HO aware. Pt +99.5 cc at midnoc, pt -10 L LOS. Midnoc lasix dose held d/t pt still diuresing with dose given late at ( was due 1600), pt MAPs<60 this am-dose held, HO aware.\n\nNeuro: Pt sleeping throughout most of night, cooperative with care, A & O x 3, MAE.\n\nA/P: 59 y/o female continues on milrinone gtt, BP dropping slightly with MAPS >55, midnoc lasix dose held. CO/CI improved from last set. Continue to monitor rhythm, BP and given meds as ordered/ pt tol. Continue to monitor I&O's, u/o. Follow up wiht am labs and replete as necessary. Continue to assist pt in advancing activity as tol. Continue to provide emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-01 00:00:00.000",
"description": "Report",
"row_id": 1569259,
"text": "ccu npn\no- afebrile. cv- hr 80s vpaced, no vea. cont. on same milrinone and heparin iv, amiodarone po. isordil, lasix, bisoprolol held in am d/t low bp. bp 80s-90s/. after discussion w/ho, bisoprolol given 2pm with map low 60s. digoxin level added on and pnd. dig load ordered pnd level. 2nd iv in this pm w/plans to d/c pa line. heparin to be held this pm for pa line d/c. pt eval for picc for ?home milrinone. iv to try picc in am. case manager looking into picc/insurance for home milrinone, ?goes through infusion clinic.\nresp- on r/a sats high 90s. l/s clear w/faint exp. wheeze. no sob. u/o adeq to low and concentrated.\ngi- app. fair, no bm.\nms-a+x3, states needs to think about whether or not wants to go home on milrinone, and she was told would need a home health visit qd.\nactivity- oob to chair most day, tol well.\na- bp somewhat higher while awake, tol bisoprolol.\np- ?give lasix depending on bp, check w/ho. start digoxin depending on level. hold heparin for pa line/cordis d/c. oob/PT as tolerated. ?picc . cont. emotional support. f/u insurance, infusion clinic teaching w/picc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-02 00:00:00.000",
"description": "Report",
"row_id": 1569260,
"text": "ccu npn 11p-7a\nCarevue System down most of shift. Vital signs kept onto flow sheet, then entered into carevue at 0400 when system available. Written note entered into Pt's green chart. See chart for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-30 00:00:00.000",
"description": "Report",
"row_id": 1569252,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: IT HURTS WHEN I TAKE A DEEP BREATH IN:\n\nO: NEURO: PT. AWAKE AND ALERT, ORIENTED X3. PLEASANT AND COOPERATIVE. MOVING ALL EXTREMITIES. TURNS SELF IN BED. C/O PAIN UNDER LEFT BREAST WORSENING WITH DEEP INSPIRATION. GIVEN OXYCODONE 5 MG PO X1 AND TYLENOL 650 MG PO X1 WITH FAIR RELIEF FROM PAIN. SLEPT IN SHORT NAPS DURING NOC.\n\nCV: SEE FLOW SHEET FOR HEMODYNAMIC #'S. CO/CI STABLE ON PRESENT REGIME OF MEDS; NIPRIDE 2 MCG/KG/MIN, MILRINONE 0.385 MCG/KG/MIN. HR 80 SR NO VEA NOTED. LYTES REPLETED IN EVENING AND REPEAT LABS WNL.\n\nRESP: LUNGS CRACKLES IN BASES WITH EXP WHEEZE NOTED IN UPPER AIRWAYS. O2 SAT ON ROOM DOWN TO 88-89%. PUT ON 2L NC WITH IMPROVING O2 SAT TO 94-96%. DENIES C/O SOB.\n\nGU: URINE OUTPUT TRENDING DOWN AFTER LASIX GTT WEANED TO OFF. I/O (+) 350 OVER 24HRS. (STILL (-) 8L FOR LOS). URINE BLOOD TINGED, CLOUDY. HCT STABLE @ 34. COUMADIN RESTARTED ON . RECEIVING LASIX 80 MG IV BID.\n\nGI: ABD SL DISTENDED, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM . APPETITE FAIR.\n\nSKIN: INTACT, NO BREAKDOWN NOTED. RIGHT ARM HAS SEVERAL ECCHYMOTIC AREAS FROM NIBP CUFF. LOWER EXTREMITY EDEMA LESSENING. NOW 2+ TO KNEES.\n\nA/P: CO/CI STABLE, URINE OUTPUT LESS OFF LASIX GTT. STILL NEG. PAIN UNDER LEFT BREAST ? PLEURITIC. FAIR RELIEF FROM PAIN WITH OXYCODONE.\n? WEAN NIPRIDE AS CI TOL (KEEP CI > 2.2). MONITOR LYTES AND REPLETE AS NEEDED, UPDATE PT. ON PLAN OF CARE PER TEAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-07 00:00:00.000",
"description": "Report",
"row_id": 1569267,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\n\n\nS- \"I STILL HAVE A BIT OF HEADACHE BUT THOSE MEDICINES HELP \"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\nCV- VS REMAINS STABLE- HR- 90'S VPACED WITH OCCASIONAL PVC'S.\nBP- 95/63- NO HYPOTENSION THIS SHIFT AT ALL.\nREMAINS ON HEPARIN GTT 1000U AND MILRINONE 0.375.\nRECEIVED 20 KCL FOR K-3.7\n\nRESP- 02 SATS >95% ON 2L NP, SOME CX AT BASE AND REMAINS TACHYPNIC WITH EXERTION. NONPRODUCTIVE COUGH.\nRECEIVED 1 L NS FOR (+) BUMP CREATININE AFTER LASIX AND (+) DEHYDRATION PRESUMED. I/O (+) 1700CC AS OF 12AM. NO DISTRESS FROM RESP STANDPOINT.\n\nID- AFEBRILE ALL DAY YESTERDAY AND TONITE- NO VANCO SATURDAY NITE OR SUNDAY MORNING D/T HIGH LEVELS- CHANGED TO Q 24/RENAL DOSE- TO RECHECK TROUGH WITH AM LABS. D/C FLAGYL FOR R/O S DIFF. REMAINS ON IMIPENEM Q 6 HOUR TO TREAT GM (-) RODS BACTEREMIA WITH PYLONEPHRITIS AS SOURCE.\n\nGU- OOB X 2 TO COMMODE FOR UO- REMAINS AMBER IN COLOR AND MINIMAL AMOUNTS. NO FURTHER IV FLUID THIS SHIFT.\nSENT URINE LYTES FOR ASSESSMENT OF HYPONATREMIA /BUMP IN CREATININE AND BETTER ASSESS FLUID STATUS.\n\nGI- LIX STOOL X 1 WITH URINE- UNABLE TO TEST FOR GUAIC.\nTAKING IN MEDS AND LIX, NO FOOD ON EVES/NITES CURRENTLY.\nNO NAUSEA.\n\n PT IN GOOD SPIRITS THIS EVENING- C/O HEADACHE BUT BETTER CONTROL OF PAIN WITH FIORICET. CURRENTLY SLEEPING AFTER CLONAZEPAM AND ZOLOFT.\nSPEAKING A LOT ABOUT CONCERNS WITH RETURN TO HOME ON IV MILRINONE ETC, SUPPORT SERVICES TO BE PROVIDED. APPEARS ENCOURAGED FEVERS GONE AND INFECTION CONTROLLED BY CURRENT ANTIBX.\n\nA/ PT CURRENTLY HEMODYNAMICALLY STABLE S/P CHF EXACERBATION C/B UROSEPSIS.\n\nCONTINUE ANTIBX AS ORDERED TO TREAT GM (-) RODS.\nWATCH FOR FURTHER FEVERS OR ANY HEMODYNAMIC COMPROMISE.\nRECHECK AM TROUGH LEVEL VANCO DOSE- GIVE IF LEVEL WNL.\nASSESS URINE LYTES FOR ? MORE FLUID BOLUSES TODAY.\n? RELOAD COUMADIN TODAY, CONTINUE HEPARIN GTT AT 1000U PENDING AM PTT LEVELS.\nPT IS DNR,\nKEEP PT AWARE OF PLAN OF CARE, CONTINUE D/C PLANNING\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-07 00:00:00.000",
"description": "Report",
"row_id": 1569268,
"text": "Nursing Progress Note\nS: \" I still have this awful headache.\"\n\nO: Please see flow sheet for objective data. Milrinone d/c'd after rounds secondary to severe headaches. Tele AF with periods of V pacing. SBP > 90. IV heparin dc'd at 1 pm for ? aspiration of neck. Ultrasound done of neck and L arm. IV Heparin restarted at 1000u/hr at 5pm.\n\nResp: Lungs with crackles throughout the bases. Pt is dyspneic with minimal exertion although sats unchanged 96-99% on 2 l nasal prongs.\n\nNeuro: Pt is alert and oriented. Able to MAE. OOB to comode several times with minimal assistance. Conts to c/o headache more severe this pm after ultrasound. Given fioricet 2 tabs with some effect.\n\nGU/GI: Appetite remains poor. Denies any nausea. Taking in mostly liquids. Abd is soft with bowel sounds present. 1 liquid stool today.\nVoiding in sm amts of amber to red urine. No further IV fluids today. Diuretics held today.\n\nID: TM 99.4. Vanco and Imipenem dc'd. Started on Ceftriaxone 1 gm Q 24hr. ( Urine sensitivity).\n\nA&P: Milrinone dc'd secondary to severe headaches. Monitor BP and urine output. ? dopamine Bp drops. Fioricet prn headaches. Cont POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-08 00:00:00.000",
"description": "Report",
"row_id": 1569269,
"text": "CCU NPN 1900-0700\nS: \" My head still hurts \"\nO: TM 99.8po. on ceftriax q24hr. (first dose 4/11)\nHR 80 Vpaced. BP 90-117/60's. off milrinone gtt since d/t headaches.\nheparin at 1000uhr. AM labs pnd at 0600.\n\nvoided x1 for 300cc amber urine. neg. 300cc for and total 12L neg. LOS.\npt. c/o SOB x1 in middle of night but also with increase in headache and due for pain meds. lung exam unchanged. sats good. discussed with intern and did not give lasix. intern stated that prelim. plan for AM is to restart milrinone gtt since headache has not abated off gtt.\nsats 98% on 2lnc. RA sat same. LS crackles right base to 1/3 up.\nRR 30-40.\n\nvery dyspneic with any activity. does not sleep well. oxycontin 2tabs in eve and then flouricet repeated at 0330. pt. reports this morning that headache feels the same- has not abated. sleeping in short periods. short periods of apnea. sats stable.\n\n assist OOB to commode.\n\nA/P: AM labs pnd. poor u/o. no lasix. ? plan to restart milrinone gtt. monitor and assess headache. pain meds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-10 00:00:00.000",
"description": "Report",
"row_id": 1569277,
"text": "7p-11p CCU Nursing Progress Notes\nC/V: on Dopamine 2.5mcg/kg/min. HR 80-81 V-paced, no ectopy noted. BP 101/65 - 105/67.\n\nNeuro: A&Ox3, cooperative. no c/o pain or headache.\n\nResp: On room air maintaining sats high 90's-100. RR 19-22.\n\nGI/GU: foley draining clear dk yellow urine, hourly urine output decreasing since :00 (140 -> 120 -> 26cc/hr). +bs, -bm. Patient ate 90cc Jello, drank 220cc cranberry juice.\n\nID: afebrile, cont. on Ceftriaxone q24h.\n\nSocial: and sister called.\n\nAccess: 22 r forearm, flushed and clamped. PICC infusing Dopamine 2.5mcg/kg/min.\n\nA: Monitor headache, nutrition & fluid status.\nP: ? plan to move to floor tomorrow.\n\nNote entered by: , Student Nurse \n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-11 00:00:00.000",
"description": "Report",
"row_id": 1569278,
"text": "CCU NPN 11p-7a\nS: \"I still have the headache.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 80-81 AV paced, NBP 95-107/36-72, pt continues on dopamine gtt 2.5 mcg/kg/min. AM labs pending.\n\nResp: Pt RR regualar and even 19-22 at rest, RR up to 30 with ambulation to commode, O2 sats 94-100 on room air.\n\nGI/GU: Pt abd soft, +BS x4. Pt with lg amt loose brown stool x 1. Pt with foley cath draining clr dark yellow to yellow urine 20-225 cc/hr. Pt -355cc at midnoc, - cc LOS.\n\nNeuro: Pt alert and oriented, cooperative with care. Pt ambulated OOB to commode x 1 overnoc, pt steady on feet. Tylenol given x 1 for headache, pt refused morphine. Pt did not c/o pain until asked if in pain.\n\n\nID: Pt afebrile, cont on abx.\n\nA/P: Pt continues on dopamine with adequate MAPS and u/o. Continue to monitor hemodynamics, continue to monitor u/o and resp status. Continue to follow lytes and LFTs, continue to assist pt in activity and enc nutrition. Monitor HA and provide pain meds and emotional support. Continue with plan per CCU Team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-28 00:00:00.000",
"description": "Report",
"row_id": 1569249,
"text": "ccu npn\no-id- afebrile.\ncv- hr 70s afib in am, pacer rate increased to 80 by ep and then converted to sr with pacing w/occ to freq pvcs, more in am vs occ. pacing in am. pads 36 to 28, cvp 23 to 14, co 4.4, up to 5.3 this pm ci 2.73, svr 863. hct 35.2, ptt 78.9, inr 1.6. cont. on same doses nipride, heparin, milrinone, lasix. diuresing well in am, then u/o up to 300-575cc/hr this pm. i+o neg about 1500cc currently. k- 3.6, re'd 40meq (started on nocts) kcl iv and then 40meq kcl po, repeat lytes pnd this pm.\nresp- on 3l sats 96-100. l/s clear with cxs/coarse sounds lower, esp. r. sob on exertion more in am. u/o as above.\ngi-abd soft w/bowel sounds. app fair to good, limiting po fluids well.\nms- a+o x3, slept in naps off/on in am.\nskin- has ecchymosis r arm bp cuff changed to l arm, small r hip. has no breakdown. repos. side to back per pt. comfort, moves self around bed also.\nsocial- fx called, updated on pt's condition and plan. teaching done w/pt also regarding progress, pa line, meds, etc. understands.\na- diuresing well. ci improved with increased hr, more pacing.\np- cont. same iv meds. follow rhythm, bp, co/ci/svr, diuresis. check lytes sent, replace as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-29 00:00:00.000",
"description": "Report",
"row_id": 1569250,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I CAN'T BELIEVE HOW SWOLLEN MY LEGS ARE\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3. PLEASANT, COOPERATIVE. MOVING ALL EXTREMITIES.\n\nCV: HR 82-86 SR WITH OCC PVC. BP 94/49-102/64. PA 60/21-55/20 CVP 6-11. DENIES C/O CP. REMAINS ON NIPRIDE 2.2 MCG/KG/MIN, LASIX DECREASED TO 5 MG/HR, HEPARIN 1000 UNITS/HR, MILRINONE 0.385 MCG/KG. LOWER EXTREMITIES 3+ PITTING EDEMA.\n\nRESP: O2 3L VIA NC. CRACKLES NOTED IN BASES. OCC CONGESTED COUGH, NON PRODUCTIVE.\n\nGU: URINE CLEAR YELLOW. I/O (-) 2.5 L OVER 24 HRS. (-) 6.6 L FOR LOS.\n\nGI: ABD SOFT, + BOWEL SOUNDS. NO BM OVERNIGHT. LAST BM .\n\nSKIN: INTACT, NO BROKENS AREAS.\n\nC/O PAIN AT SG CATH (RIGHT IJ). GIVEN TYLENOL WITH RELIEF FROM PAIN. SLEPT IN SHORT NAPS OVERNIGHT.\n\nA/P: STABLE ON PRESENT MEDS, DIURESING WELL. MONITOR LYTES, REPLETE AS NEEDED. MAINTAIN CI 2.2. UPDATE PT. AND FAMILY ON PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-06 00:00:00.000",
"description": "Report",
"row_id": 1569265,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CHF; PYLONEPHRITIS\n\nS- \" I NEED TO GET UP SO QUICK TO MAKE THE BATHROOM..I DON'T HAVE TIME TO CALL YOU..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE WITH HR- 90'S V PACED, OCC VEA ON MILRINONE 0.375, HEPARIN GTT 1000U/HOUR. BP- 95/55- 100/60.\nNO HYPOTENSION OR ARRYTHMIAS THIS SHIFT.\nAM LABS PENDING CURRENTLY\n\nRESP- O2 SATS ALL > 95% ON 2L NP- TACHYNPNIC WITH ANY EXERTION- CX AT BASE- LEFT > RT.\nGIVEN 80 LASIX IVP D/T I/O (+)500CC\nOF NOTE, NO FOLEY CURRENTLY TO PROVIDE HOURLY ACCURATE U.O.\nCOMFORTABLE AT REST, NONPRODUCTIVE COUGH\n\nID- SPIKED AGAIN TO 102 9P- GIVEN TYLENOL 650- REMAINS ON IMIPENUM TO COVER GM (-) RODS. HELD 12AM VANCO DOSE D/T HIGH TROUGH LEVEL 33.\nHO AWARE.\nNO CHANGES TO ANTIBX REGIMEN CURRENTLY- STOOL SPECIMENS FROM MICRO PENDING- REMAINS ON FLAGYL TID PO.\n\nGU- FOLEY CATH D/C ON DAYS.\nPT FOUND TO BE GETTING OOB ON OWN IN SPITE OF INSTRUCTION TO CALL FOR ASSIST.\nAMBER DARK URINE X 2 AFTER LASIX- TOTAL ABOUT 500CC IN ALL WITH LIX STOOL AS WELL.\n\nGI- LIX STOOL X 2- UNABLE TO TEST/GUAIC- UP TO COMMODE ON OWN .\nC DIFF R/O PENDING\nCONTINUES ON FLAGYL\nPOOR APPETITE, TAKING MEDS AND LIX WITHOUT PROBLEM\nNO NAUSEA\n\nMS- SLEPT WELL TONITE\nC/O HEADACHE- GIVEN TYLENOL\nUNDERSTANDS CURRENT PLAN OF CARE AND SOURCE OF INFECTION\nUNDERSTANDS NEED FOR ASSIST TO GET UP TO COMMODE.\n\nA/ PT S/P LONG COURSE FOR CHF EXACERBATION/CM CURRENTLY ADMITTED TO CCU FOR SEPSIS/PYLONEPHRITIS.\n\nCONTINUE CURRENT ANTIBX TX\nWATCH FOR FURTHER RESULTS OF SPECIMENS TO MICRO\n? D/C FLAGYL IF (-) STOOL.\n? RECHECK VANCO LEVEL PRE-12NOON VANCO DOSE.\nCONTINUE CV MEDS AS ORDERED- WATCH HEMODYNAMICS CLOSELY.\nCONSIDER RE-LOAD COUMADIN IF CONTINUES TO BE HEMODYNAMICALLY STABLE AND IN NO NEED OF INVASIVE LINE PLACEMENT\nPT IS DNR.\nKEEP PT AWARE OF PLAN OF CARE, SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-06 00:00:00.000",
"description": "Report",
"row_id": 1569266,
"text": "ccu nursing progress note\ns: the headache is somewhat better after that medicine(fiorocet)\no: pls see carevue flowsheet for complete vs/data/events\nid: t max 100.3. wbc 15. cont on imipenum. vanco to cont but level 21.9 for trough before scheduled q 24hr dose. level will be checked in am and dosed as indicated. po flagyl dc'd as cdiff specs have been neg to date and no stool since last night. contact precautions dc'd.\ncv: hr 80-90s paced, occ pvc. k 3.4, repleted w 40 po and k 3.7 this eve. will replete additional 20meq. bp 90-100/50-60. not orthostatic this am. cont on milrinone, dose unchanged.\nheparin at 1000units/hr. ptt 92. inr 1.8.\nresp: rr 20s. labored w activity. basilar cxs. sats 95-100% on 2l nc.\ngi: ate toast this eve. good po intake of fluids. no n/v. no stool this am.\ngu: cr bumped to 1.9(1.4). na 121(124, 128, 132). felt pt dry. rec'd 1l ns at 150cc/hr over course of day. will resend unrine lytes and chemistries this eve. voiding drk brn cloudy urine at bedside commode.\nms: alert. c/o mod-severe ha . underwent head ct, no acute process noted. med w oxycodone ^to 10mg without relief. rec'd dose of fiorocet w some effect. sister visited.\na: ha. hyponatremia, cr bumped. fever abated.\np: follow response to hydration, assess for resp compromise. med for comfort. supprort to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-09 00:00:00.000",
"description": "Report",
"row_id": 1569274,
"text": "CCU NURSING 1500-1900\nS. \"I'VE NEVER HAD A HEADACHE LIKE THIS BEFORE - ITS THROBBING!\"\n\nO. SEE CAREVUE FOR VS/OBJECTIVE DATA\n\nCV: HR 80 V-PACED W/PVC'S/OCCS COUPLETS, BP 99-106/50-60'S ON DOPAMINE @ 2.5MCGS; HEPARIN REMAINS AT 800U/HR W/PTT W/I RANGE 83\n\nRESP: SATS 98-99% ON 2L NC, SATS 89-92% ON ROOM AIR, LUNGS - FEW CRACKLES AT BASES\n\nALT COMFORT: PT CONTINUES C/O HA - 2MG IV MSO4 GIVEN X1 W/SOME RELIEF - SLEEPING OFF/ON\n\nGI: LIVER US REVEALED INFLAMMATION OF COMMON BILE DUCT PER TECH\nNO STOOL\n\nGU: FOLEY DRAINING YELLOW URINE I/O'S EVEN FOR DAY\n\nSOCIAL: - WILL CALL IN AM\n\nA: VS UNCHANGED AFTER CHANGE FROM MILRINONE TO DOPAMINE\n CONTINUED HA - UNKNOWN ETIOLOGY\n\nP: MONITOR VS, CONT DOPA/HEPARIN, ASSESS HEADACHE - MEDS FOR COMFORT AND ASSESS EFFECTIVENESS - CONT FOLLOW LFT'S, ASSESS MENTAL STATUS,\nCONT SUPPORTIVE CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-10 00:00:00.000",
"description": "Report",
"row_id": 1569275,
"text": "CCU NPN 1900-0700\nS: \" I still have a headache \"\nO: afeb. contin. on ceftriax.\nHR 80's V paced with occas. PVC's. one run of VT 8bts, rate 150. asympt. K+ 4.4. BP 97/62- 109/69.\ncontin. on dopamine at 2.5mcq/k/min. and heparin 800u/hr. AM PTT 69.\ndig. contin. on hold. contin. on aldactone, bisoprolol. amio QD.\n\nGU: u/o 60-75cc/hr. neg. 200cc for , currently ~ even since MN.\nGI: only asking for cranberry juice. not hungry for boost. discussed need for more nutrition. pt. states she will try to drink nutritional supplements.\nResp: LS crackles bases which is baseline. sats 99% on 2lnc. DOE noted even with sitting up, etc. RR 30-40\n\npt. slept well tonight, wakes easily to name and appears less lethargic when awake. contin. to c/o headache but only when asked about it. offered morphine but pt. refused- able to fall asleep again.\n\nA: improved u/o on dopa. headache unchanged but tolerable to pt. no morphine since . poor nutrition status- enc. supplements.\nOOB QD as tol. follow plan per interdis. team.\nP:\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-10 00:00:00.000",
"description": "Report",
"row_id": 1569276,
"text": "Nursing Progress Note\n\nS: \" My headache feels a little better.\"\n\nO: Please see flow sheet for objective data. Dopamine remains at 2.5mcgs/kg/min. IV Heparin dc'd at 12n d/t elevated INR. Tele paced rhythm with occ AF. Mg 1.6 repleted.\n\nResp: Pt conts to have dyspniec with exertion. Lungs scattered rales at bases. O2 sats 95-98% on RA.\n\nNeuro: Pt is alert and oriented. Less sleepy today. Conts to c/o headache although much less than over past couple of days. Denies need for any meds. OOB to chair with minimal assistance. Slightly unsteady on her feet. OOB ambulating x's1 short distance with PT.\n\nGU/GI: Appetite remains poor. Pt taking in good amts of liquids very little solid food. Denies N/V. Abd is soft with bowel sounds present. Sm amt of brown liquid stool this am. LFT's trending down. Foley draining yellow urine with some sediment. Creat .8. Diuretics held today. Aldactone dc'd d/t sodium 129.\n\nA&P: Tolerating dopa after dc of Milrinone. I&O even today. Encourage po intake. Encourage ambulation. Cont with POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-27 00:00:00.000",
"description": "Report",
"row_id": 1569246,
"text": "CCU NSG NOTE: ALT IN CV\nS: \"I've had this before and it was an ordeal\"\nO: For complete VS see CCU flow sheet.\nThis 59y old woman was transfered to CCU for swan placement and taylored therapy. THis pt with known heart failure with EF <15% was admitted to 6 with increasing sob. She was started on milronone and diuresed, but remains profoundly anasarcic.\nCV: HR has been in 70s, afib, multiple PVCs and occasional paced beats. BP stable in 1-teens/ 60-70s. She conts on milrinone .385 mic/kilo. She was consented for swan placement, which is occuring now. SHe has been K+ replaced and is receiving IV mag now.She is usually on coumadin, but has been off it since yesterday.\nRESP: She has bbr, but sats 97-99% on RA\nRENAL: Foley was inserted. I & O from Fa 6 added up and pt is ~2 liters neg LOS. SHe received lasix 40IV at 0830 this am.\nGI: Pt has been NPO\nMS: Pt A & O X 3. She is divorced. SHe has 1 son who is her proxy, but with whom she does not communicate. SHe has 2 neices who are very close with her and who will be in tonight.\nA: End stage heart failure pt admitted for swan\nP: Get numbers once swan in. Confirm with pt if she still wants son to be proxy. Monitor for change. Careful I & O\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-27 00:00:00.000",
"description": "Report",
"row_id": 1569247,
"text": "CCU Nurse Progress Notes 7a-7p\n59 yo patient transferred today from 6 for swan placement and diuresis. Full code.\n\nCV: Swan placed, numbers at placement were (16:00): pap 79/36, pcwp 36, cvp 24, co 3.8, ci 1.87, svr 1221, MV sat 55%. Started on Nipride gtt (titrate to MAP >= 60), at 1mcg/kg/min numbers were: pap 73/36, pap mean 49, cvp 22, co 3.6, ci 1.77, svr 1267, MV sat 50%. Increased Nipride to 3mcg/kg/min and will recheck numbers. Lasix gtt started at 5mg/hr, increased to 10mg/hr. Labs (18:00) Mg 1.7, repleting w/ 4gm Mag Sulfate IV. K 3.4, will replete w/ 60mEq sliding scale when Mg is complete. Heparin gtt at 1000units/hr, started without a bolus. HR 73-85 A-fib, occ. PVC's., BP 96-116/54-74. Pt denies CP/SOB. Dig level 0.7, was held on floor for elevated level, not yet reordered here.\n\nNeuro: Pt was given 2mg IV Ativan, total 75mcg fent and 1.5mg versed during swan insertion. Pt remains A&Ox3, calm & cooperative. C/O HA, given tylenol.\n\nResp: RR low-mid 20's. O2 sat high 90's-100, room air. LS RUL, LUL expiratory wheezes, RLL, LLL crackles. 21:00 placed on 3L nc d/t sats dropping to 89% when asleep.\n\nGI/GU: +bs, -bm. Foley draining clear dark, yellow urine. Given 5mg/hr Lasix IV drip at 19:00, increased to 10mg/hr. UO up to 90-140cc/hr last couple hours. BUN/Cr 23/0.7\n\nSocial: This shift, pt changed proxy to her two nieces, form completed and in front of chart, copies given to pt/neices. Contact info on board in room for spokesperson. The two nieces were in to visit, and the patient's son called.\n\nID: afebrile, no abx. c-diff neg.\n\nSkin: intact.\n\nA/P: 59 yr old with CHF, volume overloaded, transferred to CCU for tailored therapy, swan, IV milrinone, Nipride, lasix, Monitor hemodynamics, fluid balance, lytes, and PTT needed at 01:00. increase Milrinone if #'s not improved on higher Nipride dose. Support pt and family.\n\nNote entered by: , Student Nurse \n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-28 00:00:00.000",
"description": "Report",
"row_id": 1569248,
"text": "Neuro a/ox3 slept comfortably most of the night\ncvs HR 60-70's afib with pvc K+ 3.4 tx 60 meq kcl IV repeat K+ pnding, bp 96/64-110/66. On nipride 2.0 mcg/kg/min, lasix 10 mg IV q hr, milronone .385 mcg/kg/min and heparin 1000u IV C.O. 3.4, CI 1.82 SVR 1412, CVP 20, P/D 70/31 nipride increased to 2.5 mcg/kg/min CO 5.0, CI 2.67, SVR 896, CVP 16 P/D 60/30. PTT within parameters am pnding skin w+d pitting edema to LE pp+\nResp 3lnp lungs faint exp wheeze b/l am faint crackles b/l throughout o2 sats 96-99%, mixed venous 55-68%\ngu lasix 10 mg IV gtt neg 1194 from mn to 0500 cr.7 bun 11\nGI abd snt bs+ no stool alt 61, ast 86, ld 327, total bili 2.3 alk phos 124\nID wbc 8 afebrile\na. cmp ef < 15%, severe MR \nafib\nLFT elevated\np. monitor CO, CI, titrates gtt accordingly, replete lytes per scale, IV heparin, monitor LFT abd exam\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 1569255,
"text": "ADDENDUM\nO:BP TRENDING LOWER. MILRINONE DOWN TO 0.18MCG/KG/MIN. REPORTED TO DR. . PT , SBP SLT IMPROVED WHILE AWAKE. MHR INTERMITTANTLY V-PACING W/ UNDERLYING AFIB. EKG DONE, MD NOTIFIED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-04 00:00:00.000",
"description": "Report",
"row_id": 1569261,
"text": "Nursing Progress Note\n\n59yo women with known CAD s/p Mi , s/p CABG x's1 severe MR & TR,pul HTN, PAF EF 15% with h/o VT with placement of BIV pacer. Several admits for CHF excacerbation. Recent admit to CCU for tailored therapy with transfer to 6 on . Plan was for home infusion of Milrinone. PICC was placed with much difficulty. Today pt spiked at temp to 102.4 with elevated WBC. Urine and bld cultures sent. Started on Vanco and Zosyn pending cultures. Hemodynamcially stable so far. Concern for sepsis with little reserve.To be transfered to CCU for close observation. Pt has been made a DNR/DNI and she has refused a heart transplant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-05 00:00:00.000",
"description": "Report",
"row_id": 1569262,
"text": "CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\n S- \" I AM SO TIRED I JUST WANT TO SLEEP\"\n\nO- SEE FLOWSHEET FOR ALL OBJECTIVE DATA\nPLEASE REFER TO EXCELLENT / MEDICAL NOTES FOR DETAILS R/T EXTENSIVE AND COMPLICATED HPI/PMH.\n\nIN BRIEF, THIS IS A 59 YR OLD PT WITH EXTENSIVE CV HX SIGNIFICANT FOR\nMI, CAD, S/P CABG AND ISCHEMIC/DILATED CM (EF- 15%) AS WELL AS SEVERE TR/MR. SHE IS S/P BIVENT PACER/ICD INSERTION, PULM HTN, RESTRICTIVE LUNG DX, PAF, LAD DISSECTION AND ANEURISM. PT ALSO HAS DX- ON SYTHROID AND S/P THYROTOXICOSIS D/T AMIO.\n\nTHIS PT WAS ADMITTED TO CV STEPDOWN FOR CHF EXACERBATION WITH C/O SOB AND FEVERS FOR SEVERAL DAYS PTA. SHE WAS STARTED ON INOTROPY AND DIURESIS WITHOUT MUCH IMPROVEMENT AND TRANSFERED TO CCU ON FOR PA LINE AND FINE TUNING OF HER MEDICAL REGIMEN. PT WAS STARTED ON NIPRIDE IN ADDITION TO HER MILRINONE WITH 12 L DIURESIS AS A RESULT AND WEANED OFF THE NIPRIDE, STARTED ON DIGOXIN WITH HOPES OF A MILRINONE WEAN. SHE DEVELOPED PAF AND WAS STARTED ON AMIODORONE LOAD WHICH IS FINISHED AS OF AND HER BIVENT PACER/ICD WAS INTERROGATED AND ADJUSTED TO ALLOW FOR BETTER SYNCHRONY.A PICC LINE WAS INSERTED IN RT AC FOR PLAN FOR D/C TO HOME ON MILRINONE AND ON , PT DEVELOPED FEVERS TO 102.9 WITH WC AND BANDEMIA. SHE WAS PAN CULTURED AND STARTED ON VANCO/ZOSYN/PO FLAGYL FOR R/O CDIFF( S/P SOME GI COMPLAINTS/ABD PAIN, EMESIS/NAUSEA, LOOSE STOOL), AND SENT TO CCU 7P .\nPT WAS TX WITH TYLENOL, CONTINUED ON MILRINONE/HEP/DIG/AMIO AND DID NOT EXHIBIT ANY CV INSTABILITY. NO FURTHER FEVERS,BUT ID RECOMMENDED CHANGING OVER FROM ZOSYN TO IMIPENUM.LATER THIS SHIFT, B/C WERE CALLED BACK FOR (+) GM (-) RODS AND HO CALLED. NO CHANGE TO THERAPY AT THIS TIME, PT REMAINS CV STABLE AND AFEBRILE, HERE FOR CLOSER MONITORING.\n\nREVIEW OF SYSTEMS:\nPLEASE REFER TO CAREVUE/FLOWSHEET.\n\nCV- VSS- BP-90-108/50-60 WITH HR- 90'S V PACED. RECEIVED 3 GM MG/40 KCL ON EVES FOR LOW LEVELS.\n\nRESP- CLEAR- NO TROUBLE WITH SOB, BREATHING AT MID 20'S, O2 SATS- 97%.\nOFF ALL DIURESIS. REMAINS ON 2L NP.\n\nID- AFEBRILE- SEE ABOVE-\nIMIPENUM, VANCO, PO FLAGYL.\nGM (-) RODS BC.\nCONTACT PRECAUTIONS FOR R/O CDIFF.\n\nGU- FAIR UO- 20-30CC/HOUR, DARK AMBER CLEAR VIA FOLEY.\n\nGI- TOOK PM MEDS WITHOUT PROBLEM, NO NAUSEA THIS SHIFT, NO STOOL- RECEIVED ANZIMET UPON TRANFER FROM 6, (+) BOWEL SOUNDS.\nDECLINING ANY FOOD/CRACKERS/TOAST AT THIS TIME,,JUST WANTS TO SLEEP.\n\"FEELS LOUSY\"\n\n PT LETHARGIC FROM ANZIMET AND OVERALL FEELING \"LOUSY\"\nA AND O X 3- SISTER CALLED AS WELL AS FRIEND- SPOKE TO FRIEND ON THE PHONE. SLEPT REST OF SHIFT,\nDENIES PAIN, SOB.\n\nA/ PT WITH EXTENSIVE CV HX/CM CURRENTLY ADMITTED WITH R/O SEPSIS\n\nCONTINUE TO CLOSELY MONITOR CV STATUS AS WELL AS ? FEVER/RESULTS OF URINE AND STOOL SPECIMENS. CONTINUE MILRINONE/DIG/HEPARIN AS ORDERED.\nREPEAT BLOOD CULTURE THIS AM WITH AM LABS.\nREPLETE LYTES AS NEEDED.\nWATCH RENAL FX/BUN/CREAT/UO- ? NEED FOR GENTLE HYDRATION IF WORSENS IN SETTING OF S/P FEVERS ETC.\nCONTINUE ANTIBX AS ORDERED.\nCOMFORT/SUPPORT\nPT IS DNR/DNI AS OF .\nC/O TO FLOOR\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-05 00:00:00.000",
"description": "Report",
"row_id": 1569263,
"text": "CCU RE-ADMISSION NOTE: S/P CHF C/B R/O SEPSIS\n(Continued)\n ONCE MEDICALLY APPROPRIATE.\nCONTACT PRECAUTIONS UNTIL CDIFF R/O.\nKEEP PT AWARE OF PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-05 00:00:00.000",
"description": "Report",
"row_id": 1569264,
"text": "ccu nursing progress note\ns: i just feel chills, like when you have the flu\no: pls see carevue flowsheet for complete vs/data/events\nid: t spike to 102.0 po. wbc to 20(18). gr neg rods id'd in bld cultures from . 2 sets of cultures pend from .(1 of which was drawn peripherally this am). urine poss source w ua +wbc and bacteria. need further speciation. cont on vanco(needs trough before mdnoc dose), po flagyl and imipenum.\nhad abd ct which noted l pylonephritis.\ncv: hr 80-100, mostly vpaced. occ intrinsic rhythm when>90. bp 90-105/50-60. cont on milrinone at .38mcg/kg/min. heparin at 1000units/hr. inr 1.6, ptt 78.\ndig level 3.4 this am and dose was held.\nna 124(128). holding lasix in setting of bacterimia.\nk 5.0, mg 2.1.\nresp: labored w min exertion. sats >95% on 2l nc. faint cxs at bases.\ngi: anorexia, declining any food. had 2 lrg liquid stools. sample sent for cdiff. taking ice chips, encouraged po's as tol.\ngu: concentrated urine w o/p 10-20cc/hr. foley dc'd per ccu team's order at 2pm. pt dtv 8-10pm. cr 1.4(1.1).\nskin: intact. access: l single lumen picc, 1peripheral.\nms: lethargic most of day. cooperative. oob w assist to use bedside commode. c/o headache most of day w little relief from oxycodone +/- tylenol. c/o photophobia as well. c/o l flank pain mostly w palpation.\nsocial: friend visited. called.\na: pyleonephritis and bactermia. bp stable. hyponatremia and ^cr...likely dry intravasc.\np: follow fever. await further id of organism. monitor hemodynamics and volume status. med for comfort. support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-09 00:00:00.000",
"description": "Report",
"row_id": 1569272,
"text": "CCU NPN 2300-0700\nO:\nTM 99po. contin. on ceftriax q24hr. WBC 15.\nBC/urine pnd from .\n\nHR 80's vpaced. occas. PVC. underlying rhythm NSR. contin. on amio 400mgpo. BP 99/57-110/58. milrinone .38mcq/k/min and heparin at 1000u/hr. PTT 133.6- hep. off x1hr and will restart at 800u/hr at 0630. K+ 3.7- 40KCL IV.\nu/o 50-100cc/hr, concentrated. even for and currently neg. ~ 200cc since MN.\n\nsats 88-90% on RA , occas. apnea noted. 2lnc placed with sats improving to 98%. crackles at bases. shallow breathing pattern. RR 30-40.\n\npt. contin. to c/o headache, states that she did get some relief from morphine. 2mg x2 during night. slept better tonight.\n\nno stool. thirsty. asking for juice.\n\nA/P: slept better- better paincontrol with morphine. VSS. u/o improved on milrinone. K+ repletion.\ncheck PTT at 1230. OOB today. assess effectiveness of morphine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-04-09 00:00:00.000",
"description": "Report",
"row_id": 1569273,
"text": "ccu npn\no- id-afebrile. cont. abx, recent c+s pnd.\ncv- hr 80s vpaced with occ to freq pvc, occ. couplet. bp 100-114/50s. k-re'd total 40meq iv/po for 3.7, mg 1.7 re'd 1 amp iv. po4 1.3, re'd neutraphos. hct 32.1. milrinone d/c'd and started on dopamine about 1hr later at 2.5mic/kg/min without change in bp/hr/vea. u/o slightly less, still adequate, ho aware, prefered not to increase dopamine. ptt 83.8 on decreased heparin 800units/hr.\nresp- on r/a sats high 90s most day, down to 90-92 this pm while asleep. l/s cxs/coarse sounds lower bilat. sob with any exertion in am, even talking, less sob this pm. u/o about 50cc/hr. i+o goal even day, about even 2pm.\ngi-abd soft w/bowel sounds. poor appetite, ate banana in am, taking juice. ordered choc. boost and boost pudding, none arrived, called this pm for boost. inc.small smear liquid stool in am, yellow/brn.\nlfts up, down to ultrasound for liver us 3pm.\nms/pain-a+o x3, sleepy all day, somewhat more awake this pm. c/o still h/a, re'd morphine 2mg iv x1 11:30am w/some relief.\nskin- intact. lots ecchymosis, esp arms.\nactivity- oob to chair most day, tol well, needs assist of 2 to stand/pivot,unsteady on her feet. back to bed this pm for liver us.\naccess- picc patent, dsg/cap changed. peripheral iv for routine change, unable to restart, iv coming to try to restart.\na- changed to dopamine. lfts elevated, down for liver us.\np- cont. dopamine, increase if u/o or bp falls, sats drop. monitor also for increased hr/bp, vea. o2 prn. f/u liver us results. goal i+o even. enc. try boost/boost pudding. enc. oob as tolerated. f/u new iv per iv team.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 1569256,
"text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\n\ns: \"it's hard to believe i can get this tired just sitting up\"\no: cv: vpaced in the 80s. underlying rhythm afib. no vea. maps cont low 54-62 on low dose milrinone. holding am meds d/t hypotension. discussed on rounds team concerned that new recurrent afib (poss brought on by milrinone) was contributing to hypotension and felt bp may improve off milrinone and then add back oral agents. milrinone dc'd at 10am. no change in bp appreciated. ci 1.9(2.5 on milrinone), svr 1000(850 on milrinone). bp starting to trend up in afternoon w maps to 65 and systolic 85/ . will resume valsartan at lower dose if map >60. then eval other oral agents.\n\npt oob all morning, transfered w min assist. had trans c/o dizzyness while sitting up and bp <80/ . but did not appear to be postural.\npap 40-50/22-27, cvp 7-12.\nheparin at 1000units/hr. ptt 82. inr 1.4. cont coumadin dosing daily. plan to possibly remove pa line this eve(discussed w team concern of starting longacting anticoagulants with vague plans to remove invasive lines). a peripheral line was placed by the iv team.\n\nresp: basilar cxs. labored w activity but maintains sats >93% on ra. no sob at rest. had minor nose bleed but also had clot about the size of an egg pass from her nose.\n\ngi: good intake. no bm this shift.\ngu: poor uop. lasix held d/t hypotension. cr 0.7.\nms: alert, oriented, cooperative. c/o pain at insertion site, med w oxycodone w good effect. also cont on tid clonipin.\n\na: afib, hypotension, poor uop.\np: cont to follow hemodynamics, volume status. resume oral meds and monitor closely. med for comfort. support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-30 00:00:00.000",
"description": "Report",
"row_id": 1569253,
"text": "CCU NSG NOTE: ALT IN CV/HEART FAILURE\nS: \"I can see my ankles!\"\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nCV: Nipride being weaned. She started the day on 2 mic/kilo and is now down to .5mic/kilo since 1630. Last numbers on 1 mic/kilo were index of 2.9 and SVR 771. She received 40mg valsartin this am and pm dose will be increased to 80mg and nipride will be shut off. She conts on milrinone .385 and heparin at 1000u hr. She conts on po dig and coumadin. HR is in 80 and today she is primarily in NSR, though occasional paced beats are seen. BP has been in mid 90s/60s. PAPs are slowly decreasing to 40-50s/19-25 with RA . K+ was at 1600 and mag 1.5, she will be replaced.\nRESP: Lungs sounded clear this afternoon. When lying in bed sat will drop to 94%, but with deep breathing she quickly comes up to high 90s. She denies any SOB\nRENAL: She received lasix 80mg iv at 8am with fair response. Lasix had been changed to Q d. BUt a second dose of 80mg was given at 1630 and pt is now 430cc neg since midnight with todays goal neg 1 liter, and neg >9liters LOS. She initially had hematuria, but it has since resolved.\nGI: Pt conts to have excellent apetite. She had G- bm this evening.\nACTIVITY: Pt OOB with minimal assist this afternoon. SHe becomes dypnic with minor activity, but it resolves quickly. She needs encouragement to maintain independence. She will need PT once the swan is out.\nMS/COMFORT: Pt A & O X 3, cooperative. She c/o of discomfort in left axilla area with nearly resolves with tylenol and oxycodone 5mg, last given at 3pm. She has had continuous low level chest pain for many years.\nA: Weaning nipride/conts on milrinone\nP: ?Increase valsartin for 8pm. Keep careful I & O. REpleat lytes. Assist pt with postion changes. DIetary consult is needed as pt is unclear on low salt/heart failure diet as well as daily weights and how to deal with weight gain. She will also need PT consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 1569254,
"text": "CCU NURSING NOTES\nS:I'M FEELING BETTER THIS EVENING.\nO:59YR OLD FEMALE W/ DILATED CM, CHF MANAGEMENT CCU DAY 4, REMAINS ON MILRINONE, HEPARIN, LASIX . SNP WEANED OFF AND VALSARTAN INCREASED TO 80MG. IMPROVED MV 72% AND CI >3. PCWP OF 24. CONTINUED DIURESES UNTIL MINNOC. NEG >1L AT 2300 LAST EVENING. 10L. MHR 80S SR, NO VEA. MAGNESIUM AND POTASSIUM REPLACED. +MUR. DP PALP. C/O SORENESS AT SWAN INSERTION SITE. PT MED W/ OXYCODONE AND TYLENOL W/ GOOD EFFECTS.\nRESP:LUNGS W/ CRACKLES AT BASES OTHERWISE CLR. SATS 97% ON 3L. SOME DOE BUT PT ABLE TO REPOSITION HERSELF IN BED W/O ASSIST.\nGI:ABD SOFT, +BS.\nGU:+HEMATURIA, PINK COLORED URINE.\nA/P:SLOW IMPROVEMENT OF CHF, CONTINUE TO MONITOR HEMODYNAMICS AS PT IS WEANED OF MILRINONE. CONTINUE DIURESIS AS TOLERATED. PT TEACHING FOR CHF MANAGEMENT, NUTRITION. PT TO ASSIST W/ RECONDITIONING.\n"
},
{
"category": "ECG",
"chartdate": "2166-04-11 00:00:00.000",
"description": "Report",
"row_id": 284072,
"text": "There is atrial and ventricular pacing. Compared to the previous tracing\nthe atria are now paced.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-09 00:00:00.000",
"description": "Report",
"row_id": 284073,
"text": "Atrial sensed ventricular paced\nVentricular premature complexes\nSince previous tracing of , atrial fibrillation now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-07 00:00:00.000",
"description": "Report",
"row_id": 284074,
"text": "Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-14 00:00:00.000",
"description": "Report",
"row_id": 283843,
"text": "A-V sequential pacing\n*** complex QRS morphology - no further analysis ***\nSince previous tracing, the heart rate is faster\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-06 00:00:00.000",
"description": "Report",
"row_id": 284075,
"text": "Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of , sinus rhythm now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-03 00:00:00.000",
"description": "Report",
"row_id": 284076,
"text": "Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\nof atrial fibrillation is no longer recorded and the rhythm is sinus\nwith atrial sensing and ventricular pacing.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-04-01 00:00:00.000",
"description": "Report",
"row_id": 284077,
"text": "Regular ventricular pacing. Pacemaker rhythm. No further analysis. Compared to\nthe previous tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 284078,
"text": "Regular ventricular pacing. Pacemaker rhyth. No further analysis. Compared to\nthe previous tracing no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-31 00:00:00.000",
"description": "Report",
"row_id": 284079,
"text": "Ventricular paced rhythm\nAtrial mechanism appears to be flutter/? fibrillation\nSince previous tracing of , sinus rhythm now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-29 00:00:00.000",
"description": "Report",
"row_id": 284080,
"text": "Atrial sensed ventricular paced\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-28 00:00:00.000",
"description": "Report",
"row_id": 284081,
"text": "Atrial sensed ventricular paced\nVentricular premature complexes\nSince previous tracing of , atrial fibrillation now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-28 00:00:00.000",
"description": "Report",
"row_id": 284082,
"text": "Atrial fibrillation. Ventricular couplets. Marked left axis deviation.\nIntraventricular conduction defect. Left ventricular hypertrophy. Intermittent\nventricular paced rhythm. Since the previous tracing of there is a run\nof ventricular paced rhythm.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-25 00:00:00.000",
"description": "Report",
"row_id": 284083,
"text": "Atrial fibrillation and demand ventricular pacing\nIntraventricular conduction delay - left axis deviation\nSince previous tracing, atrial fibrillation is new\n\n"
},
{
"category": "ECG",
"chartdate": "2166-03-24 00:00:00.000",
"description": "Report",
"row_id": 284084,
"text": "Paced rhythm\nSince previous tracing, no significant change\n\n"
}
] |
22,071 | 125,295 | During his cardiac catheterization on the day of admission, there was a complication involving the PTCA/stent of OM causing jailing of his AV groove, left circumflex with loss of dissection of his lower OM. Post procedure the patient experienced persistent chest pain, hypotension to the 60's/30's and was noted to have hematocrit drop from 44 to 34.9. Also with increasing right groin pain. The patient had CT of abdomen and pelvis showing mild to moderate hematoma and no retroperitoneal bleed. Patient also had several episodes of bradycardia requiring Atropine. He was transferred to the CCU on for further management of his chest pain, hypotension and decreased hematocrit. The patient ruled in for an MI by enzymes, likely secondary to include OM/jailed AV groove, left circumflex with positive CKs which peaked at 763/45 on . The patient was maintained on Aspirin, Lipitor and Plavix. Once he became hemodynamically stable on he was started on Metoprolol and Captopril which were titrated upwards as blood pressure tolerated. He continued to have mild to moderate pain intermittently on and without EKG changes in response to sublingual Nitroglycerin. The patient's episodes of hypotension responded well to 4-6 liters of IV fluids on to , as well as two units of packed red blood cells. This was thought to be secondary to difference in blood pressure cuff measurements between the floor and CCU as his blood pressure was not as low when measured in the CCU after. The patient had a bedside echo on which was notable for a limited view of left ventricular ejection fraction of 50%, no obvious effusion but could not rule out possible effusion, no tamponade was noted. An official TTE on showed post echo density consistent with pericardial effusion hematoma, etc. The patient will most likely get an outpatient stress test with EF evaluation as an outpatient. The patient's initial hematocrit drop of 10 points may have reflected blood loss from two catheterizations and dilution after 4-6 liters of fluid resuscitation, however, he received two units of packed red blood cells on the morning of and his hematocrit was checked , remaining fairly stable. He was guaiac negative throughout. On he was noted to have non palpable right foot pulses found on the evening of . The patient complained of increasing right groin pain and was found to have a right groin bruit on exam. Ultrasound was done on revealing a 5 by 3 bilobed pseudoaneurysm with a narrow neck associated with the right common femoral artery. The patient's hematocrit remained stable. The patient underwent an interventional radiology procedure with thrombin injection on . A repeat ultrasound was done on the day of discharge which revealed a successful thrombosing of the right groin pseudoaneurysm. The patient did not require any additional intervention with regard to the right groin pseudoaneurysm. The patient did well throughout the remainder of his hospital stay, remained hemodynamically stable with stable hematocrit. He was noted to have several bradycardic episodes overnight with heart rate as low as mid 40's, but these only occurred overnight while the patient was sleeping. Since these episodes were not symptomatic and did not occur during the day, the patient was continued on his Atenolol. The patient was discharged stable. | VOIDING WELL .,IF HCT STABLE BE TRANS . Mild tricuspid [1+]regurgitation is seen. FINDINGS: Duplex evaluation was performed of the right lower extremity. FINAL REPORT INDICATION: Right groin hematoma/pseudoaneurysm. FINAL REPORT HISTORY: Right inguinal pseudoaneurysm. R GROIN ECCYMOTIC ,SOFT HEMATOMA UNCHANGED.ULTRASOUND SHOWS PSEUDOANEURYSM. sp stent om,complicated by hypotension,hematomaAM CK RISING . There is an echo-dense space seen posteriorly at the level ofthe AV groove c/w pericardial effusion, hematoma, etc. The basal inferoposterior wall ishypokinetic. This is in comparison to the above studies which showed a right common femoral artery pseudoaneurysm which underwent initially felt to be failed thrombin injection IMPRESSION: Thrombosed right femoral artery pseudoaneurysm. Pericardial effusion.Height: (in) 69Weight (lb): 260BSA (m2): 2.31 m2BP (mm Hg): 118/65Status: InpatientDate/Time: at 15:39Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of theinteratrial septum.LEFT VENTRICLE: The left ventricular cavity size is normal.RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter. pericardial fat).Compared with the prior study of , images are still suboptimal. There is a moderate echo-dense space seen posteriorly c/wpericardial effusion, blood, pericardial fat, etc.Follow-up study is recommended. with R groin pseudoaneurysm. with R groin pseudoaneurysm. There is at least mildmitral regurgitation. scale and Doppler son of the right common femoral artery and vein were performed. BP STABLE ,TOL LOPRESSER AND ACE . Left atrial abnormality. RIGHT; GUID FOR COMPRESS/REPAIR OF AVF/PSEUDO RIGHT Reason: arterial duplex with thrombin injection of pseudoaneurysm. The remaining basal segments are contracting well (the apex isnot seen). Pt has significant caridac hx.Neuro: Pt intact. First degree A-V block. First degree A-V block. First degree A-V block. First degree A-V block. Sinus bradycardia. CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse calcification of the abdominal aorta. There is moderate pulmonary artery systolichypertension. R. GROIN WITH SMALL OOZE & MOD. U/O 45-180CC/HR.ID: T(MAX)98.3(PO).LABS: HCT 36.2, PT 12.7, PTT 26.4, INR 1.0, K 4.0, BUN/CREAT 13/0.7, BS 112, CA 7.0, MG 1.6, PO4 4.4, ALB 3.3, & CK 217 WITH MB16%.PLAN: CONT. FINDINGS: The patient has a right inguinal pseudoaneurysm arising off the common femoral artery. Suboptimalimage quality due to body habitus.Conclusions:The left atrium is moderately dilated. Mitralregurgitation is present but cannot be quantified.TRICUSPID VALVE: The tricuspid valve leaflets are normal. TRANSFUSED 1U PRBC FOR HCT 34.9. The inferior wallis akinetic. There is an echo-denseseen anteriorly (? pseudoaneurysm r groin sp stent,miSR TO SB NO ECTOPY . REASON FOR THIS EXAMINATION: follow right groin pseudoaneurysm. a complication from cath developed a hematoma in R groin. The left ventricle is borderline tomildly hypertrophied. Minimal stranding is seen about the right lower psoas and iliacus muscles. T waveinversions in leads I and aVL suggest possible anterolateral ischemia. Evaluate for pseudoaneurysm. Compared to tracing #1 nodiagnostic interim change.TRACING #2 Now with decreased hematocrit and increasing mass in right groin. This appears to be a small hematoma. IMPRESSION: Findings most consistent with a 5.0 x 3.0 bilobed pseudoaneurysm with a narrow neck associated with the right common femoral artery. DISTAL PULSES BY DOPPLER . Status post attempted thrombin injection. REASON FOR THIS EXAMINATION: arterial duplex with thrombin injection of pseudoaneurysm. SIZE HEMATOMA. PATIENT/TEST INFORMATION:Indication: Hypotension, S/P intervention.? On limited views, rightventricular systolic function is good. +BPPP. Hct, and extreme TN in right groin. E/D WELL. TECHNIQUE: Multiple axial images were obtained from the mid abdomen to the upper thigh without IV contrast. VOIDING LG AMTS BLD TINGED URINE .ALERT/ORIENTED/ COOPERATIVERI BY CK, BE DEVELOPING PSEUDO ANUERYSMFOLLOW HCT, MONITOR SIZE HEMATOMA For Thrombin injection. There is moderate pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal. Compared to tracing #3 nodiagnostic interim change.TRACING #4 ULTRASOUND ORDERED . Pt to cath lab on stented OM. The common femoral vein were both somewhat compressed under this large pulsatile lesion. Sinus bradycardia - first degree A-V blockLateral ST-T changes may be due to myocardial ischemia Effusion.BP (mm Hg): 78/45Status: InpatientDate/Time: at 22:11Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:TRICUSPID VALVE: The tricuspid valve is not well visualized.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.Conclusions:Views are limited. C/O PERSISTENT CP # ON SCALE 1-10, UNRELIEVED BY IV MSO4. MED C PERCOCETTE FOR PAIN C RELIEF . BS CLEAR BUT SLIGHTLY DIMINISHED AT BASES. 9:20 AM FEMORAL VASCULAR US RIGHT Clip # Reason: follow right groin pseudoaneurysm. There is a small high attenuation fluid collection medial and inferior to this soft tissue stranding measuring approximately 3cm in largest diameter. IMPRESSION: 1) Right upper thigh and groin soft tissue stranding with adjacent small high attenuation fluid collection. The left ventricle may be hypertrophied. Pt especially needs to keep R leg .Cardiac: Pt in SR/SB do ectopy. This did not yield complete occlusion of the pseudoaneurysm, slight decrease in size after injection. Monitor dopplers and hematoma carefully! BS+. REPEAT HCT PENDING . BP 88-119/39-58. The right ventricle is not seen. The aortic and mitral valves aregrossly normal. The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. DID WELL ON PRONGS FOR REMAINDER OF NOC. Pt had an episode of CP at 0250 pt claims it was non radiationg CP, pt received 1 SL NTG, relief with NTG, EKG done no significant changes.Resp: Pt has hx of sleep apenia. | 15 | [
{
"category": "Nursing/other",
"chartdate": "2138-08-14 00:00:00.000",
"description": "Report",
"row_id": 1551775,
"text": "pseudoaneurysm r groin sp stent,mi\nSR TO SB NO ECTOPY . BP STABLE ,TOL LOPRESSER AND ACE . R GROIN ECCYMOTIC ,SOFT HEMATOMA UNCHANGED.ULTRASOUND SHOWS PSEUDOANEURYSM. MED C PERCOCETTE FOR PAIN C RELIEF . HCT STABLE AT 32. DISTAL PULSES BY DOPPLER . BS CL, SAT 98 RM AIR . WILL USE BIBAP TONITE . E/D WELL. VOIDING WELL .,IF HCT STABLE BE TRANS .\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-08-13 00:00:00.000",
"description": "Report",
"row_id": 1551772,
"text": "SEE ADMISSION HISTORY/ICU EVENTS FORM FOR DETAILS OF PMH.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE.\nRESP: O2->2L NP. O2 SATS 97-100%. RR 11-16. BS CLEAR BUT SLIGHTLY\n DIMINISHED AT BASES. ATTEMPTED BIPAP BRIEFLY WHEN GOING TO SLEEP\n (D/T SLEEP APNEA), BUT HOSPITAL BIPAP MACHINE DIFFERENT THAN\n HIS OWN & HE FELT LIKE HE WAS NOT GETTING ENOUGH AIR. RPT AWARE\n & ATTEMPTED TO ASSIST PT TO NO AVAIL. DID WELL ON PRONGS FOR\n REMAINDER OF NOC. NO APNEA ALARMS.\nCARDIAC: HR52->73 SR WITH NO ECTOPY. BP 88-119/39-58. C/O PERSISTENT\n CP # ON SCALE 1-10, UNRELIEVED BY IV MSO4. R. GROIN WITH\n SMALL OOZE & MOD. SIZE HEMATOMA. +BPPP. TRANSFUSED 1U PRBC\n FOR HCT 34.9. IV 1/2NS 150CC/HR.\nGI: ABD. SL. DISTENDED. BS+. NO STOOL. NPO X MEDS & FEW ICE CHIPS.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 45-180CC/HR.\nID: T(MAX)98.3(PO).\nLABS: HCT 36.2, PT 12.7, PTT 26.4, INR 1.0, K 4.0, BUN/CREAT 13/0.7,\n BS 112, CA 7.0, MG 1.6, PO4 4.4, ALB 3.3, & CK 217 WITH MB16%.\nPLAN: CONT. TO CYCLE CK'S(NEXT DRAW 0800). CONT. TO FOLLOW HCTS &\n ASSESS R. GROIN HEMATOMA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-08-13 00:00:00.000",
"description": "Report",
"row_id": 1551773,
"text": "sp stent om,complicated by hypotension,hematoma\nAM CK RISING . C/P 4 AT IPM . NO EKG CHANGES . PAIN RELIEVED BY 3 SL NITROS . 4 PM CK PENDING . ALSO C/O HOT FLASHES .\n\nPT C/O POPPING,INCREASED PAIN IN GROIN , BRUIT NOW PRESENT . ULTRASOUND ORDERED . REPEAT HCT PENDING . PULSES BY DOPPLER DISTAL.\n\nSAT 100 RM AIR. NO EPISODES SLEEP APNEA\n\nE/D WELL .NO STOOL\n\nFOLEY DC . VOIDING LG AMTS BLD TINGED URINE .\n\nALERT/ORIENTED/ COOPERATIVE\n\nRI BY CK, BE DEVELOPING PSEUDO ANUERYSM\n\nFOLLOW HCT, MONITOR SIZE HEMATOMA\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-08-14 00:00:00.000",
"description": "Report",
"row_id": 1551774,
"text": "CCU Nursing Progress Note\nPt is a 54 y.o male RI for MI. Pt to cath lab on stented OM. S/P stent placement, pt had complications of a hematoma in R groin, Episodes of CP, and hypotension. Pt has significant caridac hx.\n\nNeuro: Pt intact. A&O x3. Pt moves all extremeties well. Pt instructed to remain flat until told otherwise. Pt frustrated but very cooperative. Pt especially needs to keep R leg .\n\nCardiac: Pt in SR/SB do ectopy. BP in 100's to 130's systolic. a complication from cath developed a hematoma in R groin. Area is ecchymotic and very painful upon palpation, and pain without manipulation. Hematoma expanding and is marked. HCT remaining stable at 34. Dopplerable pulses fluxuating with amplitude of doppler. Pt also has pseudo anneurysm, and bruiet. Pt receiving percocet q 6/hr for pain. Pt had an episode of CP at 0250 pt claims it was non radiationg CP, pt received 1 SL NTG, relief with NTG, EKG done no significant changes.\n\nResp: Pt has hx of sleep apenia. Pt is on bi-pap at night, and 4L NC when off bipap. BS clear.\n\nGI: Pt on infrequent liquids, with meds, pt had coffee brought in by family and did not tolerate well. Guiac all stools x3, none have been done. BS present pt obese\n\nGU: Pt on sips for meds. Pt voids good urine output, No IVF at this time. Urine creatinine and microalbumin sent at 2100.\n\nMisc: Ultrasound in AM for hematoma. Family supportive. Monitor dopplers and hematoma carefully!\n"
},
{
"category": "Echo",
"chartdate": "2138-08-12 00:00:00.000",
"description": "Report",
"row_id": 65879,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension, S/P intervention.\n? Effusion.\nBP (mm Hg): 78/45\nStatus: Inpatient\nDate/Time: at 22:11\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nViews are limited. The left ventricle may be hypertrophied. The inferior wall\nis akinetic. The remaining basal segments are contracting well (the apex is\nnot seen). The right ventricle is not seen. The aortic and mitral valves are\ngrossly normal. There is a moderate echo-dense space seen posteriorly c/w\npericardial effusion, blood, pericardial fat, etc.\n\nFollow-up study is recommended.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2138-08-13 00:00:00.000",
"description": "Report",
"row_id": 65773,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nS/P intervention (circumflex stent).\n? Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 260\nBSA (m2): 2.31 m2\nBP (mm Hg): 118/65\nStatus: Inpatient\nDate/Time: at 15:39\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mitral\nregurgitation is present but cannot be quantified.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. There is no pulmonic valve stenosis.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality due to body habitus.\n\nConclusions:\nThe left atrium is moderately dilated. The left ventricle is borderline to\nmildly hypertrophied. Views are limited. The basal inferoposterior wall is\nhypokinetic. The remaining basal segments are contracting well. The apex is\nnot seen. The LVEF cannot be accurately estimated. On limited views, right\nventricular systolic function is good. The aortic leaflets (3) appear\nstructurally normal with good leaflet excursion. Aortic regurgitation cannot\nbe excluded. The mitral leaflets are mildly thickened. There is at least mild\nmitral regurgitation. There is moderate pulmonary artery systolic\nhypertension. There is an echo-dense space seen posteriorly at the level of\nthe AV groove c/w pericardial effusion, hematoma, etc. There is an echo-dense\nseen anteriorly (? pericardial fat).\nCompared with the prior study of , images are still suboptimal. There\nhas probably been no significant change (views not entirely comparable).\n\n\n"
},
{
"category": "ECG",
"chartdate": "2138-08-14 00:00:00.000",
"description": "Report",
"row_id": 142248,
"text": "Sinus bradycardia\n - first degree A-V block\nLateral ST-T changes may be due to myocardial ischemia\n\n"
},
{
"category": "ECG",
"chartdate": "2138-08-13 00:00:00.000",
"description": "Report",
"row_id": 142249,
"text": "Normal sinus rhythm. First degree A-V block. Compared to tracing #3 no\ndiagnostic interim change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2138-08-12 00:00:00.000",
"description": "Report",
"row_id": 142250,
"text": "Sinus bradycardia. First degree A-V block. Compared to tracing #2 no diagnostic\ninterim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2138-08-12 00:00:00.000",
"description": "Report",
"row_id": 142251,
"text": "Normal sinus rhythm. First degree A-V block. Compared to tracing #1 no\ndiagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2138-08-12 00:00:00.000",
"description": "Report",
"row_id": 142252,
"text": "Normal sinus rhythm. First degree A-V block. Left atrial abnormality. T wave\ninversions in leads I and aVL suggest possible anterolateral ischemia. T wave\nflattening in leads V5-V6. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-08-18 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 743691,
"text": " 9:20 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: follow right groin pseudoaneurysm.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p M.I. with R groin pseudoaneurysm. Failed thrombin injection\n on Friday.\n REASON FOR THIS EXAMINATION:\n follow right groin pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right groin hematoma/pseudoaneurysm. Status post attempted\n thrombin injection.\n\n FINDINGS: Duplex evaluation was performed of the right lower extremity. The\n study compared to and . On the current study there is no evidence\n of right groin pseudoaneurysm or AV fistula. The common femoral artery and\n common femoral vein are patent without evidence of obstruction. This is in\n comparison to the above studies which showed a right common femoral artery\n pseudoaneurysm which underwent initially felt to be failed thrombin injection\n\n IMPRESSION: Thrombosed right femoral artery pseudoaneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-08-15 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 743568,
"text": " 2:52 PM\n ART DUP EXT LO UNI;F/U; TRANS THERAPY, EMBO S&I RIGHT Clip # \n TRANS-CATH OCC./EMBO . RIGHT; GUID FOR COMPRESS/REPAIR OF AVF/PSEUDO RIGHT\n Reason: arterial duplex with thrombin injection of pseudoaneurysm.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p M.I. with R groin pseudoaneurysm.\n REASON FOR THIS EXAMINATION:\n arterial duplex with thrombin injection of pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right inguinal pseudoaneurysm. For Thrombin injection.\n\n FINDINGS: The patient has a right inguinal pseudoaneurysm arising off the\n common femoral artery. Under real-time ultrasound evaluation, after\n discussion with the patient, a 20 g. needle was placed within the\n pseudoaneurysm. Approximately 1000 units of Thrombin was injected. This did\n not yield complete occlusion of the pseudoaneurysm, slight decrease in size\n after injection. No change in peripheral exam.\n\n IMPRESSION: Persistent right common femoral artery pseudoaneurysm after 1000\n units of Thrombin (currently measuring 1.2 X 2.3 cm). Size is such that would\n recommend follow up in 2 or 3 days as this may spontaneously thrombose. If\n persistence is documented at that time, would consider open repair.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-08-14 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 743503,
"text": " 1:05 PM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: 54 yo man question pseudoaneurysm post cardiac catheterizati\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with . Hct, and extreme TN in right groin.\n REASON FOR THIS EXAMINATION:\n 54 yo man question pseudoaneurysm post cardiac catheterization. Please\n evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n LOWER EXTREMITY ULTRASOUND\n\n CLINICAL INDICATION: 54 year old man status post cardiac catheterization. Now\n with decreased hematocrit and increasing mass in right groin. Evaluate for\n pseudoaneurysm.\n\n scale and Doppler son of the right common femoral artery and vein\n were performed. There is a bilobed hypoechoic structure measuring\n approximately 5.0 x 3.0 cm anterior to the common femoral artery with a small\n neck communicating with the artery. The common femoral vein were both\n somewhat compressed under this large pulsatile lesion. This lesion contains\n arterial waveforms. No definite evidence of AV fistula was demonstrated,\n although the proximal common femoral vein waveform appeared somewhat mixed,\n likely secondary to reverberations from the adjacent pulsatile mass.\n\n IMPRESSION: Findings most consistent with a 5.0 x 3.0 bilobed pseudoaneurysm\n with a narrow neck associated with the right common femoral artery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-08-12 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 743411,
"text": " 9:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal hematoma\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p cardiac cath today now with hypotension, right groin and\n back pain, and 10 point Hct drop.\n REASON FOR THIS EXAMINATION:\n evaluate for retroperitoneal hematoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P cardiac catheterization with hypotension, groin and back pain\n at 10 point HCT drop.\n\n TECHNIQUE: Multiple axial images were obtained from the mid abdomen to the\n upper thigh without IV contrast.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse calcification of the\n abdominal aorta. There is residual contrast within the collecting systems\n bilaterally. Minimal stranding is seen about the right lower psoas and iliacus\n muscles. More prominent soft tissue stranding is seen within the right groin\n above the common femoral vessels. There is a small high attenuation fluid\n collection medial and inferior to this soft tissue stranding measuring\n approximately 3cm in largest diameter. There is no free fluid within the\n pelvis. The rectum and prostate are normal in appearance. There is a Foley\n catheter within the bladder.\n\n Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: 1) Right upper thigh and groin soft tissue stranding with adjacent\n small high attenuation fluid collection. This appears to be a small hematoma.\n There is mild stranding along the psoas and iliacus which may relate to this\n same process. No retroperitoneal hematoma is identified.\n\n These findings were communicated to the team caring for the patient.\n\n"
}
] |
62,594 | 185,555 | 65 year old female with a history of ESLD NASH c/b portal hypertension, esophageal varices, portal gastropathy, and recurrent GI bleeds who presents with altered mental status. . # Shock: The patient presented wth altered mentas status and given known cirrhosis and h/o encephalopathy was high on differential. The patient had been intubated at an OSH for airway protection. Ammonia elevated at OSH. Infection was considered although the patient was afebrile, without leukocytosis. Recent paracentesis 2 days ago without e/o SBP. No current peritoneal signs. No pna on CXR althouth + effusion on R. No UTI on U/A. The patient had TCAs on tox but on amitriptyline. Also has benzos on tox and not on home med list. Could be contributing. CT head negative. Given roving eyes on exam, must also consider seizure activity. The patient was treated for hepatic encephalopathy with lactulos and rifaximin, however her mental status did not improve. . The patient was cultured, however over her two day hospital course the patients blood pressure continued to fall. A central line was attempted but complicated line placement in the patients carotid artery. Vascular surgery was consulted, the patient was given FFP and the line was removed. A femoral line was placed and the patient started on pressers. However the patients BP remained low, her LFTs rose, and the patient went into ARF requiring placement of a dialysis line. However, not long after line placement the patients pressures continued to drop requiring three pressers. A decision was made by the family to withdraw care. The patient was made CMO, extubated, and the patient expired after a brief period. Post-Mortem examination was declined by the family. | Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Left retrocardiac atelectasis is again noted. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Response: CRRT on hold given worsening hemodynamic picture Plan: Dialysis on hold Hypotension (not Shock) Assessment: Worsening hypotension Action: Pt on max dose levophed and neosynephrine gtt, and map <60, vasopressin gtt added with map 57-60. Albuterol/atrovent MDI given. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. Called vascular who later removed after FFP. Called vascular who later removed after FFP. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. Started peripheral neo and dopamine. Started peripheral neo and dopamine. CXR w/R opacity ?pleural effusion. Hold diuretics. Endotracheal tube tip is again seen to be low, about 1 cm above the carina, again advised repositioning. Plan per MICU attending to take pt to OR for removal d/t coagulopathy and high risk of thrombus. - repeat ABG here - treat as above - repeat lytes in am . Agree with plan to treat altered mental status and acute respiratory failure as presumed hepatic encephalopathy. Check Abd US w/Doppler. A diagnostic paracentesis r/out sbp at that time as well. Likely hypovolemic/circulatory from sepsis. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. Action: Tx w/ lactulose q 2 h for goal stool x/day for likely hepatic encephalopathy. - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . - volume resuscitate with NS - hold diuretics - eval for evidence of infection as above - Aline placed for CVL . CT head negative for acute process. CT head negative for acute process. CT head negative for acute process. CT head negative for acute process. HPI: Discharged from after admit for pain, melena and anemia. Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Treat for acute ECG changes - consider kayexalate . Called vascular who later removed after FFP. Called vascular who later removed after FFP. Called vascular who later removed after FFP. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Attempted RIJ placement but was in R carotid. Albuterol/atrovent MDI given. Albuterol/atrovent MDI given. Started peripheral neo and dopamine. Started peripheral neo and dopamine. Started peripheral neo and dopamine. - repeat K now - check ECG. - repeat K now - check ECG. - repeat K now - check ECG. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. # ESLD: NASH with cirrhosis and portal hypertension. Will treat with albumin for ascites. A diagnostic paracentesis r/out sbp at that time as well. Likely hypovolemic. Likely hypovolemic. Likely hypovolemic. Possibly due to diuretics. Possibly due to diuretics. Possibly due to diuretics. # Hypotension: Pt had relative hypotension on arrival to ICU with associated tachycardia. Agree with holding off on antibiotics (will continue prophylactic cipro) 2) Acute respiratory failure - intubated for airway protection 3) Hypotension - likely volume depleted, in setting of diuretics, slightly elevated Hct, tachycardia. - repeat ABG here - treat as above - repeat lytes in am . - repeat ABG here - treat as above - repeat lytes in am . # respiratory failure: intubated for airway protection in the setting of altered mental status. # respiratory failure: intubated for airway protection in the setting of altered mental status. # respiratory failure: intubated for airway protection in the setting of altered mental status. # DISP: ICU RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ALTERED MENTAL STATUS (NOT DELIRIUM) HYPOTENSION (NOT SHOCK) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) ICU Care Nutrition: Glycemic Control: Lines: Arterial Line - 08:30 AM 20 Gauge - 06:00 PM Multi Lumen - 08:03 PM 22 Gauge - 11:59 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. | 38 | [
{
"category": "Radiology",
"chartdate": "2145-01-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053327,
"text": " 10:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia, pulm edema vs other pulmonary process as etiology\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with ESLD, cirrhosis found unresponsive, intubated.\n REASON FOR THIS EXAMINATION:\n pneumonia, pulm edema vs other pulmonary process as etiology of presentation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH, , AT 2236 HOURS.\n\n HISTORY: End-stage liver disease, cirrhosis, found unresponsive and\n intubated. Assess for pneumonia, edema.\n\n COMMENT: AP view of chest provided. Comparison is made with at 1434\n hours.\n\n FINDINGS: There is a new small right pleural effusion. There is also\n increased opacity of the right hemithorax which could be due to layering\n fluid; however, the patient was imaged in the upright position. Previously,\n the patient had interstitial lung disease primarily in the apices. This is no\n longer seen; however, there now appears to be some pulmonary vascular\n congestion and probable mild edema.\n\n The endotracheal tube tip is 1 cm above the carina. Recommend repositioning.\n Nasogastric tube is coiled in the region of the stomach.\n\n Findings regarding endotracheal tube were discussed with the patient's nurse,\n , on at 1600 hours.\n\n IMPRESSION:\n 1. New right pleural effusion and mild pulmonary edema.\n\n 2. Low position of endotracheal tube. Advise repositioning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1053409,
"text": " 3:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval line placement\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with recent line placement\n REASON FOR THIS EXAMINATION:\n please eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n Single portable radiograph of the chest demonstrates interval placement of a\n right-sided central venous catheter. The catheter position is unusual as the\n catheter seen to cross to the patient's left of midline. The catheter\n projects over the aortic root. There is an endotracheal tube present with its\n tip located 2 cm above the carina. Bibasilar atelectasis and right-sided\n effusion are again seen. No pneumothorax is identified. The nasogastric tube\n is again seen to be present within the stomach.\n\n IMPRESSION:\n\n Persistent bibasilar atelectasis and right-sided pleural effusion.\n\n Interval placement of right neck central venous catheter. The catheter\n position is unusual as it crosses to the patient's left of midline and\n projects over the aortic root. The catheter is likely located within the\n right common carotid artery with the tip in the aortic root.\n\n The remaining support lines are in place.\n\n Findings were discussed with the MICU nurse caring for the patient, \n at at 7:45 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053451,
"text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with ESLD cirrhosis, r pleural effusion\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion.\n\n Single portable radiograph of the chest demonstrates a persistent right-sided\n pleural effusion. Increased opacities involving both lungs are worse when\n compared to . There is a small left-sided effusion. The\n cardiomediastinal contours are unchanged. The endotracheal tube and\n nasogastric tube are unchanged. The right neck central venous catheter has\n been removed. No pneumothorax.\n\n IMPRESSION:\n\n Worsening airspace opacities involving both lungs. Finding represents\n pulmonary edema and/or pneumonia.\n\n Right-sided effusion, similar to that seen previously.\n\n Support lines in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-16 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1053359,
"text": ", A. MED MICU 7:37 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n PFI REPORT\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\n thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-16 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1053358,
"text": " 7:37 AM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 11:34 AM\n Suboptimal study limited by patient's dyspnea; no evidence for portal vein\n thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n portal hypertension, type 2 diabetes, altered mental status for evaluation of\n liver abnormalities.\n\n LIVER ULTRASOUND: -scale and color Doppler son images were\n obtained that demonstrate the liver is of heterogeneous echogenicity with no\n focal liver lesions demonstrated. There is a persistent large right pleural\n effusion. The study is limited and only the main hepatic artery is\n demonstrated with a normal-appearing waveform. Wall-to-wall flow is\n demonstrated in the portal vein with no evidence of thrombus. There is a\n patent umbilical vein. Minor ascites is seen. The gallbladder appears normal\n and is not distended and the common bile duct measures to 4.4 mm. The left\n kidney measures 10.1 cm, the right kidney is not fully visualized but there is\n no evidence for hydronephrosis or nephrolithiasis. The spleen measures 11.9\n cm.\n\n IMPRESSION: Limited son study; no evidence for portal vein thrombosis\n or major ascites or hydronephrosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-01-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053334,
"text": " 12:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: UPRIGHT\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with cirrhosis, DM, layering effusion on supine CXR. Please\n perform semi-upright to better characterize effusion\n REASON FOR THIS EXAMINATION:\n UPRIGHT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM AT 0040 HOURS\n\n HISTORY: Cirrhosis and layering effusion on chest radiograph. Better\n characterize.\n\n COMMENT: AP view of chest provided. Comparison is made with at 2236\n hours.\n\n FINDINGS: Again seen is a moderate right pleural effusion, which appears\n mildly increased than the previous study. This could be due to differences in\n patient position. Pulmonary vascular congestion and mild edema is again\n noted. The nasogastric tube is coiled in the stomach. Endotracheal tube tip\n is again seen to be low, about 1 cm above the carina, again advised\n repositioning. Left retrocardiac atelectasis is again noted. It is mild in\n amount.\n\n IMPRESSION:\n 1. Moderate right pleural effusion more conspicuous than on the previous\n study, which may be due to change in position of the patient.\n\n\n"
},
{
"category": "General",
"chartdate": "2145-01-17 00:00:00.000",
"description": "ICU Event Note",
"row_id": 651543,
"text": "Clinician: Resident\n Spoke with Ms. HCP, her son Chip about her turn for the worse\n today. She appear to have overwhelming sepsis with acute renal failure\n and hypotension that is not responding to 3 pressors. Her son called\n her family in and wishes to withdraw care as this is consistent with\n her prior stated wishes for no agressive measures if she gets to a\n point where she is not likely to get better. Her family is now at the\n bedside and we will proceed with withdrawal of ETT and pressors. They\n are aware that she will likely pass away very quickly.\n Total time spent: 60 minutes\n"
},
{
"category": "General",
"chartdate": "2145-01-17 00:00:00.000",
"description": "ICU Event Note",
"row_id": 651544,
"text": "Clinician: Resident\n Called at 20:35 to see patient for pronouncement of death. Patient\n does not respond to tactile stimuli or verbal stimuli, Pupils are fixed\n and dilated, carotid pulses absent, no heart sounds, no spontaneous\n respirations, extremities warm.\n TIME OF DEATH: 8:37PM\n Family present and declined post-mortem examination. Attending and\n admitting notified.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651529,
"text": "65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Increased peep and fio2 for desatting\n Action:\n Pt presently on ac 12 450 peep 10 100%, vent support slowly increased\n over shift due to intolerance with movement, laying flat. Pt being sx\n via ett for sm-copious amount thin frothy yellow secretions.\n Family meeting held and pt made DNR, with plans to make pt when\n other children come in to visit.\n Response:\n Poor tolerance to activity and increased vent support\n Plan:\n Plan to make pt \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Worsening creat, anuria, acidosis\n Action:\n Left Femoral Hd line placed by Renal team without incident, line\n transduced and cvp type waveform noted. Plans for CRRT, due to volume\n overload, and worsening acidosis, but unable to start due to\n hypotension despite 3^rd pressor being added, MICU team aware.\n Response:\n CRRT on hold given worsening hemodynamic picture\n Plan:\n Dialysis on hold\n Hypotension (not Shock)\n Assessment:\n Worsening hypotension\n Action:\n Pt on max dose levophed and neosynephrine gtt, and map <60, vasopressin\n gtt added with map 57-60. Pt received albumen 75gm iv with no change in\n bp. EKG done with no new changes, trop sent 1.54, team aware. Cvo2 72%.\n Pt with coffee grounds noted in GI aspirates this am, hct slowly\n trending down.\n Worsening anasarka noted, arms and legs tense with edema.\n Pt received vi gent 100mg iv, and started on IV cipro.\n Response:\n Pt remains hypotensive now on 3 pressors\n Plan:\n Awaiting other family members visit.\n Altered mental status (not Delirium)\n Assessment:\n Pt min responsive n fent gtt\n Action:\n Pt intermittently opens eyes to stimulation, spont moves all\n extremites, but does not follow commands, conts on fent gtt at 25mcg/hr\n Pupils remains unequal\n GI aspirates high, unable to receive q2 lactulose doses, moving bowels,\n x2 this shift.\n Response:\n No change in mental status\n Plan:\n Cont fent gtt.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651452,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed. Now on Levophed and neo.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Had BM x 2 with lactulose\n Coffee grounds emesis from OGT this am\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated, not responsive\n to voice or sternal rub\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\n bilateral exp wheezes, palpable on exam\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\n paracentesis CDI\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\n Skin: Warm, diaphoretic\n Neurologic: Not responsive to stimuli, sedated\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\n congestion\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n .\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection given septic physiology although not febrile but\n does have new leukocytosis, likely from stress response. Recent\n paracentesis rules out SBP although could have developed secondary\n peritonitis from tap. No current peritoneal signs on exam. No focal\n infiltrate on CXR although + effusion on R and may have aspitated. No\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\n amitriptyline, will d/c. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u sputum culture and (GPC)\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs\n - would not tolerate tap R pleural effusion\n - f/u culture data\n - continue broad abx with vanc/cefepime\n .\n # Hypoxemic respiratory failure: intubated for airway protection in the\n setting of altered mental status and has had persistent hypoxia, most\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\n ventilation and oxygenation at OSH. Has large right pleural effusion,\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\n aspiration and was 9 L positive yesterday, likely complicating picture.\n - VAP ppx\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\n - Increase PEEP as BP tolerates to increase recruitment\n - Serial ABGs\n - treat altered MS as below\n - try to improve fluid status by improving renal function, fluid\n mobilization, may need CVVH vs HD\n .\n # Hypotension: Pt had relative hypotension on arrival to ICU with\n associated tachycardia. Likely has low baseline from liver disease.\n Given altered mental status, concern for infection/sepsis especially\n given persistent pressor requirement, elevated WBC although ahs not had\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\n signs of bleeding until coffee grounds this am. Likely\n hypovolemic/circulatory from sepsis. Could also have component of\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \n also be related to sedation.\n - Serial HCT\n - hold diuretics\n - Abx for possible sepsis (source pulmonary vs abdominal)\n - Aline placed for monitoring\n - continue pressors, wean as tolerated, goal MAP>65\n - albumin for volume resuscitation\n - check random cortisol\n - defer para for now since minimal ascites, on broad coverage for abx\n and would be risk given coagulopathy, unsafe for transport\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\n perfusion with hypotension and may have component of ATN from prolonged\n hypotension yesterday. Fena 0.1. have component of HRS.\n - albumin 1g/kg\n - hold diuretics for now\n - maintain MAP>65\n - may need CVVH since UOP poor despite total body volume overloaded\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\n .\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\n hypotension.\n - appreciate liver recs- hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers without PV thrombosis\n - add albumin to regimen\n .\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\n transfusion in setting of UGIB. Has known iron deficiency anemia and\n has had multiple episodes of UGI bleeding from portal gastropathy and\n varices.\n - 2 large bore IVs\n - type and screen\n - CBC\n - cont iron\n - PPI \n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\n starting, had been holding Po meds for residuals concern for\n aspiration. Slowly introduce meds. Give reglan if high residuals\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\n .\n # CODE: FULL. Will have family discussion today regarding goals of\n care, may need dialysis\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651288,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n Cx: pending\n CXR: upright image shows R pleural effusion\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 651308,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n Cx: pending\n CXR: upright image shows R pleural effusion\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 65 year old female with a history of ESLD \n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\n gastropathy, and recurrent GI bleeds who presents with altered mental\n status. Last admitted for GAVE/UGIB in and similar admission other\n hospital admit in . Recent GAVE treatment with thermal\n therapy. Recent d/c after tap for ?SBP\n neg. 2 days later was\n found on floor next to bed by son, last seen night before, brought to\n where intubated for a/w protection. CT head -\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\n Urine tox pos for TCA, benzo.\n Here at , intubated/sedated. Unclear if not taking lactulose, but\n dietary indiscretion was a possibility over holidays. Treated for\n encephalopathy, initially held off on antibiotics other than FQ\n prophylaxis. Awaiting pan-cultures. Also rehydrated overnight. Other\n history notable for encephalopathy and SBP in past. Meds at home, FQ,\n fluoxetine, rifaximin, iron, lactulose, PPI, lasix, spironolactone,\n albuterol, advair, metformin. ?all to bactrim, but has taken in past.\n Lives in by herself, no etoh/tob currently.\n Exam notable for Tm BP HR RR with sat on 450 x 12, PEEP 5, FiO2 .4 w/\n 7.48/25/132 Post surgical pupils, roving eye movements, hard collar,\n reg RR, soft Syst murmur, nontender +BS, 2+ LE edema, w/draw to painful\n stimuli. Labs notable for WBC 8.3K, HCT 31, K+ 5.1, Cr 1.0. CXR with ,\n ABG 7.5/24/97 on Fio2 .4.\n Agree with plan to treat altered mental status and acute respiratory\n failure as presumed hepatic encephalopathy. Aggressively continue\n lactulose. Check Abd US w/Doppler. No evidence for acute infection,\n but will begin broad spectrum antibiotics pending full culture data.\n Respiratory failure likely due to mental status, wean ventilator as\n tolerated. Hypotension responding to IVF, but may require pressors.\n Hold diuretics. Continue rifaximin. Holding metformin and monitoring\n BS. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:24 ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651367,
"text": "65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presented from an osh intubated after being found down at\n home. She was recently discharged home following a week long stay for a\n gib. At that time, an egd revealed grade II esophageal varices and she\n was transfused w/2 units prbc\ns. A diagnostic paracentesis r/out sbp at\n that time as well. She was sent home on .\n She was admitted to the micu from on \n after being found unresponsive by her son. decreased responsiveness\n is felt to be d/t encephalopathy likely r/t her underlying liver\n disease, ?dietary indiscretion over the holiday, and noncompliance with\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\n benzos although benzo use is not part of her medical regimen. Also of\n note, her left pupil was found to be dilated and nonreactive, but a\n head ct was reportedly negative. Additonally, her micu stay has been\n c/b hypotension requiring pressor support despite aggressive fluid\n resuscitation w/o evidence of any active gi bleeding. There is no clear\n source of infection.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651441,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH. Has large right pleural effusion, volume\n overloaded. ETT approx. 2cm above carina. also have VAP vs\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n - consider\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure.\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651186,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/.4/+6 peep\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: underlying illness\n not resolved\n Respiratory Care Shift Procedures: RSBI\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651281,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651253,
"text": ". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given. Fentanyl iv push\n given\n Response:\n O2 sats 96-98%, blood gas 7.50/24/97\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics. For abd ultrasounds today.and liver consult\n in Am\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 80-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat 27/1.1, UO 5ml/hr even after fluid bolus\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651343,
"text": "PMH: Pt is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive. According to report, she was discharged from on\n and had been in her usual state of health. She was last seen well\n the evening of at ~ 8 pm when her son dropped her off at home.\n Son tried to contact her today but she did not pick up the phone. She\n was then found this am, unresponsive, slumped out of bed onto the\n floor. EMS was called and she was brought to hospital. EMS\n reported she was unable to respond verbally. ? blown pupil on left per\n EMS report. There she was intubated for airway protection. At\n hospital, CT head was negative. CXR showed opacity in R\n hemithorax c/w layering R pleural effusion and pulmonary vascular\n congestion. Urine tox screen positive for benzos and TCAs. She was\n recently admitted with abdominal pain, melena, and low Hct\n (33->23 in 1 wk). She underwent EGD which showed grade II varices,\n portal gastropathy, and angioectasias in the antrum which were treated\n with thermal therapy. She received 2 units PRBCs with Hct 23->29. She\n also received an ultrasound guided paracentesis without evidence of\n SBP. She was also admitted for slow Hct drop (24->20\n over 1 wk) and guiaic positive stools. She received 2 units PRBCs with\n Hct 20->26. She was treated with octreotide, PPI gtts. EGD showed\n gastric antral ectasia with varices but without an active source of\n bleed. Hct remained stable throughout admission. During the last\n admission she was found to have an area of cellulitis at the area of an\n outpt Derm biopsy and she received Augmentin and Bactrim for 7 day\n course. Her U/A at that time was negative but grew out E coli sensitive\n to Bactrim. She was due to follow up at for repeat endoscopy.\n However, in the interim she was admitted to hospital for GI\n bleeding. She was transfused 4 units PRBCs and had EGD which showed\n small esophageal varices and portal hypertension. She was then seen in\n liver f/u on and was complaining of abdominal and ankle swelling\n in the setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black\n stools. Upon arrival to ICU, patient is intubated and sedated.\n Events : A line placed in AM. Attempt at RIJ triple lumen\n placement failed: line placed in carotid artery as evidenced by chest\n film and pulsatile waveform. Plan per MICU attending to take pt to OR\n for removal d/t coagulopathy and high risk of thrombus.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS course w/ crackles and insp/exp wheeze throughout day. Pt intubated\n on AC 40%/450/12/5. Sp02 variable 89-100%. Mod amts thick tan\n secretions sux\ned throughout day. ABG in afternoon 7.25/32/72.\n Action:\n Fi02 increased to 60%. Nebs prn via ET tube.\n Response:\n Sp02 100%. Pt appears dusky. UOP minimal at 10-20 ml/hr.\n Plan:\n Maintain ABPs w/ pressors, attempt diuresis when appropriate.\n Altered mental status (not Delirium)\n Assessment:\n PT does not follow commands, L pupil non reactive, R pupil reactive.\n Pt withdraws to painful stim, non-purposeful movt all extremities.\n Action:\n Tx w/ lactulose q 2 h for goal stool x/day for likely hepatic\n encephalopathy.\n Response:\n Pt had 1 med BM today.\n Plan:\n Cont bowel regimen.\n Hypotension (not Shock)\n Assessment:\n A line placement confirms hypotension, SBP drops to 60s- 70s,\n particularly w/ sedation (fentanyl bolus). MAPs dropping to 40-50.\n Action:\n Total of 6 L NS fluid bolus since admission. Phenylephrine and\n dopamine gtts started at 1800 via PIV (only access at this time). MICU\n attending and team placing fem line now for central access.\n Response:\n Pt remains hypotensive during line placement.\n Plan:\n Maintain pressors via CVL.\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651345,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n Pt remained on AC 40% most of shift until PaO2 dropped to 72 late\n afternoon. FiO2 to 60%. BS worsening combination of coarse crackles,\n rhonchi, wheeze not responding to inhaled dilators. Presents as fluid\n overload but is hypotensive and agitated. Unable to adequately sedate\n hypotension. Placing central line at present to get more accurate\n picture of fluid status. Wean FiO2 when possible.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 651167,
"text": "Chief Complaint: altered MS\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Discharged from after admit for pain, melena and\n anemia. Was in usual health, dropped off at home by son last night at\n 8pm after party, this AM did not answer phone, son found pt slumped\n against bed on floor, not following commands. Pt brought to by EMS - afebrile, stable BP>100 syst, tachycardic, intubated\n for airway protection, CT head was negative, CXR c/w layering R pleural\n effusion and pulmonary vascular congestion. Labs were remarkable for\n WBC 6.5, Hct 35 (28.9 ), Na 132(stable), K 5.5 (5.1 on ),\n Bicarb 18 (25 ), Cr 1.1 (stable). ALT/AST similar to recent admit,\n Tbili down to 3.4 from 6.6. Ammonia 182 (last checked in our system 112\n on ). Urine tox screen positive for benzos and TCAs.\n Patient was admitted in for pain and melena, on endoscopy\n had angioectasia treated with thermal therapy.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she\n Transfer from other hospital\n History obtained from Family / Friend\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Other medications:\n Amitriptyline 10 mg PO HS\n Ciprofloxacin 250 mg Q24H\n Fluoxetine 10 mg PO DAILY\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \n Rifaximin 600 mg \n Triamcinolone Acetonide 0.1 % Topical TID\n Ferrous Sulfate 325 mg TID\n Lactulose Thirty ML PO QHS\n Lactulose (45) ML PO BID\n Omeprazole 20 mg \n Lasix 40 mg once a day\n Spironolactone 50 mg once a day\n Albuterol Sulfate Two q4h prn\n Calcitrate-Vitamin D 315-200 mg-unit\n Metformin 500 mg twice a day\n Past medical history:\n Family history:\n Social History:\n # ESLD NASH with cirrhosis and portal hypertension\n - followed by Dr. \n - on transplant list\n - history of Grade II esophageal varices\n # GAVE (gastral antral vascular ectasia)\n # h/o SBP\n # h/o gastritis\n # anemia\n - iron deficiency by labs\n - elevated MCV, B12/folate nl\n # Hypertension\n # diabetes mellitus type II\n # Psoriasis\n # depression\n # s/p C-section\n # s/p appy\n # s/p knee surgery for meniscal tear\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: lives in alone, 3 children, nonsmoker and has not had\n any alcohol in 2 years, but no hx of heavy drinking, no illicit drug\n use. She is not married. She has not worked for 4-5 months and was\n released from her job as a cashier due to confusion.\n Review of systems:\n Flowsheet Data as of 12:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 111 (111 - 114) bpm\n BP: 88/40(53) {88/39(53) - 130/92(102)} mmHg\n RR: 21 (21 - 23) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -224 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (601 - 601) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 42.9 cmH2O/mL\n SpO2: 99%\n ABG: ////\n Ve: 15.4 L/min\n Physical Examination\n Eyes / Conjunctiva: roving eyes, post- pupil\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed, withdraws all 4 extrem to\n painful stimuli, equivocal plantars\n Labs / Radiology\n 225 K/uL\n 31.0 %\n 10.9 g/dL\n 8.3 K/uL\n [image002.jpg]\n 10:42 PM\n WBC\n 8.3\n Hct\n 31.0\n Plt\n 225\n Other labs: Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\n Eos:0.5 %\n Imaging: CXR reviewed - probable layering right effusion\n EGD : Grade 2 esophageal varices\n Portal hypertensive gastropathy, angioectasias in antrum\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n Issues being addressed include:\n 1) altered MS - likely hepatic encephalopathy, possibly due to dietary\n indiscretion, unclear if compliant with meds/lactulose. No evidence for\n acute GI bleed or infection. Doubt meningitis. CT head reported to be\n without bleed or acute process. Roving eyes likely due to metabolic\n coma. Will treat with lactulose and rifaximin. u/s to look for\n ascites, unlikely SBP. need repeat CT or MRI, consider LP, EEG if\n no improvement by AM. Agree with holding off on antibiotics (will\n continue prophylactic cipro)\n 2) Acute respiratory failure - intubated for airway protection\n 3) Hypotension - likely volume depleted, in setting of diuretics,\n slightly elevated Hct, tachycardia. Possibly sepsis but less likely -\n no obvious source. Agree with volume resuscitation, hold diuretics\n 4) ESLD due to NASH with cirrhosis and portal hypertension - Alb 2.8,\n INR 1.7, liver consult in am, treatment of hepatic encephalopathy as\n above\n Rest of plan as detailed in Dr. note. Son \n has been updated.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 10:05 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU, Total time spent: 39 minutes, Patient is critically\n ill\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 651168,
"text": "Chief Complaint: unresponsive\n PCP: ,\n GI: \n HPI:\n Ms. is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Labs\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\n positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. The remainder of her hospital course in unclear as there is not\n currently a discharge summary available. She also received an\n ultrasound guided paracentesis without evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amitriptyline 10 mg PO HS\n Ciprofloxacin 250 mg Q24H\n Fluoxetine 10 mg PO DAILY\n Fluticasone-Salmeterol 100-50 mcg/Dose Disk \n Rifaximin 600 mg \n Triamcinolone Acetonide 0.1 % Topical TID as needed for psoriasis.\n Ferrous Sulfate 325 mg TID\n Lactulose Thirty ML PO QHS\n Lactulose (45) ML PO BID\n Omeprazole 20 mg \n Lasix 40 mg once a day\n Spironolactone 50 mg once a day\n Albuterol Sulfate Two puffs every four hours as needed\n Calcitrate-Vitamin D 315-200 mg-unit once a day\n Metformin 500 mg twice a day\n Past medical history:\n Family history:\n Social History:\n # ESLD NASH with cirrhosis and portal hypertension\n - followed by Dr. \n - on transplant list\n - history of Grade II esophageal varices\n # GAVE (gastral antral vascular ectasia)\n # h/o SBP\n # h/o gastritis\n # anemia\n - iron deficiency by labs\n - elevated MCV, B12/folate nl\n # Hypertension\n # diabetes mellitus type II\n # Psoriasis\n # depression\n # s/p C-section\n # s/p appy\n # s/p knee surgery for meniscal tear\n mother with lung CA, 3 brothers with DM\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She lives in alone. She has 3 children who live in\n , , and . Their ages are 37, 40, and 45. She is a\n nonsmoker and has not had any alcohol in 2 years. Apparently, she was\n not a heavy drinker. She has no illicit drug use. She is not married\n and does not have a current partner. She has not worked for 4-5 months\n and was released from her job as a cashier due to confusion. She has\n applied for disability.\n Review of systems:\n Flowsheet Data as of 12:27 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.4\n HR: 113 (111 - 114) bpm\n BP: 107/38(57) {88/38(53) - 130/92(102)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 155 mL\n 186 mL\n PO:\n TF:\n IVF:\n 155 mL\n 186 mL\n Blood products:\n Total out:\n 240 mL\n 20 mL\n Urine:\n 240 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 166 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 601) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n PIP: 12 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.1 cmH2O/mL\n SpO2: 99%\n ABG: ///19/\n Ve: 14.8 L/min\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\n exp wheezes\n Abdominal: Soft, Non-tender, No(t) Distended, No(t) Tender: , site of\n prior LLQ paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, Movement: Purposeful,\n Sedated, Tone: Normal, withdraws all extremities to painful stimuli.\n Roving eye movements. CN 2-12 grossly intact. Plantar responses mute B\n Labs / Radiology\n 225 K/uL\n 10.9 g/dL\n 102 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 19 mEq/L\n 109 mEq/L\n 5.1 mEq/L\n 138 mEq/L\n 31.0 %\n 8.3 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 10:42 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.3\n Hct\n 31.0\n Plt\n 225\n Cr\n 1.0\n Glucose\n 102\n Other labs: PT / PTT / INR:18.6/37.4/1.7, ALT / AST:36/87, Alk Phos / T\n Bili:91/4.0, Differential-Neuts:77.9 %, Lymph:15.2 %, Mono:6.4 %,\n Eos:0.5 %, Albumin:2.6 g/dL, LDH:403 IU/L, Ca++:8.3 mg/dL, Mg++:1.7\n mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: from :\n ABG 7.48/25/132 on PSV 15/10 with FiO2 50%.\n .\n PT 19.3, PTT 37.9, INR 1.7\n .\n WBC 6.5, Hct 35.9, plts 208\n .\n Na 132, K 5.5, Cl 101, CO2 18, BUN 27, Cr 1.1, Glu 114, Ca 9.3, Tbili\n 3.4, AST 84, ALT 37, Ammonia 182, alb 2.8, AP 108, CK 337, MB 11, TnT\n 0.04\n .\n Tox screen: positive for TCAs, positive for benzos, negative for\n opiates, barbs, amph, cocaine, THC\n .\n U/A: negative\n Imaging: EGD :\n Grade 2 esophageal varices\n Portal hypertensive gastropathy\n Angioectasias in the antrum (thermal therapy)\n .\n colonoscopy :\n Diverticulosis of the sigmoid colon\n Otherwise normal colonoscopy to cecum\n ECG: ECG : abnormal p wave axis. ? sinus tach vs Atach. Low limb\n lead voltage. Tall TWs, not hyperacute. Compared to prior ECG ,\n inferior QWs have resolved, p wave axis is different, and TWs are more\n prominent.\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651178,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651179,
"text": ". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Labs\n there remarkable for normal WBC at 6.5, Hct 35 (28.9 ), Na\n 132(stable), K 5.5 (5.1 on ), Bicarb 18 (25 ), Cr 1.1\n (stable). ALT/AST similar to recent admit, Tbili down to 3.4 from 6.6.\n Ammonia 182 (last checked in our system 112 ). Urine tox screen\n positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. The remainder of her hospital course in unclear as there is not\n currently a discharge summary available. She also received an\n ultrasound guided paracentesis without evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651180,
"text": ". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651391,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic, C-collar in place\n Cardiovascular: S1S2 RRR no mrg\n Respiratory / Chest: coarse breath sounds w/ scant bilaterally exp\n wheezes\n Abdominal: Soft, Non-tender, not distended, site of prior LLQ\n paracentesis, CDI\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, appears agitated at times but\n not responsive and does not follow commands\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection not febrile, with no leukocytosis. Recent\n paracentesis rules out SBP. No current peritoneal signs. No PNA on CXR\n although + effusion on R. No UTI on U/A. Has TCAs on tox but on\n amitriptyline. Also has benzos on tox and not on home med list. Could\n be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u abdominal US\n - send blood cultures\n - sputum culture\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs (? Antibiotics)\n - ? tap R pleural effusion\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic. Responded to fluid resuscitation with stable\n BPs however UOP was still poor this morning.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - Aline placed for CVL\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n -consider adding albumin to regimen\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651392,
"text": "65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presented from an osh intubated after being found down at\n home. She was recently discharged home following a week long stay for a\n gib. At that time, an egd revealed grade II esophageal varices and she\n was transfused w/2 units prbc\ns. A diagnostic paracentesis r/out sbp at\n that time as well. She was sent home on .\n She was admitted to the micu from on \n after being found unresponsive by her son. decreased responsiveness\n is felt to be d/t encephalopathy likely r/t her underlying liver\n disease, ?dietary indiscretion over the holiday, and noncompliance with\n lactulose regimen. Curiouslyly, her initial tox screen was positive for\n benzos although benzo use is not part of her medical regimen. Also of\n note, her left pupil was found to be dilated and nonreactive, but a\n head ct was reportedly negative. Additionally, her micu stay has been\n c/b hypotension requiring pressor support despite aggressive fluid\n resuscitation. There is no overt evidence of any active gi bleeding.\n There is no clear source of infection.\n Events overnight included removal of the right ij that was placed\n arterially. The line was removed w/o incident by surgery. There is no\n hematoma/edema at the insertion site.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on ac 12x450 w/peep5 and o2 60%.\n SRR 12-14/min. MV 15-19 liters. Diffuse rhonchi and expiratory wheezing\n noted on lung exam. Repeat abg this am showing a worsening acidosis\n although oxygenation has improved: 25/94/7.26/12/-13.\n She has been suctioned for small to moderate amts of thick, pink-tinged\n sputum w/?aspiration.\n Action:\n Sputim culture repeated for ?aspiration. Metabolic acidosis worsening\n this morning with a rise in creat level.\n Response:\n Although ogt initially placed to suction for ?aspiration, ogt is now\n clamped and being used for po meds.\n Plan:\n Follow lung exam, serial abg results closely. Suction as needed and\n monitor for possible aspiration.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains unresponsive but transiently agitated. She was placed on a\n low dose fentanyl drip after receiving several boluses. She has\n received lactulose q4hrs overnight and has had one moderate sized bowel\n movement. Left pupil remains dilated and unresponsive. +corneals.\n Action:\n Placed on a low dose fentanyl drip for comfort. No change in mental\n status/neuro exam noted overnight despite rtc lactulose.\n Response:\n More comfortable on a fentanyl drip.\n Plan:\n Follow neuro exam closely. Con\nt rtc lactulose and fentanyl drip for\n now.\n Hypotension (not Shock)\n Assessment:\n Received pt on maximum doses of both levophed and neo. Both drip rates\n were weaned slowly although the levophed drip rate has since been\n increased d/t persistent hypotension in the setting of a worsening\n acidosis. Of note, wbc elevated from 10 to 15 this morning. Pt has\n been afebrile. Awaiting culture results from yesterday.\n Action:\n Slowly weaning pressor support. Hypotension may be r/t sepsis given new\n leukocytosis.\n Response:\n Although requiring an increase in levophed this morning, the pt has\n tolerated an overall reduction in pressor support.\n Plan:\n Follow hemodynamic status closely. Wean pressors as pt tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rise in creat level from 1.1 to 1.5 this morning. As noted above,\n metabolic acidosis is worsening. Uop 0-10cc/hr at the present time. +3\n pitting edema now present.\n Action:\n None.\n Response:\n Unchanged.\n Plan:\n Follow serial lab results, monitor uop, edema closely.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651503,
"text": "65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651388,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651546,
"text": "Following another family meeting this evening, the pt\ns children\n made the decision to withdraw from aggressive care measures and\n redirect care to cmo status. The family expressed a desire to extubate\n as well as discontinue all vasopressors. The pt was extubated with\n discontinuation of triple pressors ~ and expired @2037.\n The micu team did offer an autopsy to the family which was declined.\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651229,
"text": ". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given.\n Response:\n O2 sats 96-98%,\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 90-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651230,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 651231,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:36 PM\n EKG - At 12:10 AM\n URINE CULTURE - At 12:36 AM\n SPUTUM CULTURE - At 01:37 AM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 112 (108 - 114) bpm\n BP: 115/43(57) {86/38(53) - 130/92(102)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 1,030 mL\n 1,683 mL\n PO:\n TF:\n IVF:\n 1,030 mL\n 1,683 mL\n Blood products:\n Total out:\n 240 mL\n 70 mL\n Urine:\n 240 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 790 mL\n 1,613 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 451 (450 - 601) mL\n Vt (Spontaneous): 677 (677 - 677) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 6 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n Plateau: 20 cmH2O\n Compliance: 32.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.50/24/96./19/-2\n Ve: 13.5 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.6 g/dL\n 73 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 5.0 mEq/L\n 27 mg/dL\n 110 mEq/L\n 140 mEq/L\n 30.7 %\n 10.0 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n WBC\n 8.3\n 10.0\n Hct\n 31.0\n 30.7\n Plt\n 225\n 226\n Cr\n 1.0\n 1.1\n TCO2\n 19\n Glucose\n 102\n 73\n Other labs: PT / PTT / INR:19.6/38.5/1.8, CK / CKMB /\n Troponin-T:1024//, ALT / AST:39/103, Alk Phos / T Bili:88/4.4,\n Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %, Eos:1.2 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:405 IU/L, Ca++:7.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status.\n .\n # altered mental status: multiple possible etiologies. Given known\n cirrhosis and h/o encephalopathy, high on differential. Rapid onset\n possibly d/t dietary indiscretion. Ammonia elevated at OSH. Must also\n consider infection although although afebrile, with no leukocytosis.\n Recent paracentesis 2 days ago without e/o SBP. No current peritoneal\n signs. No pna on CXR althouth + effusion on R. No UTI on U/A. Has TCAs\n on tox but on amitriptyline. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative. Given roving eyes on\n exam, must also consider seizure activity.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - abdominal u/s to eval for ascites for dx para\n - send blood cultures\n - sputum culture\n - repeat U/A here\n - repeat CXR\n - if no improvement with hepatic encephalopathy, consider MRI, LP, and\n Neuro consult for EEG\n - hold off on abx (except for Cipro ppx) for now w/o obvious source of\n infection\n - consider tap of R sided pleural effusion if further evidence of\n infection and no improvement with above measures\n - no flumazenil given concern possibility of seizures\n .\n # respiratory failure: intubated for airway protection in the setting\n of altered mental status. ABG showed adequate ventilation and\n oxygenation at OSH.\n - VAP ppx\n - daily wake and RSBIs with SBT\n - treat altered MS as above\n .\n # hypotension: relative hypotension on arrival to ICU with associated\n tachycardia. Given altered mental status, raises concern for infection\n although no obvious evidence to suggest this. Unlikely GIB given normal\n Hct. Likely hypovolemic.\n - volume resuscitate with NS\n - hold diuretics\n - eval for evidence of infection as above\n - CVL prn for vasopressors\n .\n # non-AG metabolic acidosis: Bicarb 19. AG 10. Unclear cause.\n Hyperchloremic currently. Most likely due to GI losses. Slightly\n improved from OSH.\n - repeat ABG here\n - treat as above\n - repeat lytes in am\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.1. Possibly due to diuretics. Hepatorenal syndrome also\n possibility.\n - IVF resuscitation\n - hold diuretics for now\n - U/A with urine lytes\n .\n # ESLD: NASH with cirrhosis and portal hypertension. Alb 2.8. INR\n 1.7.\n - liver consult in am\n - hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers\n .\n # anemia: Hct at OSH above most recent dc value after transfusion in\n setting of UGIB. Has known iron deficiency anemia and has had multiple\n episodes of UGI bleeding from portal gastropathy and varices.\n - 2 large bore IVs\n - type and screen\n - Qday CBC unless evidence of active bleeding\n - cont iron\n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: hyperkalemic at OSH. Potentially related to spironolactone use\n as well as increased Cr.\n - repeat K now\n - check ECG. Treat for acute ECG changes\n - consider kayexalate\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2\n .\n # CODE: FULL\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651233,
"text": ". is a 65 year old female with a history of ESLD NASH c/b\n portal hypertension, esophageal varices, portal gastropathy, and\n recurrent GI bleeds who is transferred from OSh after being found\n unresponsive.\n .\n According to report, she was discharged from on (see below)\n and had been in her usual state of health. She was last seen well the\n evening of at ~ 8 pm when her son dropped her off at home. Son\n tried to contact her today but she did not pick up the phone. She was\n then found this am, unresponsive, slumped out of bed onto the floor.\n EMS was called and she was brought to hospital. EMS reported\n she was unable to respond verbally. ? blown pupil on left per EMS\n report. There she was intubated for airway protection. At \n hospital, CT head was negative. CXR showed opacity in R hemithorax c/w\n layering R pleural effusion and pulmonary vascular congestion. Urine\n tox screen positive for benzos and TCAs.\n .\n She was recently admitted with abdominal pain, melena, and\n low Hct (33->23 in 1 wk). She underwent EGD which showed grade II\n varices, portal gastropathy, and angioectasias in the antrum which were\n treated with thermal therapy. She received 2 units PRBCs with Hct\n 23->29. She also received an ultrasound guided paracentesis without\n evidence of SBP.\n .\n She was also admitted for slow Hct drop (24->20 over 1\n wk) and guiaic positive stools. She received 2 units PRBCs with Hct\n 20->26. She was treated with octreotide, PPI gtts. EGD showed gastric\n antral ectasia with varices but without an active source of bleed. Hct\n remained stable throughout admission. During the last admission she\n was found to have an area of cellulitis at the area of an outpt Derm\n biopsy and she received Augmentin and Bactrim for 7 day course. Her U/A\n at that time was negative but grew out E coli sensitive to Bactrim.\n .\n She was due to follow up at for repeat endoscopy. However, in the\n interim she was admitted to hospital for GI bleeding. She\n was transfused 4 units PRBCs and had EGD which showed small esophageal\n varices and portal hypertension. She was then seen in liver f/u on\n and was complaining of abdominal and ankle swelling in the\n setting of a change in her diuretic doses during her Southshore\n hospitalization. She also complained of intermittend dark black stools.\n .\n Upon arrival to ICU, patient is intubated and sedated. Further\n ROS cannot be obtained.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated for airway protection and on A?C mode,\n bilateral lung sounds clear and occasionally coarse and exp wheeze. O2\n sats 98-100%.\n Action:\n Vent changes to low tidal volume and FiO2 down to 40% from 100%, Blood\n gas PCo2 was 2. and fentanyl 25mcg iv puish given as patient was\n overbreathing with vent. Albuterol/atrovent MDI given.\n Response:\n O2 sats 96-98%,\n Plan:\n Continue monitor resp status and wean vent accordingly\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive, not opening eyes or following commands, nonpurposeful\n movements noted, patient with ESLD on transplant list\n Action:\n Minimal sedation, treat hepatic encephalopathy with lactulose po, blood\n urine and sputum culture sent to R/O sepsis, cervical collar in place,\n Response:\n Continue to be unresponsive, patient has non purposeful movements on\n her neck and UE,\n Plan:\n F/U culture results to r/o sepsis, continue lactulose, minimal sedation\n and continue antibiotics. For abd ultrasounds today.and liver consult\n in Am\n Hypotension (not Shock)\n Assessment:\n Sbp 80-100 monitored via NIBP\n Action:\n Fluid bolus to 3L NS\n Response:\n SBP 90-110\n Plan:\n Monitor blood pressure, fluid bolus, ? line placement to monitor CVP to\n challenge fluid and A line to monitor blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Low urine output 5-10ml/hr\n Action:\n Fluid bolus given, U/A sent with urine lytes\n Response:\n Bun/creat\n Plan:\n Monitor UO and bun/creat, continue fluid bolus.\n ,\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651225,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/.4/+6 peep\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: underlying illness\n not resolved\n Respiratory Care Shift Procedures: RSBI 48\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-16 00:00:00.000",
"description": "ICU Attending Event Note",
"row_id": 651322,
"text": "Clinician: Attending\n MICU ATTENDING CRITICAL CARE NOTE:\n Notified by housestaff that CXR on patient following central line\n placement suggests line is arterial rather than in internal jugular.\n We have transduced the line and indeed the waveform is arterial. Given\n underlying coagulopathy from liver disease, will consult Vascular\n Surgery and have them assist in removing the line. Will likely need\n additional FFP to try to correct coagulopathy. MICU housestaff will\n also notify patient\ns son by telephone.\n Patient remains critically ill\n Total time 20 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651384,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 52.2\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: airway protection\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:diffuse i/e wheeze/rhonchi needing freq repeated sxn.\n Secretions\n Sputum color / consistency: Rusty/bright yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 450x12/+5 peep/.6\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping, Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway\n Continues profoundly acidotic (metabolic) despite Ve 17-19 L.\n"
},
{
"category": "Respiratory ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651534,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Frothy\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues with refractory hyoxemia and metabolic acidosis. Awaiting\n arrival of family member before withdrawing support.\n"
},
{
"category": "Physician ",
"chartdate": "2145-01-17 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 651465,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:30 AM\n ULTRASOUND - At 08:47 AM\n MULTI LUMEN - START 03:45 PM\n MULTI LUMEN - STOP 05:34 PM\n MULTI LUMEN - START 08:03 PM\n SPUTUM CULTURE - At 10:03 PM\n In am, hypotensive SBPs 70s, only minimally responsive to IVF.\n Attempted RIJ placement but was in R carotid. Called vascular who later\n removed after FFP.\n Meanwhile, SBPs 60s. Started peripheral neo and dopamine. Right femoral\n CVL placed. Now on Levophed and neo.\n Liver Recs: Diagnostic tap, UA, Abx, consider albumin, give lactulose\n and rifaximin\n Concern for aspiration\n Abdominal U/S without PV thrombosis. Suboptimal study\n Had BM x 2 with lactulose\n Coffee grounds emesis from OGT this am\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 03:39 PM\n Cefipime - 09:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.8 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Fentanyl - 09:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 100 (99 - 108) bpm\n BP: 96/52(66) {61/37(-13) - 128/64(84)} mmHg\n RR: 28 (21 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 9,369 mL\n 635 mL\n PO:\n TF:\n IVF:\n 7,755 mL\n 475 mL\n Blood products:\n 1,389 mL\n Total out:\n 239 mL\n 90 mL\n Urine:\n 239 mL\n 40 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 9,130 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 451) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 13 cmH2O\n SpO2: 94%\n ABG: 7.33/23/70/11/-11\n Ve: 19.8 L/min\n PaO2 / FiO2: 117\n Physical Examination\n General Appearance: Well nourished, intubated, sedated, not responsive\n to voice or sternal rub\n Eyes / Conjunctiva: anisocoria, L>R pupil, equally responsive\n Head, Ears, Nose, Throat: Normocephalic. R neck site without drainage\n Cardiovascular: tachy. Difficult to hear secondary to rhonchorous BS\n Respiratory / Chest: Loud coarse rhonchorous breath sounds w/\n bilateral exp wheezes, palpable on exam\n Abdominal: Soft, Non-tender, mildly distended, site of prior LLQ\n paracentesis CDI\n Extremities: Diffuse anasarca. Left groin line without drainage/oozing\n Skin: Warm, diaphoretic\n Neurologic: Not responsive to stimuli, sedated\n Labs / Radiology\n 216 K/uL\n 9.3 g/dL\n 115 mg/dL\n 1.5 mg/dL\n 11 mEq/L\n 4.7 mEq/L\n 31 mg/dL\n 111 mEq/L\n 138 mEq/L\n 28.0 %\n 15.1 K/uL\n [image002.jpg]\n 10:42 PM\n 01:30 AM\n 03:45 AM\n 09:58 AM\n 05:28 PM\n 07:01 PM\n 07:18 PM\n 03:45 AM\n WBC\n 8.3\n 10.0\n 15.1\n 15.1\n Hct\n 31.0\n 30.7\n 28.4\n 28.0\n Plt\n 16\n Cr\n 1.0\n 1.1\n 1.5\n TCO2\n 19\n 15\n 15\n 13\n Glucose\n 102\n 73\n 115\n Other labs: PT / PTT / INR:20.2/41.0/1.9, CK / CKMB /\n Troponin-T:1024//, ALT / AST:93/366, Alk Phos / T Bili:85/5.2, Amylase\n / Lipase:71/45, Differential-Neuts:75.9 %, Lymph:16.3 %, Mono:6.4 %,\n Eos:1.2 %, Lactic Acid:2.8 mmol/L, Albumin:2.8 g/dL, LDH:621 IU/L,\n Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.4 mg/dL\n CXR: ETT 2-3cm above carina. Right pleural effusion. Pulmonary vascular\n congestion\n Assessment and Plan\n 65 year old female with a history of ESLD NASH c/b portal\n hypertension, esophageal varices, portal gastropathy, and recurrent GI\n bleeds who presents with altered mental status now with hypotension,\n persistent respiratory failure, acute renal failure.\n .\n # Altered mental status: Given known cirrhosis and h/o encephalopathy,\n high on differential especially with ammonia elevated at OSH. Also of\n concern is infection given septic physiology although not febrile but\n does have new leukocytosis, likely from stress response. Recent\n paracentesis rules out SBP although could have developed secondary\n peritonitis from tap. No current peritoneal signs on exam. No focal\n infiltrate on CXR although + effusion on R and may have aspitated. No\n UTI on U/A. Will follow up culture. Has TCAs on tox but on\n amitriptyline, will d/c. Also has benzos on tox and not on home med\n list. Could be contributing. CT head negative for acute process.\n - treat for hepatic encephalopathy with lactulose, rifaximin\n - f/u sputum culture and (GPC)\n - consider neuro consult for possible CNS involvement, ? LP\n - f/u liver recs\n - would not tolerate tap R pleural effusion\n - f/u culture data\n - continue broad abx with vanc/cefepime\n .\n # Hypoxemic respiratory failure: intubated for airway protection in the\n setting of altered mental status and has had persistent hypoxia, most\n recent paO2 90s on 60%FiO2. ABG had initially shown adequate\n ventilation and oxygenation at OSH. Has large right pleural effusion,\n volume overloaded. ETT approx. 2cm above carina. also have VAP vs\n aspiration and was 9 L positive yesterday, likely complicating picture.\n - VAP ppx\n - Continue Vanc/cefepime for now for possible PNA (aspiration vs HAP)\n - Increase PEEP as BP tolerates to increase recruitment\n - Serial ABGs\n - treat altered MS as below\n - try to improve fluid status by improving renal function, fluid\n mobilization, may need CVVH vs HD\n .\n # Hypotension: Pt had relative hypotension on arrival to ICU with\n associated tachycardia. Likely has low baseline from liver disease.\n Given altered mental status, concern for infection/sepsis especially\n given persistent pressor requirement, elevated WBC although ahs not had\n fever or hypothermia. Unlikely GIB given normal Hct and no obvious\n signs of bleeding until coffee grounds this am. Likely\n hypovolemic/circulatory from sepsis. Could also have component of\n adrenal insufficiency. Still requiring 2 pressors with poor UOP. \n also be related to sedation.\n - Serial HCT\n - hold diuretics\n - Abx for possible sepsis (source pulmonary vs abdominal)\n - Aline placed for monitoring\n - continue pressors, wean as tolerated, goal MAP>65\n - albumin for volume resuscitation\n - check random cortisol\n - defer para for now since minimal ascites, on broad coverage for abx\n and would be risk given coagulopathy, unsafe for transport\n .\n # ARF: BL Cr 0.5-0.9 but had been 1.1 on most recent admission.\n Currently 1.5. Most likely prerenal from hypovolemia, decreased renal\n perfusion with hypotension and may have component of ATN from prolonged\n hypotension yesterday. Fena 0.1. have component of HRS.\n - albumin 1g/kg\n - hold diuretics for now\n - maintain MAP>65\n - may need CVVH since UOP poor despite total body volume overloaded\n .\n # AG and nonAG acidosis: Likely secondary to lactic acidosis (lactic\n acid 6). Delta AG/Delta Bicarb . Likely also secondary to renal\n failure. Continue to follow. need bicarb and/or CVVH if worsens.\n .\n # ESLD/elevated LFTs: NASH with cirrhosis and portal hypertension.\n Alb 2.8. INR 1.7. Elevated LFts likely from ischemia yesterday during\n hypotension.\n - appreciate liver recs- hepatic encephalopathy treatment as above\n - abdominal u/s with dopplers without PV thrombosis\n - add albumin to regimen\n .\n # anemia/coffee grounds: Hct at OSH above most recent dc value after\n transfusion in setting of UGIB. Has known iron deficiency anemia and\n has had multiple episodes of UGI bleeding from portal gastropathy and\n varices.\n - 2 large bore IVs\n - type and screen\n - CBC\n - cont iron\n - PPI \n .\n # diabetes mellitus type II: hold metformin\n - insulin SS\n .\n # depression: hold amytriptyline and fluoxetine\n .\n # FEN: replete lytes prn. Repeat in pm. Currently no TFs. Will consider\n starting, had been holding Po meds for residuals concern for\n aspiration. Slowly introduce meds. Give reglan if high residuals\n .\n # PPx: heparin sc. PPI. lactulose\n .\n # ACCESS: 20G PIV x 2, A-line, R fem CVL\n .\n # CODE: FULL. Will have family discussion today regarding goals of\n care, may need dialysis\n .\n # COMM: (son) \n .\n # DISP: ICU\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 AM\n 20 Gauge - 06:00 PM\n Multi Lumen - 08:03 PM\n 22 Gauge - 11:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 65 year old female with a history of ESLD \n NASH c/b portal hypertension, Gr 2 esophageal varices, portal\n gastropathy, and recurrent GI bleeds who presents with altered mental\n status. Last admitted for GAVE/UGIB in and similar admission other\n hospital admit in . Recent GAVE treatment with thermal\n therapy. Recent d/c after tap for ?SBP\n neg. 2 days later was\n found on floor next to bed by son, last seen night before, brought to\n where intubated for a/w protection. CT head -\n negative. CXR w/R opacity ?pleural effusion. Labs 6K WBC, no drop in\n HCT, K5.5, Bicarb 18, Alb 2.8, Tbili 3.4. NH4 182 (high for this pt).\n Urine tox pos for TCA, benzo.\n Here at , intubated/sedated. Unclear if not taking lactulose, but\n dietary indiscretion was a possibility over holidays vs mild sepsis\n following GI procedure for GAVE. Treated for encephalopathy, treated\n with broad spectrum antibiotics and FQ prophylaxis. Awaiting\n pan-cultures. Over last 24 hr, initially responded to fluids, then\n required CVL\n line placed in R carotid, line removed by vascular and\n new line placed in femoral vein. Requiring neo and levophed to\n maintain pressure. Abd US showing no portal vein thrombosis,\n continuing on antibiotics, lactulose and rifaximin.\n Intubated/sedated, unresponsive, Exam notable for Tm 99.1 BP 96/52 HR\n 88 RR 28 with sat 98 on AC 450 x 12, PEEP 5, FiO2 .6 w/ 7.26/25/94.\n Bladder pressure 18. 9L+ yesterday. Post surgical pupils, coarse BS,\n reg RR, soft Syst murmur, nontender +BS, 3+ LE edema, minimal w/draw to\n painful stimuli. Labs notable for WBC 15.1K, HCT 28, K+ 4.7, Cr 1.5\n HCO3 11, Lactate 6.4. UNa 10 FeNa .1, INR 1.9. TBili 5.2, CK 1024.\n CXR worsening R base effusion.\n Agree with plan to treat altered mental status and acute respiratory\n failure as presumed hepatic encephalopathy vs sepsis now with\n progressive respiratory and renal failure. Her status is declining with\n anasarca and increasing oxygen and pressor requirement. Attempt\n increase in PEEP and continue aggressive therapy including possible\n CVVH. We will also continue to update the family. No evidence for\n acute infection, but will remains on broad spectrum antibiotics pending\n full culture data. Will treat with albumin for ascites. Continue\n rifaximin and lactulose. Holding metformin and monitoring BS.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:15 ------\n"
}
] |
17,449 | 179,268 | Hospital Course/Assessment and Plan: Patient is an 84 year old female with a history of atrial fibrillation, normocytic anemia, diabetes and hypertension who presented with weakness and a hematocrit drop from the mid 30's to 17. Patient's INR elevated, guaiac postive, but EGD negative. Received two units of packed red cells and FFP and guaiac positive. . . 1) GI bleed: Patient initially found to be guaiac positive. INR 2.7 NG lavage negative. Patient received one unit of FFP and 2 units of packed red blood cells and hematocrit demonstrated appropriate increase. Initially monitored in the MICU. EGD on did not demonstrate any active bleeds. Biopsy performed of gastric ulcers. Pathology results pending. Colonoscopy did not reveal any active bleeding lesions. Biopsy results pending. -Hematocrit stable at 28.3. On admission, hematocrit 17. -H. pylori positive. Placed on omeprazole 20 , amoxicillin 500mg , clarithromycin 500bid for ten days. After ten days, will switch to omeprazole 20mg qd. -Restarted coumadin upon discharge, with goal INR between 2 and 3. Will instruct patient to have INR and hematocrit levels to be measured by VNA. -GI recommends capsule endoscopy as outpatient in the week after discharge. Provided phone number for patient's family to arrange. Follow up EGD and potential colonoscopy in eight weeks. To be arranged by PCP. . 2) Anemia: Patient has history of normocytic anemia. Believed to be component of iron deficiency as well as B12 deficiency and is followed by Dr. . Haptoglobin 144, ferritin 24, TRF 307, TIBC 399. Folate 5.9 and B12 971. Continued on iron replacement and B12 replacement. -Scheduled for aranesp injection with Dr. on . Follow up appointments with Dr. on . . 3) Diabetes Type II: Patient's hemoglobin A1c 9.1. Blood sugar levels have been slightly elevated lately, with some glucosuria on UA. - Continued on insulin sliding scale. Restart home oral hypoglycemics. Consider increasing dose as outpatient if blood glucose levels elevated. . 4) Atrial fibrillation: Initially, well rate controlled in the 80s. Held diltiazem as concern that patient couldn't mount an adequate compensatory response if decreased volume from GI bleed. Held coumadin dose, initially, due to concern for GI bleed. Patient's rate on transfer in the low 100's. Received 10 mg IV and 60mg PO diltiazem. transfer to floor, elevated heart rate to 140's. Discharged home on home diltiazem dose of 360qd. . 5) Crackles on examination: No evidence of consolidation. Slight pulmonary edema. Will cautiously try to diurese fluid, now that perceived to be hemodynamically stable. Restarted lasix on home dose of 20qAM. . 6) Questionable Hyperparathyroidism: Patient with elevated PTH (155), in setting of elevated calcium. UPep, SPep, and vitD 1,25 levels sent. Pending. Consider outpatient follow-up. 7) Hypertension: Initially, blood pressure medications held, in setting of GI bleed. Restarted and tolerated well. . 8) Prophylaxis: Placed on PPI, . On discharge, omeprazole, amoxicillin, and clarithromycin for ten days. -Will hold fosamax until appointment with PCP . Discontinued Foley on . . 9) CODE: FULL. Confirmed with patient and daughter. | IMPRESSION: PA and lateral chest compared to : Borderline cardiomegaly unchanged. Stable interstitial abnormality, perhaps edema. IMPRESSION: 1. BS. LBM was but pt. neg. neg. per report.Neuro: pt. Grossly unchanged appearance of the interstitial edema and left basal atelectasis. There is right basilar atelectasis and a probable effusion, probably unchanged, allowing for differences in technique. ABD soft, NT. foley placed. Question free air. pt. pt. Compared to the previous tracing of nomajor change.TRACING #1 BP 139/75-167/63. Small right pleural effusion stable. Cardiac and mediastinal contours are unchanged. rectal exam was guiac pos. NPO except small amt. plan for endoscopy for .GU: foley. denies pain. Cardiomediastinal silhouette is grossly unchanged with unchanged appearance to mild bilateral hilar fullness and interstitial edema. monitor VSS - Hx HTN. INR 2.6- Vit K+ sc. Non-diagnosticrepolarization abnormalities. no VEA. did not observe.VSS in EW. Otherwise, no major change.TRACING #2 no c/o pain, N/V. trop and urine neg per report.Arrived to CCU ~ 2100 accomp. WBC 9.2. urine neg. GI to consult. 0600 HCT is pnd with AM labs.protonix IV q12hours. IMPRESSION: Findings consistent with mild volume overload/pulmonary edema. pos. Compared to the previoustracing the ventricular rate is somewhat reduced. Lungs clear. 1.8L LOS.ID: TM 99.6 -99.4po. lytes WNL.denies CP/SOB.GI: no stool. The mediastinal contours are within normal limits allowing for patient position. There are probably small bilateral pleural effusions. u/o ~ 100cc/hr. SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH There is grossly unchanged appearance to elevation of the left hemidiaphragm, likely indicating underlying atelectasis with no definite parenchymal consolidation identified bilaterally. COMPARISON: None. plan for endoscopy today. HCT 20. recv'd 2UPRBC, 1.5L NS. lavage was negative. Atrial fibrillation, average ventricular rate 105. Comparison is made to prior radiograph dated . Granulomatous lymph node calcifications noted in the mediastinum. daughter states baseline BP ~ 140's/. Diffuse interstitial abnormality is not significantly changed. IMPRESSION: No evidence of free air. able to make needs known. is able to understand limited english. AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is upper limits of normal. CHEST, AP VIEW: Comparison is made to earlier on the same day. 25.6 at 0200. The lungs are otherwise clear without consolidations or effusions. lives alone with senior housing, has VNA ~ 1x/month.CV: HR 80-100 Afib. ice. There is bilateral hilar fullness, with pulmonary vascular redistribution. Atrial fibrillation, average ventricular rate 89. HCT 25.5 on admit to CCU. is A/O x3 per daughter who is translating. There are degenerative changes along the thoracic spine. No definite evidence of pneumonia. There is no evidence of free air. by daughter who assisted with translation. No pulmonary edema or focal pulmonary abnormality of concern. daughter Gen went home but is expected back early this AM to help with translation throughout the day.endo: FS 180- covered with SSRI.A/P: HCTs q4hr. all cardiac meds are being held for now. discomfort, s/p endoscopy, nontender exam REASON FOR THIS EXAMINATION: evaluate for free air under diaphragm FINAL REPORT INDICATIONS: 84-year-old woman with abdominal pain status post endoscopy. 6:08 PM CHEST (PORTABLE AP) Clip # Reason: evaluate for free air under diaphragm Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with abdominal pain. CCU NPN 1900-0700S/O: 84yo Russian speaking woman with hx DM, HTN and anemia who presented to ED from PMD's office with report of generalized weakness and HCT 17. 4:58 PM CHEST (PA & LAT) Clip # Reason: r/o infiltrate, pna Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with recent Hct drop, with crackles at L base, question of PNA REASON FOR THIS EXAMINATION: r/o infiltrate, pna FINAL REPORT PA AND LATERAL CHEST FROM HISTORY: Recent hematocrit drop, crackles at the lung bases. 11:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: pls eval for PNA, particularly at L base Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED MEDICAL CONDITION: 84 year old woman with recent Hct drop, with crackles at L base, question of PNA REASON FOR THIS EXAMINATION: pls eval for PNA, particularly at L base FINAL REPORT HISTORY: Left base crackles. | 7 | [
{
"category": "Radiology",
"chartdate": "2131-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946717,
"text": " 11:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for PNA, particularly at L base\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent Hct drop, with crackles at L base, question of\n PNA\n REASON FOR THIS EXAMINATION:\n pls eval for PNA, particularly at L base\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left base crackles.\n\n Comparison is made to prior radiograph dated .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH\n\n There is grossly unchanged appearance to elevation of the left hemidiaphragm,\n likely indicating underlying atelectasis with no definite parenchymal\n consolidation identified bilaterally. There are probably small bilateral\n pleural effusions. Cardiomediastinal silhouette is grossly unchanged with\n unchanged appearance to mild bilateral hilar fullness and interstitial edema.\n\n IMPRESSION:\n\n 1. Grossly unchanged appearance of the interstitial edema and left basal\n atelectasis. No definite evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946659,
"text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: nausea gi bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n nausea gi bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with nausea and gastrointestinal bleed.\n\n COMPARISON: None.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is upper limits of\n normal. The mediastinal contours are within normal limits allowing for\n patient position. There is bilateral hilar fullness, with pulmonary vascular\n redistribution. The lungs are otherwise clear without consolidations or\n effusions. There are degenerative changes along the thoracic spine.\n\n IMPRESSION: Findings consistent with mild volume overload/pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-02-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 947125,
"text": " 4:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate, pna\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent Hct drop, with crackles at L base, question of\n PNA\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, pna\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Recent hematocrit drop, crackles at the lung bases.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Borderline cardiomegaly unchanged. Lungs clear. Small right pleural effusion\n stable. Granulomatous lymph node calcifications noted in the mediastinum. No\n pulmonary edema or focal pulmonary abnormality of concern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-02-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946855,
"text": " 6:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for free air under diaphragm\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with abdominal pain. discomfort, s/p endoscopy,\n nontender exam\n REASON FOR THIS EXAMINATION:\n evaluate for free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 84-year-old woman with abdominal pain status post endoscopy.\n Question free air.\n\n CHEST, AP VIEW: Comparison is made to earlier on the same day. Cardiac and\n mediastinal contours are unchanged. Diffuse interstitial abnormality is not\n significantly changed. There is right basilar atelectasis and a probable\n effusion, probably unchanged, allowing for differences in technique. There is\n no evidence of free air.\n\n IMPRESSION: No evidence of free air. Stable interstitial abnormality,\n perhaps edema.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-02-08 00:00:00.000",
"description": "Report",
"row_id": 272162,
"text": "Atrial fibrillation, average ventricular rate 89. Compared to the previous\ntracing the ventricular rate is somewhat reduced. Otherwise, no major change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-02-08 00:00:00.000",
"description": "Report",
"row_id": 272163,
"text": "Atrial fibrillation, average ventricular rate 105. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of no\nmajor change.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-02-09 00:00:00.000",
"description": "Report",
"row_id": 1490977,
"text": "CCU NPN 1900-0700\nS/O: 84yo Russian speaking woman with hx DM, HTN and anemia who presented to ED from PMD's office with report of generalized weakness and HCT 17. LBM was but pt. did not observe.\nVSS in EW. HCT 20. recv'd 2UPRBC, 1.5L NS. foley placed. no c/o pain, N/V. lavage was negative. rectal exam was guiac pos. INR 2.6- Vit K+ sc. neg. trop and urine neg per report.\n\nArrived to CCU ~ 2100 accomp. by daughter who assisted with translation. pt. lives alone with senior housing, has VNA ~ 1x/month.\n\nCV: HR 80-100 Afib. no VEA. BP 139/75-167/63. all cardiac meds are being held for now. lytes WNL.\ndenies CP/SOB.\nGI: no stool. ABD soft, NT. pos. BS. HCT 25.5 on admit to CCU. 25.6 at 0200. 0600 HCT is pnd with AM labs.\nprotonix IV q12hours. NPO except small amt. ice. plan for endoscopy for .\n\nGU: foley. u/o ~ 100cc/hr. neg. 1.8L LOS.\nID: TM 99.6 -99.4po. WBC 9.2. urine neg. per report.\nNeuro: pt. is A/O x3 per daughter who is translating. pt. is able to understand limited english. denies pain. able to make needs known. daughter Gen went home but is expected back early this AM to help with translation throughout the day.\n\nendo: FS 180- covered with SSRI.\n\nA/P: HCTs q4hr. plan for endoscopy today. GI to consult. monitor VSS - Hx HTN. daughter states baseline BP ~ 140's/.\n"
}
] |
99,268 | 197,102 | 59 year old female with a history of metastatic breast CA presenting with complaints of HA and confusion, found to have a frontal mass with vasogeneic edema and mass effect on MRI. . # Brain mass: Initial neurosurgery assessment in the ED was that the patient's condition was not a surgical emergency but needed oncological staging work up first. She was started on dexamethasone and keppra. MRI revealed a solitary peripheral right frontal lobe mass with extensive vasogenic edema and mass effect. After further discussion between the oncology, neuro-oncology, and neurosurgery services, the patient was felt to be a surgical candidate, and was transferred to the neurosurgery service. She went to the operating room on . . # Breast Cancer: Per the patient's primary oncologist, the patient's capecitabine was held, as the acute surgical issues were being addressed. On she underwent MRI wand study for intraop image guidance and was taken to the OR where under general anesthesia she underwent right frontal craniotomy with excision of mass. She tolerated this well, was extubated and transferred to ICU for close monitoring. She woke up slowly and head CT was done which showed good post op appearance with no hemorrhage but slight edema. She was neurologically intact. On POD#1 she was transferred to the floor, diet and activity were advanced. Incision was clean and dry. A slow steroid taper was begun. She was transferred to the floor. Her wound was clean and dry. She remained neurologically intact.:physical therapy evaluated the patient and felt that she needed one more day of acute physical therapy. : The patient was seen by physical therapy and was given a walker for ambulation to assist in balance and energy conservation. The patient will be sent home with physical therapy and directions to ambulate with the walker at all times. On , the patient is looking forward to discharge. The patient husband is at the bedside. The patient is neurologically stable, ambulating with a walker, oriented to person place and time. | HEAD CT WITHOUT IV CONTRAST: There has been right frontal craniectomy, with resection of a mass in the right frontal lobe. UA negative .Cefzol preop Lines / Tubes / Drains:RIJ/left a line/PIV Wounds: Imaging:CT Fluids:NS Consults:neurosurg Billing Diagnosis: Prophylaxis: DVT:SCD Stress ulcer:PPI VAP bundle: + Comments: Communication:Comments: Code status:FULL Disposition:SICU Time spent: 35 ICU Care Lines: Multi Lumen - 12:21 AM Arterial Line - 12:30 AM 20 Gauge - 02:08 AM 18 Gauge - 02:15 AM Total time spent: UA negative .Cefzol preop Lines / Tubes / Drains:RIJ/left a line/PIV Wounds: Imaging:CT Fluids:NS Consults:neurosurg Billing Diagnosis: Prophylaxis: DVT:SCD Stress ulcer:PPI VAP bundle: + Comments: Communication:Comments: Code status:FULL Disposition:SICU Time spent: 35 ICU Care Lines: Multi Lumen - 12:21 AM Arterial Line - 12:30 AM 20 Gauge - 02:08 AM 18 Gauge - 02:15 AM Total time spent: FINAL REPORT INDICATION: Right frontal lesion, status post resection, to evaluate for postop/residual tumor. Cancer (Malignant Neoplasm), Brain Assessment: Pt s/p right frontal crani for Brain Mass Pt with PMH of systemic Breat CA metastatis Arrived to sicu with anesthesia Goal SBP <140 Pt arrived only following commands on right None verbal but appearing like she may be trying to talk Concern for possible SZ activity Pt was loaded with Dilantin prior to SICU arrival Q1hr neuro Action: STAT head CT done CT scan okay MD but noted much swelling Response: MD pt given 10mg decadron Pt was going to get additional Dilantin but Neurology resident that has been following pt came into MD request and felt that pt was jittery and with Nystagmus related to Dilantin and MD he did not feel like she was SZing just a reaction to too much Dilantin. Subsequent work up revealed esophageal metastasis for which she received radiation Surgery / Procedure and date: Right frontal Craniotomy for Brain Mass Latest Vital Signs and I/O Non-invasive BP: S:113 D:57 Temperature: 98 Arterial BP: S:119 D:62 Respiratory rate: 15 insp/min Heart Rate: 80 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: Nasal cannula O2 saturation: 97% % O2 flow: 3 L/min FiO2 set: 24h total in: 2,844 mL 24h total out: 4,460 mL Pertinent Lab Results: Sodium: 133 mEq/L 02:17 AM Potassium: 3.8 mEq/L 02:17 AM Chloride: 101 mEq/L 02:17 AM CO2: 20 mEq/L 02:17 AM BUN: 19 mg/dL 02:17 AM Creatinine: 1.1 mg/dL 02:17 AM Glucose: 303 mg/dL 02:17 AM Hematocrit: 34.8 % 02:17 AM Finger Stick Glucose: 220 08:00 AM Valuables / Signature Patient valuables: Other valuables: OR holding. Post-surgical changes along with hemorrhage in the surgical resection cavity and significant mass effect on the right lateral ventricle and leftward shift of the midline structures, the latter not significantly changed compared (Over) 9:35 PM MR HEAD W & W/O CONTRAST Clip # Reason: 59 year old woman with s/p right fronatl resection, please c Admitting Diagnosis: BRAIN MASS Contrast: MAGNEVIST Amt: 20 FINAL REPORT (Cont) to the prior study. | 11 | [
{
"category": "Nursing",
"chartdate": "2117-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 610486,
"text": "Cancer (Malignant Neoplasm), Brain\n Assessment:\n Pt s/p right frontal crani for Brain Mass\n Pt with PMH of systemic Breat CA metastatis\n Arrived to sicu with anesthesia\n Goal SBP <140\n Pt arrived only following commands on right\n None verbal but appearing like she may be trying to talk\n Concern for possible SZ activity\n Pt was loaded with Dilantin prior to SICU arrival\n Q1hr neuro\n Action:\n STAT head CT done\n CT scan okay MD but noted much swelling\n Response:\n MD pt given 10mg decadron\n Pt was going to get additional Dilantin but Neurology\n resident that has been following pt came into MD request\n and felt that pt was jittery and with Nystagmus related to Dilantin and\n MD he did not feel like she was SZing just a reaction to too much\n Dilantin. Keppra dose increased\n Starting in CT scan pt moving left side more\n Between am pt was MAE R>L alert and oriented X3\n Pt with soft voice chemo for esophageal CA which was\n diagnosed in 07\n Plan:\n Repeat CT scan possibly today\n Q1 hr neuro until 24hr post op\n Cont to monitor pain and MS \n Cont with current plan of care\n"
},
{
"category": "Physician ",
"chartdate": "2117-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 610516,
"text": "SICU\n HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\n chemotherapy, now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is\n currently on Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass.\n Oncologist is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 02:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.6\nC (96.1\n T current: 35.6\nC (96.1\n HR: 65 (64 - 87) bpm\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\n RR: 14 (13 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 121 mL\n PO:\n Tube feeding:\n IV Fluid:\n 121 mL\n Blood products:\n Total out:\n 0 mL\n 3,210 mL\n Urine:\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,089 mL\n Respiratory support\n SPO2: 100%\n ABG: 7.40/36/120//-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\n stimuli), moves R>L\n Labs / Radiology\n [image002.jpg]\n 02:25 AM\n TCO2\n 23\n Assessment and Plan\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\n ,metastatic breast ca\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\n ,. Decrease dex\n Cardiovascular:goal SBP 140-160\n Pulmonary:FM\n Gastrointestinal / Abdomen:NPO ,PPI\n Nutrition:NPO\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\n Hematology:EBL 200 ,F/UP HCT\n Endocrine:\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\n Lines / Tubes / Drains:RIJ/left a line/PIV\n Wounds:\n Imaging:CT\n Fluids:NS\n Consults:neurosurg\n Billing Diagnosis:\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Lines:\n Multi Lumen - 12:21 AM\n Arterial Line - 12:30 AM\n 20 Gauge - 02:08 AM\n 18 Gauge - 02:15 AM\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2117-12-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 610530,
"text": "HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\n now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\n Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass. Oncologist\n is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Cancer (Malignant Neoplasm), Brain\n Assessment:\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\n Original OR dsg dry and intact,\n Action:\n q 1 hour neuro checks changed to q 2,\n given morphine 2 mg IV prn pain,\n turned and repositioned for comfort.\n started on regular diet,\n Response:\n neuro status unchanged.\n Plan:\n transfer to 11.\n"
},
{
"category": "Nursing",
"chartdate": "2117-12-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 610536,
"text": "HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation, chemotherapy,\n now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is currently on\n Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass. Oncologist\n is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read -.edema +\n Cancer (Malignant Neoplasm), Brain\n Assessment:\n POD 1 craniotomy for tumor resection, Patient is lethargic but oriented\n x 3, able to move all extremities with equal strength, Pupils 1-2 mm\n both equally and briskly reactive to light. c/o 5 out of 10 headache.\n Original OR dsg dry and intact,\n Action:\n q 1 hour neuro checks changed to q 2,\n given morphine 2 mg IV prn pain,\n turned and repositioned for comfort.\n started on regular diet,\n Response:\n neuro status unchanged.\n Plan:\n transfer to 11.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n BRAIN MASS\n Code status:\n Height:\n Admission weight:\n 90 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Migraines, systemic metastatic Breast CA initially\n presented in she had a left mastectomy and Chemo with 5yrs of\n Tamoxifen. She was well untill when she developed a cough and a\n chest Xray showed a shadow. Biopsy showed adenocarcinoma treated with\n Faslodex. Subsequent work up revealed esophageal metastasis for which\n she received radiation\n Surgery / Procedure and date: Right frontal Craniotomy for Brain\n Mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:57\n Temperature:\n 98\n Arterial BP:\n S:119\n D:62\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,844 mL\n 24h total out:\n 4,460 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 02:17 AM\n Potassium:\n 3.8 mEq/L\n 02:17 AM\n Chloride:\n 101 mEq/L\n 02:17 AM\n CO2:\n 20 mEq/L\n 02:17 AM\n BUN:\n 19 mg/dL\n 02:17 AM\n Creatinine:\n 1.1 mg/dL\n 02:17 AM\n Glucose:\n 303 mg/dL\n 02:17 AM\n Hematocrit:\n 34.8 %\n 02:17 AM\n Finger Stick Glucose:\n 220\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: OR holding.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 11\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2117-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 610475,
"text": "SICU\n HPI:\n Ms. is a 59yo right handed woman with metastatic breast cancer\n on xeloda now presenting with headache, found to have right frontal\n brain mass on MRI\n Chief complaint:\n presenting with headache\n PMHx:\n 1) Breast cancer- dx in , s/p lumpectomy, radiation,\n chemotherapy, now complicated by esophageal mets and right\n mainstem bronchus mets, s/p mediastinal radiation. She is\n currently on Xeloda (capecitabine) oral therapy that she takes\n . PET from with new FDG avid adrenal mass.\n Oncologist is Dr. at .\n 2) ? Aura without migraine-\n 3) UTI\n Past Surgical History: None other than her left lumpectomy,\n esophageal biopsy, and transbronchial biopsy\n Current medications:\n :\n Xeloda PO BID\n Bactrim (started a few days ago by her PCP)\n Omeprazole 20mg daily\n 24 Hour Events:\n s/p right frontal craniotomy for tumor resection .\n CT post op final read pending.edema +\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 02:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.6\nC (96.1\n T current: 35.6\nC (96.1\n HR: 65 (64 - 87) bpm\n BP: 111/55(77) {110/52(77) - 143/77(99)} mmHg\n RR: 14 (13 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 121 mL\n PO:\n Tube feeding:\n IV Fluid:\n 121 mL\n Blood products:\n Total out:\n 0 mL\n 3,210 mL\n Urine:\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,089 mL\n Respiratory support\n SPO2: 100%\n ABG: 7.40/36/120//-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), (Responds to: Verbal\n stimuli), moves R>L\n Labs / Radiology\n [image002.jpg]\n 02:25 AM\n TCO2\n 23\n Assessment and Plan\n ASSESSMENT:59 yr old F s/p right frontal craniotomy for tumor resection\n ,metastatic breast ca\n Neurologic:drowsy on arrival to ICU,follows verbal commands ,moves R>L\n Cardiovascular:goal SBP 140-160\n Pulmonary:FM\n Gastrointestinal / Abdomen:NPO ,PPI\n Nutrition:NPO\n Renal:creat 1 .urine output good,got mannitol and lasix intraop\n Hematology:EBL 200 ,F/UP HCT\n Endocrine:\n ID:?UTI bactrim started by PCP. UA negative .Cefzol preop\n Lines / Tubes / Drains:RIJ/left a line/PIV\n Wounds:\n Imaging:CT\n Fluids:NS\n Consults:neurosurg\n Billing Diagnosis:\n Prophylaxis:\n DVT:SCD\n Stress ulcer:PPI\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Lines:\n Multi Lumen - 12:21 AM\n Arterial Line - 12:30 AM\n 20 Gauge - 02:08 AM\n 18 Gauge - 02:15 AM\n Total time spent:\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-21 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1112367,
"text": " 3:45 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o mets\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with met breast cancer with new onset of headaches, nausea,\n dizziness and confusion\n REASON FOR THIS EXAMINATION:\n r/o mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Brain MRI.\n\n HISTORY: 59-year-old female with metastatic breast cancer presents with new\n onset of headaches and confusion.\n\n COMPARISON: No prior brain imaging.\n\n TECHNIQUE: Sagittal T1, axial pre- and post-gadolinium T1, T2 FSE, T2 FLAIR,\n T2 GRE, diffusion, sagittal post-gadolinium MP-RAGE with axial and coronal\n reformatted sequences of the brain were obtained.\n\n FINDINGS: There is a heterogeneously enhancing 2.6 x 3.0 mass within the\n right frontal lobe. There is extensive vasogenic edema extending into the\n corpus callosum. There is approximately 15 mm of leftward shift of midline\n structures. There is no significant associated restricted diffusion. No\n additional enhancing lesions are identified. There are scattered subcortical\n T2 hyperintensities, which may reflect microvascular disease. Bone marrow\n signal is lower than expected on T1-weighted sequences, without focal\n abnormality. There is no hydrocephalus.\n\n IMPRESSION: Solitary peripheral right frontal lobe mass with extensive\n vasogenic edema and mass effect. Given the patient's history, this is\n concerning for a metastatic tumor, though a primary brain tumor cannot be\n excluded.\n\n The findings were discussed with Dr. immediately upon termination\n of the examination, at 17:00 hours on . Plans were made to\n transfer the patient to the emergency department.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1112714,
"text": " 1:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P RESECTION\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with R frontal crani, tumor resection from breast primary.\n REASON FOR THIS EXAMINATION:\n please eval for post op hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 3:24 AM\n No post-operative hemorrhage, continued left 8mm subfalcine herniation. Post-\n operative pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 59-year-old female with right frontal craniectomy, tumor resection\n for breast primary. Evaluate for postoperative hemorrhage.\n\n COMPARISON: MRI performed one day prior.\n\n TECHNIQUE: Axial imaging was performed from the foramen magnum to the cranial\n vertex without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There has been right frontal craniectomy, with\n resection of a mass in the right frontal lobe. There is expected\n pneumocephalus, as well as edema in the postoperative site. There has been no\n significant degree of hemorrhage. However, the right lateral ventricle\n remains compressed, and there is again shift of midline structures to the\n right of approximately 9 mm, which is similar to the preoperative study\n . No other site of hemorrhage is identified. There is no evidence of\n transtentorial herniation. Osseous structures and soft tissues elsewhere\n appear unremarkable.\n\n IMPRESSION:\n 1. Status post right frontal craniectomy with expected edema in the\n postoperative site and continued subfalcine herniation of approximately 8 mm.\n 2. No unexpected postoperative hemorrhage.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1112715,
"text": " 1:38 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: RIJ position\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right frontal craniotomy\n REASON FOR THIS EXAMINATION:\n RIJ position\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Right frontal craniotomy, assess for right IJ position.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax or pleural\n effusion. Cardiomediastinal contours are unchanged. Patient has known\n mediastinal lymphadenopathy including a large calcified lymph node in the AP\n window. The lungs are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-23 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 1112663,
"text": " 3:10 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: Surgical planning for \n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right frontal lesion, please do on at 3pm\n for or 5PM\n REASON FOR THIS EXAMINATION:\n Surgical planning for \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right frontal lesion. Presurgical planning.\n\n COMPARISON: MRI of the brain from .\n\n TECHNIQUE: Post-contrast axial MP-RAGE with coronal and sagittal reformats;\n and axial, coronal, and sagittal T1 post-contrast images of the brain were\n obtained.\n\n LIMITED POST-CONTRAST MRI OF THE BRAIN: There has been no significant change\n compared to two days prior. Again seen is a heterogeneously enhancing mass in\n the right frontal lobe measuring 1.9 cm AP x 2.6 cm TRV x 2.4 cm SI. There is\n again extensive vasogenic edema extending into the corpus callosum and\n approximately 12 mm of leftward midline shift. The right lateral ventricle is\n effaced. No additional enhancing lesions are identified. No hydrocephalus.\n\n IMPRESSION: Redemonstration of solitary right frontal mass with extensive\n vasogenic edema and mass effect with leftward midline shift. No change from 2\n days prior. Please refer to detailed report of the complete MRI from\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-25 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1112956,
"text": " 9:35 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 59 year old woman with s/p right fronatl resection, please c\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with s/p right fronatl resection, please check post op for\n residual\n REASON FOR THIS EXAMINATION:\n 59 year old woman with s/p right fronatl resection, please check post op for\n residual\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SUN 9:57 AM\n Post-surgical changes and hemorrhage in the surgical resection bed;\n significant surroudning edema, mass effect on the lateral ventricles and\n leftward subfalcine herniation by 9mm- not significantly changed; at risk for\n ACA involvement- continued close f/u with CT Head as clinically indicated.\n Residual tumor not adequately assessed given the hemorrhage in the resection\n bed. F/u.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right frontal lesion, status post resection, to evaluate for\n postop/residual tumor.\n\n COMPARISON: MR of the head done on and 17/09.\n\n TECHNIQUE: MR of the head without and with contrast.\n\n FINDINGS:\n\n There is evidence of craniotomy on the right side, in the frontal and the\n parietal regions, with post-surgical changes. Areas of blood\n products/hemorrhage are noted in the surgical resection cavity with a fluid\n level. There is significant vasogenic edema and mass effect on the frontal\n of the right lateral ventricle and mass effect on the right lateral\n ventricle, and mild shift of the midline structures to the left side by 9 mm,\n representing subfalcine herniation. There is no significant change in the\n mass effect compared to the prior study. A few small scattered FLAIR\n hyperintense foci are noted in the cerebral white matter, elsewhere, likely\n related to small vessel ischemic changes.\n\n On the post-contrast images, there is mild enhancement in the periphery of the\n hemahorrhagic focus as well as in the adjacent dura, at the surgical resection\n site. However, evaluation for residual tumor is limited due to the presence\n of pre-contrast T1 hyperintense appearance of the areas of hemorrhage.\n\n IMPRESSION:\n 1. Post-surgical changes along with hemorrhage in the surgical resection\n cavity and significant mass effect on the right lateral ventricle and leftward\n shift of the midline structures, the latter not significantly changed compared\n (Over)\n\n 9:35 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 59 year old woman with s/p right fronatl resection, please c\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to the prior study.\n\n Evaluation for residual tumor is limited on the present study. Consider\n followup, after resolution of the post-surgical changes, to assess for\n residual tumor.\n\n Close followup with CT head to assess for interval change in the mass effect,\n as clinically indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-22 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1112531,
"text": " 9:21 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BRAIN MASS\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with metastatic breast ca and new brain met. needs pre-op\n chest xray.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old female with metastatic breast cancer and new brain\n metastasis. Preoperative radiograph.\n\n COMPARISON: Head CT .\n\n TWO VIEWS OF THE CHEST: The cardiomediastinal contour is normal. The heart\n is not enlarged. The lungs are clear. A calcified aorticopulmonary window\n node is seen projecting over the left mediastinum. Osseous structures and\n soft tissues appear unremarkable.\n\n IMPRESSION: No evidence of acute process.\n\n"
}
] |
56,714 | 173,051 | 48-year-old male with history of type I DM c/b DKA, gastroparesis, neuropathy and retinopathy who presents with DKA. DIABETIC KETOACIDOSIS, TYPE I DIABETES UNCONTROLLED WITH COMPLICATIONS: admitted to ICU and started on an insulin drip. Rehydrated and ACUTE ON CHRONIC RENAL FAILURE improved. He was seen by consult and insulin was transitioned to sc and adjusted. His A1c was noted to be 12.7%. He was discharged home on an increased dose of insulin and adjustments to his sliding scale, and will f/u with his endocrinologist. | ST-T wave abnormalities. Possible septal myocardialinfarction. Sinus tachycardia. Sinus tachycardia. Sinus rhythm. Since the previous tracing of T waves are more prominenton the present tracing.TRACING #1 Diffuse low amplitude T wavechanges are non-specific. 5:49 AM CT HEAD W/O CONTRAST Clip # Reason: ? Compared to the previous tracing of sinustachycardia is now present and delayed R wave progression pattern is moreprominent. IMPRESSION: No acute intracranial process. Late R wave progression. Delayed R wave progression is non-diagnostic but cannot excludepossible prior anterior myocardial infarction. The cardiomediastinal silhouette, hilar contours and pleural surfaces are normal. Baseline artifact. IMPRESSION: No acute intrathoracic process. 5:51 AM CHEST (PA & LAT) Clip # Reason: ? COMPARISON: Chest radiograph from . Since theprevious tracing T wave abnormalities are more prominent.TRACING #2 ICH, signs of edema No contraindications for IV contrast WET READ: ASpf FRI 6:25 AM no acute intracranial process. TECHNIQUE: MDCT images were acquired through the head without contrast. The visible paranasal sinuses and mastoid air cells are well aerated. FINDINGS: No acute hemorrhage, large vascular territory infarct, shift of midline structures or mass effect is present. pulm path FINAL REPORT INDICATION: 48-year-old man with altered mental status. A needle is noted in the posterior subcutaneous tissues at the thoracolumbar junction. The ventricles and sulci are normal in size and configuration. A needle is noted in the posterior soft tissues near the thoracolumbar junction on the lateral view. COMPARISON: None available. No pleural effusions or pneumothorax is present. FINAL REPORT INDICATION: A 48-year-old man with altered mental status, question intracranial hemorrhage or signs of edema. ICH, signs of edema MEDICAL CONDITION: 48 year old man with AMS REASON FOR THIS EXAMINATION: ? Multiplanar reformations were obtained and reviewed. Healed rib fractures are noted on the left. TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. pulm path MEDICAL CONDITION: 48 year old man with AMS REASON FOR THIS EXAMINATION: ? | 5 | [
{
"category": "Radiology",
"chartdate": "2132-04-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1182712,
"text": " 5:51 AM\n CHEST (PA & LAT) Clip # \n Reason: ? pulm path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AMS\n REASON FOR THIS EXAMINATION:\n ? pulm path\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with altered mental status.\n\n COMPARISON: Chest radiograph from .\n\n TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The\n cardiomediastinal silhouette, hilar contours and pleural surfaces are normal.\n No pleural effusions or pneumothorax is present. A needle is noted in the\n posterior soft tissues near the thoracolumbar junction on the lateral view.\n Healed rib fractures are noted on the left.\n\n IMPRESSION: No acute intrathoracic process. A needle is noted in the\n posterior subcutaneous tissues at the thoracolumbar junction.\n\n These findings were communicated to at 6:21 a.m. on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1182711,
"text": " 5:49 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH, signs of edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AMS\n REASON FOR THIS EXAMINATION:\n ? ICH, signs of edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf FRI 6:25 AM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old man with altered mental status, question\n intracranial hemorrhage or signs of edema.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Multiplanar reformations were obtained and reviewed.\n\n FINDINGS:\n\n No acute hemorrhage, large vascular territory infarct, shift of midline\n structures or mass effect is present. The ventricles and sulci are normal in\n size and configuration. The visible paranasal sinuses and mastoid air cells\n are well aerated.\n\n IMPRESSION:\n\n No acute intracranial process.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-25 00:00:00.000",
"description": "Report",
"row_id": 125144,
"text": "Baseline artifact. Sinus tachycardia. ST-T wave abnormalities. Since the\nprevious tracing T wave abnormalities are more prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-25 00:00:00.000",
"description": "Report",
"row_id": 125145,
"text": "Sinus tachycardia. Late R wave progression. Possible septal myocardial\ninfarction. Since the previous tracing of T waves are more prominent\non the present tracing.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-26 00:00:00.000",
"description": "Report",
"row_id": 126063,
"text": "Sinus rhythm. Delayed R wave progression is non-diagnostic but cannot exclude\npossible prior anterior myocardial infarction. Diffuse low amplitude T wave\nchanges are non-specific. Compared to the previous tracing of sinus\ntachycardia is now present and delayed R wave progression pattern is more\nprominent.\n\n"
}
] |
85,845 | 156,194 | 71yo M with CAD, Afib on coumadin, and s/p right inguinal hernia repair on complicated by post-op urinary retention now presenting with 3 days of malaise, nausea, chills and acute on chronic PO intake found to be febrile with pyuria. Stabilized in MICU and transferred to medicine floor. . # SEPSIS: Mr. was admitted to the MICU with hypotension and fever concerning for sepsis. He was started on Cipro for positive UA and blood cultures and was ultimately found to have gram negative rods in his blood and urine (serratia marcesens) susceptible to Cipro. He continued on this abx for intended 14day course. His fevers improved. He was weaned off pressors immediately after ICU admission. Surgery was consulted due to recent inguinal hernia repair. He has a seroma at the site of his prior inguinal hernia repair which did not appear to be infected and surgery did not recommend draining it. His foley was initially removed prior to discharge but a post-void residual was >300 so it was replaced. Urology was called due to urinary retention and recommended waiting 2 days until septic illness has improved, then attempting another voiding trial. While on antibiotics his coumadin dose was decreased to 2mg daily. He was stabilized and transferred to general medicine floors. He was afebrile and continued to show clinical improvement on Ciprofloxacin for 14 day course. Repeat blood cxr pending. MRSA screen negative. CT abdomen/pelvis pending final read, did not show evidence of abscess or other potential infectious site. . # Urinary Retention: Retention since eval by Dr. . Unclear etiology for retention, likely infection. Urine output via foley cath adequate. c/o internal discomfort w/foley. Afebrile. Trial to void on with urine output 250cc and 150cc in first few hours after discontinuation of foley cath. Pt ambulating and reported resolution of severe discomfort from catheter. PVR in afternoon was 58cc. He was monitored for urinary retention with PVR. Plan for retention: update urology, options to replace foley cath or teach self catheterization. Follow up with Dr. as outpatient. . # Hepatic lesions: Incidentally discovered on CT abd/pelvis for evaluation of possible second site of infection and prostate tenderness. Question of cysts vs liver neoplasm on CT. He was sent for MRI abdomen to evaluate for hepatic malignancy given systemic symptoms of malaise, early satiety, decreased po intake, and wt loss for several months. MRI showed multiple liver cysts, no suggestion of malignancy. . #Seroma: Not currently concerning for infection. Surgery is following, thinks it will resolve spontaneously, and if not improved, consider U/S of seroma as an outpatient. . # Hypophosphatemia: Pt has chronic low phosphate levels managed on neutraphos at home. Also labs calcium and slightly elevated PTH. Endocrine consult in MICU suggested evaluation of fasting urine phos/creat with juxtaposed blood phos/creatinine. Per note, differential includes acquired RTA, vitamin D deficiency, and myeloma given anemia. Secondary hyperparathyroidism felt to be unlikely given low/normal Ca. Pt received IV repletion of phos in the unit and on the floor. Total protein 5.6. SPEP and UPEP levels pending, to evaluate myeloma. Endocrine recs are to follow up with Dr. 1 month after discharge for assessment of pending labs and further clinical workup. Vit D levels = pending. . # Weight loss: Patient reports several months of weight loss, nausea, anorexia, and early satiety. PSA 1 yr ago normal. Prostate tender on exam and pt denying pelvic discomfort. CT abdomen/pelvis prelim above suggests ?focal lesions in liver. MRI abd to eval liver lesions, r/o neoplasm vs cysts. MRI showed hepatic cysts, study nonsuggestive of hepatic malignancy. . # AFIB: Rate controlled with metoprolol instead of home atenolol. He was continued on Digoxin and monitored. Coumadin dose reduced to 2mg per day with abx/ciprofloxacin use and with currently therapeutic INR. . # CAD. Continued on asa, statin. . #Hypotension - on admission, likely sepsis. Repleted with IVF. Currently normotensive. | The spleen appears within normal limits with the exception of a few sub-3-mm T2 hyperintense lesions consistent with cysts along the inferior tip. CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with associated dependent and compressive atelectasis. The kidneys appear within normal limits with the exception of small cysts within the right kidney. A small amount of fat is noted herniating through the inguinal ring, suggestive of persistent inguinal hernia. For example, an 11-mm lesion within medial left hepatic lobe (902, 57) appears multiseptated. MRI ABDOMEN: Small bilateral pleural effusions are present. Mild multilevel degenerative change of the thoracolumbar spine is noted. Small amount of fat herniating through inguinal ring suggestive of persistent partial inguinal hernia. Small amount of fat herniating through inguinal ring suggestive of persistent inguinal hernia. Small amount of fat herniating through inguinal ring suggestive of persistent inguinal hernia. Small bilateral pleural effusions. Small bilateral pleural effusions. Intra-abdominal small and large bowel loops appear normal in caliber. The gallbladder appears unremarkable. REASON FOR THIS EXAMINATION: w contrast please; please eval for etiology of n/v/weight loss No contraindications for IV contrast PFI REPORT Small bilateral pleural effusions. A subcentimeter T2 hyperintense ovoid lesion within L3 vertebral body, upon correlation with CT from , is consistent with hemangioma. Moderate lumbar osteoarthritis. Probable post-operative seroma in the right lower abdominal wall. Probable post-operative seroma in the right lower abdominal wall. Probable post-operative seroma in the right lower abdominal wall. In addition, there is some ill-defined stranding just anterior to the femoral vessels, likely postoperative. Multiple small T2 hyperintense nonenhancing lesions are scattered throughout the liver, consistent with cysts. Sub-3-mm splenic cysts. Atherosclerotic calcification of the abdominal aorta is noted. No free air below the right hemidiaphragm is seen. Non-specific inferior T wave changes.Compared to the previous tracing of no diagnostic interim change. The opacified stomach and intra-abdominal loops of bowel are normal. The distal ureters, seminal vesicles, sigmoid colon, and rectum are normal. Multiple hypodensities are noted throughout the liver, most of which are subcentimeter in size and too small to further characterize. left adrenal gland fullness. Tiny locules of gas are seen tracking into the right hemiscrotum. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but incompletely evaluated on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. IMPRESSION: No acute findings in the chest. No concerning focal liver lesion. The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal. Bone marrow signals are otherwise within normal limits. TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis after administration of 130 cc of IV Optiray contrast. No solid concerning hepatic lesion is identified. There is grade 1 retrolisthesis of L5 on S1. REASON FOR THIS EXAMINATION: w contrast please; please eval for etiology of n/v/weight loss No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 10:55 PM Small bilateral pleural effusions. COMPARISON: CT from . The kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or hydroureter. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but a neoplastic etiology cannot be excluded on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. Multiple incompletely evaluated hypodensities in the liver measuring up to 11 mm without rim enhancement could represent simple cysts but a neoplastic etiology cannot be excluded on this limited single-phase CT. Further evaluation could be obtained with MRI or ultrasound as clinically indicated. This lesion has a low density of 13 Hounsfield units. (Over) 5:10 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: w contrast please; please eval for etiology of n/v/weight lo Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: OPTIRAY Amt: FINAL REPORT (Cont) CT PELVIS WITH IV CONTRAST: In the lower right anterior abdominal wall, just lateral to the lower right rectus muscle, there is a 9.5 x 2.8 x 9.0 cm fluid collection which is likely postoperative given the recent hernia repair. Cardiomediastinal silhouette appears grossly stable and normal. of note, surgical hx +midline abd hernia repair REASON FOR THIS EXAMINATION: liver lesions visualized on ct abd - question of cysts vs liver malignancy No contraindications for IV contrast WET READ: PPcb SUN 1:41 PM multiple liver cysts some with think septations. The pancreas and adrenal glands are unremarkable. No mesenteric or retroperitoneal lymphadenopathy meeting CT criteria for pathological enlargement is noted. The largest lesion is located within segment VIII, measuring 12 mm (902,34). The largest lesion is in segment VIII measuring 10 x 11 mm. Coronal and sagittal reformats were displayed. No pelvic or inguinal lymphadenopathy meeting criteria for pathologic enlargement is noted. FINDINGS: PA and lateral views of the chest were obtained. An additional 10-mm lesion within segment II is also septated. (Over) 1:36 PM MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: liver lesions visualized on ct abd - question of cysts vs li Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS Contrast: MAGNEVIST Amt: 15 FINAL REPORT (Cont) Marked lumbar spondylosis with endplate degenerative changes are most pronounced at L2-3. | 5 | [
{
"category": "Radiology",
"chartdate": "2105-06-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1146512,
"text": " 5:02 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, postop, + cough\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: 71-year-old man with fever, postop, positive cough,\n question pneumonia.\n\n FINDINGS: PA and lateral views of the chest were obtained. There is no\n evidence of pneumonia or CHF. No pleural effusion or pneumothorax is seen.\n Cardiomediastinal silhouette appears grossly stable and normal. Bones appear\n intact. No free air below the right hemidiaphragm is seen.\n\n IMPRESSION: No acute findings in the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-27 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 1146929,
"text": " 1:36 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: liver lesions visualized on ct abd - question of cysts vs li\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man adm'd for urosepsis and urinary retention s/p R inguinal hernia\n repair on w c/o nausea, anorexia, wt loss and early satiety x several\n months. ?malignancy given systemic complaints. of note, surgical hx +midline\n abd hernia repair\n REASON FOR THIS EXAMINATION:\n liver lesions visualized on ct abd - question of cysts vs liver malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PPcb SUN 1:41 PM\n multiple liver cysts some with think septations. no enhancement. left adrenal\n gland fullness.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male here for urosepsis, status post right inguinal\n repair on , now presents with nausea, anorexia, and weight loss as well\n as incidental findings of liver cysts on CT. Question further\n characterization of liver lesions.\n\n COMPARISON: CT from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 3D imaging obtained prior to, during, and\n following uneventful intravenous administration of 0.1 mmol/kg (15 mL) of\n Magnevist. Multiplanar 2D and 3D reformations and subtraction images were\n generated on an independent workstation.\n\n MRI ABDOMEN: Small bilateral pleural effusions are present.\n\n Multiple small T2 hyperintense nonenhancing lesions are scattered throughout\n the liver, consistent with cysts. The largest lesion is located within segment\n VIII, measuring 12 mm (902,34). Some of these lesions are septated. For\n example, an 11-mm lesion within medial left hepatic lobe (902, 57) appears\n multiseptated. An additional 10-mm lesion within segment II is also septated.\n No solid concerning hepatic lesion is identified.\n\n There is no intra- or extra-hepatic biliary dilatation. The gallbladder\n appears unremarkable. The spleen appears within normal limits with the\n exception of a few sub-3-mm T2 hyperintense lesions consistent with cysts\n along the inferior tip. The pancreas and adrenal glands are unremarkable.\n The kidneys appear within normal limits with the exception of small cysts\n within the right kidney. There is no hydronephrosis or hydroureter.\n\n Intra-abdominal small and large bowel loops appear normal in caliber. There\n is no lymphadenopathy or free fluid within the abdomen. Great vessels are\n normal in caliber.\n\n (Over)\n\n 1:36 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: liver lesions visualized on ct abd - question of cysts vs li\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Marked lumbar spondylosis with endplate degenerative changes are most\n pronounced at L2-3. A subcentimeter T2 hyperintense ovoid lesion within L3\n vertebral body, upon correlation with CT from , is consistent\n with hemangioma. Bone marrow signals are otherwise within normal limits.\n\n Multiplanar 2D and 3D reformations (185, 186) provided multiple perspectives\n for the dynamic series.\n\n IMPRESSION:\n 1. Numerous sub-1.5-cm liver cysts scattered throughout the liver. No\n concerning focal liver lesion.\n 2. Sub-3-mm splenic cysts.\n 3. Small bilateral pleural effusions.\n 4. Moderate lumbar osteoarthritis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-26 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1146837,
"text": " 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\n of decreased apetite and weight loss.\n REASON FOR THIS EXAMINATION:\n w contrast please; please eval for etiology of n/v/weight loss\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg FRI 10:55 PM\n Small bilateral pleural effusions. Multiple incompletely evaluated\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\n represent simple cysts but a neoplastic etiology cannot be excluded on this\n limited single-phase CT. Further evaluation could be obtained with MRI or\n ultrasound as clinically indicated. Probable post-operative seroma in the\n right lower abdominal wall. Small amount of fat herniating through inguinal\n ring suggestive of persistent inguinal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with Gram-negative rod bacteremia and urinary\n retention with two months of decreased appetite and weight loss. Evaluate for\n etiology of nausea, vomiting, and weight loss. Patient had right inguinal\n hernia repair 7 days ago.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis after administration of 130 cc of IV Optiray contrast. Oral contrast\n was also administered. Coronal and sagittal reformats were displayed.\n\n CT ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions with\n associated dependent and compressive atelectasis. Lung bases are otherwise\n clear.\n\n Multiple hypodensities are noted throughout the liver, most of which are\n subcentimeter in size and too small to further characterize. The largest\n lesion is in segment VIII measuring 10 x 11 mm. This lesion has a low density\n of 13 Hounsfield units. There is no rim enhancement around these lesions\n which could represent simple cysts or congenital biliary hamartomas, but are\n incompletely evaluated on this single phase CT.\n\n The gallbladder, pancreas, spleen, and bilateral adrenal glands are normal.\n The kidneys enhance and excrete contrast symmetrically without evidence of\n hydronephrosis or hydroureter. The opacified stomach and intra-abdominal\n loops of bowel are normal. No mesenteric or retroperitoneal lymphadenopathy\n meeting CT criteria for pathological enlargement is noted. There is no free\n air or fluid in the abdomen. Atherosclerotic calcification of the abdominal\n aorta is noted.\n\n (Over)\n\n 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS WITH IV CONTRAST: In the lower right anterior abdominal wall, just\n lateral to the lower right rectus muscle, there is a 9.5 x 2.8 x 9.0 cm fluid\n collection which is likely postoperative given the recent hernia repair. There\n is no rim enhancement. Tiny locules of gas are seen tracking into the right\n hemiscrotum. In addition, there is some ill-defined stranding just anterior\n to the femoral vessels, likely postoperative. A small amount of fat is noted\n herniating through the inguinal ring, suggestive of persistent inguinal\n hernia.\n\n The urinary bladder is collapsed around a Foley catheter. The prostate is\n enlarged measuring up to 5.7 cm with calcifications centrally. The distal\n ureters, seminal vesicles, sigmoid colon, and rectum are normal. There is no\n free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting\n criteria for pathologic enlargement is noted.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n Mild multilevel degenerative change of the thoracolumbar spine is noted. There\n is grade 1 retrolisthesis of L5 on S1.\n\n IMPRESSION:\n\n 1. Small bilateral pleural effusions.\n\n 2. Multiple incompletely evaluated hypodensities in the liver measuring up to\n 11 mm without rim enhancement could represent simple cysts but incompletely\n evaluated on this limited single-phase CT. Further evaluation could be\n obtained with MRI or ultrasound as clinically indicated.\n\n 3. Probable post-operative seroma in the right lower abdominal wall. Small\n amount of fat herniating through inguinal ring suggestive of persistent\n partial inguinal hernia.\n\n 4. Enlarged prostate.\n\n Findings discussed with Dr. at 5:30 p.m. on .\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-25 00:00:00.000",
"description": "Report",
"row_id": 109762,
"text": "Atrial fibrillation. Rightward axis. Non-specific inferior T wave changes.\nCompared to the previous tracing of no diagnostic interim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-26 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1146838,
"text": ", MED FA5 5:10 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: w contrast please; please eval for etiology of n/v/weight lo\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with GNR bacteremia and urinary retenetion along with 2 months\n of decreased apetite and weight loss.\n REASON FOR THIS EXAMINATION:\n w contrast please; please eval for etiology of n/v/weight loss\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Small bilateral pleural effusions. Multiple incompletely evaluated\n hypodensities in the liver measuring up to 11 mm without rim enhancement could\n represent simple cysts but a neoplastic etiology cannot be excluded on this\n limited single-phase CT. Further evaluation could be obtained with MRI or\n ultrasound as clinically indicated. Probable post-operative seroma in the\n right lower abdominal wall. Small amount of fat herniating through inguinal\n ring suggestive of persistent inguinal hernia.\n\n"
}
] |